What is the treatment for staphylococcal scalded skin syndrome?

Treatment of Staphylococcal Scalded Skin Syndrome (SSSS)

Prompt intravenous anti-staphylococcal antibiotics are the cornerstone of treatment for staphylococcal scalded skin syndrome, with nafcillin, oxacillin, or flucloxacillin as first-line options for methicillin-susceptible strains. 1

Initial Assessment and Diagnosis

• SSSS is caused by toxigenic strains of Staphylococcus aureus that produce exfoliative toxins, resulting in disruption of keratinocyte adhesion and cleavage within the stratum granulosum 1
• Diagnosis is primarily clinical, based on findings of tender erythroderma, bullae, desquamation with scalded appearance, periorificial crusting, positive Nikolsky sign, and absence of mucosal involvement 1
• Obtain cultures from skin lesions, blood, and potential primary infection sites to guide antibiotic therapy 2

Antibiotic Treatment

First-line therapy:

• For hospitalized patients with SSSS, intravenous anti-staphylococcal penicillins are the treatment of choice:
  • Nafcillin or oxacillin: 50-100 mg/kg/day IV in divided doses every 4-6 hours for children; 250-500 mg IV every 4-6 hours for adults with mild-moderate infections, or 1 gram IV every 4-6 hours for severe infections 2, 3, 1

For penicillin-allergic patients:

• Clarithromycin or cefuroxime may be used in patients with penicillin allergy 1
• Clindamycin 10-13 mg/kg/dose IV every 6-8 hours (to administer 40 mg/kg/day) in children; 600 mg IV or PO 3 times daily in adults 2

For suspected or confirmed MRSA:

• Vancomycin should be used if the patient is critically ill, not improving on initial therapy, or in communities with high MRSA prevalence 1, 4
• Linezolid 600 mg PO/IV twice daily for children >12 years of age and 10 mg/kg/dose PO/IV every 8 hours for children <12 years of age is an alternative 2

Duration of therapy:

• Continue antibiotics for 7-14 days, individualizing based on clinical response 2
• Treatment should be continued for at least 48 hours after the patient becomes afebrile, asymptomatic, and cultures are negative 3

Supportive Care

• Fluid management is crucial to replace losses from exfoliation and maintain hemodynamic stability 4
• Apply bland emollients to the whole skin to support barrier function, reduce transcutaneous water loss, and encourage re-epithelialization 2
• Use appropriate dressings on exposed dermis to reduce fluid and protein loss, limit microbial colonization, help with pain control, and accelerate re-epithelialization 2
• Consider vaseline and sterile gauge dressings for wound care 5
• Monitor for signs of secondary infection or sepsis, including confusion, hypotension, reduced urine output, reduced oxygen saturation, increased skin pain, rise in C-reactive protein, and neutrophilia 2

Special Considerations

• Neonates and children under 5 years are particularly susceptible to SSSS 6
• Adults with SSSS often have underlying conditions like renal insufficiency that impair toxin clearance and typically have higher mortality rates 7
• Avoid medications that reduce renal function as they may impair clearance of exotoxins 4
• Do not administer prophylactic systemic antibiotics indiscriminately as this may increase skin colonization, particularly with Candida albicans 2

Prevention of Recurrence

• For recurrent staphylococcal skin infections, consider the following preventive measures:
  • Keep wounds covered with clean, dry bandages 2
  • Maintain good personal hygiene with regular bathing and hand cleaning 2
  • Focus cleaning on high-touch surfaces that contact bare skin 2
  • Consider decolonization strategies for recurrent infections:
    • Nasal mupirocin twice daily for 5-10 days 2
    • Topical body decolonization with chlorhexidine for 5-14 days or dilute bleach baths 2

By following this treatment approach, most patients with SSSS will show improvement within a few days, with complete re-epithelialization typically occurring within 7-10 days 5.