Treatment of bullous impetigo and the staphylococcal scalded skin syndrome in infants

Is my baby normal? A review of seemingly worrisome but normal newborn signs, symptoms and behaviors

Infant patients are a unique challenge to emergency department (ED) physicians as the spectrum of normal infant signs, symptoms and behaviors are often difficult to differentiate from abnormal and potentially life-threatening conditions. In this article, we address some common chief complaints of neonates and young infants presenting to the ED, and contrast reassuring neonatal and young infant signs and symptoms against those that need further workup and intervention.

Staphylococcal-scalded skin syndrome: evaluation, diagnosis, and management

BACKGROUND

Staphylococcal-scalded skin syndrome (SSSS), also known as Ritter disease, is a potentially life-threatening disorder and a pediatric emergency. Early diagnosis and treatment is imperative to reduce the morbidity and mortality of this condition. The purpose of this article is to familiarize physicians with the evaluation, diagnosis, and treatment of SSSS.

DATA SOURCES

A PubMed search was completed in Clinical Queries using the key terms "Staphylococcal scalded skin syndrome" and "Ritter disease".

RESULTS

SSSS is caused by toxigenic strains of Staphylococcus aureus. Hydrolysis of the amino-terminal extracellular domain of desmoglein 1 by staphylococcal exfoliative toxins results in disruption of keratinocytes adhesion and cleavage within the stratum granulosum which leads to bulla formation. The diagnosis is mainly clinical, based on the findings of tender erythroderma, bullae, and desquamation with a scalded appearance especially in friction zones, periorificial scabs/crusting, positive Nikolsky sign, and absence of mucosal involvement. Prompt empiric treatment with intravenous anti-staphylococcal antibiotic such as nafcillin, oxacillin, or flucloxacillin is essential until cultures are available to guide therapy. Clarithromycin or cefuroxime may be used should the patient have penicillin allergy. If the patient is not improving, critically ill, or in communities where the prevalence of methicillin-resistant S. aureus is high, vancomycin should be used.

CONCLUSION

A high index of suspicion is essential for an accurate diagnosis to be made and treatment promptly initiated.

Bullous Impetigo Rapid Diagnostic and Therapeutic Quiz: A Model for Assessing Basic Dermatology Knowledge of Primary Care Providers

BACKGROUND/OBJECTIVES

Bullous impetigo (BI) is a common dermatologic condition, particularly in children, yet confusion regarding its diagnosis and treatment persists. This study measured pediatricians' ability to diagnose and appropriately treat BI and explored factors that might influence pediatricians' accuracy in managing BI.

METHODS

We administered an expert-validated survey to 64 pediatrics house staff and faculty at three Johns Hopkins Medicine facilities. The survey requested demographic information, diagnoses for five "unknown" cases, and preferred treatments for localized and widespread BI.

RESULTS

Overall, BI was diagnosed correctly 31.9% of the time. There was little difference between house staff and faculty performance, although faculty 50 years of age and older demonstrated better diagnostic acumen. Regarding treatment of localized BI, 92% of faculty members and 84.6% of house staff listed mupirocin as first- or second-line treatment. The second most common medication listed for localized BI was bacitracin. Regarding treatment of widespread BI, faculty listed cephalexin or clindamycin as first- or second-line treatment 56.0% of the time and house staff listed one of these two medications 51.3% of the time. Results for faculty 50 years of age and older were comparable.

CONCLUSIONS

Improved pediatrician proficiency in the diagnosis and treatment of BI is needed for safe, cost-effective management. Physician age and experience appear to have a limited effect on the accuracy of BI diagnosis and management. Future educational efforts must be directed at trainees and their instructors.

A Systemic Review on Staphylococcal Scalded Skin Syndrome (SSSS): A Rare and Critical Disease of Neonates

The symptoms of Staphylococcal scalded skin syndrome (SSSS) include blistering of skin on superficial layers due to the exfoliative toxins released from Staphylococcus aureus. After the acute exfoliation of skin surface, erythematous cellulitis occurs. The SSSS may be confined to few blisters localized to the infection site and spread to severe exfoliation affecting complete body. The specific antibodies to exotoxins and increased clearence of exotoxins decrease the frequency of SSSS in adults. Immediate medication with parenteral anti-staphylococcal antibiotics is mandatory. Mostly, SSSS are resistant to penicillin. Penicillinase resistant synthetic penicillins such as Nafcillin or Oxacillin are prescribed as emergency treatment medicine. If Methicillin-resistant Staphylococcus aureus (MRSA) is suspected), antibiotics with MRSA coverage (e.g., Vancomycin or Linezolid) are indicated. Clindamycin is considered as drug of choice to stop the production of exotoxin from bacteria ribosome. The use of Ringer solution to to balance the fluid loss, followed by maintainence therapy with an objective to maintain the fluid loss from exfoliation of skin, application of Cotrimoxazole on topical surface are greatlly considered to treat the SSSS. The drugs that reduce renal function are avoided. Through this article, an attempt has been made to focus the source, etiology, mechanism, outbreaks, mechanism, clinical manisfestation, treatment and other detail of SSSS.

Clinical Approach to Diffuse Blisters

Some blistering eruptions are self-limited, but others are life threatening, and prompt diagnosis and management are critical. The clinical presentation of vesicles and bullae suggests a broad differential and this article (1) highlights some common diagnoses that may be encountered by primary care physicians and subspecialists; (2) provides a possible systematic diagnostic approach to such patients, including history, physical examination, and relevant work-up.

Staphylococcal Scalded Skin Syndrome in Neonate

We described a case of Staphylococcal Scalded Skin Syndrome in infant age of 21 days by discussing clinical and management issues. This newborn presented large erythematous, eroded, and oozing areas covered by epidermal skin flap. The average surface of cutaneous unsticking on admission was 31.35% of body surface area corresponding to lesions of superficial second-degree burns. An important biological inflammatory syndrome including positive C-reactive protein was found. Under treatment, erythroderma decreased within 7 to 10 days and the newborn was completely healed after 3 weeks of followup, with the disappearance of the inflammatory syndrome and total body surface restored. This clinical case report showed that SSSS remains a major dermatological problem in neonates. Therefore, its diagnosis should be made without doubt and its care should start earlier in a neonate emergency unit in order to have good prognosis. And the rigorous "search and destroy" policy based on screening of staff and patients and isolation of identified patients advocated in the United Kingdom should be applied in neonate units in Côte d'Ivoire.

Recent developments in the management of common childhood skin infections

A literature review and clinical commentary on diagnosis and treatment of common childhood bacterial, fungal and viral skin infections is presented including impetigo, folliculitis, staphylococcal scalded skin syndrome, tinea capitis, warts and molluscum contagiosum.

Staphylococcal scalded skin syndrome in neonates: an 8-year retrospective study in a single institution

Staphylococcal scalded skin syndrome (SSSS) is a rare disorder in children. Complications may occur without timely treatment. Mortality in children with SSSS is approximately 4%. Other than a limited number of case reports, data on SSSS in neonates are limited. The objective of the current study was to investigate SSSS in neonates. A retrospective review of neonates with a diagnosis of SSSS from January 2004 to January 2012 was performed. Population distribution, historical features, physical examination findings including laboratory tests, antibiotic therapies, and outcomes were evaluated. Thirty-nine cases were included, 31 (79.5%) in the last 4 years. The mean patient age was 17.4 ± 7.7 days. Boys (25 cases) were more commonly affected, and occurrence during summer and autumn months was more frequent. The face was the most common body part affected and the area most commonly initially affected. Fever, high white blood cell count, and high C-reactive protein levels were uncommon. Pneumonia was the most frequent complication (74.4%). The positive rate of Staphylococcus aureus isolation was low (23.5%). Drug susceptibility tests showed that amoxicillin with clavulanic acid and cephalosporins were effective in practice. The median length of hospitalization was 9.0 days. All of the 39 neonates were cured without scarring. This study established basic epidemiologic characteristics of a group of neonates diagnosed with SSSS. In the presence of a clinical suspicion of SSSS, even with apparently normal laboratory tests, immediate treatment with cephalosporins, β-lactamase-resistant semisynthetic penicillin, or both is advocated.

The use of typing methods and infection prevention measures to control a bullous impetigo outbreak on a neonatal ward

BACKGROUND

We describe an outbreak of Bullous Impetigo (BI), caused by a (methicillin susceptible, fusidic acid resistant) Staphylococcus aureus (SA) strain, spa-type t408, at the neonatal and gynaecology ward of the Jeroen Bosch hospital in the Netherlands, from March-November 2011.

METHODS

We performed an outbreak investigation with revision of the hygienic protocols, MSSA colonization surveillance and environmental sampling for MSSA including detailed typing of SA isolates. Spa typing was performed to discriminate between the SA isolates. In addition, Raman-typing was performed on all t408 isolates.

RESULTS

Nineteen cases of BI were confirmed by SA positive cultures. A cluster of nine neonates and three health care workers (HCW) with SA t408 was detected. These strains were MecA-, PVL-, Exfoliative Toxin (ET)A-, ETB+, ETAD-, fusidic acid-resistant and methicillin susceptible. Eight out of nine neonates and two out of three HCW t408 strains yielded a similar Raman type. Positive t408 HCW were treated and infection control procedures were reinforced. These measures stopped the outbreak.

CONCLUSIONS

We conclude that treatment of patients and HCW carrying a predominant SA t408, and re-implementing and emphasising hygienic measures were effective to control the outbreak of SA t408 among neonates.

Pyodermitis

Pyodermitis are primary skin infections mainly caused by pyogenic bacteria of the Staphylococcus and Streptococcus genera. They are relatively common diseases that affect adults and children. There have been frequent reports of bacterial resistance to the recommended antibiotics over the last few years; however, new substances are in use or under development, and this represents an evolution in the treatment of pyodermitis. This review aims at describing clinical, diagnostic and therapeutical features of major pyodermitis: impetigo, ecthyma, erysipelas, staphylococcal scalded skin syndrome and folliculitis.

Staphylococcal scalded skin syndrome in the Czech Republic: an epidemiological study

OBJECTIVE

To identify the basic epidemiological characteristics of children hospitalized with diagnosis of Staphylococcal scalded skin syndrome in the Czech Republic in the years 1994-2009.

INTRODUCTION

Staphylococcal scalded skin syndrome (SSSS) is a relatively rare disease in childhood. This syndrome was first defined in 1878 by Baron Gottfried Ritter von Rittershainem and belongs to the group of diseases called Burn-like syndromes. It is a bullous skin disease caused by exfoliative toxins which are produced by certain types of Staphyloccocus aureus. Typical structures affected by these toxins are desmosome proteins called Desmoglein-1 located in the stratum granulosum of epidermis. Unlike in Lyell's syndrome or Stevens-Johnson's syndrome, the exfoliation is caused by loss of adhesivity particularly in the stratum granulosum and not by induction of apoptosis in the dermo-epidermal junction.

MATERIAL AND METHODS

This retrospective study was conducted on patients hospitalized in the Czech Republic in the period from 1.1.1994 to 31.12.2009. The basic condition for the inclusion in the retrospective study was age under 1 year and hospitalization due to SSSS. A total of 399 children (177 girls) fulfilled the criteria for inclusion into the study. Information was obtained from a central data depository, the Department of Health Information and Statistics, Czech Republic.

RESULTS

A total of 399 children under 1 year were hospitalized for the diagnosis of SSSS in the study period. The group included 177 girls and 222 boys. M:F ratio was 1.25:1. The average incidence of SSSS in the Czech Republic was 25.11 cases per 100,000 children under 1 year of age. The highest recorded incidence in the followed period was in 1994, when a total of 57 cases of SSSS was reported, namely 53.47 per 100,000 children. By contrast, in 2003, there were reported only 12 cases and the incidence of 12.81 per 100,000 children. The average length of hospitalization was 6.39 days. In 1995, the highest average length of hospitalization was reported, which was 8.1 days, and then in 2007, the lowest average length of hospitalization, 4.4 days. There was no significant difference in the length of hospitalization in boys and girls. None of the 399 children in the population died.

CONCLUSION

In our retrospective study, we established basic epidemiological characteristics of a group of children aged under 1 year with diagnosis of SSSS. As epidemiological data show, the occurrence of this syndrome is not sporadic, but steady.

Plakoglobin rescues adhesive defects induced by ectodomain truncation of the desmosomal cadherin desmoglein 1: implications for exfoliative toxin-mediated skin blistering

Desmoglein 1 (Dsg1) is a desmosomal cadherin that is essential to epidermal integrity. In the blistering diseases bullous impetigo and staphylococcal scalded-skin syndrome, pathogenesis depends on cleavage of Dsg1 by a bacterial protease, exfoliative toxin A, which removes residues 1 to 381 of the Dsg1 ectodomain. However, the cellular responses to Dsg1 cleavage that precipitate keratinocyte separation to induce blister formation are unknown. Here, we show that ectodomain-deleted Dsg1 (Δ381-Dsg1) mimics the toxin-cleaved cadherin, disrupts desmosomes, and reduces the mechanical integrity of keratinocyte sheets. In addition, we demonstrate that truncated Dsg1 remains associated with its catenin partner, plakoglobin, and causes a reduction in the levels of endogenous desmosomal cadherins in a dose-dependent manner, leading us to hypothesize that plakoglobin sequestration by truncated Dsg1 destabilizes other cadherins. Accordingly, a triple-point mutant of the ectodomain-deleted cadherin, which is uncoupled from plakoglobin, does not impair adhesion, indicating that this interaction is essential to the pathogenic potential of truncated Dsg1. Moreover, we demonstrate that increasing plakoglobin levels rescues cadherin expression, desmosome organization, and functional adhesion in cells expressing Δ381-Dsg1 or treated with exfoliative toxin A. Finally, we report that histone deacetylase inhibition up-regulates desmosomal cadherins and prevents the loss of adhesion induced by Dsg1 truncation. These findings further our understanding of the mechanism of exfoliative toxin-induced pathology and suggest novel strategies to suppress blistering in bulbous impetigo and staphylococcal scalded-skin syndrome.

Acute skin conditions in children

This article covers four acute skin conditions seen in children. Early recognition and appropriate prompt treatment is important as significant morbidity may ensue.

Current options for the treatment of impetigo in children

Impetigo contagiosa is a common, superficial, bacterial infection of the skin characterised by an inflamed and infected epidermis caused by Staphylococcus aureus, Streptococcus pyogenes or both. The less common bullous impetigo is characterised by fragile fluid-filled vesicles and flaccid blisters, and is invariably caused by pathogenic strains of S. aureus. In bullous impetigo, exfoliative toxins are produced, although these are restricted to the area of infection and bacteria can be cultured from the blister contents. In the rare variant, staphylococcal scalded skin syndrome, the exfoliative toxins are spread haematogenously from a localised source causing widespread epidermal damage at distant sites.