Definition

Staphylococcal Scalded Skin Syndrome (SSSS) is a serious bacterial skin infection caused by Staphylococcus aureus. These bacteria can produce an exfoliative toxin that causes the outer layer of skin to peel off in most parts of the body, making the skin look like it has been scalded or burned by hot liquids. This disease is also often referred to as Ritter's disease.

SSSS is considered a rare case of infection. The incidence rate is estimated at 56 cases out of 100,000 people. The infection is usually more common in infants and young children under the age of six. In newborns, typical skin changes may occur around the umbilical cord or diaper area. Symptoms in older children and adults generally develop on the torso, arms, legs, or face. The infection may also occur in older people with kidney failure or those with weakened immune systems.

Causes

SSSS is an infection caused by Staphylococcus aureus bacteria. This type of bacteria normally lives on the human body, including the nose, groin, armpits, and other areas. Usually, these bacteria are harmless or cause only minor skin infections. Problems arise when bacteria enter the body's deeper layers through skin openings, especially when there is a wound.

Some strains of Staphylococcus aureus can produce toxins that travel through the bloodstream and bind with a protein in the skin's outer layer, desmoglein-1, which is essential for the cells of the skin's outer layer to stick together. This causes the entire skin to turn red, develop blisters, and break out.

Infections caused by Staphylococcus aureus typically spread through direct skin-to-skin contact. However, the infection can also be spread by touching objects contaminated with the bacteria, such as towels or other personal items. The bacteria can also spread from one area of the body to another through dirty hands or nails.

Risk factor

Newborns are especially vulnerable to SSSS because they lack antibodies to fight the infection, and their kidneys are underdeveloped, unable to help clear toxins from the body. Children over six have antibodies to this toxin in their blood, which can help prevent it from happening.

SSSS is rare in adults as most already have antibodies against this infection; however, adults with weakened immune systems are at a higher risk, such as in

• People with HIV, including those with AIDS
• People undergoing chemotherapy
• People taking drugs to suppress the immune system
• People with poor kidney function
• People with chronic kidney disease

Symptoms

Symptoms of SSSS usually begin with a fever, a fussy child, and skin redness that becomes widespread. Within 24-48 hours, fluid-filled blisters will form that burst easily and leave an area of skin that looks like a burn.

The characteristics of the SSSS rash include:

• The skin wrinkles are tissue-paper-like, followed by the appearance of large fluid-filled blisters (bullae) in the armpits, groin, and body openings such as the nose and ears.
• The rash may spread to other body parts, including arms, legs, and torso. It is often found in the diaper area or around the umbilical cord in newborns.
• The top layer of skin will begin to peel off in strips, leaving a moist, reddish-looking, tender area.

Other symptoms that may arise include:

• Pain around the site of infection
• Weakness or fatigue
• Dehydration
• Lack of appetite
• Top layer of skin that peels off easily with slight friction or pressure
• Conjunctivitis (inflammation or infection of the clear film covering the white part of the eyeball)
• Sore throat

Diagnosis

In diagnosing SSSS, the doctor will interview the child's parents or caregivers. The doctor will ask about the child's symptoms, when the symptoms began, how the rash progressed, where the rash appeared, and any risk factors contributing to the disease's onset.

Next, the doctor will perform a physical examination by looking directly at the affected skin. The doctor may gently rub the skin to check for Nikolsky marks, a blister that forms in response to slight pressure. In addition, the doctor may also perform other additional tests to help confirm the diagnosis of SSSS, such as:

• Tzanck smear examination
• Skin biopsy, where the doctor will take a small sample of skin for laboratory examination
• Bacterial culture of skin, blood, urine, or umbilical cord samples (in newborns)

Management

The management of SSSS will depend on various factors, including:

• The age of the child
• The child's previous medical history
• The child's overall health
• How severe the SSSS symptoms are

Most cases of SSSS typically require inpatient management, as antibiotics by injection are generally required to eradicate the bacterial infection such as Flucloxacillin Nafcillin, Oxacillin, Cephalosporin, and Clindamycin. Vancomycin may also be used in suspected methicillin-resistant infections (MRSA). Depending on the patient's response to treatment, antibiotics may be changed to oral tablets within a few days. The patient may be discharged from the hospital to continue treatment at home. Corticosteroid medications may slow down the healing process and should not be given to patients with SSSS.

Other management of SSSS may include:

• Paracetamol when needed for fever and pain.
• Monitor and maintain fluid and electrolyte intake.
• Skin treatment (skin is often very fragile). Petroleum jelly should be applied to keep the skin moisturized.
• Newborns with SSSS are usually treated in an incubator.

Although the symptoms of SSSS may appear bad, children will generally recover well and recovery usually occurs within 5-7 days after starting treatment.

Complications

SSSS will generally resolve completely within 10 days without causing complications. However, some complications may occur, such as:

• Shock
• Dehydration
• Bacteremia, which occurs when the infection gets into the blood
• Sepsis, which occurs when the body responds to the infection by damaging its own tissues
• Hypothermia
• Spread of infection
• Secondary infection

Prevention

Staphylococcus aureus bacteria can survive in extreme temperatures, dryness, and stomach acid. SSSS can be prevented by preventing the spread of bacteria, such as by doing:

• Washing hands frequently.
• Take a shower every day.
• Keep cuts and rashes clean and covered.
• Do not share towels, bed sheets, or any personal items if a member of your family is infected.

When to see a doctor?

If your child shows symptoms that may indicate SSSS, it's important to consult with a doctor.

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