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Recognizing staphylococcal scalded skin syndrome

Dudley, Montina BSN, RN; Parsh, Bridget EdD, RN, CNS

doi: 10.1097/01.NURSE.0000504683.43755.18

Montina Dudley is a clinical nurse on the transitional care unit at the Sacramento (Calif.) VA Medical Center. Bridget Parsh is an associate professor in the school of nursing at California State University Sacramento in Sacramento, Calif.

The authors have disclosed no financial relationships related to this article.

STAPHYLOCOCCAL scalded skin syndrome (SSSS), also known as Ritter disease, is a bacterial infection of the skin that usually begins in the oral or nasal cavity, umbilicus, or nasopharynx.1 Outbreaks are typically due to asymptomatic carriers who spread the disease to susceptible individuals.

Staphylococcus aureus produces exfoliative toxins that cause the skin to shed in layers.2 Children younger than age 6, especially those who are immunocompromised or newborn, are at a greater risk of contracting SSSS due to their immature immune system and renal system, where the clearance of exotoxins occurs.3 Because its appearance is similar to that of immersion scald burns, this disorder can easily be mistaken for a sign of child abuse.4 Cases of SSSS can occur both individually and in a nursery outbreak situation, usually due to the presence of asymptomatic carriers who spread the disease to susceptible infants.1

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Signs and symptoms

SSSS starts as a generalized red macular sandpaper-like rash that evolves into erythema with edema and a blistering eruption. The skin becomes wrinkled and bullous. The patient can have facial edema, periorificial scabs, and peeling in friction zones.3 The skin becomes extremely tender, and the patient may have a positive Nikolsky sign. That is, gentle pressure on the skin causes exfoliation, leaving wet, shiny, red areas on the superficial layer of epidermis.5,6 Infected infants are febrile and irritable.7

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Although diagnosis is usually clinical, definitive diagnosis of SSSS depends on positive culture results of blood, urine, umbilicus, nasopharynx, abnormal skin, or other potential sources of infection, and on biopsy results.7 Although biopsy is rarely required, SSSS can be confirmed with skin biopsies.7

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Treatment includes administering I.V. antibiotics, usually penicillinase-resistant penicillin, such as nafcillin or oxacillin.7,8 Supportive care includes maintaining normothermia with antipyretics, preventing dehydration and electrolyte imbalances by administering I.V. fluids, and burn wound care as prescribed.7 Involve the burn unit to manage skin and fluid issues.6 Handle the skin carefully to avoid causing secondary infection or pain.

Steroids are contraindicated because they may decrease immune function.3,5 Nonsteroidal anti-inflammatory drugs and other drugs that could decrease renal function should also be avoided.8

Possible complications include hypovolemia, hypothermia, and sepsis.9 Surprisingly, even with extensive exfoliation, scarring is rare and healing occurs in 10 to 14 days.6

Be sure to involve the family in caring for children with SSSS. Taking time to teach pain management, signs of infection, and wound care can empower patients' families while in the hospital or at home.

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1. King R. Staphylococcal scalded skin syndrome in emergency medicine. 2016.
2. Saida K, Kawasaki K, Hirabayashi K, et al. Exfoliative toxin A staphylococcal scalded skin syndrome in preterm infants. Eur J Pediatr. 2015;174(4):551–555.
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4. Hilton L. Cutaneous clues of child abuse. Contemp Pediatr. 2015;32(10):24–33.
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6. Aydin D, Alsbjørn B. Severe case of staphylococcal scalded skin syndrome in a 5-year-old child – case report. Clin Case Rep. 2016;4(4):416–419.
7. Pielop JA. Vesiculobullous and pustular lesions in the newborn. UpToDate. 2016.
8. King R. Staphylococcal scalded skin syndrome treatment and management. 2016.
9. King R. Staphylococcal scalded skin syndrome follow-up. 2016.
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