What is the treatment for Staphylococcus (Staph) scalded skin syndrome?

Treatment of Staphylococcal Scalded Skin Syndrome (SSSS)

Initiate immediate intravenous anti-staphylococcal antibiotics with nafcillin, oxacillin, or flucloxacillin as first-line therapy, while providing aggressive supportive care including fluid resuscitation and wound management. 1, 2

Initial Antibiotic Selection

First-Line Therapy for Methicillin-Susceptible Infections

• Start with IV nafcillin or oxacillin as the empiric treatment of choice for SSSS, as most cases are caused by toxigenic strains of Staphylococcus aureus that are penicillin-resistant but methicillin-susceptible 3, 2
• Flucloxacillin is an alternative penicillinase-resistant penicillin that can be used 2
• These beta-lactam antibiotics target the bacterial cell wall and should be initiated immediately upon clinical diagnosis 1, 2

Penicillin Allergy Alternatives

• Use cefazolin if the patient has a non-type 1 hypersensitivity penicillin allergy (i.e., no anaphylaxis, angioedema, or urticaria history) 1
• Clarithromycin or cefuroxime are recommended alternatives for patients with true penicillin allergy 2

When to Cover MRSA

You must escalate to MRSA-active therapy in three specific scenarios:

• The patient is critically ill or not improving on beta-lactam therapy after 24-48 hours 1, 2
• Your community has high prevalence of methicillin-resistant S. aureus (MRSA) 1, 2
• Culture results confirm MRSA infection 1

MRSA-Active Antibiotic Options

• Vancomycin 15 mg/kg/dose IV every 6 hours for children is the primary MRSA-active agent 1, 3
• Linezolid is an alternative: 10 mg/kg/dose PO/IV every 8 hours for children <12 years 1
• Linezolid offers the advantage of oral bioavailability for transition therapy 1

Adjunctive Clindamycin Therapy

Add clindamycin 10-13 mg/kg/dose IV every 6-8 hours to your primary antibiotic regimen to actively suppress exotoxin production at the ribosomal level, particularly if the patient is critically ill or has extensive disease 1, 3

• Clindamycin works by inhibiting bacterial protein synthesis, thereby stopping production of the exfoliative toxins responsible for the skin manifestations 3
• This can be used in stable hospitalized children without ongoing bacteremia ONLY if local clindamycin resistance rates are <10%, with transition to oral therapy if the strain is susceptible 1
• The dual mechanism of cell wall-active antibiotics plus toxin suppression provides optimal therapy 1, 3

Supportive Care Measures

Fluid Management

• Administer Ringer's solution to balance fluid loss from extensive skin exfoliation, followed by maintenance therapy to replace ongoing losses 3
• Treat SSSS patients similarly to burn patients regarding fluid requirements, as the pathophysiology involves widespread epidermal loss 2, 4
• Avoid drugs that reduce renal function, as toxin clearance is critical 3

Wound Care

• Apply topical mupirocin 2% ointment to localized areas of infection 1
• Topical cotrimoxazole application to denuded surfaces can be considered 3
• Maintain adequate local hygiene to prevent secondary infection 5

Duration of Therapy

• Continue treatment for 7-14 days, guided by clinical response 1
• Most patients show improvement within 48-72 hours of appropriate antibiotic therapy 2, 6
• Transition to oral antibiotics once the patient is afebrile, clinically improving, and able to tolerate oral intake 1

Critical Diagnostic Distinction

You must differentiate SSSS from Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) by assessing for mucosal involvement (absent in SSSS, present in SJS/TEN) and obtaining skin biopsy if diagnostic uncertainty exists 7, 2

• SSSS shows cleavage within the stratum granulosum (superficial epidermis) on histology 2, 4
• SJS/TEN shows full-thickness epidermal necrosis 7
• Frozen section processing can expedite this critical distinction 4
• The positive Nikolsky sign, periorificial crusting, and absence of mucosal involvement are key clinical features of SSSS 2

Key Clinical Pitfalls to Avoid

• Never use tetracyclines in children <8 years of age due to risk of tooth discoloration and bone growth effects 1
• Do not delay antibiotic therapy while awaiting culture results—SSSS is a clinical diagnosis requiring immediate empiric treatment 2, 6
• Avoid using intravenous immunoglobulin (IVIG), as recent evidence associates its use with prolonged hospitalization without clear benefit 4
• Recognize that mortality is <10% in children with prompt treatment but can reach 40-63% in adults, emphasizing the importance of early aggressive therapy 4

Monitoring and Complications

Watch for the most feared complications:

• Sepsis and pneumonia are the primary life-threatening complications requiring intensive monitoring 4
• Monitor for signs of systemic illness including fever, tachycardia, and hypotension 2, 6
• Assess renal function as exotoxin clearance depends on adequate kidney function 3