Staphylococcal scalded skin syndrome: Clinical features, ancillary testing, and patient management.

BACKGROUND/OBJECTIVES: The utility of ancillary testing in improving diagnostic precision or improving patient outcomes in staphylococcal scalded skin syndrome (SSSS) is unclear. Similarly, an optimal antibiotic regimen has yet to be established. Our goal was to describe clinical characteristics and ancillary work-up of SSSS, report bacterial resistance patterns, and examine patient outcomes under varying therapeutic strategies with the aim of developing an evidence-based management algorithm. METHODS: We performed a retrospective review of pediatric patients diagnosed with SSSS at Intermountain Healthcare facilities between 2010 and 2021. A Kruskal-Wallis rank sum test was used to assess median length of stay between different antibiotic regimens. RESULTS: Eighty-five cases were identified. The most common ancillary tests obtained were a complete blood count (88%), followed by chemistry analysis (80%). Blood cultures were collected in more patients (79%) compared to aerobic cultures (60%). No blood culture was positive for Staphylococcus aureus. All S. aureus isolates were methicillin-sensitive. Of those found resistant to clindamycin (36%), all demonstrated macrolide-induced clindamycin resistance. None were constitutively resistant to clindamycin. There was no statistical difference between antibiotic regimen and length of stay (p = .691). Receiving opiate medications was the only risk factor associated with prolonged hospitalization (p = .001). CONCLUSIONS: Ancillary testing does not improve diagnostic precision and can be reduced. Clindamycin does not improve patient outcomes, suggesting beta-lactams should be considered first line. Susceptibility patterns in our cohort demonstrate inducible clindamycin resistance as opposed to constitutive.

Staphylococcal Scalded Skin Syndrome, Identification, and Wound Care: A Case Report Series.

INTRODUCTION: Methicillin-susceptible Staphylococcus aureus (MSSA) infections cause diseases ranging from localized skin infections to serious invasive infections. Neonates are immunosuppressed, placing them at increased risk for MSSA infections, including staphylococcal scalded skin syndrome (SSSS), a rare severe skin presentation of MSSA. CLINICAL FINDINGS: We present a case series of 3 preterm infants with SSSS receiving care at a level 3 neonatal intensive care unit. PRIMARY DIAGNOSIS: The infants presented with symptoms of sepsis, including temperature instability, apnea, and bradycardia episodes. The infants had peeling skin at sites of external pressure, including peripheral intravenous (IV) sites, under dressings, or where devices had been in contact with skin. INTERVENTIONS: The infants were soaked in a tub with gel baby wash and water to remove leads without traumatizing the skin. Laboratory values were drawn, and cultures were obtained. Wound care was provided using mupirocin, soft silicone mesh wound contact layer, and soft cotton bandage gauze. Supportive respiratory care was provided, and IV antibiotics were administered. OUTCOMES: The infants were discharged to their homes with intact skin. One infant experienced a loss of pigment that persisted several weeks. All patients were without scarring by early childhood. PRACTICE RECOMMENDATIONS: Thorough assessment and careful hygiene of neonates' skin is crucial. MSSA is an infection that can appear on the skin. It is important to quickly diagnose and treat this type of infection, especially when it presents as a localized pustule, boil, tear, peeling, or crust before it becomes systemic.

Feeling the burn: Sunburn recall in staphylococcal scalded skin syndrome.

Staphylococcal scalded skin syndrome (SSSS) occurs primarily in infants and young children due to hematogenous dissemination of Staphylococcus aureus (S. aureus) exfoliative toxin resulting in painful erythema and superficial desquamation of the skin. Herein, we discuss a 7-year-old patient with SSSS in classic locations who additionally presented with photodistributed erythema without desquamation on the chest, arms, and back in locations of a recently healed sunburn. In this report, we discuss sunburn recall phenomenon as a result of SSSS.

Recognizing and Managing Staphylococcal Scalded Skin Syndrome in the Emergency Department.

ABSTRACT: Staphylococcal scalded skin syndrome is a superficial blistering disorder caused by exfoliative toxin-releasing strains of Staphylococcus aureus. Bacterial toxins are released hematogenously, and after a prodromal fever and exquisite tenderness of skin, patients present with tender erythroderma and flaccid bullae with subsequent superficial generalized exfoliation. The head-to-toe directed exfoliation lasts up to 10 to 14 days without scarring after proper treatment. Children younger than 6 years are predominantly affected because of their lack of toxin-neutralizing antibodies and the immature renal system's inability to excrete the causative exotoxins. The epidemiology, pathophysiology, and essential primary skin lesions used to diagnose staphylococcal scalded skin syndrome are summarized for the pediatric emergency medicine physician.

Staphylococcal Scalded Skin Syndrome and Bullous Impetigo.

Staphylococcal scalded skin syndrome (SSSS) and bullous impetigo are infections caused by Staphylococcus aureus. The pathogenesis of both conditions centers around exotoxin mediated cleavage of desmoglein-1, which results in intraepidermal desquamation. Bullous impetigo is due to the local release of these toxins and thus, often presents with localized skin findings, whereas SSSS is from the systemic spread of these toxins, resulting in a more generalized rash and severe presentation. Both conditions are treated with antibiotics that target S. aureus. These conditions can sometimes be confused with other conditions that result in superficial blistering; the distinguishing features are outlined below.

[Staphylococcal scalded skin syndrom: a case report]. / Syndrome de Lyell staphylococcique: à propos d'un cas.

Staphylococcal scalded skin syndrom is a bullous dermatosis induced by exfoliating staphylococcal exotoxins. Children are most often affected. We report the case of a 6-month-old infant who had angina in the few days before leading up to bullous erythroderma and whose skin biopsy showed characteristic appearance of staphylococcal scalded skin syndrom. The development was rapidly unfavourable and the infant died in a refractory septic shock chart, despite the introduction of norepinephrine and anti-SAMR antibiotic therapy. The term staphylococcal scalded skin syndrome (SSSS) was separated from the toxic or allergic epidermal necrolysis by Lyell into the opposite anatomical aspect of these two entities: in scalded skin syndrome, Skin detachment is done by cleavage of the superficial part of the epidermis at the granular layer, while in toxic Lyell syndrome, the cleavage sits deeper at the level of the mucous body.

Demographic characteristics, clinical features, and optimal management of hospitalized patients with staphylococcal scalded skin syndrome.

BACKGROUND/OBJECTIVES: Optimal management of staphylococcal scalded skin syndrome (SSSS) has not been established. Clindamycin may benefit patients via inhibition of ribosomal toxin production, but resistance patterns suggest penicillinase-resistant penicillins or cephalosporins should be the first line. Our goal was to describe demographic and clinical characteristics of SSSS patients at our institution, delineate bacterial resistance patterns, and examine outcomes of varying therapeutic strategies in SSSS. METHODS: We performed a retrospective review of patients under the age of 18 with confirmed clinical SSSS diagnosis by the dermatology consult team at the University of North Carolina (UNC) Hospitals from January 2008 to April 2017. Median hospital and ICU length of stay (LOS) were compared using a Wilcoxon Rank Sum Test. RESULTS: We found 59 SSSS patients. Coverage with clindamycin and vancomycin versus absence of that combination was associated with shorter ICU LOS. Although trending toward reduced hospital LOS, this was not significantly altered with the use of vancomycin and clindamycin after adjustment for multiple comparisons. Individual use of either clindamycin or vancomycin did not significantly alter overall hospital or ICU LOS. Among 24 patients with a pathogen identified on culture, 18 (75.0%) revealed resistance to clindamycin, and 2 (8.3%) revealed MRSA. CONCLUSIONS: Clindamycin resistance is more prevalent in hospitalized SSSS patients compared to our pediatric outpatient population. The combination of vancomycin and clindamycin results in shorter ICU LOS. Individual use of clindamycin or vancomycin does not significantly reduce hospital or ICU LOS after adjustment for multiple comparisons.

Antimicrobial Resistance and Molecular Analysis of Staphylococcus aureus in Staphylococcal Scalded Skin Syndrome among Children in Korea.

BACKGROUND: Staphylococcal scalded skin syndrome (SSSS) is a skin disease characterized by blistering and desquamation caused by exfoliative toxins (ETs) of Staphylococcus aureus (S. aureus). Although many countries show predominance of methicillin-susceptible S. aureus (MSSA), cases of methicillin-resistant S. aureus (MRSA) have been reported. METHODS: Twenty-six children aged <15 years diagnosed with SSSS from January 2010 to December 2017 from three hospitals were included. S. aureus isolates from cases were analyzed for multilocus sequence types and ETs. Medical records were reviewed for clinical characteristics, treatment, and antimicrobial susceptibility patterns of S. aureus. RESULTS: Among the 26 cases, mean age was 2.3 years. According to skin manifestations patients were classified as generalized (n = 10, 38.5%), intermediate (n = 11, 42.3%), and abortive (n = 5, 19.2%). Among all cases, 96.2% (25/26) were due to MRSA and the macrolide-resistance rate was 92.3% (24/26). ST89 (n = 21, 80.8%) was the most prevalent clone, followed by single clones of ST1, ST5, ST72, ST121, and ST1507. The eta gene was detected in one (3.8%) isolate which was MSSA. The etb gene was detected in 14 (53.8%) isolates, all of which were ST89. Nafcillin or first-generation cephalosporin was most commonly prescribed (n=20, 76.9%). Vancomycin was administered in four patients (15.4%) and clindamycin in nine patients (34.6%). Among MRSA cases, there was no difference in duration of treatment when comparing the use of antimicrobials to which the causative bacteria were susceptible or non-susceptible (9.75 vs. 8.07 days, P > 0.05). CONCLUSION: S. aureus isolated from children with SSSS in Korea demonstrated a high prevalence of methicillin-resistant ST89 clones that harbored the etb gene. The predominance of MRSA suggests that antibiotics to which MRSA are susceptible may be considered for empirical antibiotic treatment in children with SSSS in Korea. Further studies on the role and effectiveness of systemic antibiotics in SSSS are warranted.

Staphylococcal scalded skin syndrome: An epidemiological and clinical review of 84 cases.

BACKGROUND: Staphylococcal scalded skin syndrome (SSSS) is a toxin-mediated, blistering skin disorder that mainly affects infants and children. There is limited literature regarding pediatric SSSS. The purpose of this study was to describe the epidemiology, clinical features, and management of pediatric SSSS. METHODS: Retrospective cohort study of pediatric patients with a clinical diagnosis of SSSS seen at the Hospital for Sick Children in Toronto, Ontario, Canada, from January 1994 to March 2016. RESULTS: We included 84 patients with a clinical diagnosis of SSSS; 49/84 (58%) were male. Mean age of diagnosis was 3.1 ± 2.4 years. All patients presented with erythema and exfoliation, while 64/84 (76%) presented with vesicles/ bullae. Skin tenderness was the most common symptom, present in 68/84 (81%) subjects. Staphylococcus aureus was more commonly isolated from periorificial cultures than from bullae. Mean hospitalization was 4.7 ± 2.3 days. No difference was found in admission duration between children receiving clindamycin and those that did not (3.6 ± 2.2 vs 3.9 ± 2.34 days, P = .63). Skin debridement was the only risk factor leading to more complications and prolonged hospitalization (P = .03). Severe complications were seen in 4 (5%) cases, and no fatalities were observed. CONCLUSIONS: Healthcare providers should be aware of SSSS and consider it in the differential diagnosis of infants and children with new onset erythema, exfoliation, and/or vesiculation. Suspected culprit pathogens were more often obtained from periorificial swabs; however, these isolates were not tested for exfoliative toxin to confirm causality. Antibiotic treatment should be guided by sensitivity testing. Addition of clindamycin as an anti-toxin agent had no effect on the duration of hospitalization, and this should be further investigated. Surgical debridement of the skin in patients with SSSS should be discouraged.

Pediatric dermatology emergencies.

Many pediatric skin conditions can be safely monitored with minimal intervention, but certain skin conditions are emergent and require immediate attention and proper assessment of the neonate, infant, or child. We review the following pediatric dermatology emergencies so that clinicians can detect and accurately diagnose these conditions to avoid delayed treatment and considerable morbidity and mortality if missed: staphylococcal scalded skin syndrome (SSSS), impetigo, eczema herpeticum (EH), Langerhans cell histiocytosis (LCH), infantile hemangioma (IH), and IgA vasculitis.

[Staphylococcal scalded skin syndrome in a pediatric patient with atopic dermatitis]. / Síndrome de la piel escaldada estafilocócica en un paciente pediátrico con dermatitis atópica.

The staphylococcal scalded skin syndrome is a rare dermatological entity that in early stages may be confused with a flare-up of a rush of atopic dermatitis. We present the case of an 8-year-old boy with a history of atopic dermatitis and egg allergy that went to the Emergency Department for erythematous-bullous lesions on the skin. Symptoms began as an erythema in areas of flexures, which associated conjunctivitis and bilateral eyelid erythema. After 24 hours, a generalized erythema appeared with flaccid blisters predominating in flexural areas, accompanied by hyperkeratosis and perioral xerosis. Due to the clinical suspicion of staphylococcal scalded skin syndrome, empirical treatment with cloxacillin with favorable response was initiated. This case highlights the importance of making a correct differential diagnosis of skin lesions of patients with atopic dermatitis in order to apply the most appropriate treatment.

El síndrome de la escaldadura estafilocócica es una entidad dermatológica poco frecuente que, en fases iniciales, puede ser confundida con una reagudización de un brote de dermatitis atópica. Se presenta el caso de un niño de 8 años, con antecedentes de dermatitis atópica y alergia al huevo, que acudió al Servicio de Urgencias por lesiones eritematoampollosas en la piel. La sintomatología comenzó como un eritema en áreas de flexuras, que asociaba conjuntivitis y eritema palpebral bilateral. A las 24 horas, apareció un eritema generalizado con ampollas flácidas de predominio en áreas flexurales, acompañado de hiperqueratosis y xerosis perioral. Ante la sospecha clínica de síndrome de escaldadura estafilocócica, se inició el tratamiento empírico con cloxacilina, con respuesta favorable. Con este caso, se destaca la importancia de realizar un correcto diagnóstico diferencial de las lesiones cutáneas de los pacientes con dermatitis atópica, con el objetivo de aplicar el tratamiento más adecuado.

The spectrum of staphylococcal scalded skin syndrome: a case series in children.

Staphylococcal scalded skin syndrome (SSSS) is a disease caused by certain toxigenic strains of Staphylococcus aureus. While the classic severe phenotype is widely recognized in children, SSSS in fact exists on a spectrum with mild and moderate variants. Misunderstanding the phenotypic spectrum of SSSS may result in misdiagnosis of an otherwise treatable condition. To increase awareness of the heterogeneity of SSSS, we report four cases that together represent a range of clinical presentations.