Dermatologic Manifestations of Staphylococcal Scalded Skin Syndrome Treatment & Management

  • Author: Jessica H Kim, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 12, 2012
 

Medical Care

  • Direct the therapy for staphylococcal scalded skin syndrome (SSSS) at eradication of the staphylococcal focus of infection, which generally requires intravenous, penicillinase-resistant, antistaphylococcal antibiotics. The current treatment of choice is cloxacillin.
    • Oral antibiotic therapy can be substituted within several days or sooner.
    • Antibiotics, supportive care, and appropriate attention to fluid and electrolyte management because of disrupted epidermal barrier function usually ensure rapid recovery. Moist, denuded areas should be lubricated with a bland emollient to decrease pruritus and tenderness.
  • Exchange transfusion has been shown to be beneficial in a preterm infant with severe staphylococcal scalded skin syndrome with sepsis and hyperbilirubinemia, by reducing the bacterial load and exfoliative toxins in the blood.[23] In another case report of staphylococcal scalded skin syndrome in a premature neonate, a single intravenous dose of intravenous immunoglobulin (IVIG) was administered at 1 g/kg dose, with clinical improvement occurring within a few days. The presence of antiexfoliative toxin antibodies in commercial IVIG preparations has been reported previously.
  • Recognizing the potential for epidemic scalded skin syndrome in neonatal care units is important.[24]
    • Identification of health care workers colonized or infected with toxigenic S aureus is an integral part of managing the problem. Receiving more than one early umbilical care procedure by the same ancillary nurse was the only risk factor identified in a nosocomial outbreak in a maternity unit in France. The ancillary nurse had chronic dermatitis on her hands that favored S aureus carriage.[25]
    • Apply control measures, including strict enforcement of chlorhexidine hand washing, barrier nursing protocols, administration of an oral antibiotic therapy for workers who are infected, and application of mupirocin ointment for eradication of persistent nasal carriage.
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Consultations

  • Children with severe staphylococcal scalded skin syndrome (>50% body surface area) may need to be transferred to a tertiary pediatric burn unit for multidisciplinary care in a critical care environment.
    • Fluid overload and hyponatremia are common complications of staphylococcal scalded skin syndrome. This is not surprising because hyponatremia is common in severe infections and inappropriate vasopressin secretion occurs in patients with burns.[26]
    • For treatment of toxemia, consider using fresh frozen plasma (FFP) at 10 mL/kg in children who are systemically unwell because this is likely to contain antibodies to the exotoxins. If a second dose is required, it should come from a different donor because the possibility exists that the first donor did not have antibodies against the epidermolytic toxins. A 5-day course of pooled human immunoglobulin (0.4 g/kg/d) should also be considered if little or no improvement is noted after 2 doses of FFP.
    • Many children require an opioid infusion, such as fentanyl (1-4 mcg/kg/h) for analgesia. Nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated in the acute phase because the damaged skin is already prone to bleeding and renal excretion of the exotoxins makes maximized renal function important. Gabapentin is useful if itching becomes a problem (100 mg/kg once on day 1, twice a day on day 2, and then three times each day) and may need to be continued for a few months.
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Diet

  • Enteral nutrition must be commenced if oral intake is not possible. This may be achieved with a nasogastric tube, but a nasojejunal tube is preferable because avoids the need to discontinue feeds prior to anesthesia. Nasojejunal (or nasogastric) tubes are likely to require suturing into place owing to epidermal damage on the face.
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Activity

  • Physiotherapy is important to encourage mobilization in general, and specifically of the affected limbs. Because staphylococcal scalded skin syndrome tends to affect the flexures most severely, children often limit flexion of the limbs owing to discomfort, and physiotherapy is very helpful in preventing this. Involvement of play therapists also helps encourage gentle mobilization and prevent boredom.
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Contributor Information and Disclosures
Author

Jessica H Kim, MD  Clinical Assistant Professor, Division of Dermatology, University of Washington School of Medicine; Dermatology Consultant, Cascade Eye & Skin Centers

Jessica H Kim, MD is a member of the following medical societies: American Academy of Dermatology, American Contact Dermatitis Society, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, National Psoriasis Foundation, Washington State Medical Association, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Paul Benson, MD  Chief, Program Director, Dermatology Service, Walter Reed Army Medical Center; Associate Professor, Department of Dermatology, Uniformed Services University of the Health Sciences at Bethesda

Paul Benson, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Leonard Sperling, MD  Chair, Professor, Department of Dermatology, Uniformed Services University of the Health Sciences

Leonard Sperling, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Edward F Chan, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

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An infant with characteristic coloring in the skin that looks as though the child has been scalded.
Staphylococcal scalded skin syndrome in an adult.
 
 
 
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