Staphylococcal scalded skin syndrome (SSSS)

• Staphylococcal scalded skin syndrome (SSSS)
  • is a rare toxin-mediated condition caused by Staphylococcus aureus
    • usually a group 2 S. aureus, mainly serotypes 3A, 3B, 3C, 55 and 71
      • rare cases due to MRSA (methicillin-resistant S. aureus)
    • generally seen in children less than 5 years of age, who have not yet developed protective antibodies against the staphylococcal toxins
      • also may occur in adults with significant underlying morbidity
    • characterised by blistering and desquamation of the skin and Nikolsky's sign (shearing of the epidermis with gentle pressure), even in areas that are not obviously affected
    • SSSS in children usually begins with a prodrome of pyrexia and malaise, often with signs and symptoms of an upper respiratory tract infection
      • discrete erythematous areas then develop and rapidly enlarge and coalesce, leading to generalised erythema - often worse in the flexures with sparing of the mucous membranes
      • large, fragile bullae form in the erythematous areas and then rupture
        • causes large areas of epidermis to slough off resulting in the appearance of scalded skin
    • main complications are:
      • hypothermia
      • dehydration due to fluid loss through the damaged skin
      • secondary infection

Management:

• seek expert advice
• may we require referral to a tertiary burns unit for care in a critical care environment
  • allows management by an appropriate multi-disciplinary team
• immediate management of a patient with SSSS should follow basic resuscitation guidelines, with assessment of the airway, breathing and circulation taking priority
  • fluid bolus(es) are likely to be required, due to toxaemia and to fluid loss through the damaged skin
• treatment of toxaemia
  • benzylpenicillin and an intravenous penicillinase-resistant penicillin should be commenced at high doses as soon as blood cultures have been taken. (If the patient is allergic to penicillins, clarithromycin or cefuroxime would be appropriate)
    • will not halt the progression of the disease until the circulating exotoxin has been neutralised by antibodies or excreted from the body by the kidneys
    • topical antibiotics should be prescribed for conjunctivitis, if present, but there is no role for topical antibiotics for the skin term lesions as this is not the site of primary infection and the blister fluid will be sterile initially

Mortality rates of 60% in adults, and up to 11% in children may occur.

Reference:

• 1. Blyth M et al. Severe staphylococcal scalded skin syndrome in children. Burns 2008; 34 (1):98-103.