Scalded Skin Syndrome

Staphylococcal scalded skin syndrome, SSSS, is a potentially fatal toxin-mediated disease that occurs mainly in infants but can also occur in children and adults.


As the name suggests, the skin appears to be scalded (figure 22.4). SSSS begins as a generalized redness of the skin affecting 20% to 100% of the body. Other symptoms, such as malaise—a vague feeling of discomfort and uneasiness—irritability, and fever are also present. The nose, mouth, and genitalia may be painful for one or more days before the typical features of the disease become apparent. Within 48 hours after the redness appears, the skin becomes wrinkled, and large blisters filled with clear fluid develop. The skin is tender to the touch and looks like sandpaper.

Causative Agent

Staphylococcal scalded skin syndrome is caused by toxins called exfoliatins produced by certain strains of Staphylococcus aureus.

Blister Wrist Producing Clear Liquid

Figure 22.4 Staphylococcal Scalded Skin Syndrome (SSSS) A toxin called exfoliatin, produced by certain strains of Staphylococcus aureus, causes the outer layer of skin to separate.

22.3 Bacterial Skin Diseases

Table 22.4 Staphylococcal Scalded Skin Syndrome


Tender red rash with sandpaper texture, malaise, irritability, fever, large blisters, peeling of skin

Incubation period

Variable, usually days

Causative agent

Strains of Staphylococcus aureus that produce exfoliatin toxin


Exfoliatin toxin is produced by staphylococci at an infection site, usually of the skin, and carried by the bloodstream to the epidermis, where it causes a split in a cellular layer; loss of body fluid and secondary infections contribute to mortality


Person-to-person transmission; seen mainly in newborns, but can occur at any age

Prevention and treatment

Isolation of the victim to protect from environmental potential pathogens; penicillinase-resistant penicillins; removal of dead tissue

Figure 22.4 Staphylococcal Scalded Skin Syndrome (SSSS) A toxin called exfoliatin, produced by certain strains of Staphylococcus aureus, causes the outer layer of skin to separate.

These toxins destroy material that binds together the layers of skin. At least two kinds of exfoliatins exist: one is coded by a plas-mid gene, and the other is chromosomal. ■ plasmids, pp. 66,209


Exfoliatin, released by S. aureus at the site of infection, is absorbed and carried by the bloodstream to large areas of the skin. In the skin, it causes a split in the cellular layer of the epidermis just below the dead keratinized outer layer. Staphylococcus aureus is usually not present in the blister fluid. Because the outer layers of skin are lost as in a severe burn, there is marked loss of body fluid and danger of secondary infection with Gramnegative bacteria such as Pseudomonas sp., or with fungi such as Candida albicans. Secondary infection means invasion by a new organism of tissues damaged by an earlier infection. Mortality can range up to 40%, depending on how promptly the disease is diagnosed and treated, and the patient's age and general health. ■ Candida albicans, p. 311


About 5% of S. aureus strains produce exfoliatins. The disease can appear in any age group but occurs most frequently in newborn infants, the elderly, and immunocompromised adults. Transmission is generally person-to-person. Staphylococcal scalded skin syndrome usually appears in isolated cases, although small epidemics in nurseries sometimes occur.

Prevention and Treatment

There are no preventive measures except to place patients suspected of having SSSS in protective isolation. These measures help to limit spread of the pathogen to others and help prevent secondary infection of the isolated patient. Initial therapy includes a bactericidal antistaphylococcal antibiotic such as methi-cillin, a penicillinase-resistant derivative of penicillin. All dead skin and other tissue are removed to help prevent secondary infection. Table 22.4 describes the main features of this disease.

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