Bacterial Infections

Scalded Skin Syndrome

Skin infection caused by staphlococcal bacteria. Appearance ischaracterised by red peeling skin. It is causd by the release of two toxins (epidermolytic toxins A and B) of from toxigenic strains of the bacteria Staphylococcus aureus.

--------------

Scalded Skin Syndrome

(Ritter-Lyell Syndrome)

Acute, widespread erythema and epidermal peeling caused by staphylococcal exotoxin.
Staphylococcal scalded skin syndrome (SSSS) almost always occurs in infants, children <>

Etiology

Group II coagulase-positive staphylococci, usually phage type 71 and often resistant to penicillin, elaborate exfoliatin (also called epidermolysin), an epidermolytic toxin that splits off the upper part of the epidermis just beneath the granular cell layer. The inciting infection may be on the skin but usually is in the eye or nasopharynx. The toxin enters the circulation and affects the skin systemically, as in scarlet fever.

Symptoms and Signs

In infants, illness often begins during the first few days of life with a localized crusted infection (often impetigo-like), most often at the umbilical stump or in the diaper area. Sporadic cases often start with a superficial crusted lesion, frequently around the nose or ear. Within 24 h, tender scarlet areas appear around the crusted area and may become painful and generalized. Large, flaccid blisters arise on the erythematous skin and quickly break to produce erosions. The epidermis peels off easily, often in large sheets, when the red areas are rubbed (Nikolsky's sign). Widespread desquamation of the skin occurs within 36 to 72 h (see Plate 112-1-2), and patients may become very ill with systemic manifestations (eg, malaise, chills, fever). Loss of the protective skin barrier can lead to sepsis and to fluid and electrolyte imbalance.

Diagnosis

Symptoms and signs are indistinguishable clinically from toxic epidermal necrolysis (TEN--see Ch. 118); yet SSSS must be distinguished rapidly from TEN (see Table 112-2) because therapy is different. Consultation with a dermatologist is recommended. Cultures should be obtained from the skin and nasopharynx. Diagnosis is confirmed by skin biopsy and examination of frozen tissue sections or exfoliative cytology. Although final biopsy results may not be available until well after treatment has been started, frozen tissue sections and cytology can provide rapid confirmation.

Differential diagnosis includes drug hypersensitivity (most notably, TEN), viral exanthemas, and scarlet fever, but none of these causes a painful rash. Bullae, erosions, and an easily loosened epidermis occur in thermal burns, genetic bullous diseases (eg, some types of epidermolysis bullosa), and acquired bullous diseases (eg, pemphigus vulgaris, bullous pemphigoid [see Ch. 120]).

Treatment

With prompt diagnosis and therapy, death rarely occurs. Systemic penicillinase-resistant antistaphylococcal antibiotics (eg, cloxacillin, dicloxacillin, cephalexin) must be started as soon as the clinical diagnosis is made, without waiting for culture results. In early-stage disease, oral cloxacillin 12.5 mg/kg q 6 h (for infants and children weighing <= 20 kg) and 250 to 500 mg q 6 h (for older children) may be given; in severe disease, nafcillin or oxacillin 100 to 200 mg/kg/day IV in 4 divided doses should be given until improvement is noted, followed by oral cloxacillin 25 mg/kg/day up to 100 mg/kg/day for >= 10 days. Corticosteroids are contraindicated, and topical therapy and patient handling must be minimized. If the disease is widespread and the lesions are weeping, the skin should be treated as if it were burned (see Ch. 276). Hydrolyzed polymer gel dressings may be very useful, and the number of dressing changes should be minimized. Because the split is high in the epidermis, the stratum corneum is quickly replaced and healing is usually within 5 to 7 days after the start of treatment. Steps to detect carriers and prevent or treat nursery epidemics are described in Neonatal Nosocomial Infection under Neonatal Infections in Ch. 260.

Merck

---------------

Scalded Skin Syndrome

Alternative names Ritter disease; Staphylococcal scalded skin syndrome (SSS)

Definition Return to top

Scalded skin syndrome is a skin infection characterized by damage to the skin with marked shedding (exfoliation). It usually affects infants and children under the age of 5.

Causes, incidence, and risk factors Return to top

Scalded skin syndrome is caused by infection with certain strains of a bacteria called staphylococcus. During the infection, the staphylococci produce a poison (exotoxin) that is responsible for the skin damage. Onset of the illness may be heralded by fever and skin tenderness.

The effects of the toxin first produces reddening of the skin. Fluid collects beneath the skin loosening it. Subsequently, light rubbing of the skin may pull away large sheets of skin leaving a raw red base (this effect is called the Nikolsky sign). These bare areas dry out and crust over.
It is found most commonly in infants and very young children.

Symptoms Return to top

fever
redness of the skin (erythema) which spreads to cover most of the body
skin slips off with gentle pressure leaving wet red areas (Nikolsky sign)
large areas of skin peel or fall away (exfoliation or desquamation)
painful skin
infant appears quite ill
Signs and tests Return to top
positive Nikolsky's sign (skin slipping off when rubbed)

Tests include:

Complete blood count (CBC)
cultures of the skin and throat (often yield staphylococci)
skin biopsy (done only in rare cases where diagnosis is in question, such as when the skin condition may be due to a drug reaction known as toxic epidermal necrolysis or TEN)
check of electrolytes to see if fluid loss has caused difficulties

Treatment Return to top

Intravenous antibiotics that are specific for staphylococcus are given to help fight the infection. Because much fluid is lost through the open skin, supplemental intravenous fluid is important to prevent dehydration.

Moist compresses to the skin may improve comfort. An emollient may be applied to keep the skin moist. Healing begins in about 10 days following treatment.

Expectations (prognosis) Return to top

The prognosis is usually excellent. A full recovery is expected.

Complications Return to top

severe bloodstream infection (septicemia)
fluid regulation problems causing dehydration or electrolyte imbalance
poor temperature control (in young infants)
spread to deeper skin infection (cellulitis)

Calling your health care provider Return to top

Call your health care provider or go to the emergency room if symptoms of this disorder appear.
Prevention Return to top

The disorder may not be preventable. Prompt treatment of any staphylococcus infection may be helpful.

Update Date: 1/20/2004
Updated by: John Goldenring, M.D., M.P.H., Department of Pediatrics, Children's Hospital, San Diego, CA. Review provided by VeriMed Healtchare Network.

Medline Plus

# posted by Pat O'Connor @ 3:30 AM