Staphylococcal Scalded Skin Syndrome
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- A spectrum of generalized exfoliative skin disease with blistering of the upper layer of skin caused by an epidermolytic toxin produced by certain strains of Staphylococcus aureus
- In neonates and young infants, also known as Ritter disease or pemphigus neonatorum
- Classically described as skin tenderness and erythema, with bullae formation and desquamation
- Severity of the disease ranges from
- Few blisters localized to site of infection
- Mild illness with desquamation of skinfolds following impetigo
- Generalized severe exfoliation involving much of the body (typically seen in neonates)
- Classic staphylococcal scalded skin syndrome (SSSS): tenderness, erythema, desquamation, or bullae formation. May resemble scalding injury
- Failure to differentiate from streptococcal disease, as SSSS requires treatment with penicillinase-resistant antibiotic therapy (e.g., nafcillin)
- Late recognition leading to delayed therapy and shock
- Not appreciating increased fluid losses through affected skin
- Differentiation from toxic epidermal necrolysis (TEN) is critical, as therapy is very different.
- Most cases occur in neonates and children.
- 62% of affected children are <2 years of age.
- 98% of affected children are <6 years of age.
- Rare in adults due to increased circulating antibodies and adult kidney excretion of the toxin
- No differences in incidence based on gender in children; however, in adults, the male-to-female ratio is 2:1.
- Immunocompromised state (in children or adults)
- Maternal antibodies transferred via breast milk are partially protective, but neonatal cases can still occur.
- Increased S. aureus carriage and susceptibility to toxin (usually in adults)
- Renal impairment either due to immature renal clearance of toxin in children or underlying renal disease
- Good hand hygiene practices, including adherence to contact precautions in hospitalized patients, to prevent spread from asymptomatic carriers
- Prevent skin from becoming overly moist or macerated.
- Isolation of hospitalized patient
- Suspected or documented cases should be placed in contact isolation.
- Exfoliative toxins circulate throughout the body, causing blisters at sites distant from the infection.
- Destruction of protein desmoglein 1 (attachment protein found only in the superficial epidermis) by exfoliative toxin A (ETA) and exfoliative toxin B (ETB) cause intraepidermal splitting leading to bullae development and skin desquamation.
- Exfoliative toxin released by S. aureus:
- 2 major serotypes of the toxin: ETA and ETB
- Mostly caused by S. aureus belonging to phage group II, types 71 and 55
Commonly Associated Conditions
- Skin and soft tissue infections or abscesses
- Bullous impetigo