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Updated: Sep 20 2018

Staphylococcal Scalded Skin Syndrome (SSSS)

  • Snapshot
    • A 3-year-old girl presents to her pediatrician with a widespread rash. She recently had fevers and a sore throat. She has perioral fissues and a desquamating rash in the groin and neck. When light pressure is applied, the skin easily sloughs off. Superficial wound cultures and bacterial cultures are negative.
  • Introduction
    • Clinical definition
      • exfoliative skin infection caused by Staphylococcus aureus toxins
    • Epidemiology
      • incidence
        • 9-25 per 100,000 children
      • demographics
        • affects neonates and children
    • Pathophysiology
      • mechanism of injury
        • systemic spread of Staphylococcus aureus toxins exfoliative exotoxins A (ETA) or B (ETB)
          • both are trypsin-like serine proteases that digest desmoglein-1, a cadherin that mediates keratinocyte adhesion in the epidermis
          • loss of cell-cell adhesion in stratum granulosum leads to bullae and sloughing
    • Associated Staphylococcus aureus conditions
      • children
        • preceding respiratory tract infection
        • preceding conjunctivitis
        • preceding otitis media
    • Prognosis
      • survival with treatment
        • very good
  • Presentation
    • Symptoms
      • primary symptoms
        • prodrome with irritability, malaise, fever, and sore throat
    • Physical exam
      • erythematous tender patches progressing to painful desquamation and superficial skin sloughing with “scalded” appearance
      • generalized and flaccid bullae
      • perioral and periorbital fissures
      • mucous membranes not involved
      • positive Nikolsky sign which describes a
        • separation of epidermis from dermis with slight pressure
      • distribution is often in the face, neck, groin, axillae, and other flexural surfaces
      • mucosal surfaces not involved (vs. SJS & TEN)
  • Studies
    • Labs
      • blood cultures typically negative
      • superficial wound cultures and bullae fluid cultures are sterile
    • Biopsy
      • indications
        • if diagnosis of toxic epidermal necrolysis needs to be ruled out
    • Histology
      • intraepidermal cleavage
  • Differential
    • Toxic epidermal necrolysis
      • full thickness epidermal cell necrosis and supepidermal cleavage
    • Bullous impetigo
      • honey-crusted erosions
      • more widespread
      • positive superficial wound cultures
  • Treatment
    • Medical
      • intravenous anti-staphylococcal antibiotics
        • indications
          • administered in the treatment of staphlococcal scalded skin syndrome
        • modalities
          • nafcillin or oxacillin in methicillin-sesitive Staphylococcus aureus (MSSA)
          • vancomycin in cases of methicillin-resistant Staphylococcus aureus (MRSA)
  • Complications
    • Secondary infection of denuded skin
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