Staphylococcal scalded skin syndrome (SSSS) is an acute epidermolysis caused by staphylococcal toxins, mostly in infants and children, and is characterized by extensive bullae with epidermal desquamation, with a good prognosis.


Causes

Staphylococcal skin scald syndrome is mainly caused by coagulase-positive staphylococcus aureus of phage group II, mostly type 71. This type of staphylococci can produce epidermolytic toxin (ET) A, B, D, namely, exfoliative toxins, causing skin damage. It has been found that certain staphylococci in phage group I and group III can also produce epidermolytic toxins, which is increased in serum and causes skin damage and exfoliation. Staphylococcal skin scald syndrome in adults is more common in patients with nephritis, uremia, immune dysfunction, or severe staphylococcus aureus septicemia.


Signs and Symptoms

Staphylococcal skin scald syndrome occurs mostly in 1 – 5 weeks old infants, occasionally in adults, with sudden onset. Perioral and periocular erythema occurs initially, quickly spreading to the trunk and proximal limbs, even the whole body, with obvious tenderness. Loose bullae may occur on the basis of erythema, and perioral and periocular scabs occur within 1 - 2 days, with or without decrustation, leaving radial chaps. Superficial folds occur in other areas, large pieces of epidermal exfoliation occurs when slightly rubbing, and bright red edematous erosions are exposed, that is, positive Nikolsky sign is present, resembling scalded lesions. Epidermidolysis is present at the boundaries of erosions, desquamation from the glove or sock areas can be present, and then erosions turn gradually from bright red to purple and dark red, without new exfoliation. Scaly desquamation occurs, and patients heal in 7 - 14 days. Most patients have no obvious mucosal damage except for cheilitis, stomatitis, and conjunctivitis. Generally, systemic symptoms, such as fever, anorexia, vomiting, and diarrhea, are present. Other complications may include septicemia, cellulitis, and pneumonia.


Diagnosis

On the basis of clinical findings, such as 1 - 5 weeks old infants, rapid onset, loose bullae on the basis of erythema, large exfoliation of the epidermis, and positive Nikolsky sign, diagnosis is not difficult. ET-A, ET-B, ET-D tests can be performed if necessary.


Treatment

If with early diagnosis and treatment, death is rare. The stratum corneum can be quickly renewed, and patients can heal within 5 - 7 days.

Intravenous penicillin-resistant anti-staphylococcus antibiotics, such as nafcillin, should be immediately used after diagnosis, until symptoms are improved. Oral cloxacillin is followed. Vancomycin can be used in areas with high incidence of staphylococcus aureus MRSA or in patients with poor initial treatment response. Glucocorticoids are contraindicated. Emollients such as white petrolatum are sometimes used to prevent further loss of water from ulcerated skin. Local treatment and touch should be minimized.

If with extensive exudates, treatment for scalding can be applied. Hydrating polymer hydrogels can be very useful, and the frequency of dressing changes should be lowered.