Treatment of Toxic Shock Syndrome with Desquamation
The treatment of toxic shock syndrome (TSS) with desquamation requires immediate hospitalization, aggressive supportive care, appropriate antimicrobial therapy, and specific management of desquamation. 1
Initial Management
Immediate Interventions
- Transfer patient to an intensive care unit or burn center if >10% body surface area (BSA) is affected 1
- Assess severity using SCORTEN score to predict mortality 1
- Identify and remove the source of infection (tampons, nasal packing, infected wounds) 1
- Obtain blood cultures before starting antibiotics (but do not delay treatment) 1
Antimicrobial Therapy
For staphylococcal TSS:
- Clindamycin (to suppress toxin production) PLUS
- Antistaphylococcal penicillin (nafcillin/oxacillin) or vancomycin (for MRSA) 1
For streptococcal TSS:
- Clindamycin PLUS
- Penicillin 1
Supportive Care
- Aggressive fluid resuscitation to maintain adequate blood pressure and organ perfusion 1
- Vasopressors if fluid resuscitation fails to restore blood pressure 1
- Monitor for signs of systemic infection (confusion, hypotension, reduced urine output, reduced oxygen saturation) 1
- Careful monitoring of electrolytes, renal and hepatic function 1
Management of Desquamation
Wound Care
- Handle skin with extreme care to minimize shearing forces and prevent further detachment 1
- Gently cleanse wounds using warmed sterile water, saline, or diluted chlorhexidine (1/5000) 1
- Apply greasy emollient (50% white soft paraffin with 50% liquid paraffin) over the entire epidermis, including denuded areas 1
- Leave detached epidermis in place to act as a biological dressing 1
- Decompress blisters by piercing and expressing or aspirating fluid 1
Dressing Application
- Apply non-adherent dressings (Mepitel™ or Telfa™) directly to denuded dermis 1
- Use secondary foam dressings to collect exudate (e.g., Exu-Dry™) 1
- Consider silver-containing products for areas with signs of infection (limit use if extensive areas need treatment) 1
Special Considerations
Infection Control
- Monitor for secondary infection of denuded skin areas 1
- Apply topical antimicrobials only to sloughy areas, not to all affected skin 1
- Avoid prophylactic systemic antibiotics as they may increase skin colonization, particularly with Candida albicans 1
- Institute antimicrobial therapy only if there are clinical signs of infection 1
Adjunctive Therapies
- Consider intravenous immunoglobulin (IVIG) for refractory toxic shock syndrome 1
- For severe cases with extensive skin involvement, consider transfer to a burn center 1
- Maintain ambient temperature between 25°C and 28°C to prevent hypothermia 1
Monitoring and Follow-up
- Monitor for signs of multiorgan dysfunction (renal, hepatic, hematologic, neurologic) 2, 3
- Watch for signs of secondary infection (increased pain, rising C-reactive protein, neutrophilia) 1
- Expect desquamation to continue for 1-2 weeks after onset of illness 4, 5
- Monitor for complications such as scarring or permanent skin changes
Pitfalls to Avoid
- Delaying antimicrobial therapy while waiting for culture results 1
- Aggressive debridement of detached skin (may worsen condition) 1
- Overaggressive fluid resuscitation (may cause pulmonary, cutaneous, and intestinal edema) 1
- Failure to recognize and control the source of infection 1
- Using adhesive dressings that can further damage fragile skin 1
By following this comprehensive approach to managing toxic shock syndrome with desquamation, mortality and morbidity can be significantly reduced through prompt intervention and appropriate supportive care.