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Scalded Skin Syndrome

Related Terms: Staphylococcal scalded skin syndrome, Exfoliative toxin; Desmoglein-1, Epidemiology, lymphedema, Septic knee arthritis, Intra-articular injection, Staphylococcal, methicillin-resistant Staphylococcus aureus,multiplex PCR, real-time PCR, SSSS, Vitamin K, MRSA, Newborn infant, Hospital outbreak, Exfoliative dermatitis, Exfoliative toxins, Non-Hodgkin’s lymphoma, Nikolsky’s sign


A type of dermal infection in which the infected skin becomes damaged and sheds. As with other infections, I have included a page on this because it is important to remember that our lymphedematous limbs are immunocompromisedand any type of infection can quickly spread and become life threatening. Other at risk patients such as cancer patients, HIV, are also at risk because of the depleted or destroyed immune system.


Scalded Skin Syndrome is a bacterial infection caused by strains of the Staphylococcus family and is most commonly found in infants and children under the age of 15.


Symptoms include: Blisters, Fever, Large areas of skin peel or fall away (exfoliation or desquamation), Painful skin, Redness of the skin (erythema), which spreads to cover most of the body, Skin slips off with gentle pressure, leaving wet red areas (Nikolsky's sign)


Diagnoses can be achieved through physical examination, the presence of blisters, fever, Large areas of skin peel or fall away (exfoliation or desquamation), Painful skin, Redness of the skin (erythema), which spreads to cover most of the body, Skin slips off with gentle pressure, leaving wet red areas (Nikolsky's sign)

Other indicators include an elevated white blood count (WBC), Erythrocyte sedimentation rate (ESR) may also be elevated.

A polymerase chain reaction (PCR) serum test for the toxin is available. Typing of staphylococcal isolates for phage and subtype and the presence of exotoxin production is usually not necessary but is available at some centers.

Cultures of bullae are negative in the absence of contamination.

Blood culture is usually negative in children (but positive in bullous impetigo) and is usually positive in adults A Gram stain and/or culture from the remote infection site may confirm staphylococcal infection. (1)


Fluid regulation problems causing dehydration or electrolyte imbalance, Poor temperature control (in young infants), Severe bloodstream infection (septicemia), Spread to deeper skin infection cellulitis (2)


Treatment is through the administration of antibiotics. Oral antibiotics may be used, with intravenous antibiotics being given for more difficult cases.

Moist compresses may also be used to improve comfort and emollient may also be used to help skin moisture.

Fluid hydration should also be given, and pain medication may be given.

Antibiotics generally administered include: Sulfamethoxazole and trimethoprim (Bactrim, Bactrim DS, Cotrim, Cotrim DS, Septra, Septra DS), Nafcillin (Nafcil, Unipen), Penicillin G procaine (Crysticillin, Wycillin), Amoxicillin and clavulanate (Clavulin, Augmentin), Cefazolin (Ancef, Kefzol, and Zolicef), Cephalexin (Keflex, Biocef), Clindamycin (Cleocin), Gentamicin (Garamycin, Gentacidin), Tobramycin (Nebcin), Erythromycin (E-mycin, Ery-Tab, Erythrocin), Vancomycin (Vancocin)


Healing will begin to be seen in about 10 days after treatment.

Recovery is excellent, especially if treated promptly. In immunocompromised patients, prognoses would depend upon the severity of the immunodeficiency and/or other accompanying comorbidity.


Feb 2, 2012

(1) eMedicine

(2) NIH

Abstracts and Studies

Langerhans cell antigen capture through tight junctions confers preemptive immunity in experimental staphylococcal scalded skin syndrome

Dec 2011

Ouchi T, Kubo A, Yokouchi M, Adachi T, Kobayashi T, Kitashima DY, Fujii H, Clausen BE, Koyasu S, Amagai M,Nagao K.


Department of Dermatology, Keio University School of Medicine, Shinjuku-ku, Tokyo 160-8582, Japan.

Correspondance: Keisuke Nagao:


Epidermal Langerhans cells (LCs) extend dendrites through tight junctions (TJs) to survey the skin surface, but their immunological contribution in vivo remains elusive. We show that LCs were essential for inducing IgG(1) responses to patch-immunized ovalbumin in mice that lacked skin dendritic cell subsets. The significance of LC-induced humoral responses was demonstrated in a mouse model of staphylococcal scalded skin syndrome (SSSS), a severe blistering disease in which the desmosomal protein Dsg1 (desmoglein1) is cleaved by Staphylococcus aureus-derived exfoliative toxin (ET). Importantly, ET did not penetrate TJs, and patch immunization did not alter epidermal integrity. Nevertheless, neutralizing anti-ET IgG(1) was induced after patch immunization and abolished upon LC depletion, indicating that antigen capture through TJs by LCs induced humoral immunity. Strikingly, the ET-patched mice were protected from developing SSSS after intraperitoneal ET challenge, whereas LC-depleted mice were susceptible to SSSS, demonstrating a vital role for LC-induced IgG(1) in systemic defense against circulating toxin in vivo. Therefore, LCs elicit humoral immunity to antigens that have not yet violated the epidermal barrier, providing preemptive immunity against potentially pathogenic skin microbes. Targeting this immunological process confers protection with minimal invasiveness and should have a marked impact on future strategies for development of percutaneous vaccines.

Journal of Experimental Medicine

Staphylococcal scalded skin syndrome in the Czech Republic: an epidemiological study.

October 2011

Lipový B, Brychta P, Chaloupková Z, Suchánek I.


Department of Burns and Reconstructive Surgery, University Hospital Brno, Czech Republic; Medical Faculty, Masaryk University in Brno, Czech Republic.


Keywords: Staphylococcal scalded skin syndrome; Exfoliative toxin; Desmoglein-1; Epidemiology

OBJECTIVE: To identify the basic epidemiological characteristics of children hospitalized with diagnosis ofStaphylococcal scalded skin syndrome in the Czech Republic in the years 1994-2009.

INTRODUCTION: Staphylococcal scalded skin syndrome (SSSS) is a relatively rare disease in childhood. Thissyndrome was first defined in 1878 by Baron Gottfried Ritter von Rittershainem and belongs to the group of diseases called Burn-like syndromes. It is a bullous skin disease caused by exfoliative toxins which are produced by certain types of Staphyloccocus aureus. Typical structures affected by these toxins are desmosome proteins called Desmoglein-1 located in the stratum granulosum of epidermis. Unlike in Lyell's syndrome or Stevens-Johnson's syndrome, the exfoliation is caused by loss of adhesivity particularly in the stratum granulosum and not by induction of apoptosis in the dermo-epidermal junction.

MATERIAL AND METHODS: This retrospective study was conducted on patients hospitalized in the Czech Republic in the period from 1.1.1994 to 31.12.2009. The basic condition for the inclusion in the retrospective study was age under 1 year and hospitalization due to SSSS. A total of 399 children (177 girls) fulfilled the criteria for inclusion into the study. Information was obtained from a central data depository, the Department of Health Information and Statistics, Czech Republic.

RESULTS: A total of 399 children under 1 year were hospitalized for the diagnosis of SSSS in the study period. The group included 177 girls and 222 boys. M:F ratio was 1.25:1. The average incidence of SSSS in the Czech Republic was 25.11 cases per 100000 children under 1 year of age. The highest recorded incidence in the followed period was in 1994, when a total of 57 cases of SSSS was reported, namely 53.47 per 100000 children. By contrast, in 2003, there were reported only 12 cases and the incidence of 12.81 per 100000 children. The average length of hospitalization was 6.39 days. In 1995, the highest average length of hospitalization was reported, which was 8.1 days, and then in 2007, the lowest average length of hospitalization, 4.4 days. There was no significant difference in the length of hospitalization in boys and girls. None of the 399 children in the population died.

CONCLUSION: In our retrospective study, we established basic epidemiological characteristics of a group of children aged under 1 year with diagnosis of SSSS. As epidemiological data show, the occurrence of this syndrome is not sporadic, but steady.


Staphylococcal scalded skin syndrome after intra-articular injection of hyaluronic acid.

Jun 2011

Kunugiza Y, Tani M, Tomita T, Yoshikawa H.


Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, Yamadaoka 2-2, Suita, Osaka, Japan.


Keywords: Staphylococcal scalded skin syndrome – Septic knee arthritis – Intra-articular injection

One of the severe adverse effects of intra-articular injection in the knee is septic arthritis of the knee joint. Staphylococcus aureus is the most frequent pathogen of septic arthritis. Staphylococcal scalded skin syndrome (SSSS) refers to a spectrum of blistering skin diseases caused by S. aureus exfoliative toxins. Although SSSS is rarely observed in adults, the mortality rate is high in adult cases. We report a case of SSSS due to septic knee arthritis after intra-articular hyaluronic acid injections.


Nosocomial Staphylococcal scalded skin syndrome caused by intra-articular injection.

Feb 2011

Emberger M, Koller J, Laimer M, Hell M, Oender K, Trost A, Maass M, Witte W, Hintner H, Lechner AM.


Department of Dermatology, Paracelsus Private Medical University of Salzburg, Salzburg, Austria.


BACKGROUND: The pathogenic role of nasal carriage as a source for cutaneous and soft-tissue Staphylococcus aureus (SA) infections, and Staphylococcal scalded skin syndrome (SSSS) in particular, is unclear.

OBSERVATION: We herein describe a nosocomial outbreak of SSSS in three orthopaedic patients who received intra-articular injections by a single orthopaedic surgeon. Bacteriological samples from the index patients and medical personnel involved in their care were assessed by phage typing, polymerase chain reaction for exfoliative toxin genes, SmaI macro-restriction analysis and molecular spa-typing. These studies first revealed SA cultural growth in synovial fluid of all three patients as well as nasal mucosa of one medical assistant. Moreover, all SA isolates had the same phage typing and antibiotic susceptibilities and were positive for exfoliative toxin ETa by polymerase chain reaction. SmaI macro-restriction and spa-typing further confirmed all proband isolates to be identical.

CONCLUSION: These findings provide evidence that SA nasal colonization of otherwise healthy carriers is a risk factor for SA infections, including SSSS, in predisposed individuals.

Wiley Online

Use of skin substitute dressings in the treatment of staphylococcal scalded skin syndrome in neonates and young infants.


Baartmans MG, Dokter J, den Hollander JC, Kroon AA, Oranje AP.


Department of Paediatrics, Maasstadziekenhuis, Rotterdam, The Netherlands.


Key Words: Infants, neonates, Staphylococcal infections, Staphylococcal scalded skin syndrome, Skin substitutes, Guidelines

BACKGROUND: Staphylococcal scalded skin syndrome (SSSS) is a rare toxin-mediated skin disease caused by Staphylococcus aureus and seen in infants and children younger than 5 years.

OBJECTIVES: The supportive role of skin substitutes in SSSS is stressed as a new and relatively unknown method.

METHODS: Retrospective observational case-series study, in neonates and young infants diagnosed with SSSS.

RESULTS: Seven infants with SSSS, treatment with antibiotics, skin substitutes, strict pain relief strategy and prognosis were described. One of them was severely affected and deceased.

CONCLUSION: This study describes 7 infants with SSSS and stresses the important role of skin substitutes as Omiderm® and Suprathel® as valuable adjuvant treatment modality.


Staphylococcal scalded skin syndrome in an adult patient with T-lymphoblastic non-Hodgkin's lymphoma.

Nov 2008

Scheinpflug K, Schalk E, Mohren M.


Klinik fur Hamatologie/Onkologie, Universitatsklinikum Magdeburg, Magdeburg, Germany.


Key Words: Staphylococcal scalded skin syndrome, Exfoliative dermatitis, Exfoliative toxins, Non-Hodgkin’s lymphoma

BACKGROUND: Staphylococcal scalded skin syndrome (SSSS) is an exfoliative dermatitis caused by Staphylococcus aureus infection. In contrast to infants, it is rarely observed in adults. SSSS in adults usually occurs in predisposed individuals such as those with renal failure or immunodeficiency, but has also been reported in otherwise healthy subjects. The reported mortality rate in adults is usually high because of serious underlying disease.

PATIENT AND METHODS: We report a case of SSSS in a young female patient with T-lymphoblastic lymphoma, who survived this potentially lethal complication.

CONCLUSIONS: To the best of our knowledge, this is the first case of SSSS in an adult patient with T-lymphoblastic non-Hodgkin's lymphoma. Clinicians should be aware of SSSS as a rare but potentially fatal disorder, particularly in adult patients with malignancies undergoing aggressive chemotherapy.


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scalded_skin_syndrome.txt · Last modified: 2012/10/16 14:40 (external edit)