The Chief Complaint of “rash” is such a misleading complaint. It seems so innocuous…“I’ll just run in this room real quick and diagnose non-specific viral rash in a well appearing kid and be done.” But, we all know that there are a few specific characteristics of rashes that catch our attention and, perhaps, portend something more concerning occurring somewhere underneath the skin. Let us look at one of these concerning entities: Staph Scalded Skin Syndrome.

A General Approach to Rashes

• Some attention grabbing rash characteristics [I often comment on the lack of these (hopefully) in all of my non-specific rash patients]
  – Petechiae, Purpura, Vesicles, Bullae, Peeling / Desquamation, Target Lesions
• Certainly, these don’t always mean there is “badness” lurking… but they do make you think a little harder (ex. Petechiae above the nipple line in a child with significant coughing or vomiting may not warrant any further work-up for the rash).

Staph Scalded Skin Syndrome

• Blistering disorder due to S. aureus infection producing an Exfoliative Toxin
• Most common in first 3 months of life and in children <5yrs, but can occur in adults as well.
• Severity ranges from localized blistering (bullous impetigo) to generalized desquamation (Staph Scalded Skin Syndrome).
• Skin Lesions
  • Initially, a fine scarlatiniform rash may be seen
  • Over the next 24hrs, an increasing erythema develops, especially around the mouth and nose, face, neck, axillae, and groin. This can be tender.
  • This becomes more widespread over 24-48 hours.
  • Sloughing occurs initially over face, flexural areas, and pressure points.
    • + Nikolsky’s sign
    • Flaccid bullae easily rupture leaving red, moist erosions.
  • Desquamation will heal without scarring.
  • Mucous membranes are NOT involved with SSSS.

Staph Scalded Skin Syndrome Management Considerations

• Mortality is low (as it can be treated effectively with antibiotics), but Morbidity is high.
• Diagnosis is Clinical!!
  • Confirmation can be done with skin biopsy (but not in the ED)
  • Cultures can be misleading – ~50% of Toxic Epidermal Necrolysis will have + cultures.
  • Most often confused with TEN – but management is different (TEN often responds to steroids, which would potentially worsen SSSS).
    • SSSS doesn’t involve Mucous Membranes
    • TEN often associated with medications or viral illness
    • SSSS usually evolves gradually, starting with a localized exfoliating rash.

• Management
  • If diagnosed early, with only localized involvement, and the child is well-appearing, may begin therapy with oral abx (penicillinase-resistant penicillins) and follow-up within 48hrs (often in the first 24 hrs, toxins will still produce new lesions).
  • If rash continues to spread after 48 hours, or at any time the child becomes toxic, than admission for close monitoring of fluid status is recommended.
  • If the patient initially presents with a generalized involvement, then admission is recommended.
  • Extensive exfoliation may best be managed in a burn center.
  • Most do not need broad-spectrum antibiotics; however, there are several reports of MRSA leading to SSSS… so keep that in mind.

Ladhani S, Joannou C. Difficulties in diagnosis and management of staphylococcal scalded skin syndrome. Pediatr Infect Dis J, 2000; 19: 819-821.

“Staphylococcal Scalded-Skin Syndrome” in Fizpatrick’s Color Atlas and Synopsis of Clinical Dermatology: 5th Edition. Wolff K, Johnson RA, Suurmond D. 2005. Pp. 620-623.