Staphylococcal Scalded Skin Syndrome (SSSS)

Algorithm Steps

1. ▶

   Start

   Suspected SSSS

   Child with fever, tender erythema, superficial skin peeling

   1. ●

      Action

      Recognize Clinical Features

      Toxin-mediated superficial epidermal disease

      • Prodrome: Fever, irritability, skin tenderness
      • Erythema: Begins on face, spreads to trunk/extremities
      • Nikolsky sign positive: Gentle pressure causes skin to separate
      • Superficial blisters that rupture easily
      • MUCOUS MEMBRANES SPARED (key differentiator from TEN)
      • Usually in children <5 years, neonates
      1. ◆

         Decision

         Differentiate from TEN

         Critical distinction - TEN is drug-induced with worse prognosis

         • SSSS: Mucous membranes SPARED
         • TEN: Mucous membranes ALWAYS involved (mouth, eyes, GU)
         • SSSS: Superficial (granular layer) cleavage
         • TEN: Full-thickness epidermal necrosis
         • SSSS: Usually children
         • TEN: Usually adults after medication
         • If uncertain: Skin biopsy distinguishes
         1. ●

            Action

            SSSS Confirmed

            Mucous membranes spared, clinical picture consistent

            1. ●

               Action

               Identify S. aureus Source

               Find and treat primary infection

               • Skin: Impetigo, wound infection
               • Conjunctivae
               • Nasopharynx (may be colonization site)
               • Umbilicus (neonates)
               • Blood cultures if systemically ill
               • Culture from site of infection (NOT blisters - usually sterile)
               1. ●

                  Action

                  Antistaphylococcal Antibiotics

                  Start immediately - do not wait for cultures

                  • MSSA: Nafcillin or Oxacillin 50-100 mg/kg/day IV divided q6h
                  • Alternative: Cefazolin 50-100 mg/kg/day IV divided q8h
                  • If MRSA suspected: Vancomycin 40-60 mg/kg/day IV divided q6h
                  • Or Clindamycin 25-40 mg/kg/day IV divided q8h
                  • Duration: IV until improving, then oral to complete 7-10 days
                  • Oral step-down: Cephalexin, dicloxacillin, or clindamycin
                  1. ●

                     Action

                     Supportive Care

                     Similar to burn care but less aggressive

                     • Fluid resuscitation (less than TEN - superficial involvement)
                     • Temperature regulation - warm environment
                     • Gentle handling of skin
                     • Emollients - petroleum-based
                     • Pain management
                     • Electrolyte monitoring
                     • Nutritional support
                     1. ◆

                        Decision

                        Admission Decision

                        Based on extent and patient factors

                        1. ●

                           Action

                           Inpatient Management

                           Most pediatric cases require admission

                           • Extensive disease (>10% BSA)
                           • Neonates
                           • Systemic toxicity
                           • Unable to take oral medications
                           • IV antibiotics initially
                           1. ✓

                              Outcome

                              Recovery

                              Excellent prognosis in children

                              • Re-epithelialization in 5-7 days
                              • Complete recovery typically 2 weeks
                              • NO scarring (superficial cleavage)
                              • Mortality 1-5% in children
                              • Recurrence rare
                           2. ⚠

                              Warning

                              Complications

                              Rare but can be serious

                              • Sepsis (usually from primary infection site)
                              • Pneumonia
                              • Cellulitis
                              • Dehydration/electrolyte imbalance
                              • Adult SSSS: Mortality 50-60% (underlying comorbidities)
                              • ICU transfer if hemodynamically unstable
                        2. ●

                           Action

                           Outpatient (Rare)

                           Only for mild, localized disease

                           • Very limited involvement
                           • Older child, reliable family
                           • Close follow-up in 24-48 hours
                           • Clear return precautions
                  2. ●

                     Action

                     Wound Care

                     Gentle, conservative approach

                     • Leave blisters intact if possible
                     • Non-adherent dressings (petrolatum gauze)
                     • Avoid adhesive tape on affected skin
                     • Silver sulfadiazine controversial (not usually needed)
                     • Daily wound assessment
         2. ⚠

            Warning

            TEN Suspected

            Mucosal involvement present

            • Refer to SJS/TEN algorithm
            • Stop all suspect medications
            • Burn unit transfer
            • Much higher mortality