Staphylococcal Scalded Skin Syndrome (SSSS)
Summary
SSSS is a toxin-mediated exfoliative dermatitis caused by Staphylococcus aureus (Phage Group II). It primarily affects infants and young children due to immature renal clearance of the toxin. The condition mimics a widespread partial-thickness burn. It is distinguished from Toxic Epidermal Necrolysis (TEN) by its superficiality (intra-epidermal split) and relative sparing of mucous membranes. Prognosis is generally excellent with antibiotic therapy. [1,2]
Clinical Pearls
The "Sad Man" Facies: Children often develop radial crusting and fissuring around the mouth and eyes, giving them a miserable, wizened appearance.
Sterile Blisters: The blisters in SSSS are caused by the toxin, not the bacteria itself. Therefore, culturing the blister fluid is usually negative. You must swab the focus of infection (nose, umbilicus, eye, throat) to find the organism.
The "Clindamycin Switch": While Flucloxacillin kills the bacteria, Clindamycin is often added because it is a ribosome inhibitor – it switches off the production of the bacterial toxin, halting disease progression faster.
Demographics
- Age: 98% of cases are < 6 years old. Rare in adults (unless renal failure/immunocompromised).
- Outbreaks: Occasional nursery outbreaks.
Why Children?
- Renal Clearance: Immature kidneys cannot excrete the toxin efficiently.
- Immunity: Lack of specific antitoxin antibodies (which most adults have acquired).
- Desmoglein: Differences in Desmoglein-1 distribution in neonatal skin.
Mechanism
- Source: Staph aureus infection at a distant site (e.g., conjunctivitis, otitis, impetigo).
- Toxin: Release of Exfoliative Toxin A (ETA) or B (ETB) into blood.
- Target: The toxin acts as a "molecular scissors", specifically cleaving Desmoglein-1 (a desmosomal adhesion protein).
- Split: Dsg-1 is abundant in the Granular Layer (high up in epidermis). Cleavage causes cells to separate (Acantholysis), and the superficial skin peels off.
- Healing: Because the split is superficial and the basal layer is intact, it heals without scarring.
(Note: Pemphigus Foliaceus affects the same target, Dsg-1).
Phases
- Prodrome: Fever, irritability, malaise. Localised infection (sticky eye etc).
- Erythroderma: Within 24-48h, diffuse faint red rash ("Sandpaper rash"). Accentuated in flexures (groin/axilla).
- Exfoliation:
- Large, flaccid bullae form.
- Skin wrinkles and peels off in sheets.
- Underlying skin is moist, red, and glistening (like a scald).
- Desquamation (Healing): Dry flaky peeling after 3-5 days.
Signs
SSSS vs SJS/TEN
A Critical Distinction.
| Feature | SSSS | SJS / TEN |
|---|---|---|
| Cause | Staph Toxin | Drug Reaction |
| Patient | Infant | Adult (usually) |
| Split Level | Granular (Superficial) | Dermal-Epidermal (Deep) |
| Mucosa | SPARED (Crusted mouth but no oral ulcers) | AFFECTED (Severe oral/eye ulcers) |
| Healing | No Scarring | Potential Scarring |
| Mortality | < 4% | 20-30% |
Microbiology
- Swabs: Nose, Throat, Eyes, Umbilicus, Perineum (Target the colonization sites).
- Blood Culture: Often negative (toxaemia, not bacteraemia), but check for sepsis.
Biopsy (Use Frozen Section for speed)
- SSSS: Intra-epidermal split below granular layer.
- TEN: Full thickness epidermal necrosis.
Management Algorithm
CHILD WITH 'SCALDED' SKIN
↓
ASSESS MUCOSA (Spared = SSSS)
↓
ADMIT TO PAEDIATRICS / BURNS
(Isolation Room - Infectious)
┌─────────┴─────────┐
ANTIBIOTICS SUPPORTIVE
↓ ↓
• **Flucloxacillin** • **Analgesia**
(Anti-Staph) (Paracetamol/Morphine)
IV High Dose
• **Fluids**
• **Clindamycin** (Maintenance +
(Anti-Toxin) Insensible Losses)
Adjunctive
• **Thermoregulation**
(Keep warm, Bair hugger)
• **Skincare**
(Greasy Emollients)
(Non-adherent dressings)
(Minimal Handling)
Antibiotics
- First Line: Flucloxacillin IV.
- Toxin Inhibition: Add Clindamycin.
- MRSA Risk: Vancomycin if prevalence high or failure to respond.
- Dehydration: Loss of skin barrier causes massive fluid evaporation.
- Hypothermia: Loss of thermoregulation.
- Sepsis: If bacteria invade blood.
- Scarring: Extremely rare (unlike burns/TEN).
- Paediatric: Excellent. Mortality < 3%. Re-epithelialisation begins in 48 hours and completes in 7-10 days.
- Adult: Poor. Mortality > 50%. (Reflects underlying comorbidity like renal failure or malignancy).
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| SSSS Management | BAD (British Assoc Derm) | Use of anti-staphylococcals + supportive care. |
| Feverish Child | NICE (NG143) | Sepsis screening protocols. |
Landmark Evidence
1. Ladhani et al (Clin Micro Rev 1999)
- Definitive review identifying the Exfoliative Toxins (A & B) and their specific cleavage of Desmoglein-1, explaining the superficial nature and mucosal sparing (as mucosa contains Dsg-3).
What is SSSS?
It is a skin condition caused by a Staph germ. The germ releases a "protein" (toxin) into the blood that acts like a key, unlocking the connections holding the top layer of skin on. This causes the skin to peel off in sheets, looking exactly like a scald from hot water.
Is it a burn?
No. Although it looks like a burn, the deeper layers of skin are healthy. This means it heals much faster than a deep burn and doesn't leave scars.
Why is the mouth spared?
The toxin only targets the "glue" in the outer skin. The skin inside the mouth uses a different type of glue, so it stays intact. This is a very helpful sign for doctors to tell it apart from other reactions.
Treatment
We treat the germ with antibiotics and treat the skin like a burn (painkillers, fluids, and greasy creams). It usually heals beautifully within 10 days.
Primary Sources
- Ladhani S, et al. Clinical, biological, and molecular characteristics of SSSS. Clin Microbiol Rev. 1999.
- Handler MZ, et al. Staphylococcal scalded skin syndrome: diagnosis and management. Am J Clin Dermatol. 2014.
- Mishra AK, et al. Staphylococcal scalded skin syndrome. BMJ. 2006.
Common Exam Questions
- Pathology: "Target of Exfoliative Toxin?"
- Answer: Desmoglein-1.
- Diagnosis: "Child with peeling skin but normal mouth?"
- Answer: SSSS. (Peeling skin + Ulcerated mouth = SJS/TEN).
- Treatment: "Added to stop toxin production?"
- Answer: Clindamycin.
- Investigation: "Swab result from blister fluid?"
- Answer: Negative/Sterile. (Toxin is in blood, bacteria are in nose).
Viva Points
- Nikolsky Sign: Understanding that it represents weak inter-cellular adhesion.
- Why no scarring?: Because the split is in the Granular layer (very superficial). The basal layer (the factory that makes new skin) is untouched.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.