History
A 4-year-old girl is admitted to hospital with painful raw areas in her axillae, neck and ngroin. These have developed over 24 hours. Her skin had initially become erythematous and inflamed before peeling off to leave large superficial eroded areas in her flexures. She has a history of atopic eczema but is otherwise well. Her mother had suffered recurrent boils on the lower legs following varicose vein surgery one year previously but her skin was currently clear. The patient has not travelled abroad and does not have contact with animals. She does have intermittent contact with a childminder and other young children.
Examination
On admission the child looks unwell and is in pain, and her temperature is 38.3 oC. She holds her arms away from her body. Skin inspection reveals erythema and desquamation in her axillae (Fig. 72.1), groin (Fig. 72.2) and around her neck. She has moderate eczema on her limb flexures. Her mucous membranes are normal.
Questions
• What is the clinical diagnosis?
• What are the swabs likely to isolate?
• How would you treat this patient?
Medicine
This child looked unwell and had tender skin. There was extensive erythema and desqua-mation in her groin and axillae leading to a diagnosis of staphylococcal scalded skin syn-drome (SSSS). This is an exfoliative toxin-mediated bacterial infection mainly affecting children under the age of 5 years. Flexural areas of skin are classically involved; however, the cutaneous involvement may become widespread. Children may have suffered a recent bacterial infection of their ear or throat. Children with atopic eczema are frequently colo-nized by Staphylococcus aureus, of which 5 per cent of strains produce exotoxins which are spread through the blood leading to widespread skin involvement by SSSS. Children may be pyrexial and appear unwell; they do not want their skin to be touched at the affected sites owing to tenderness/pain. Lateral pressure on affected skin can lead to a positive Nikolsky’s sign (the superficial skin sloughs-off). Swabs from involved skin usually isolate S. aureus; strain typing and identification of exotoxins can be carried out if the diagnosis is in doubt. Interestingly, blood cultures are usually negative in children.
This child’s skin swabs also isolated Pseudomonas, which is an opportunistic secondary colonizer of eroded skin.
The patient was admitted to hospital and treated with oral flucloxacillin (intravenous lines should be avoided in patients with fragile/infected skin if possible) plus topical combination fusidic acid and hydrocortisone. She washed in a mild chlorhexidine lotion as the pain settled.
This child had several episodes of SSSS over a few months. Swabs from family mem-bers and close contacts were negative for S. aureus nasal carriage. The patient therefore required a prolonged course of oral flucloxacillin to try to prevent relapse. She was also treated with clindamycin, which inhibits exotoxin formation by S. aureus. The Pseudomonas was treated with ciprofloxacin as it was felt in this case that the bacterium was having a significant secondary impact on slow skin healing. Mild topical hydrogen peroxide cream was also used as a local antiseptic.
KEY POINTS
• Staphylococcal scalded skin syndrome (SSSS) usually occurs in children under the age of 5 years.
• Erythema and desquamation, especially in the flexures, is common with SSSS and may be widespread.
• Systemic and topical antibiotics plus antiseptic washes usually settle the condition over a few weeks.
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