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The management of staphylococcal scalded skin syndrome in infants

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VOL: 99, ISSUE: 42, PAGE NO: 59

Carolyn Simpson, RGN, RSCN, is ward sister, Paediatric Medicine, Queen’s Medical Centre, Nottingham NHS Trust

Staphylococcal scalded skin syndrome (SSSS) is a disease that usually affects infants and young children who lack the antibodies to Staphylococcus aureus toxins that adults have.

It is caused by bacterial infection by group II S. aureus that produces toxins that cause exfoliation, bullae (blister) formation and redness of skin. In children mortality is low, but can be high in adults, who will usually have a serious underlying disease that makes them susceptible to infection (Kim, 2002; Ladhani and Joannu, 2000).

The causes

The symptoms of SSSS are caused by the exotoxin of group II, phage type 71 S. aureus. Two toxins are known to be involved: exfoliative toxin A (ET-A) and exfoliative toxin B (ET-B), with the former being the agent in most cases. Between 20 and 40 per cent of the healthy population carry S. aureus in their nasal cavity. Once present in the skin, S. aureus releases the exotoxins, which cause blistering by disrupting the granular cell layer of the epidermis (Kim, 2002).

Signs and symptoms

It is vital to diagnose and initiate treatment swiftly, as any delay in administering antibiotic therapy will prolong the release of exotoxins.

SSSS originates from a focus of infection such as a purulent conjunctivitis, nasopharyngeal infection or an infected umbilicus. It usually starts with a fever, irritability and a generalised faint macular erythema with cutaneous tenderness (Fig 1), which may be worse in the flexures.

Within 24 hours tissue-paper-like wrinkling of the epidermis develops, followed by the appearance of blisters in the axillae, groin and around body orifices. The epidermis easily separates from the basal layer - this is known as Nikolsky’s sign (Fig 2).

A moist, red, smooth, shiny base is exposed after the epidermis is shed. The mucous membranes are spared and healing usually takes five to seven days. Milder forms of SSSS can begin as localised bullous impetigo, but evolve to produce limited bullae and denuded areas stripped of epidermis. Other diseases can also present with a localised, exfoliative rash, so accurate diagnosis is vital (Table 1).

SSSS and non-accidental injury

The symptoms linked with SSSS have been confused with non-accidental injuries. In one case (Murphy, 2001), the parents could not account for small, round, blistered areas that looked like scalds on their child’s legs. This was treated as suspicious and inquiries were made with social services. Fortunately, a senior doctor suggested a diagnosis of SSSS.

Diagnosis

Superficial swabs taken from nose and skin lesions are not helpful in confirming a diagnosis of SSSS, because S. aureus is a common skin and nasal commensal. To confirm diagnosis, S. aureus must be isolated from the patient before demonstrating that the strain produces exotoxins. This takes several days and the test is available only from the Health Protection Agency, which covers England and Wales. The results can therefore be used only retrospectively.

Histological examination of a skin biopsy is the most useful investigation, as it can reveal the mid-epidermal separation at granular cell layer, which will exclude an alternative diagnosis of toxic epidermal necrolysis.

Management

SSSS usually presents as a localised lesion and spreads gradually. In primary care, any localised exfoliating rash that resembles localised SSSS, in an otherwise well child, should be treated with an oral antibiotic such as flucloxacillin. Because the disease is toxin-mediated, lesions may continue to appear for 24-36 hours after the start of treatment. There is little evidence to support the view that intravenous antibiotics are more effective than oral antibiotics in the treatment of SSSS (Ladhani and Joannu, 2000).

If new lesions develop after 48 hours, hospital admission is recommended for further investigation and more aggressive treatment. Whether the patient is admitted will depend on the severity of the illness. If a child has extensive exfoliation and fever, and is generally unwell, hospital admission is advisable. Broad-spectrum intravenous antibiotics may be appropriate to cover the possibility of secondary gram-negative infections.

Nursing care - It is vital to maintain the child’s body heat, replace fluid loss and control pain. The child should be nursed in a warm environment with minimal clothing. An emollient, such as a 50:50 mix of white soft paraffin and liquid paraffin, may be applied to lesions to reduce fluid loss and soothe the area.

Fluid balance - A record should be kept of measurable fluid loss and daily weight, and vital signs monitored. The child should be encouraged to drink extra fluids to compensate for fluid loss from the denuded areas of skin. Lack of fluid intake and pyrexia contribute to dehydration, which is characterised by:

- Increased thirst;

- Dry skin and mucous membranes;

- Poor skin turgor;

- Sunken eyes and fontanelle;

- Poor perfusion (slow capillary refill time); 

- Weight loss; 

- Diminished urine output;

- Tachycardia;

- Tachypnoea;

- Altered level of consciousness.

Maintaining body temperature - SSSS disturbs the thermoregulatory function of the skin, so body temperature must be monitored regularly and the ambient temperature adjusted accordingly. Small infants may require an incubator or a radiant heater panel.

Pain control - Analgesia must be administered regularly. This may range from simple paracetamol to oral morphine preparations, which may be required in cases where skin exfoliation is extensive.

Management of fragile skin - Careful handling of the child will minimise trauma to the skin. Iatrogenic injury to skin, caused by applying anaesthetic creams beneath occlusive dressings, prior to intravenous cannulation (Fig 3) can cause unnecessary trauma (Holmes et al, 2003). Such creams are best applied beneath a suitable non-adherent dressing, which can be secured by gauze or bandages, or beneath a cling-film wrap.

Once healed, a lesion usually leaves no scarring. Emollient should be applied until full healing has occurred, and the skin looks and feels supple and smooth. If a lesion needs to be covered, a non-adherent dressing should be applied and secured with a bandage. Adhesive tape must not be used.

Infection control

Infection control procedures must be followed. Lesions remain infectious for the first 48 hours of antibiotic administration, and thereafter the child will need to be protected from infection until the skin has healed. All staff must follow local hand-hygiene policies.

Outbreaks of SSSS sometimes occur in neonatal units. Where extensive, it is vital to identify if any health care worker is infected. Strict enforcement of infection-control measures will be necessary, with handwashing/alcohol hand rubs made available and treatment of infected staff with oral antibiotics and mupirocin ointment.

Complications

These are rare but include cellulitis, sepsis and pneumonia. SSSS is usually associated with a trivial infective focus. Severe infections such as sepsis are rare but have a fatality rate of three per cent (Kim, 2002).

Conclusion

Most SSSS cases are mild. If recognised and treated with antibiotics early on, they can be managed in the community. The skin heals well with no scarring, even in cases of severe exfoliation.

FURTHER INFORMATION

An advice sheet may be given to carers. This can be obtained from The Nottingham Eczema Team, c/o Sandra Lawton, consultant dermatology nurse, Queen’s Medical Centre, Derby Road, Nottingham NG7 2UH.

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