Staphylococcal Scalded Skin Syndrome - Clinicals, Diagnosis, and Management

Dermatology

Clinicals - History

Fact Explanation
Rash followed by skin exfoliation. It is induced by the exfoliative toxins (ET) of Staphylococcus aureus. These toxins cause cleavage of desmoglein 1 complex, a protein in the desmosomes, which hold keratinocytes together in the zona granulosa of the epidermis. This leads to the formation of flaccid bullae, that rupture easily . Rash followed by skin exfoliation.
It is induced by the exfoliative toxins (ET) of Staphylococcus aureus. These toxins cause cleavage of desmoglein 1 complex, a protein in the desmosomes, which hold keratinocytes together in the zona granulosa of the epidermis. This leads to the formation of flaccid bullae, that rupture easily .
Fever and malaise. These symptoms occur as part of the systemic inflammatory response . Fever and malaise.
These symptoms occur as part of the systemic inflammatory response .
Skin tenderness. Epidermal rupture results in large sheets of raw, denuded skin which is painful . Skin tenderness.
Epidermal rupture results in large sheets of raw, denuded skin which is painful .
Preceeding history of skin sepsis, sore throat, umbilical stump infection, etc. The disease is thought to arise from systemic ET absorption from these sites of staphylococcal infection followed by bloodstream diffusion to the cutaneous target . Preceeding history of skin sepsis, sore throat, umbilical stump infection, etc.
The disease is thought to arise from systemic ET absorption from these sites of staphylococcal infection followed by bloodstream diffusion to the cutaneous target .

Clinicals - Examination

Fact Explanation
Flaccid bullae and patchy, sheetlike exfoliation of skin. It is induced by the exfoliative toxins (ET) of Staphylococcus aureus. These toxins cause cleavage of desmoglein 1 complex, a protein in the desmosomes, which hold keratinocytes together in the zona granulosa of the epidermis. This leads to the formation of flaccid bullae, that rupture easily . Flaccid bullae and patchy, sheetlike exfoliation of skin.
It is induced by the exfoliative toxins (ET) of Staphylococcus aureus. These toxins cause cleavage of desmoglein 1 complex, a protein in the desmosomes, which hold keratinocytes together in the zona granulosa of the epidermis. This leads to the formation of flaccid bullae, that rupture easily .
Nikolsky sign (gentle stroking of the skin causes the skin to separate at the epidermis). Due to a weakening relationship and contact among the epidermal layers even in places between lesions on the seemingly unaffected skin indicating a plane of cleavage in the skin caused by the ET . Nikolsky sign (gentle stroking of the skin causes the skin to separate at the epidermis).
Due to a weakening relationship and contact among the epidermal layers even in places between lesions on the seemingly unaffected skin indicating a plane of cleavage in the skin caused by the ET .
Warmth and tenderness on palpation of skin. Epidermal rupture results in large sheets of raw, denuded and inflamed skin which is painful . Warmth and tenderness on palpation of skin.
Epidermal rupture results in large sheets of raw, denuded and inflamed skin which is painful .
Dry mouth, dry eyes, loss of skin turgor and other features of dehydration. The resulting raw, denuded skin tends to cause extensive fluid loss . Dry mouth, dry eyes, loss of skin turgor and other features of dehydration.
The resulting raw, denuded skin tends to cause extensive fluid loss .

Investigations - Diagnosis

Fact Explanation
Elevated white blood cell count. It occurs as part of the systemic inflammatory response to staphylococcal infection and associated toxin production . Elevated white blood cell count.
It occurs as part of the systemic inflammatory response to staphylococcal infection and associated toxin production .
Elevated erythrocyte sedimentation rate. It occurs as part of the systemic inflammatory response to staphylococcal infection and associated toxin production . Elevated erythrocyte sedimentation rate.
It occurs as part of the systemic inflammatory response to staphylococcal infection and associated toxin production .
Positive gram stain/ culture for Staphylococci at remote infection site. The disease is thought to arise from systemic ET absorption from these sites of staphylococcal infection followed by bloodstream diffusion to the cutaneous target . Positive gram stain/ culture for Staphylococci at remote infection site.
The disease is thought to arise from systemic ET absorption from these sites of staphylococcal infection followed by bloodstream diffusion to the cutaneous target .

Investigations - Management

Fact Explanation
Serum electrolytes and renal function tests. The resulting raw, denuded skin tends to cause extensive fluid loss and dehydration . Serum electrolytes and renal function tests.
The resulting raw, denuded skin tends to cause extensive fluid loss and dehydration .

Management - Supportive

Fact Explanation
Antipyretics. Eg: paracetomol 10-15 mg/kg 6 hourly. To combat the fever occurring as a result of the systemic inflammatory response . Antipyretics. Eg: paracetomol 10-15 mg/kg 6 hourly.
To combat the fever occurring as a result of the systemic inflammatory response .
Fluid rehydration. Lactated Ringer solution at 20 mL/kg initial bolus. Repeat the initial bolus, as clinically indicated, followed by maintenance therapy. The resulting raw, denuded skin tends to cause extensive fluid loss and dehydration . Fluid rehydration. Lactated Ringer solution at 20 mL/kg initial bolus. Repeat the initial bolus, as clinically indicated, followed by maintenance therapy.
The resulting raw, denuded skin tends to cause extensive fluid loss and dehydration .

Management - Specific

Fact Explanation
Topical therapy with fusidic acid or mupirocin. Organisms may be present in the lesions . Topical therapy with fusidic acid or mupirocin.
Organisms may be present in the lesions .
Nafcillin. Intravenous or intramuscular administration. 100-200 mg/kg/day in divided doses. It is a penicillinase-resistant
semisynthetic penicillin derivative . Therefore it is the drug of choice when the susceptibility of the organism is not yet known.
Nafcillin. Intravenous or intramuscular administration. 100-200 mg/kg/day in divided doses.
It is a penicillinase-resistant
semisynthetic penicillin derivative . Therefore it is the drug of choice when the susceptibility of the organism is not yet known.
Vancomycin. Intravenous or intramuscular administration. 40 mg/kg/day in divided doses. It has coverage against methicillin-resistant Staphylococcus aureus (MRSA) .Therefore it is given to those who initially appear toxic or who did not respond to nafcillin. Vancomycin. Intravenous or intramuscular administration. 40 mg/kg/day in divided doses.
It has coverage against methicillin-resistant Staphylococcus aureus (MRSA) .Therefore it is given to those who initially appear toxic or who did not respond to nafcillin.

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  1. ARORA P, KALRA VK, RANE S, MCGRATH EJ, ZEGARRA-LINARES R, CHAWLA S. Staphylococcal scalded skin syndrome in a preterm newborn presenting within first 24 h of life BMJ Case Rep [online] :bcr0820114733 [viewed 04 August 2014] Available from: doi:10.1136/bcr.08.2011.4733
  2. LADHANI S. Recent developments in staphylococcal scalded skin syndrome. Clin Microbiol Infect [online] 2001 June, 7(6):301-307 [viewed 05 August 2014] Available from: doi:10.1046/j.1198-743x.2001.00258.x
  3. MOCKENHAUPT MAJA, IDZKO MARCO, GROSBER MARTINE, SCHOPF ERWIN, NORGAUER JOHANNES. Epidemiology of Staphylococcal Scalded Skin Syndrome in Germany. J Invest Dermatol [online] 2005 April, 124(4):700-703 [viewed 04 August 2014] Available from: doi:10.1111/j.0022-202X.2005.23642.x
  4. MOSS C, GUPTA E. The Nikolsky sign in staphylococcal scalded skin syndrome Arch Dis Child [online] 1998 Sep, 79(3):290 [viewed 05 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1717681
  5. RUIZ D. E., WARNER J. F.. Nafcillin Treatment of Staphylococcus aureus Meningitis. Antimicrobial Agents and Chemotherapy [online] 1976 March, 9(3):554-555 [viewed 06 August 2014] Available from: doi:10.1128/AAC.9.3.554
  6. SCHWEIZER MARIN L, FURUNO JON P, HARRIS ANTHONY D, JOHNSON J KRISTIE, SHARDELL MICHELLE D, MCGREGOR JESSINA C, THOM KERRI A, COSGROVE SARA E, SAKOULAS GEORGE, PERENCEVICH ELI N. Comparative effectiveness of nafcillin or cefazolin versus vancomycin in methicillin-susceptible Staphylococcus aureus bacteremia. Array [online] 2011 December [viewed 06 August 2014] Available from: doi:10.1186/1471-2334-11-279
  7. YAMASAKI O., YAMAGUCHI T., SUGAI M., CHAPUIS-CELLIER C., ARNAUD F., VANDENESCH F., ETIENNE J., LINA G.. Clinical Manifestations of Staphylococcal Scalded-Skin Syndrome Depend on Serotypes of Exfoliative Toxins. Journal of Clinical Microbiology [online] December, 43(4):1890-1893 [viewed 05 August 2014] Available from: doi:10.1128/JCM.43.4.1890-1893.2005