STAPHYLOCOCCAL SCALDED SKIN SYNDROME

Etiology

• caused predominantly by phage group 2 staphylococci, particularly strains 71 and 55

• found in nasopharynx and, less commonly, the umbilicus, urinary tract, a superficial abrasion, conjunctivae, and blood

• spreads hematogenously

Nelson’s Textbook of Pediatrics. 19th Edition

Epidemiology

• predominantly in infants and children younger than 5 years of age and rarely occurs in adults

• Due to circulating antibodies and renal excretion of toxins

• most cases are caused by type 71 strain (75%)• no differences in incidence based on gender

nor economic status

Nelson’s Textbook of Pediatrics. 19th EditionSchwartz, M. William. The 5 minute pediatric consult. 2nd ed.

PATHOPHYSIOLOGY

• Caused by an exfoliative toxin: ETA and ETB• The toxins likely act as proteases that target

the protein desmoglein-1 (DG-1)• Exotoxin causes separation of the epidermis

beneath the granular cell layer.

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY

DIAGNOSIS

• Gram stain or Culture: from the remote site of infection

• Skin biopsy or Frozen Section• PCR

Management

Pharmacologic

• Systemic therapy, either orally, in cases of localized involvement, or parenterally, with a semisynthetic penicillinase-resistant penicillin, should be prescribed because the staphylococci are usually penicillin resistant

• Clindamycin may be added to inhibit bacterial protein (toxin) synthesis

Review of Medication:

• Hydroxyzine 2mg/ml, 2.5 ml every 6 hours PRN for pruritus

• Mupirocin ointment, apply over nasal mucosa using cotton buds, 3x a day for 7 days

• Erythromycin eye oitment, 1 strip to both lower lids 2x a day

• Cloxacillin 250mg/ml, 2ml every 6 hours on an empty stomach, 1 hour prior to meals

Non-pharmacologic

• The skin should be gently moistened and cleansed.

• Application of an emollient provides lubrication and decreases discomfort.

• Topical antibiotics are unnecessary.

Prognosis

• Recovery is usually rapid, but complications such as excessive fluid loss, electrolyte imbalance, faulty temperature regulation, pneumonia, septicemia, and cellulitis may cause increased morbidity.

Blepharitis

• Chronic inflammation of the eyelid• Associated with tear film disruption• Anterior – Affecting the anterior lid margin and eyelashes

• Posterior– Affecting the Meibomian glands

Symptoms• Watery eyes• Red eyes• Burning sensation in eyes• Eyelids that appear greasy• Itchy eyelids• Red, swollen eyelids• Flaking of the skin around the eyes• Crusted eyelashes upon awakening• Eyelid sticking• More frequent blinking• Sensitivity to light• Eyelashes that grow abnormally (misdirected eyelashes)• Loss of eyelashes

Anterior Blepharitis

• Staphylococcal bacteria• Seborrheic dermatitis• Manifestations– Foreign body sensation, burning sensation,

matting of eyelashes, ring like formation around the lash shaft

– Presence of madarosis, chalazion or hordeolum

Posterior Blepharitis

• Inflammation of eyelids secondary to dysfunction of meibomian glands

• Associations– Rosacea• Facial redness

– Demodex mites• Affinity for hair follicles

Treatment

• Proper hygiene– This condition is primarily treated with advocating

cleaning of the affected area regularly– Warm water and mild shampoo for eyelashes

• Antibiotics• Steroid Eyedrops• Artificial Tears

An innovative local treatment for staphylococcal scalded skin syndrome

E. Mueller & M. Haim & T. Petnehazy & B. Acham-Roschitz & M. Trop

Case Report

• Male infant– Different congenital malformations– Delivered via caesarean section at 36 weeks AOG

due to oligohydramnios– Left lower limb deformity consisting of tibial and

distal femoral aplasia, club foot and mirror foot– Multiple vertebral anomalies at different levels of

the spine– Renal agenesis on the right and hydronephrosis on

left kidney

Course in the Ward

• 11 months of age– Severe diaper dermatitis with ulceration caused by

intractable diarrhea secondary to short bowel syndrome and renal insufficiency

– Microbial analysis: presence of Escherichia coli, Enterobacter cloacae, Klebsiella pneumoniae and Enterococcus faecalis, and S. aureus.

Course in the Ward

• 14 months of age:– Developed fever, malaise and more irritable– Erythematous rash on skin of the trunk and facial

area tender and painful skin and small flaccid bullae erupted

– Cefuroxime IV, increased parenteral fluid support and transferred to children’s burn unit

Course in the Ward

• Skin biopsy (right flank): mid-epidermal cleavage with minimal inflammation

• Culture: methicillin-sensitive S. aureus (MSSA) producing ETB

• Cefuroxime IV was adapted based on the impaired renal function

• Suprathel® treatment as a whole-body dressing

Staphylococcal Scalded Skin Syndrome

• Standard treatment: systemic antibiotics• Silver sulfadiazine is not recommended for SSSS • Steroids are contraindicated on the basis of

both experimental and clinical evidence • Severe blistering skin diseases are better

managed in burns units • Core temperature and room temperature need

to be monitored carefully

Suprathel®

• Synthetic copolymer consisting mainly of DL-lactide (>70%), trimethylene carbonate and ε-caprolactone

• Imitates the properties of natural epithelium and consists of a membrane with 80% porosity

• Permeable to oxygen and moisture

With Suprathel® in place:• Relieves pain• Prevents heat loss and secondary infection• Accelerates wound healing• Does not need to be changed (daily care is

easier)