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 CAHS clinical disclaimer

Aim

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

Background^1,2

• 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 exfoliative toxins produced by certain strains of Staphylococcus aureus 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^1,2 

• 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^1,2,3

• Children should be hospitalised for intravenous antibiotics
• Blood culture
• Swabs taken from the nose and any infected sites
• Refer to Severe skin and soft tissue infection in the ChAMP – Skin and Soft Tissue Infections.

If large areas of skin are involved:

• Fluid and electrolyte management
• Pain control (consider referral to Acute Pain Service) 
• 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.

References

1. McMahon, P (2022) Staphylococcal Scalded Skin Syndrome. UpToDate. Accessed at https://www-uptodate-com.pklibresources.health.wa.gov.au/contents/staphylococcal-scalded-skin-syndrome
2. Leung AKC, Barankin B, Leong KF. Staphylococcal-scalded skin syndrome: evaluation, diagnosis, and management. World J Pediatr 2018; 14:116. 
3. Braunstein I, Wanat KA, Abuabara K, et al. Antibiotic sensitivity and resistance patterns in pediatric staphylococcal scalded skin syndrome. Pediatr Dermatol 2014; 31:305.

Endorsed by:	Co-director, Surgical Services (Nursing)	Date:	Oct 2023
		Review date:	Oct 2026

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