FFinalistSouthampton · 2027
Dermatology
AKT · Dermatology/Dermatological emergencieslow yield

Staphylococcal scalded skin syndrome

S. aureus exfoliative toxin (cleaves desmoglein-1)

Overview

A toxin-mediated blistering disease of YOUNG CHILDREN: Staphylococcus aureus exfoliative toxins (A/B) cleave desmoglein-1, splitting the superficial epidermis. Diffuse tender erythema then superficial peeling, but — unlike SJS/TEN — the MUCOSAE ARE SPARED. The Staph focus is often elsewhere (conjunctivitis, umbilicus, nose).

Recognise

  • Young child, fever and irritability, with diffuse tender erythema then flaccid blisters and superficial peeling (scalded look), accentuated in the flexures and around the mouth
  • Positive Nikolsky sign (skin shears with pressure) — but the split is high/superficial
  • MUCOSAE ARE SPARED (the key difference from SJS/TEN); perioral radial crusting/fissuring is typical

Red flags

  • Dehydration and secondary infection; neonates and the systemically unwell need admission

Differentials & how to tell them apart

SJS/TENolder patients, mucosal involvement, drug trigger, full-thickness (deep) split — SSSS spares mucosae and is superficial
Bullous impetigolocalised (same toxin), not the generalised tender erythema/peeling of SSSS
Thermal scald/burnhistory of a burn, distribution matches contact

Clinical image

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Staphylococcal scalded skin syndrome — clinical imagesDermNet

Investigations

Clinical. Swab the likely Staph source (nose, conjunctiva, umbilicus, throat) — the blister fluid itself is sterile (toxin-mediated). Biopsy (if done) shows a superficial subcorneal split, distinguishing it from the deeper split of TEN.

Management

IV flucloxacillin + supportive fluid and skin care

  1. 1Admit; IV anti-staphylococcal antibiotic (flucloxacillin) + fluids, analgesia and gentle skin/wound care.Gate: SSSS SPARES the mucous membranes and the split is superficial — that, plus the young age and absence of a culprit drug, separates it from SJS/TEN (mucosal disease, deep split, drug trigger)
  2. 2Treat the primary Staph focus; monitor fluid balance and for secondary infection.
IV anti-staphylococcal antibiotic (flucloxacillin) — first-line to eradicate the toxin-producing Staph
Fluids + analgesia + emollient/wound care — supportive; manage like a superficial burn

Key points

The split is high (subcorneal) so it heals quickly without scarring once the Staph is treated — the opposite of TEN. Mucosal sparing is the bedside discriminator.

Monitor & prognosis

Hydration, temperature, secondary infection, healing.

Excellent in children with prompt antibiotics; heals without scarring.

Source: NICE CKS; StatPearls