Staphylococcal scalded skin syndrome

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim

To guide PCH ED staff with the assessment and management of staphylococcal scalded skin syndrome in children.

Background

  • This condition generally affects children < 5 years of age, and can be a severe and potentially life threatening illness, particularly in neonates
  • It is caused by dissemination of Staphylococcus aureus exfoliative toxins which causes lysis within the superficial layers of the skin, resulting in large thin-walled bullae which quickly break down, leaving raw denuded areas
    • These lesions resemble scalds from hot liquid, hence the name of the condition.

The primary site of staphylococcal infection:

  • Neonates – periumbilical infection, conjunctivitis, bullous impetigo and 'septic spots' are common sites
  • Infants – infected eczema, paronychia, boils, impetigo and skin trauma are common causes.

Assessment 

  • Initial signs and symptoms
    • +/- fever
    • Irritability
    • Generalised erythroderma (blanching) which may be scarletiniform (sandpaper-like) or tender on palpation
  • Erythroderma progresses to the formation of large, thin walled, fluid-filled bullae which typically occur in areas of mechanical stress (flexural areas, buttocks, hands & feet)
  • Gentle pressure to the skin results in separation of the upper epidermis and wrinkling of skin (Nikolsky sign).

Differential diagnosis

  • Bullous impetigo
  • Toxic epidermal necrolysis
  • Stevens Johnson syndrome
  • Scarlet fever
  • Kawasaki disease.

Management

  • Children should be hospitalised for intravenous antibiotics
  • Blood culture
  • Swabs taken from the nose and any infected sites
  • Antibiotics
    • refer to ChAMP guidelines

If large areas of skin are involved:

  • Fluid and electrolyte management
  • Pain control (consider referral to Pain Management) 
  • Wound care is important (refer to Dermatology)
  • Principles of burn wound management may apply.

Disposition 

  • With early recognition and treatment, children should recover fully
  • Permanent scarring is unlikely to occur.

Bibliography

  1. External review: Infectious Diseases Team July 2015.
  2. Clinical, microbial, and biochemical aspects of the exfoliative toxins causing staphylococcal scalded-skin syndrome.Ladhani S, Joannou CL, Lochrie DP, Evans RW, Poston SM Clin Microbiol Rev. 1999;12(2):224. 
  3. A clinical and microbiological comparison of Staphylococcus aureus toxic shock and scalded skin syndromes in children.Chi CY, Wang SM, Lin HC, Liu CC Clin Infect Dis. 2006;42(2):181.


Endorsed by:  Director, Emergency Department  Date:  Jan 2018


 Review date:   Jan 2021


This document can be made available in alternative formats on request for a person with a disability.


Related guidelines