The staph toxin syndromes comprise a wide clinical spectrum: mild bullous impetigo to toxic shock syndrome. All are due to bacterial products synthesized by toxin-producing strains of S. aureus. Staph scalded skin syndrome (SSSS) is a generalized exfoliative dermatitis occurring in infants and kids with skin lesions strikingly resembling a scald burn. Skin manifestations due to toxin from phage group II coagulase-positive staphylococcus.
Etiology and Epidemiology
– Staph is omnipresent, especially amongst medical personnel.
An infant is far more likely to harbor a staph strain from medical personnel than a maternal strain!
Source
: wash your hands
A break in infant's skin/umbilicus/circumcisions site
Þ staph infection.
Toxin:
Source: phage group II coagulase-positive staphylococci (other phage groups also have it).
Toxin ("exfoliatin"/"epidermolytic toxin") is extracellular, causing generalized erythema, blistering, exfoliation.
Skin manifestations are a result of toxin since site of staph infection may be distant from the skin.
Clinical Manifestations
– SSSS presents abruptly with generalized diffuse erythema and mild facial edema.
Within 24-48 hrs flaccid bullae appear (very tender), Niklosky sign – sloughing of skin with light stroking.
Skin appears as scald burn, sloughing of superficial epidermis leaves large areas of moist, red surface.
Within 1-3 days denuded areas become dry.
Entire body surface undergoes desquamation.
Recovery is usually complete 7-10 days after onset of erythema with a normal unscarred skin appearance.
Infants and kids are generally febrile, uncomfortable and lethargic during the exfoliative stage.
Pathology
in epidermis – intraepidermal cleavage plane forms at stratum granulosum level.
SSSS may be impossible to differentiate clinically from toxic epidermal necrolysis except histopathologically.
Diagnosis
– smear and culture of skin lesion.
Bugs may not be present within intact bullous lesions; diagnosis often made on clinical and histopathologic basis.
Differential Diagnosis
(1) Congenital syphilis and HSV can both cause bullous lesions of the infant, but can be excluded easily by serology and culture.
(2) Stevens-Johnson syndrome usually has mucous membrane involvement.
(3) Bullous impetigo closely associated with phage group II, though lesions more localized with normal surrounding skin and no systemic signs or symptoms.
(4) Toxic epidermal necrolysis (TEN) clinically similar to SSSS but histopathologically distinct: the cleavage plane of desquamation in SSSS more superficial than that of TEN. Also, SSSS smear of denuded skin shows no inflammatory cells contrary to that of TEN. TEN appears in older children beyond the newborn period.
(5) Scarlet fever causes a similar generalized erythema though without exfoliation. Desquamation of a different pattern: thin branny flakes 1-3 weeks after scarlet fever vs. Large thick flakes within 4 days of SSSS rash.
Treatment
– should be directed at eliminating the focus of infection and beginning penicillinase-resistant penicillin (i.e. nafcillin, methicillin or oxacillin).
Corticosteroids contraindicated
.
Prompt attention also directed to temperature stabilization and maintenance of fluid balance.
Prognosis
– Dependent upon underlying cause, age, extent of dermal involvement and complicating factors.
If patient is <1 year old, SSSS may be lethal.
Kids 1-5 y/o have an excellent prognosis.
Over the age of 6 years, mortality varies from 33-75%.
Disease severity related to bacterial burden, the amount of toxin produced and individual host factors.