Staphylococcal scalded skin syndrome overview

# Overview
Staphylococcal scalded skin syndrome is a dermatological condition caused by Staphylococcus aureus.

# Historical Perspective
The clinical features were first described in 1878 by Baron Gottfried Ritter von Rittershain, who observed 297 cases among children in a single Czechoslovakian children's home over a 10-year period.

# Pathophysiology
The syndrome is induced by epidermolytic exotoxins (exfoliatin) A and B, which are released by S. aureus and cause detachment within the epidermal layer; by breaking down tight-junctions.  One of the exotoxins is produced by the bacterial chromosome, while the other is produced by a plasmid.  (Bacterial plasmids are pieces of self-replicating DNA that often code for secondary characteristics, such as antibiotic resistance, and toxin production.) These exotoxins are proteases that cleave desmoglein-1, which normally holds the granulosum and spinosum layers together.

# Differentiating Staphylococcal scalded skin syndrome from other Diseases
Unlike toxic epidermal necrolysis, SSSS spares the mucous membranes. Skin biopsy may show separation of the superficial layer of the epidermis, differentiating SSSS from TEN, wherein the epidermal-dermal layer is separated in the latter. SSSS may be difficult to distinguish from toxic epidermal necrolysis and pustular psoriasis.

# Epidemiology and Demographics
It is most common in children under 6 years, but can be seen in adults who are immunosuppressed or have renal failure.

# Natural History, Complications and Prognosis
The prognosis of SSSS in children is excellent, with complete resolution within 10 days of treatment, and without significant scarring. However, SSSS must be differentiated carefully from toxic epidermal necrolysis, which carries a poor prognosis. The prognosis in adults is generally much worse, and depends upon various factors such as time to treatment, host immunity, and comorbidities.

# Diagnosis

## Physical Examination
The disease presents with the widespread formation of fluid filled blisters that are thin walled and easily ruptured and the patient can be positive for Nikolsky's sign. Ritter's Disease of the Newborn is the most severe form of SSSS with similar signs and symptoms. SSSS often includes a widespread painful erythroderma, often involving the face, diaper, and other intriginous areas. Extensive areas of desquamation might be present. Perioral crusting and fissuring are seen early in the course.

## Laboratory Findings
The diagnosis of SSSS is made clinically. This is sometimes confirmed by isolation of S. aureus from blood, mucous membranes, or skin biopsy; however, these are often negative.

# Treatment
The mainstay of treatment for SSSS is supportive care along with eradication of the primary infection. Conservative measures include rehydration, antipyretics, management of thermal burns, and stabilization. Parenteral antibiotics to cover S. aureus should be administered. Most strains of S. aureus implicated in SSSS have penicillinases, and are therefore penicillin resistant. Therefore, treatment with Nafcillin, oxacillin, or vancomycin is typically indicated. Clindamycin is sometimes also used because of its inhibition of exotoxins.