Staphylococcal scalded skin syndrome

Staphylococcal Scalded Skin Syndrome. Definition. Etiology. Pathophysiology.Diagnosis.Treatment

1. STAPHYLOCOCCAL SCALDED SKIN SYNDROME

2. Etiology caused predominantly by phage group 2 staphylococci, particularly strains 71 and 55 f ound in nasopharynx and, less commonly, the umbilicus, urinary tract, a superficial abrasion, conjunctivae, and blood s preads hematogenously Nelson’s Textbook of Pediatrics. 19 th Edition

3. Epidemiology predominantly in infants and children younger than 5 years of age and rarely occurs in adults Due to circulating antibodies and renal excretion of toxins most cases are caused by type 71 strain (75%) no differences in incidence based on gender nor economic status Nelson’s Textbook of Pediatrics. 19 th Edition Schwartz , M. William. The 5 minute pediatric consult . 2nd ed.

4. PATHOPHYSIOLOGY Caused by an exfoliative toxin: ETA and ETB The toxins likely act as proteases that target the protein desmoglein-1 ( DG-1) Exotoxin causes separation of the epidermis beneath the granular cell layer.

5. PATHOPHYSIOLOGY

6. PATHOPHYSIOLOGY

7. PATHOPHYSIOLOGY

8. DIAGNOSIS Gram stain or Culture: from the remote site of infection Skin biopsy or Frozen Section PCR

9. Management

10. Pharmacologic Systemic therapy, either orally, in cases of localized involvement, or parenterally, with a semisynthetic penicillinase-resistant penicillin, should be prescribed because the staphylococci are usually penicillin resistant Clindamycin may be added to inhibit bacterial protein (toxin) synthesis

11. Review of Medication: Hydroxyzine 2mg/ml, 2.5 ml every 6 hours PRN for pruritus Mupirocin ointment, apply over nasal mucosa using cotton buds, 3x a day for 7 days Erythromycin eye oitment, 1 strip to both lower lids 2x a day Cloxacillin 250mg/ml, 2ml every 6 hours on an empty stomach, 1 hour prior to meals

12. Non-pharmacologic The skin should be gently moistened and cleansed. Application of an emollient provides lubrication and decreases discomfort. Topical antibiotics are unnecessary.

13. Prognosis Recovery is usually rapid, but complications such as excessive fluid loss, electrolyte imbalance, faulty temperature regulation, pneumonia, septicemia , and cellulitis may cause increased morbidity.

14. Blepharitis Chronic inflammation of the eyelid Associated with tear film disruption Anterior Affecting the anterior lid margin and eyelashes Posterior Affecting the Meibomian glands

15. Symptoms Watery eyes Red eyes Burning sensation in eyes Eyelids that appear greasy Itchy eyelids Red, swollen eyelids Flaking of the skin around the eyes Crusted eyelashes upon awakening Eyelid sticking More frequent blinking Sensitivity to light Eyelashes that grow abnormally (misdirected eyelashes) Loss of eyelashes

16. Anterior Blepharitis Staphylococcal bacteria Seborrheic dermatitis Manifestations Foreign body sensation, burning sensation, matting of eyelashes, ring like formation around the lash shaft Presence of madarosis , chalazion or hordeolum

17. Posterior Blepharitis Inflammation of eyelids secondary to dysfunction of meibomian glands Associations Rosacea Facial redness D emodex mites Affinity for hair follicles

18. Treatment Proper hygiene This condition is primarily treated with advocating cleaning of the affected area regularly Warm water and mild shampoo for eyelashes Antibiotics Steroid Eyedrops Artificial Tears

19. An innovative local treatment for staphylococcal scalded skin syndrome E. Mueller & M. Haim & T. Petnehazy & B. Acham-Roschitz & M. Trop

20. Case Report Male infant Different congenital malformations Delivered via caesarean section at 36 weeks AOG due to oligohydramnios Left lower limb deformity consisting of tibial and distal femoral aplasia, club foot and mirror foot Multiple vertebral anomalies at different levels of the spine Renal agenesis on the right and hydronephrosis on left kidney

21. Course in the Ward 11 months of age Severe diaper dermatitis with ulceration caused by intractable diarrhea secondary to short bowel syndrome and renal insufficiency Microbial analysis: presence of Escherichia coli, Enterobacter cloacae, Klebsiella pneumoniae and Enterococcus faecalis , and S. aureus .

22. Course in the Ward 14 months of age: Developed fever, malaise and more irritable Erythematous rash on skin of the trunk and facial area  tender and painful skin and small flaccid bullae erupted Cefuroxime IV, increased parenteral fluid support and transferred to children’s burn unit

23. Course in the Ward Skin biopsy (right flank): mid-epidermal cleavage with minimal inflammation Culture: methicillin-sensitive S. aureus (MSSA) producing ETB Cefuroxime IV was adapted based on the impaired renal function Suprathel ® treatment as a whole-body dressing

24. Staphylococcal Scalded Skin Syndrome Standard treatment: systemic antibiotics Silver sulfadiazine is not recommended for SSSS Steroids are contraindicated on the basis of both experimental and clinical evidence S evere blistering skin diseases are better managed in burns units Core temperature and room temperature need to be monitored carefully

25. Suprathel ® S ynthetic copolymer consisting mainly of DL- lactide (>70%), trimethylene carbonate and ε-caprolactone I mitates the properties of natural epithelium and consists of a membrane with 80% porosity Permeable to oxygen and moisture

26. With Suprathel ® in place: Relieves pain Prevents heat loss and secondary infection Accelerates wound healing Does not need to be changed (daily care is easier)