Staphylococcal Scalded Skin Syndrome

The initial lesion is usually superficial and crusted. Within 24 hours, the surrounding skin becomes painful and scarlet, changes that quickly spread to other areas. The skin may be exquisitely tender and have a wrinkled tissue paper–like consistency. Large, flaccid blisters arise on the erythematous skin and quickly break to produce erosions. Blisters are frequently present in areas of friction, such as intertriginous areas, buttocks, hands, and feet. Intact blisters extend laterally with gentle pressure (Nikolsky sign). The epidermis may peel easily, often in large sheets. Widespread desquamation occurs within 36 to 72 hours, and patients become very ill with systemic manifestations (eg, malaise, chills, fever). Desquamated areas appear scalded. Loss of the protective skin barrier can lead to sepsis Sepsis and Septic Shock Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. In septic shock, there is critical reduction in tissue perfusion; acute failure... read more and to fluid and electrolyte imbalance.

Diagnosis of staphylococcal scalded skin syndrome is suspected clinically, but confirmation may require biopsy (frozen section may give earlier results). Specimens show noninflammatory superficial splitting of the epidermis.

Cultures should be taken from the conjunctiva, nasopharynx, blood, urine, and areas of possible primary infection, such as the umbilicus in a neonate or suspect skin lesions. Cultures should not be taken from bullae because they are sterile, unlike in bullous impetigo, where cultures of the blister fluid will yield a pathogen.

With prompt diagnosis and therapy, death rarely occurs; the stratum corneum is quickly replaced, and healing usually occurs within 5 to 7 days after start of treatment.

Penicillinase-resistant antistaphylococcal antibiotics given IV must be started immediately. Nafcillin 25 mg/kg/dose every 12 hours for neonates < 2 kg, 25 mg/kg/dose every 8 hours for neonates > 2 kg, and 25 to 50 mg/kg/dose every 6 hours (maximum daily dose 12 g per day) for older children is given until improvement is noted, followed by oral cloxacillin 12.5 mg/kg every 6 hours (for infants and children weighing ≤ 20 kg) and 250 to 500 mg every 6 hours (for older children). Oxacillin and cephalosporins (eg, cefazolin) are alternatives. Most cases are caused by methicillin-susceptible S. aureus (MSSA), but vancomycin, linezolid, or other drugs effective against MRSA MRSA and purulent or complicated cellulitis Cellulitis is acute bacterial infection of the skin and subcutaneous tissue most often caused by streptococci or staphylococci. Symptoms and signs are pain, warmth, rapidly spreading erythema... read more should be considered in areas with a high prevalence of methicillin-resistant S. aureus (MRSA) or in patients failing to respond to initial therapy. Corticosteroids are contraindicated.

Emollients (eg, white petrolatum) are sometimes used to prevent further insensible water loss from ulcerated skin. However, topical therapy and patient handling must be minimized.

If disease is widespread and lesions are weeping, the skin should be treated as for burns Treatment Burns are injuries of skin or other tissue caused by thermal, radiation, chemical, or electrical contact. Burns are classified by depth (superficial and deep partial-thickness, and full-thickness)... read more . Hydrolyzed polymer gel dressings may be very useful, and the number of dressing changes should be minimized.

Steps to detect carriers and prevent or treat nursery epidemics are discussed elsewhere (see prevention of neonatal hospital-acquired infection Prevention Some infections are acquired after admission to the nursery rather than from the mother in utero or intrapartum. For some infections (eg, group B streptococci, herpes simplex virus [HSV]) it... read more ).