Staphylococcal Scalded Skin Syndrome: A Case Review

Staphylococcal Scalded Skin Syndrome in Neonates: Case Series and Overview of Outbreaks

Skin and soft tissue infections caused by Staphylococcus aureus (S. aureus) cover a wide spectrum of diseases in neonates, including staphylococcal scalded skin syndrome (SSSS). We describe a representative case of SSSS in neonatal twins, which despite recurrence showed a mild clinical disease course. This case was part of a small outbreak on a neonatal intensive care unit and therefore exemplifies the existence of neonatal outbreaks with skin and soft tissue infections by S. aureus. Diagnosis is generally based on the clinical picture and response to antibiotics, but can be aided by histology and cultures. Sequence-based molecular techniques are available to evaluate typing and virulence of S. aureus in outbreak or surveillance settings. The pillars of treatment are antibiotics and supportive care. Methicillin resistance remains a topic of concern, especially in outbreak settings. Our overview of numerous outbreaks of neonatal S. aureus skin infections underlines the importance of outbreak management strategies, including screening to identify the source of the outbreak, and limiting exposure through hygienic measures and establishment of physical boundaries.

Staphylococcal Scalded Skin Syndrome in a Ten-Month-Old Male

A 10-month-old male presented with rhinorrhea and decreased oral intake and was diagnosed with an upper respiratory infection. Two days later, he returned to the clinic due to a lack of improvement and the onset of new symptoms, including facial edema and perioral skin irritation. That evening, he became febrile at 100.4 °F and went to the emergency department at the local children’s hospital. No further workup was done and the parents were instructed to continue with the current treatment regimen. Over the next 48 hours, the patient’s symptoms worsened with the new onset of bilateral extremity edema and desquamation. The patient was returned to the emergency department. A physical exam was notable for a blanching, desquamating, erythematous rash on the face and creases of the arms, legs, and groin. A positive Nikolsky sign was reported. A clinical diagnosis of staphylococcal scalded skin syndrome (SSSS) was made, and the patient was started on intravenous clindamycin. This case illustrates a severe presentation of SSSS in a pediatric patient, demonstrating the challenges it poses to diagnosis and treatment.

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.