Staphylococcal scalded skin syndrome

Background

• Caused by Staph aureus
• Most patients <2yr old, nearly all <6 yr old

Clinical Features

• Rash progresses from erythroderma to extensive areas of exfoliation
• Systemic symptoms (malaise, fever, irritability, skin tenderness) are common
• Nikolsky sign (separation of epidermis when pressure is applied) is present
• No mucous membrane involvement (differentiate from SJS/TENS)

Differential Diagnosis

• Erythema Multiforme
• Staphylococcal scalded skin syndrome
• Erythroderma
• Toxic Shock Syndrome
• Drug eruption
• Pemphigus vulgaris

Erythematous rash

• Positive Nikolsky’s sign
  • Febrile
    • Staphylococcal scalded skin syndrome (children)
    • Toxic epidermal necrolysis/SJS (adults)
  • Afebrile
    • Toxic epidermal necrolysis
• Negative Nikolsky’s sign
  • Febrile
    • Toxic shock syndrome
    • Kawasaki disease
    • Scarlet fever
    • DRESS syndrome
    • Cellulitis
    • Acute generalized exanthematous pustulosis
  • Afebrile
    • Alcohol intoxication
    • Anaphylaxis
    • Cellulitis
    • Dermatitis (multiple types)
    • Drug rash
    • Erysipelas
    • Erythema multiforme
    • Exfoliative erythroderma
    • Scombroid
    • Vancomycin infusion reaction

Evaluation

• PCR for toxin if available
• CBC - leukocytosis, though normal WBC level oftenly
• ESR elevation
• Monitor electrolytes, renal function closely in severe disease
• Blood cultures variably positive (more often pos in adults)
• CXR to rule out pneumonia

Management

• Often requires inpatient therapy, Fluid Resuscitation, parenteral antibiotics

Antibiotic Options

• Nafcillin 100mg/kg/d IV in 4 divided doses OR 50mg/kg/d in 4 divided doses PO x7-10d
• Penicillin G Procaine (300K U/d IM for <30 kg, 600K to 1 million U/d IM for >30 kg)
• Amoxicillin/Clavulanate 45mg/kg/d PO in 2 divided doses x 7-10d
• Cefazolin 100mg/kg/d IV in 4 divided doses
• Cephalexin 40mg/kg/d in 4 divided doses x 7-10d
• If possible MRSA:
  • Clindamycin 40mg/kg/d IV or PO in 4 divided doses x7-10d
  • Bactrim 10mg/kg/d in 2 divided doses x7-10d
  • Vancomycin 10-15mg/kg/d in 2 divided doses up to 1 gm q12hr

Disposition

• Transfer to burn center if diffuse
• Localized infection may discharge home with follow up

See Also

• Staphylococcus aureus