Staphylococcal scalded skin syndrome

Mishra AK, et al. A Systemic Review on Staphylococcal Scalded Skin Syndrome (SSSS): A Rare and Critical Disease of Neonates. Open Microbiol J. 2016 Aug 31;10:150-9.

The symptoms of Staphylococcal scalded skin syndrome (SSSS) include blistering of skin on superficial layers due to the exfoliative toxins released from Staphylococcus aureus. After the acute exfoliation of skin surface, erythematous cellulitis occurs. The SSSS may be confined to few blisters localized to the infection site and spread to severe exfoliation affecting complete body. The specific antibodies to exotoxins and increased clearance of exotoxins decrease the frequency of SSSS in adults. Immediate medication with parenteral anti-staphylococcal antibiotics is mandatory. Mostly, SSSS are resistant to penicillin. Penicillinase resistant synthetic penicillins such as Nafcillin or Oxacillin are prescribed as emergency treatment medicine. If Methicillin-resistant Staphylococcus aureus (MRSA) is suspected), antibiotics with MRSA coverage (e.g., Vancomycin or Linezolid) are indicated. Clindamycin is considered as drug of choice to stop the production of exotoxin from bacteria ribosome. The use of Ringer solution to to balance the fluid loss, followed by maintenance therapy with an objective to maintain the fluid loss from exfoliation of skin, application of Cotrimoxazole on topical surface are greatly considered to treat the SSSS. The drugs that reduce renal function are avoided. Through this article, an attempt has been made to focus the source, etiology, mechanism, outbreaks, mechanism, clinical manifestation, treatment and other detail of SSSS.

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Braunstein I, et  al. Antibiotic sensitivity and resistance patterns in pediatric staphylococcal scalded skin syndrome. Pediatr Dermatol. 2014 May-Jun;31(3):305-8.

Historical resistance patterns often guide empiric antibiotic choices in staphylococcal scalded skin syndrome (SSSS), but little is known about the difference in susceptibility between SSSS and other childhood staphylococcal infections. A retrospective chart review of culture-confirmed cases of SSSS seen in the inpatient dermatology consultation service at the Children’s Hospital of Philadelphia between 2005 and 2011 was performed. Most cases of SSSS at our institution are due to oxacillin-susceptible Staphylococcus aureus, and approximately half of the cases are due to clindamycin-resistant strains. Clindamycin and a penicillinase-resistant penicillin are suggested as empiric treatment for SSSS until culture susceptibility data are available to guide therapy.

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Handler MZ, Schwartz RA. Staphylococcal scalded skin syndrome: diagnosis and management in children and adults. J Eur Acad Dermatol Venereol. 2014 Nov;28(11) :1418-23.

Staphylococcal scalded skin syndrome is a potentially life-threatening disorder caused most often by a phage group II Staphylococcus aureus infection. Staphylococcal scalded skin syndrome is more common in newborns than in adults. Staphylococcal scalded skin syndrome tends to appear abruptly with diffuse erythema and fever. The diagnosis can be confirmed by a skin biopsy specimen, which can be expedited by frozen section processing, as staphylococcal scalded skin syndrome should be distinguished from life threatening toxic epidermal necrolysis. Histologically, the superficial epidermis is detached, the separation level being at the granular layer. The diffuse skin loss is due to a circulating bacterial exotoxin. The aetiological exfoliating toxin is a serine protease that splits only desmoglein 1. The exfoliative toxins are spread haematogenously from a localized source of infection, causing widespread epidermal damage at distant sites. Sepsis and pneumonia are the most feared complications. The purpose of this review is to summarize advances in understanding of this serious disorder and provide therapeutic options for both paediatric and adult patients. Recent epidemiological studies have demonstrated that paediatric patients have an increased incidence of Staphylococcal scalded skin syndrome during the summer and autumn. Mortality is less than 10% in children, but is between 40% and 63% in adults, despite antibacterial therapy. Previously, intravenous immunoglobulin had been recommended to combat Staphylococcal scalded skin syndrome, but a recent study associates its use with prolonged hospitalization.

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Kress DW. Pediatric dermatology emergencies. Curr Opin Pediatr. 2011 Aug;23(4):403-6.

“Several articles published recently added significantly to our understanding of drug reaction with eosinophilia and systemic symptoms (DRESS), eczema herpeticum, staphylococcal scalded skin syndrome and inherited ichthyosis. A review of 60 patients with DRESS showed 80% with hepatic involvement, 40% with renal involvement, 33% with pulmonary involvement and 50% with hematologic abnormalities. A review on eczema herpeticum describes several clinical scenarios in which it is vital to keep that diagnosis in mind. Another review on severe staphylococcal skin infections reminds us of the importance of covering for methicillin-resistant Staphylococcus aureus in all such cases until cultures and sensitivities show otherwise. The results of an international consensus conference on ichthyosis published this year will help all of us to better characterize these complicated patients. Additionally, the first case of hypothyroidism associated with a collodion baby was reported, as was the finding of an increased incidence of atypical nevi in patients with inherited ichthyosis.”

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Berk DR, Bayliss SJ. MRSA, staphylococcal scalded skin syndrome, and other cutaneous bacterial emergencies. Pediatr Ann. 2010 Oct;39(10):627-33.

“SSSS is caused by infections with epidermolytic (also known as exfoliative) toxin (ET)-producing S. aureus. SSSS preferentially affects newborns and children younger than 5 years. The nares, conjunctivae, perioral region, umbilicus, and perineum are common foci of infection. When involvement is localized, infections manifest as bullous impetigo. On the other hand, when hematogenous spread of ET occurs, the generalized form of SSSS develops. Cutaneous findings include widespread erythema, which may start on the head and evolve into superficial skin peeling, flaccid bullae, and denuded tender
skin (see Figure 2, page 630).”

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Blyth M, Estela C, Young AE. Severe staphylococcal scalded skin syndrome in children.
Burns. 2008 Feb;34(1):98-103.

Staphylococcal scalded skin syndrome (SSSS) is a rare toxin-mediated condition caused by Staphylococcus aureus, which causes blistering and desquamation of the skin. Between November 2005 and April 2006, four children were admitted to critical care beds in the South West Regional Paediatric Burns Unit because of SSSS affecting more than 50% of the body surface area. Details of these cases are presented, highlighting the potential severity of the condition. The cases also illustrate that fluid overload is a common complication of the condition, despite hypovolaemia being the more obvious risk, and that both hyponatraemia and leukopenia are frequent findings. These summaries clearly demonstrate the need for paediatric critical care in a tertiary burns unit for children with SSSS affecting a large proportion of the body surface area. The cluster of admissions prompted us to write a management protocol for children with severe SSSS and a summary of this is provided. Most children with SSSS will initially present to general paediatric units, where mild cases will be managed, but severe cases should be promptly referred to a tertiary paediatric burns unit for multi-disciplinary care in a critical care environment.

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More PubMed results on SSSS.

Created 3/20/13; updated 3/13/14, 11/15/16, 07/18/17.

2 thoughts on “Staphylococcal scalded skin syndrome

  1. Pingback: Bullous impetigo | Pediatric Focus

  2. Pingback: Diagnosing staphylococcal scalded skin syndrome in neonates | Pediatric Focus

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