Staphylococcal Scalded Skin Syndrome

What is staphylococcal scalded skin syndrome?

Some strains of Staphylococcus aureus make exfoliative toxins (ETA and ETB). The bacteria usually live in a small, often unnoticed spot, such as the nose, throat, eyes, umbilical stump, a diaper area infection or impetigo. The toxins travel through the bloodstream and break down desmoglein 1, a protein that holds together the upper layers of the epidermis. The top layer separates and peels away, leaving moist, raw skin underneath.

Because only the very top layer splits, the skin heals quickly once the toxin is cleared, usually without scarring.

Why it mainly affects young children

Young children do not yet have antibodies against the toxins, and their kidneys clear the toxins less efficiently. Adults are rarely affected unless they have kidney failure or a weakened immune system.

Symptoms

SSSS often develops over 24 to 48 hours:

1. Early signs: fever, irritability, and general unwellness. Often there is a localized infection such as conjunctivitis, a sore throat, an infected umbilical cord or impetigo.
2. Red, tender skin: a widespread blush, starting on the face (around the mouth, nose and eyes) and skin folds such as the neck, armpits and groin. The skin is extremely painful, so babies cry when picked up.
3. Blisters and wrinkling: large, fragile, fluid-filled blisters form and burst easily. Gentle rubbing makes the top layer slide off (Nikolsky sign).
4. Peeling: the skin peels in sheets, leaving moist red areas that look like a burn. Crusting and radial cracks around the mouth and eyes are typical, giving a "sad face" look.

The mouth and inside of the eyes are not affected by blisters, which helps distinguish SSSS from more dangerous drug reactions.

SSSS vs similar conditions

How SSSS is diagnosed

Diagnosis is usually based on the appearance and the child's age. Tests support it:

• Swabs from the nose, throat, eyes, umbilicus or any infected skin, to culture S. aureus and test antibiotic sensitivity (including MRSA). Blisters themselves are usually sterile because the toxin, not the bacteria, causes them.
• Blood cultures: often negative in children, more often positive in adults.
• Skin biopsy or frozen section of peeled skin when TEN is possible: SSSS shows a very superficial split, while TEN shows full-thickness skin death.
• Blood tests for kidney function, electrolytes and dehydration.

Treatment

Most children are admitted to hospital, sometimes to a burns unit or intensive care for large areas.

• IV antibiotics active against staph, such as flucloxacillin, nafcillin or cefazolin, often with clindamycin to reduce toxin production. Vancomycin is added if MRSA is suspected. Treatment usually switches to tablets or liquid after improvement, for a total of about 7 to 10 days.
• Fluids to prevent and treat dehydration, since raw skin loses water quickly.
• Pain relief: acetaminophen (paracetamol) and sometimes stronger medicines. Handle the child gently.
• Skin care: bland emollients such as petroleum jelly, non-stick dressings, minimal handling and keeping the child warm.
• Avoid NSAIDs in some cases because of kidney stress, and avoid steroids, which do not help.
• Infection control: contact precautions in hospital, and testing of close contacts or staff in nursery outbreaks.

Recovery and outlook

Children usually start improving within 24 to 48 hours of antibiotics. The skin heals over 5 to 14 days, typically without scars, although temporary pigment changes can occur. In children, mortality is low (under about 5%) with treatment, mainly from dehydration, sepsis or pneumonia. In adults, especially those with kidney failure or serious illness, the condition is more dangerous.

Prevention

• Treat impetigo, boils, infected cuts and conjunctivitis promptly.
• Keep newborns' umbilical stumps clean and dry.
• Wash hands before handling babies, especially if you have a skin infection.
• Nurseries and neonatal units investigate clusters to find staph carriers.

Frequently asked questions

What causes staphylococcal scalded skin syndrome?

It is caused by exfoliative toxins made by certain strains of Staphylococcus aureus. The infection itself is often small, such as in the nose, eye or umbilical cord. The toxins spread through the blood and split the top layer of skin, causing it to blister and peel.

Is SSSS contagious?

The skin peeling itself is not contagious, but the staph bacteria can spread through direct contact and shared items. Most exposed people do not develop SSSS. Good hand hygiene and treating skin infections in contacts help prevent outbreaks in nurseries and families.

How long does it take for SSSS to heal?

With antibiotics, fever and pain improve within 1 to 2 days, and the skin heals over about 1 to 2 weeks. Because only the top layer of skin is lost, it usually heals without scarring.

What is the difference between SSSS and TEN?

SSSS is caused by staph toxins, mostly in young children, and affects only the very top layer of skin, sparing the mouth. TEN is usually a reaction to a medicine in adults, causes full-thickness skin loss, and affects the mouth, eyes and genitals. TEN is more dangerous.

Can adults get scalded skin syndrome?

Yes, but rarely. Adults with kidney failure, a weak immune system or serious illness can develop SSSS because they cannot clear the toxins well. In adults it is more often linked to bloodstream infection and is more serious.