14/01/2021
🌸"Staphylococcal Scalded Skin Syndrome (Ritter Disease)"🌸
✔️SSSS is caused predominantly by phage group 2 staphylococci, particularly strains 71 and 55, which are present at localized sites of infection.
**Foci of infection include the nasopharynx and less commonly (umbilicus, urinary tract, a superficial abrasion, conjunctivae, and blood).
✔️CLINICAL MANIFESTATIONS;
▪️Staphylococcal scalded skin syndrome, which occurs predominantly in infants and children younger than 5 yr of age, includes a range of disease from localized bullous impetigo to generalized cutaneous involvement with systemic illness.
▪️Onset of the rash may be preceded by malaise, fever, irritability, and exquisite tenderness of the skin. Scarlatiniform erythema develops diffusely and is accentuated in flexural and periorificial areas.
▪️The conjunctivae are inflamed and occasionally become purulent. The brightly erythematous skin may rapidly acquire a wrinkled appearance, and in severe cases, sterile, flaccid blisters and erosions develop diffusely.
▪️Circumoral erythema is characteristically prominent, as is radial crusting and fissuring around the eyes, mouth, and nose. At this stage, areas of the epidermis may separate in response to gentle shear force (Nikolsky sign).
▪️As large sheets of epidermis peel away, moist, glistening, denuded areas become apparent, initially in the flexures and subsequently over much of the body surface .This development may lead to secondary cutaneous infection, sepsis, and fluid and electrolyte disturbances.
▪️The desquamative phase begins after 2-5 days of cutaneous erythema; healing occurs without scarring in 10-14 days.
▪️Patients may have pharyngitis, conjunctivitis, The Skin
and superficial erosions of the lips, but intraoral mucosal surfaces are spared.
**Although some patients appear ill, many are reasonably comfortable except for the marked skin tenderness.
✔️DIFFERENTIAL DIAGNOSIS;
A presumed abortive form of the disease manifests as diffuse, scarlatiniform, tender erythroderma that is accentuated in the flexural areas but does not progress to blister formation. In patients with this form, Nikolsky sign may be absent.
**Although the exanthem is similar to that of streptococcal scarlet fever, strawberry tongue and palatal petechiae are absent.
Staphylococcal scalded skin syndrome may be mistaken for a number of other blistering and exfoliating disorders, including
👉🏻bullous impetigo,
👉🏻epidermolysis bullosa,
👉🏻epidermolytic hyperkeratosis,
👉🏻pemphigus,
👉🏻drug eruption,
👉🏻erythema multiforme,
👉🏻Drug-induced toxic epidermal necrolysis.
**Toxic epidermal necrolysis can often be distinguished by a history of drug ingestion, the presence of Nikolsky sign only at sites of erythema, the absence of perioral crusting, full-thickness epidermal necrosis, and a blister cleavage plane in the lowermost epidermis.
**A subcorneal, granular layer split can be identified on skin biopsy. Absence of an inflammatory infiltrate is characteristic. Histology is identical to that seen in pemphigus foliaceus, bullous impetigo, and subcorneal pustular dermatosis.
✔️TREATMENT;
▪️Systemic therapy, given either👉🏻 orally in cases of localized involvement or 👉🏻parenterally with a semisynthetic antistaphylococcal penicillin (e.g., nafcillin), first-generation cephalosporin (e.g., cefazolin), clindamycin, or vancomycin if MRSA is considered, should be prescribed.
▪️Clindamycin is typically used in addition to other agents, as it is thought to inhibit bacterial protein (toxin) synthesis.
▪️The skin should be gently moistened and cleansed. Application of an emollient provides lubrication and decreases discomfort.
▪️Topical antibiotics are unnecessary.
▪️In neonates, or in infants or children with severe infection, hospitalization is mandatory, with attention to fluid and electrolyte management, infection control measures, pain management, and meticulous wound care with contact isolation.
▪️In particularly severe disease, care in an intensive care or burn unit is required.
✔️Recovery is usually rapid, but complications, such as excessive fluid loss, electrolyte imbalance, faulty temperature regulation, pneumonia, septicemia, and cellulitis, may cause increased morbidity.
"Nelson edition 21( page 3553)"
