Diagnosis

Staphylococcal scalded skin syndrome

Etiology

Cause [4i6]

• Staphylococcus aureus (exotoxin-producing strain are less than 5%)

Pathophysiology [4i6][tsp]

1. Some strains of Staphylococcus aureus produce exfoliative toxins

2. The exfoliative toxins are spread hematogenously from a localized source

   • Nasopharynx

   • Conjunctivae

   • Staphylococcal pneumonia

   • Bacteremia

3. The toxins act as proteases that target the protein desmoglein-1 (a cell-to-cell attachment protein found only in the superficial epidermis)

4. Loss of cellular adhesion among keratinocytes

5. Severety varies:

   • A few blisters localized to the site

   • Severe exfoliation affecting almost the entire body (dangerous)

6. SSSS is much less common in adults because of neutralizing antibodies and efficient renal clearance of exotoxins from the bloodstream

7. Loss of the protective skin barrier --> risk for complications

Risk factors [4i6]

• Children

• Immunocompromised adults

Complications [4i6]

• Hypothermia

• Dehydration from fluid loss

• Secondary infections

• Electrolyte imbalance

• Sepsis

• Acute kidney injury

• Scarring

Epidemiology

Incidence per 100.000 [4i6][zkt][tsp][svn][q1a]

Approach

• Blood test: electrolytes, renal function

• PCR

• Bulla culture

• Culture with S. aureus from skin, umbilicus, nasopharynx, conjunctiva, and diaper area

• Blood culture

• Gram stain

• Skin biopsy

Treatment

1. Fluid resuscitation (denuded skin --> water loss) [4i6]

2. IV antibiotics: [4i6][tsp]

   • Penicillinase-resistant Cefazolin 50-100 mg/kg daily, divided every 8 hours

   • Clindamycin

   • Dicloxacillin 500 mg every 6 hours

   • Trimethoprim/sulfamethoxazole 160/800 mg every 12 hours

   • Vancomycin if MRSA

3. Skin care:

   • Wound cleansing

   • Moist dressings/Vaseline

   • Antiseptic or hydrocolloid ointment and creams

4. Monitoring to avoid hypothermia and hemodynamic instability

Differential diagnoses

Acute exanthematic pustulosis, Burn wound, Cellulitis, Drug side effects, Eczema, Epidermolysis bullosa, Erysipelas, Erythema multiforme, Gas gangrene, Graft-versus-host disease, Impetigo, Kawasaki disease, Necrotizing fasciitis, Pemphigus foliaceus, Pemphigus vulgaris, Scarlet fever, Stevens-Johnson syndrome, Toxic epidermal necrolysis, Toxic shock syndrome