Staphylococcal scalded skin syndrome: Case

This neonate presents generalised staphylococcal scalded skin syndrome, or Ritter disease, with the characteristic prodrome of irritability and poor feeding, scarlet erythema around the mouth and in the nappy area, and sheet-like peeling with a positive Nikolsky sign. The sticky eye over the preceding three days is the likely staphylococcal focus generating the toxin, which is the typical pattern in a neonate. The intact oral and conjunctival mucosae confirm the diagnosis against Stevens-Johnson syndrome, in which the mucosae would be ulcerated. ^[2]

Clinical findings

The key findings are the extensive superficial skin loss, the tenderness, and the tachycardia with a prolonged capillary refill that signal fluid loss and evolving dehydration. The candidate should estimate the extent of skin involvement as a percentage of body surface area, because the fluid and heat losses scale with that figure in a small neonate. The intact mucosae should be documented explicitly, because their involvement would shift the diagnosis toward a drug-induced reaction rather than SSSS. ^[3]

The sticky eye is the portal of entry, and the candidate should examine the conjunctiva, the umbilicus, the nasopharynx, and the nappy area for the staphylococcal focus. Blood cultures should be drawn but are usually negative, because only the toxin circulates and the organism stays at its local focus. A swab of the sticky eye is more likely to grow the toxigenic Staphylococcus aureus and confirm the source. A skin biopsy is rarely required in a typical case, because the clinical picture is characteristic. ^[2]