Updated: 12/16/2021

Staphylococcal Scalded Skin Syndrome (SSSS)

Review Topic
  • Snapshot
    • A newborn boy is brought to the emergency room for the evaluation of fever, red skin, and irritability. For the past few days he has been refusing to eat and had minimal urinary output. Vitals signs are significant for a temperature of 100.8°F (38.2°C). On physical examination there is diffuse erythematous non-blanching tender patches. There is also superficial skin sloughing and multiple fragile and flaccid bullae. Superficial wound cultures are sterile.
  • Introduction
    • Clinical definition
      • exfoliative skin infection caused by Staphylococcus aureus toxins
    • Associated Staphylococcus aureus conditions
      • children
        • preceding respiratory tract infection
        • preceding conjunctivitis
        • preceding otitis media
      • adults
        • renal dysfunction
        • immunocompromise
        • septic arthritis
        • pneumonia
  • 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
    • Children are at risk due to naïve immune system
    • Adults at risk usually have underlying immune compromise
  • 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
        • separation of epidermis from dermis with slight pressure
      • distribution is often in the face, neck, groin, axillae, and other flexural surfaces
  • Studies
    • Labs
      • blood cultures typically negative
      • superficial wound and bullae fluid cultures are sterile, which differentiates this from
        • bullous impetigo that has positive superficial wound cultures
    • 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
  • Prognosis
    • Survival with treatment
      • very good
      • higher mortality in adults
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