Staphylococcal Scalded Skin Syndrome (SSSS) Clinical Presentation

Updated: Nov 03, 2022

Author: Randall W King, MD, FACEP; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD more...

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Staphylococcal Scalded Skin Syndrome (SSSS)

Sections Staphylococcal Scalded Skin Syndrome (SSSS)
Overview
Presentation
- History
- Physical
- Causes
- Show All
DDx
Workup
Treatment
Medication
Follow-up
Questions & Answers
Media Gallery
References

Presentation

History

Staphylococcal scalded skin syndrome (SSSS) presents as a macular erythema followed by diffuse epidermal exfoliation.

A prodromal localized S aureus infection of the skin, throat, nose, mouth, umbilicus, or GI tract occurs. Such an infection often is not apparent before the SSSS rash appears.

The following may be noted:

General malaise
Fever
Irritability
Skin tenderness

Next:

Physical

The following may be noted:

Fever, although patients may be afebrile
Tenderness to palpation
Warmth to palpation
Skin erythema
Facial edema
Conjunctivitis
Perioral crusting, but mucous membranes are spared
Most patients do not appear severely ill.
Dehydration may be present and significant.
Nikolsky sign (gentle stroking of the skin causes the skin to separate at the epidermis)^{[23, 24]}

Diffuse erythematous rash often begins centrally, is sandpaperlike (progressing into a wrinkled appearance, and accentuated in flexor creases. See the images below.

Staphylococcal scalded skin syndrome. Photograph b

Staphylococcal scalded skin syndrome. Photograph by David Effron, MD, FACEP.

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Staphylococcal scalded skin syndrome. Photograph b

Staphylococcal scalded skin syndrome. Photograph by David Effron, MD, FACEP.

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Bullae are flaccid and ill defined. See the image below.

Staphylococcal scalded skin syndrome. Photograph b

Staphylococcal scalded skin syndrome. Photograph by David Effron, MD, FACEP.

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Exfoliation of skin, which may be patchy or sheetlike in nature, is noted. See the images below.

Staphylococcal scalded skin syndrome. Photograph b

Staphylococcal scalded skin syndrome. Photograph by David Effron, MD, FACEP.

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Staphylococcal scalded skin syndrome. Photograph b

Staphylococcal scalded skin syndrome. Photograph by David Effron, MD, FACEP.

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Staphylococcal scalded skin syndrome. Photograph b

Staphylococcal scalded skin syndrome. Photograph by David Effron, MD, FACEP.

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Causes

Infection by group 2 phage S aureus (several types) leads to release of exotoxin.

Exotoxin is a protein and is classified as either type A or B. Most are type A.

Exotoxin causes separation of the epidermis beneath the granular cell layer.

Cases of staphylococcal scalded skin syndrome (SSSS) have been reported among infants who have breastfed from mothers with S aureus breast abscess.

A case has been reported of neonatal staphylococcal scalded skin syndrome secondary to maternal-fetal transmission at birth.

Outbreaks have been reported in neonatal and newborn nurseries.^[21]

Reports implicating MRSA and community-acquired methicillin Staphylococcus aureus (CA-MRSA) as a cause of staphylococcal scalded skin syndrome are increasing.^{[25, 26, 27]}

Previous

Differential Diagnoses

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Media Gallery

Staphylococcal scalded skin syndrome. Photograph by David Effron, MD, FACEP.
Staphylococcal scalded skin syndrome. Photograph by David Effron, MD, FACEP.
Staphylococcal scalded skin syndrome. Photograph by David Effron, MD, FACEP.
Staphylococcal scalded skin syndrome. Photograph by David Effron, MD, FACEP.
Staphylococcal scalded skin syndrome. Photograph by David Effron, MD, FACEP.
Staphylococcal scalded skin syndrome. Photograph by David Effron, MD, FACEP.

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Author

Randall W King, MD, FACEP Assistant Clinical Professor of Emergency Medicine, University of Toledo College of Medicine; Director, Emergency Medicine Residency Program, Department of Emergency Medicine, Chief Medical Information Officer, Chief of Staff Elect, Mercy St Vincent Medical Center

Randall W King, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Residency Directors in Emergency Medicine, American Medical Association, Ohio State Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Heather Lyn Carone, MD Attending Physician, Department of Emergency Medicine, St Vincent Mercy Medical Center

Heather Lyn Carone, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Paul R de Saint Victor, MD, FACEP Chief of Staff, St Vincent Mercy Medical Center, Toledo

Paul R de Saint Victor, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Heart Association, National Association of EMS Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician / Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Prisma Health Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Columbia Medical Society, Society for Academic Emergency Medicine, South Carolina College of Emergency Physicians, South Carolina Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Employed contractor - Chief Editor for Medscape.

Additional Contributors

Daniel J Dire, MD, FACEP, FAAP, FAAEM Professor of Pediatrics and Emergency Medicine, University of Texas Health Science Center at San Antonio, Joe R and Teresa Lozano Long School of Medicine

Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, The Society of Federal Health Professionals (AMSUS)

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the medical review of this article by Joseph U Becker, MD.

Sections Staphylococcal Scalded Skin Syndrome (SSSS)
Overview
Presentation
- History
- Physical
- Causes
- Show All
DDx
Workup
Treatment
Medication
Follow-up
Questions & Answers
Media Gallery
References

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