Staphylococcal Scalded Skin Syndrome (SSSS): Symptoms and Treatment
Clinical Presentation
SSSS is a toxin-mediated blistering disorder characterized by tender erythroderma, bullae formation, desquamation with a scalded appearance, periorificial crusting, positive Nikolsky sign, and critically—absence of mucosal involvement. 1
Key Diagnostic Features
- Skin tenderness is the most prominent symptom, present in 81% of patients 2
- Erythema and exfoliation occur in 100% of cases 2
- Vesicles/bullae develop in 76% of patients 2
- Periorificial scabs and crusting are characteristic findings 1
- Positive Nikolsky sign (epidermis peels with minimal shearing force) 1
- Friction zones are preferentially affected 1
Critical Distinguishing Feature from TEN
The absence of mucosal involvement clinically distinguishes SSSS from toxic epidermal necrolysis (TEN). 3 In cases of diagnostic uncertainty, skin biopsy reveals intraepidermal cleavage in SSSS versus subepidermal cleavage in TEN. 3 The cleavage occurs within the stratum granulosum due to hydrolysis of desmoglein 1 by staphylococcal exfoliative toxins. 1
Epidemiology
- Mean age of diagnosis is 3.1 years, predominantly affecting infants and children under 5 years 2, 4
- Male predominance (58%) 2
- Primarily affects neonates and young children due to immature renal clearance of exotoxins and lack of specific antibodies 4
Treatment Approach
Immediate Empiric Antibiotic Therapy
Prompt empiric treatment with intravenous anti-staphylococcal antibiotics is essential and should be initiated immediately upon clinical diagnosis. 1
First-Line Agents (Penicillinase-Resistant Penicillins):
These agents are preferred as SSSS isolates are typically methicillin-sensitive and less likely to be MRSA compared to other staphylococcal infections. 5
Alternative First-Line Agents (Cephalosporins):
- Cephalosporins are favored for empiric management alongside penicillinase-resistant penicillins 5
For Penicillin Allergy:
When to Add MRSA Coverage
Vancomycin should be used if the patient is not improving after several days, is critically ill, or in communities where MRSA prevalence is high. 1, 5 Alternative MRSA-coverage agents include linezolid. 4
Adjunctive Anti-Toxin Therapy
Clindamycin is considered the drug of choice to stop exotoxin production at the ribosomal level. 4 However, recent evidence shows that adding clindamycin had no effect on duration of hospitalization (3.6 vs 3.9 days, P=0.63), and its routine use requires further investigation. 2 SSSS-associated isolates are more likely to be clindamycin-resistant than other staphylococcal infections. 5
Microbiological Evaluation
Staphylococcus aureus is more commonly isolated from periorificial cultures than from bullae fluid. 2 Obtain cultures from:
- Periorificial sites (nose, throat, conjunctiva) 6
- Blister fluid 6
- Blood cultures to identify primary focus 6
- Nasal swabs from patient and immediate family members to identify asymptomatic carriers 6
Supportive Care
- Fluid resuscitation with Ringer solution to balance fluid loss from exfoliation 4
- Maintenance fluid therapy to compensate for ongoing transepidermal water loss 4
- Topical cotrimoxazole application 4
- Avoid nephrotoxic drugs given potential for renal impairment 4
Critical Management Pitfalls
Surgical debridement of skin in SSSS patients should be discouraged. 2 Skin debridement was the only risk factor leading to complications and prolonged hospitalization (P=0.03). 2 Unlike other blistering disorders, SSSS involves superficial intraepidermal cleavage that heals spontaneously with appropriate antibiotic therapy.