From the Guidelines
Staphylococcal scalded skin syndrome (SSSS) is caused by exfoliative toxins produced by certain strains of Staphylococcus aureus, and treatment requires immediate hospitalization and administration of anti-staphylococcal antibiotics, with first-line therapy being intravenous vancomycin (15-20 mg/kg IV every 8-12 hours) due to the increasing prevalence of MRSA, as recommended by the 2018 WSES/SIS-E consensus conference 1. The etiology of SSSS involves the production of exfoliative toxins, primarily ETA and ETB, which cleave desmoglein 1, disrupting cell adhesion in the superficial epidermis.
- The treatment of SSSS typically involves:
- Immediate hospitalization
- Administration of anti-staphylococcal antibiotics
- Supportive care, including fluid replacement, pain management, temperature regulation, and gentle wound care with sterile saline or mild antiseptic solutions
- The use of vancomycin as first-line therapy is recommended due to its effectiveness against MRSA, as well as its ability to penetrate into the skin and soft tissues, as noted in the 2011 clinical practice guidelines by the Infectious Diseases Society of America 1.
- The prognosis for SSSS is generally good with prompt treatment, with healing occurring within 10-14 days without scarring in most cases, but complications are more common in neonates, immunocompromised patients, and the elderly, who require particularly close monitoring during treatment.
- It is essential to note that corticosteroids are contraindicated in the treatment of SSSS, as they can worsen the condition and increase the risk of complications.
- The management of SSSS has become more complicated due to the increasing prevalence of multidrug-resistant pathogens, such as MRSA, which highlights the importance of using effective antibiotics, such as vancomycin, as part of the treatment regimen, as recommended by the 2018 WSES/SIS-E consensus conference 1.
From the Research
Etiology of Staph Scalded Skin Syndrome
- Staphylococcal scalded skin syndrome (SSSS) is caused by toxigenic strains of Staphylococcus aureus 2, 3, 4.
- The condition occurs when staphylococcal exfoliative toxins hydrolyze the amino-terminal extracellular domain of desmoglein 1, disrupting keratinocytes adhesion and leading to bulla formation 2.
- SSSS can be caused by methicillin-resistant Staphylococcus aureus (MRSA) strains, which can produce exfoliative toxins and lead to severe exfoliation of the skin 3, 4.
Clinical Presentation
- The diagnosis of SSSS is mainly clinical, based on 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 2.
- The symptoms of SSSS include blistering of the skin on superficial layers due to exfoliative toxins released from Staphylococcus aureus, followed by erythematous cellulitis 4.
Treatment
- Prompt empiric treatment with intravenous anti-staphylococcal antibiotics, such as nafcillin, oxacillin, or flucloxacillin, is essential until cultures are available to guide therapy 2, 4.
- Clarithromycin or cefuroxime may be used if the patient has a penicillin allergy, and vancomycin should be used if the patient is not improving, critically ill, or in communities where the prevalence of MRSA is high 2, 4.
- Clindamycin is considered a drug of choice to stop the production of exotoxin from bacterial ribosomes, and Ringer solution can be used to balance fluid loss, followed by maintenance therapy to maintain fluid loss from exfoliation of the skin 4.