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Staphylococcal scalded skin syndrome

Staphlococcal toxin-mediated epidermolytic disease characterized by erythema, wide-spread detachment of superficial epidermal layers, resembling scalding. Etiology: 1) Staphylococcus aureus, phage group II, largely type 71 a) exotoxin (exfoliation) A b) exotoxin (exfoliation) B 2) derived from primary colonization a) nasopharynx b) external ear canal c) conjunctiva 3) exotoxin is transported hematogenously to the skin Epidemiology: 1) most common in neonates during 1st 3 months of age 2) rare in infants, children & adults 3) adults with immunodeficiency or renal failure Pathology: 1) acantholysis 2) intraepidermal cleavage with splitting within or below the stratum granulosum 3) exotoxin may produce symptoms at the site of toxin production a) purulent conjunctivitis b) otitis media c) nasopharyngeal infection 4) renal clearance of exotoxin, thus predilection for neonates & adults with renal insufficiency [3] Clinical manifestations: 1) bullous impetigo 2) diffuse, ill-defined erythema 3) within 24 hours, skin becomes tender with epidermolysis 4) site of infection is usually distant from site of skin damage [4] - major sites of involvement include face, retroauricular area & neck [4] - mucous membranes are not involved 5) Nikolsky's sign 6) may be associated with systemic symptoms [4] - low grade fever 7) healing occurs spontaneously in 5-7 days * image [4] Laboratory: 1) gram stain shows gram positive cocci only at site of colonization 2) bacterial culture from site of suspected primary infection a) nasopharynx b) external ear canal c) conjunctiva d) stool 3) skin biopsy Differential diagnosis: 1) toxic epidermal necrolysis 2) Kawasaki's syndrome 3) eczema herpeticum 4) toxic shock syndrome Complications: - death may occur in adults with renal insufficiency &/or immunosupression or infants with severe disease [4] Management: 1) referral to dermatologist [2] 2) baths or compresses for debridement of necrotic epidermis 3) topical antimicrobial agents for impetigo lesions a) mupirocin b) bacitracin c) silver sulfadiazine 4) systemic antibiotics a) oxacillin IV - severe disease b) dicloxacillin PO 1] after improvement with IV oxacillin 2] in cases of mild disease 5) replace water & electrolyte losses

General

Staphylococcal infection exanthem

References

  1. Color Atlas & Synopsis of Clinical Dermatology, Common & Serious Diseases, 3rd ed, Fitzpatrick et al, McGraw Hill, NY, 1997, pg 626-27
  2. Medical Knowledge Self Assessment Program (MKSAP) 15, American College of Physicians, Philadelphia 2009
  3. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
  4. Elkston CA, Elkston DM Bacterial Skin Infections: More Than Skin Deep. Medscape. July 19, 2021 https://reference.medscape.com/slideshow/infect-skin-6003449