From the Guidelines
The distinction between toxic epidermal necrolysis and staphylococcal scalded skin syndrome is based on the level of exfoliation, as confirmed by a skin biopsy or frozen section of a blister roof, which identifies the plane of cleavage. This is crucial in differentiating between the two conditions, as the level of exfoliation determines the severity of skin loss and guides treatment approaches 1. In toxic epidermal necrolysis, the separation occurs at the dermo-epidermal junction, involving the full thickness of the epidermis, resulting in deeper, more severe skin loss. In contrast, staphylococcal scalded skin syndrome features separation within the epidermis itself, specifically at the granular layer, resulting in more superficial exfoliation. Some key features of toxic epidermal necrolysis include:
- Epidermal loss and multisite mucositis, accompanied by systemic symptoms
- Mucous membrane involvement, leading to erosive and hemorrhagic mucositis
- Cutaneous pain and the presence of a Nikolsky sign, where minimal shearing forces cause the epidermis to peel back
- Extensive necrolysis resulting in the detachment of sheets of epidermis, leaving areas of exposed dermis. On the other hand, staphylococcal scalded skin syndrome is characterized by:
- Skin loss caused by circulating bacterial toxins to skin-cleavage proteins
- Absence of mucosal involvement, which clinically distinguishes it from toxic epidermal necrolysis
- Intraepidermal cleavage, as identified by skin biopsy or frozen section of a blister roof 1. Given the significant difference in mortality rates between toxic epidermal necrolysis (25-30%) and staphylococcal scalded skin syndrome (1-5% in children, higher in adults), accurate diagnosis and distinction between the two conditions is critical to guide appropriate treatment and improve patient outcomes 1.
From the Research
Distinction between Toxic Epidermal Necrolysis and Staphylococcal Scalded Skin Syndrome
The distinction between toxic epidermal necrolysis (TEN) and staphylococcal scalded skin syndrome (SSSS) is based on several factors, including:
- Level of exfoliation: TEN is characterized by a higher level of exfoliation, with the split occurring at the dermo-epidermal junction, whereas SSSS has a split at the granular layer of the epidermis 2, 3
- Histological features: SSSS is characterized by the detachment of the superficial epidermis, with the separation level being at the granular layer, whereas TEN shows a split at the dermo-epidermal junction 2
- Clinical presentation: SSSS tends to appear abruptly with diffuse erythema and fever, whereas TEN presents with a generalized, markedly tender erythema and rapidly progresses to bullous desquamation of the superficial epidermal layers and systemic toxicity 2, 4
- Response to treatment: The use of corticosteroids may inhibit the progression of epidermal necrolysis and improve the prognosis in TEN, whereas SSSS is typically treated with antibacterial therapy 2, 4
Diagnostic Techniques
Diagnostic techniques such as optical coherence tomography (OCT) can be used to distinguish between TEN and SSSS, by visualizing the bullous skin and showing distinct images for each condition 3 Skin biopsy specimens can also be used to confirm the diagnosis, with frozen section processing being a useful tool for rapid diagnosis 2
Etiology and Pathogenesis
The etiology and pathogenesis of TEN and SSSS are different, with TEN being triggered by various factors such as drugs, bacterial, viral or immunization factors, whereas SSSS is caused by certain phage group 2 staphylococci that produce an epidermolytic toxin 5, 2