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Staphylococcal-scalded skin syndrome: evaluation, diagnosis, and management

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Abstract

Background

Staphylococcal-scalded skin syndrome (SSSS), also known as Ritter disease, is a potentially life-threatening disorder and a pediatric emergency. Early diagnosis and treatment is imperative to reduce the morbidity and mortality of this condition. The purpose of this article is to familiarize physicians with the evaluation, diagnosis, and treatment of SSSS.

Data sources

A PubMed search was completed in Clinical Queries using the key terms “Staphylococcal scalded skin syndrome” and “Ritter disease”.

Results

SSSS is caused by toxigenic strains of Staphylococcus aureus. Hydrolysis of the amino-terminal extracellular domain of desmoglein 1 by staphylococcal exfoliative toxins results in disruption of keratinocytes adhesion and cleavage within the stratum granulosum which leads to bulla formation. The diagnosis is mainly clinical, based on the findings of tender erythroderma, bullae, and desquamation with a scalded appearance especially in friction zones, periorificial scabs/crusting, positive Nikolsky sign, and absence of mucosal involvement. Prompt empiric treatment with intravenous anti-staphylococcal antibiotic such as nafcillin, oxacillin, or flucloxacillin is essential until cultures are available to guide therapy. Clarithromycin or cefuroxime may be used should the patient have penicillin allergy. If the patient is not improving, critically ill, or in communities where the prevalence of methicillin-resistant S. aureus is high, vancomycin should be used.

Conclusion

A high index of suspicion is essential for an accurate diagnosis to be made and treatment promptly initiated.

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References

  1. Davidson J, Polly S, Hayes PJ, Fisher KR, Talati AJ, Patel T. Recurrent staphylococcal scalded skin syndrome in an extremely low-birth-weight neonate. AJP Rep. 2017;7:e134–7.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Ritter von Rittershain G. Die exfoliativa dermatitis jungerer Saulinge. Centralz Kinderheilk. 1878;2:3–23.

    Google Scholar 

  3. Melish ME, Glasgow LA. The staphylococcal scalded skin syndrome. N Engl Med. 1970;282:1114–9.

    Article  CAS  Google Scholar 

  4. Lamand V, Dauwalder O, Tristan A, Casalegno JS, Meugnier H, Bes M, et al. Epidemiological data of staphylococcal scalded skin syndrome in France from 1997 to 2007 and microbiological characteristics of Staphylococcus aureus associated strains. Clin Microbiol Infect. 2012;18:e514–21.

    Article  CAS  PubMed  Google Scholar 

  5. Mockenhaupt M, Idzko M, Grosber M, Schöpf E, Norgauer J. Epidemiology of staphylococcal scalded skin syndrome in Germany. J Invest Dermatol. 2005;124:700–3.

    Article  CAS  PubMed  Google Scholar 

  6. 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. 2011;2011:bcr0820114733.

    PubMed  PubMed Central  Google Scholar 

  7. Mishra AK, Yadav P, Mishra A. A systemic review on staphylococcal scalded skin syndrome (SSSS): a rare and critical disease of neonates. Open Microbiol J. 2016;10:150–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Oliveira AR, Aires S, Faria C, Santos E. Staphylococcal scalded skin syndrome. BMJ Case Rep. 2013;2013:bcr2013009478.

    PubMed  PubMed Central  Google Scholar 

  9. Handler MZ, Schwartz RA. Staphylococcal scalded skin syndrome: diagnosis and management in children and adults. J Eur Acad Dermatol Venereol. 2014;28:1418–23.

    Article  CAS  PubMed  Google Scholar 

  10. Jeyakumari D, Gopal R, Eswaran M, Maheshkumar C. Staphylococcal scalded skin syndrome in a newborn. J Glob Infect Dis. 2009;1:45–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Berk D. Staphylococcal scalded skin syndrome. Clinical decision support: pediatrics. Wilmington, delaware: decision support in medicine, LLC., 2015, electronic database. http://www.decisionsupportinmedicine.com. Accessed 13 Nov 2017.

  12. Manders SM. In: Heyman WR, Anderson BE, Hivnor C, et al, editors. Clinical Decision Support: Dermatology. Wilmington, Delaware: Decision Support in Medicine, LLC, 2015, 2nd edition, electronic database. http://www.decisionsupportinmedicine.com. Accessed 14 Nov 2017.

  13. Patel NN, Patel DN. Staphylococcal scalded skin syndrome. Am J Med. 2010;123:505–7.

    Article  PubMed  Google Scholar 

  14. Redding KS, Jones EH, Patel T, Skinner RB. Staphylococcal scalded skin syndrome in pregnancy. Cutis. 2015;96:e7–9.

    PubMed  Google Scholar 

  15. Dudley M, Parsh B. Recognizing staphylococcal scalded skin syndrome. Nursing. 2016;46:68.

    Article  PubMed  Google Scholar 

  16. Gupta A, Jacobs N. Visual diagnosis: 2-week-old has a red, peeling rash. Pediatr Rev. 2013;34:e9–12.

    Article  PubMed  Google Scholar 

  17. Haveman LM, Fleer A, Gerards LJ. Staphylococcal scalded skin syndrome in two very low birth weight infants. J Perinat Med. 2003;31:515–9.

    Article  PubMed  Google Scholar 

  18. Patel GK, Finlay AY. Staphylococcal scalded skin syndrome: diagnosis and management. Am J Clin Dermatol. 2003;4:165–75.

    Article  PubMed  Google Scholar 

  19. Farroha A, Frew Q, Jabir S, Dziewulski P. Staphylococcal scalded skin syndrome due to burn wound infection. Ann Burns Fire Disasters. 2012;25:140–2.

    CAS  PubMed  PubMed Central  Google Scholar 

  20. Hennigan K, Riley C. Staphylococcal scalded skin syndrome: a case review. Neonatal Netw. 2016;35:8–12.

    Article  PubMed  Google Scholar 

  21. Doudoulakakis A, Spiliopoulou I, Spyridis N, Giormezis N, Kopsidas J, Militsopoulou M, et al. Emergence of a Staphylococcus aureus clone resistant to mupirocin and fusidic acid carrying exotoxin genes and causing mainly skin infections. J Clin Microbiol. 2017;55:2529–37.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Kouakou K, Dainguy ME, Kassi K. Staphylococcal scalded skin syndrome in neonate. Case Rep Dermatol Med. 2015;2015:901968.

    CAS  PubMed  PubMed Central  Google Scholar 

  23. Jindal S, Bhobhe M, Jerajani H. An infant with skin rash. Indian Pediatr. 2012;49:853–4.

    Article  CAS  PubMed  Google Scholar 

  24. Aalfs AS, Oktarina DA, Diercks GF, Jonkman MF, Pas HH. Staphylococcal scalded skin syndrome: loss of desmoglein 1 in patient skin. Eur J Dermatol. 2010;20:451–6.

    CAS  PubMed  Google Scholar 

  25. Aydin D, Alsbjørn B. Severe case of staphylococcal scalded skin syndrome in a 5-year-old child—case report. Clin Case Rep. 2016;4:416–9.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Berk DR, Bayliss SJ. MRSA, staphylococcal scalded skin syndrome, and other cutaneous bacterial emergencies. Pediatr Ann. 2010;39:627–33.

    Article  PubMed  Google Scholar 

  27. Leung AK, Barankin B. A girl with widespread blistering, scabbing, and swelling: Stevens–Johnson syndrome. Consult Pediatr. 2013;13:216–9.

    Google Scholar 

  28. Leung AK, Kellner JD. Group A beta-hemolytic streptococcal pharyngitis in children. Adv Ther. 2004;21:277–87.

    Article  PubMed  Google Scholar 

  29. Mockenhaupt M. The current understanding of Steven-Johnson syndrome and toxic epidermal necrolysis. Expert Rev Clin Immunol. 2011;7:803–13.

    Article  PubMed  Google Scholar 

  30. Leung AK, Barankin B. Tender honey-colored lesion with “stuck-on” crust: Impetigo. Consult Pediatr. 2013;12:83–5.

    Google Scholar 

  31. Hon KL, Li JJ, Cheng BL, Luk DC, Murrell DF, Leung AK. Age and etiology of childhood epidermolysis bullosa mortality. J Dermatol Treat. 2015;26:178–82.

    Article  Google Scholar 

  32. Watkins J. Diagnosis, treatment and management of epidermolysis bullosa. Br J Nurs. 2016;25(8):428–31.

    Article  PubMed  Google Scholar 

  33. Verma KK, Bhat R, Singh MK. Bullous mastocytosis treated with oral betamethasone therapy. Indian J Pediatr. 2004;71(3):261–3.

    Article  PubMed  Google Scholar 

  34. Kayani M, Aslam AM. Bullous pemphigoid and pemphigus vulgaris. BMJ. 2017;357:j2169.

    Article  PubMed  Google Scholar 

  35. Murphy S. Non accidental injury vs staphylococcal scalded skin syndrome. A case study. Emerg Nurse. 2001;9:26–30.

    Article  CAS  PubMed  Google Scholar 

  36. Porzionato A, Aprile A. Staphylococcal scalded skin syndrome mimicking child abuse by burning. Forensic Sci Int. 2007;168:e1–4.

    Article  PubMed  Google Scholar 

  37. Leung AK. Kawasaki disease. In: Leung AK, editor. Common problems in ambulatory pediatrics: specific clinical problems, vol. 1. New York: Nova Science Publishers Inc; 2011. p. 385–90.

    Google Scholar 

  38. Sprecher E, Samuelov L. Peeling skin syndrome. In: Post TW, editors. UpToDate. Waltham, MA. Accessed 14 Nov 2017.

  39. Johnston GA. Treatment of bullous impetigo and the staphylococcal scalded skin syndrome in infants. Expert Rev Anti Infect Ther. 2004;2:439–46.

    Article  CAS  PubMed  Google Scholar 

  40. Braunstein I, Wanat KA, Abuabara K, McGowan KL, Yan AC, Treat JR. Antibiotic sensitivity and resistance patterns in pediatric staphylococcal scalded skin syndrome. Pediatr Dermatol. 2014;31:305–8.

    Article  PubMed  Google Scholar 

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None. There is no honorarium, grant, or other form of payment given to any of the author/coauthor.

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Authors and Affiliations

  1. Department of Pediatrics, The Alberta Children’s Hospital, The University of Calgary, Calgary, #200, 233-16th Avenue NW, Calgary, AB, T2M 0H5, Canada

    Alexander K. C. Leung

  2. Toronto Dermatology Centre, Toronto, ON, Canada

    Benjamin Barankin

  3. The Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia

    Kin Fon Leong

Authors
  1. Alexander K. C. Leung
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  2. Benjamin Barankin
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  3. Kin Fon Leong
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Contributions

AKCL wrote the first draft of the manuscript, as well as a statement of whether an honorarium, grant, or other form of payment was given to anyone to produce the manuscript. AKCL, BB, and KFL contributed to drafting and revising the manuscript. We have seen and approved the final version submitted for publication and take full responsibility for the manuscript.

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Correspondence to Alexander K. C. Leung.

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No financial or non-financial benefits have been received or will be received from any party related directly or indirectly to the subject of this article.

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Leung, A.K.C., Barankin, B. & Leong, K.F. Staphylococcal-scalded skin syndrome: evaluation, diagnosis, and management. World J Pediatr 14, 116–120 (2018). https://doi.org/10.1007/s12519-018-0150-x

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  • DOI: https://doi.org/10.1007/s12519-018-0150-x

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