Staphylococcal Scalded Skin Syndrome

Definition

Staphylococcal scalded skin syndrome (SSSS) is a disease, caused by a type of bacteria, in which large sheets of skin may peel away.

Description

SSSS primarily strikes children under the age of five, particularly infants. Clusters of SSSS cases (epidemics) can occur in newborn nurseries, when staff in those nurseries accidentally pass the causative bacteria between patients. It can also strike other age groups who have weakened immune systems. Such immunocompromised patients include those with kidney disease, people undergoing cancerchemotherapy, organ transplant patients, and individuals with acquired immunodeficiency syndrome (AIDS).

Causes and symptoms

SSSS is caused by a type of bacteria called Staphylococcus aureus. This bacteria produces a chemical called an epidermolytic toxin ("epiderm," deriving from the Greek words epi, meaning on, and derma, meaning skin, refers to the top layer of skin; "-lytic," deriving from the Greek word lysis, which literally denotes the act of undoing, means breaking or destroying; a toxin is a poison). While the bacteria itself is not spread throughout the body, it affects all of the skin by sending this toxin through the bloodstream.

SSSS begins with a small area of infection. In newborn babies, this may appear as a crusted area around the umbilicus, or in the diaper area. In children between the ages of one and six, a small, red, crusty bump appears near the nose or ear. The child may have no energy, and may have a fever. The skin becomes sensitive and uncomfortable even before the rash is fully visible. The rash starts out as bright red patches around the original area of crusting. Blisters may appear, and the skin may look wrinkled. When the blisters pop, they leave pitted areas. Even gently touching these red patches of skin may cause them to peel away in jagged sheets. The skin below is shiny, moist, and bright pink. Within a day or two, the top layer of skin all over the body is peeling off in large sheets.

The dangers of this illness include the chance that a different kind of bacteria will invade through the open areas in the skin and cause a serious systemic infection (sepsis). A lot of body fluid is lost as the skin peels away, and the layer underneath dries. Dehydration is a danger at this point.

Diagnosis

Although good patient care includes taking specimens of blister fluid and smears from the nose or throat, no bacteria are usually demonstrated. SSSS is usually diagnosed on the basis of the typical progression of symptoms in a child of this age, prone to this disorder. A sample of skin (skin biopsy) should be taken, prepared, and examined under a microscope. If the patient's disease is truly SSSS, the biopsy will show a characteristic appearance. There will be no accumulation of those cells usually present in the case of a bacterial infection. Instead, there will be evidence of disruption of only the top layer of skin (epidermis).

Treatment

Treatment involves careful attention to avoid the development of dehydration. A variety of lotions and creams are available to apply to areas where the epidermis has peeled away. This both soothes the sensitive areas, and protects against drying and further moisture loss.

Prognosis

Most patients heal from SSSS within about 10–14 days. Healing occurs without scarring in the majority of patients. Death may occur if severe dehydration or sepsis complicate the illness. About 3% of children die of these complications; about 50% of immunocompromised adults die of these complications.

Prevention

As always, good hygiene can prevent the passage of the causative bacteria between people. In the event of an outbreak in a newborn nursery, members of the staff should have nasal smears taken to identify an adult who may be unknowingly carrying the bacteria and passing it on to the babies.

BOOKS

Deresiewicz, Robert L., and Jeffrey Parsonnet. In Harrison's Principles of Internal Medicine, ed. Anthony S. Fauci, et al. New York: McGraw-Hill, 1997.

Nelson Textbook of Pediatrics. Ed. Richard E. Behrman. Philadelphia: W. B. Saunders Co., 1996.

"Staphylococci." In Sherris Medical Microbiology: An Introduction to Infectious Diseases. 3rd ed. Ed. Kenneth J. Ryan. Norwalk, CT: Appleton & Lange, 1994.

Stoffman, Phyllis. The Family Guide to Preventing and Treating 100 Infectious Diseases. New York: John Wiley & Sons, 1995.

Rosalyn Carson-DeWitt, MD

KEY TERMS

Epidermis—The top layer of skin.

Epidermolytic—Damaging to the top layer of skin.

Sepsis—An overwhelming infection affecting all the systems of the body.