What are key findings to look for on physical exam and questions to ask parents of a child with staphylococcal (Staph) skin syndrome on day 3 of hospitalization?

Day 3 Assessment of Staphylococcal Scalded Skin Syndrome in a 3-Year-Old

On day 3 of hospitalization for SSSS, focus your physical examination on monitoring for clinical improvement, assessing for complications, and evaluating response to antibiotic therapy by documenting body surface area involvement, checking for signs of secondary infection or sepsis, and examining all skin surfaces and mucous membranes. 1

Physical Examination Priorities

Skin Assessment

• Document percentage of body surface area involved using a body map or Lund-Browder chart to track progression or improvement from admission 1
• Assess for new areas of erythema, blistering, or desquamation, particularly in friction zones (axillae, groin, neck folds) and around orifices 2, 3
• Evaluate healing of denuded areas for re-epithelialization and reduction in exposed dermis 1
• Check for skin tenderness by gentle palpation, as persistent or worsening pain may indicate inadequate treatment response 3
• Examine periorificial areas (nose, mouth, eyes, genitals) for crusting, pustules, or primary infection sites 4, 3
• Inspect all IV sites, pressure points, and areas under dressings for new breakdown or infection 5

Critical Distinction: Rule Out Toxic Epidermal Necrolysis

• Confirm absence of mucosal involvement (oral mucosa, conjunctivae, genitalia) - mucosal involvement suggests TEN rather than SSSS and requires different management 6, 7
• If diagnostic uncertainty persists, a shave biopsy showing superficial cleavage (stratum granulosum) confirms SSSS versus full-thickness epidermal necrosis in TEN 6, 7

Signs of Complications or Treatment Failure

• Monitor vital signs including temperature, heart rate, blood pressure, oxygen saturation, and urine output 1
• Assess for sepsis indicators: confusion/irritability, hypotension, reduced urine output, increased work of breathing, or worsening skin pain 1
• Examine for secondary bacterial infection: increased purulence, foul odor, expanding erythema beyond original borders, or new pustules 1
• Check for fluid/electrolyte imbalance signs: poor skin turgor, dry mucous membranes, sunken fontanelle (if still open), lethargy 2

Questions to Ask Parents

Treatment Response Assessment

• "Has your child's skin pain improved since admission?" - Persistent or worsening pain suggests inadequate antibiotic coverage or complications 3
• "Is your child more comfortable and interactive today compared to yesterday?" - Clinical improvement should be evident by day 3 2
• "Have you noticed any new areas of peeling or blistering?" - Progression after 48-72 hours of IV antibiotics suggests treatment failure 2

Fever and Systemic Symptoms

• "Has your child had any fevers in the last 24 hours?" - Persistent fever beyond 48-72 hours of appropriate antibiotics warrants investigation for MRSA or occult infection source 1, 2
• "Is your child eating and drinking normally?" - Ability to tolerate oral intake is a criterion for transitioning to oral antibiotics 7

Identifying Primary Infection Source

• "Have you noticed any discharge from the nose, eyes, or ears?" - These are common primary infection sites in SSSS 4, 3
• "Does your child have any painful areas that seem infected, like around the umbilicus or diaper area?" - Identifying the primary focus guides complete treatment 4
• "Has anyone else at home or daycare had skin infections recently?" - Helps identify potential source and need for household decolonization 4

Functional Status

• "Is your child urinating normally?" - Oliguria may indicate dehydration or sepsis 1
• "Can your child move around without excessive pain?" - Improving mobility suggests healing 3
• "Is your child sleeping better?" - Improved sleep indicates reduced pain and systemic illness 3

Previous Staphylococcal Infections

• "Has your child had recurrent skin infections or boils?" - Recurrence risk is higher in children and may require decolonization strategies 1
• "Does anyone in the household carry staph bacteria in their nose?" - Family screening and decolonization may be needed 4

Laboratory Monitoring on Day 3

• Review culture results from admission (blood, skin lesions, periorificial swabs) to confirm antibiotic susceptibility and adjust therapy if needed 1, 3
• Check inflammatory markers (CBC with differential, CRP) - these should be trending down by day 3 1
• Monitor renal function and electrolytes if there was significant fluid loss or the child required aggressive resuscitation 1

Key Clinical Pitfalls to Avoid

• Do not perform surgical debridement - this is the only factor associated with prolonged hospitalization and increased complications in SSSS 3
• Do not assume improvement without documenting BSA involvement - use objective measurements rather than subjective impressions 1
• Do not miss MRSA - if the patient is not improving after 48-72 hours of beta-lactam therapy, escalate to vancomycin 15 mg/kg/dose IV every 6 hours 7, 8, 2
• Do not overlook the primary infection source - failure to identify and treat the source (often periorificial) can lead to treatment failure 4, 3