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Child Health Guideline Identifier

Staphylococcal Scalded Skin Syndrome

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Clinical Features

Certain strains of Staphylococcus aureus produce exfoliative toxins. In young infants, and in those with renal impairment, these can accumulate and result in widespread exfoliation of the skin known as Staphylococcal scalded skin syndrome (SSSS).

The initial infection is often minor or undetected.

Prodrome - malaise, irritability, fever, severe skin tenderness.

Erythema usually begins on the head and spreads, particularly involving the skin folds. The skin is fragile and the superficial layers shear off like wet tissue paper with minor pressure (Nikolsky's sign). During this time the infant is at risk of significant fluid loss though the skin, secondary infection and may experience severe pain as with a burn.

After several days the skin desquamates and then heals without scarring. Children are usually able to be discharged home within 5-10 days when no further skin loss is occurring and they are free of pain.

The differential diagnosis includes Stevens-Johnson syndrome, toxic epidermal necrolysis, autoimmune blistering diseases, epidermolysis bullosa. Skin biopsy or frozen section of the roof of a blister may assist if the diagnosis is not clinically clear. Consider dermatology referral.

Management

Children with SSSS should be admitted for appropriate fluid administration & monitoring, antibiotic and pain management.

Fluids

IV, NG or oral fluids should be administered as needed to provide to maintenance requirements and allow for excess losses through the skin. Close attention should be paid to urine output and weight.

Antibiotics

Swabs should be taken from areas of suspected infection. Anti-staphylococcal antibiotics (e.g. flucloxacillin, vancomycin) should be administered. It is unusual for these infants to have septicaemia. Caregivers should be asked about skin infections and be swabbed and treated as necessary to eradicate carriage of toxin-releasing Staphylococcus.

Analgesia

Regular analgesia should be administered to maintain the infant in a comfortable state. This may include paracetamol, oral opiates or opiate infusions.

Some infants require admission to intensive care for fluid and analgesia management.

Nursing protocol for SSSS

On admission  
Action  Rationale
Nose, throat and skin swabs for culture and antibiotic sensitivities, include a specific request for an MRSA screen For early detection of infection  
Baseline temperature, pulse, respiratory rate and blood pressure, increase frequency as indicated  To obtain the normal range and detect deterioration of condition
Height and weight  To assess fluid loss, monitor weight loss and calculate drug doses 
Assess skin and record To assess extent of condition and monitor progress 
General measures  
Action Rationale
Minimal handling  To prevent pain and damage to the skin 
Provide constant environmental temperature where possible (30-32° is optimum)  Temperature regulation is compromised due to extensive skin loss 
Nurse under contact precautions in a room  To protect against further sepsis 
Monitor core temperature closely  Skin temperature is unreliable; at risk of hypothermia because of excess heat loss 
Give practical and emotional support to the child and family  Child and family may experience high levels of distress 
Pain relief  
Action Rationale 
Ensure adequate analgesia is administered, consider IV analgesics with extensive skin involvement To ensure child is pain free, extensive skin loss causes high levels of pain that may be difficult to control with oral analgesics alone 
Skin Care  
Action  Rationale
Bathing/washes; dependent on mobility and fragility of the skin To clean the skin 
Use an oily emollient in the water. If dressings have adhered to the skin these can be soaked off in a warm bath/shower if appropriate or with warm saline soaks To prevent dryness 
Use a soap substitute such as sorbolene or emulsifying ointment Normal soaps are too astringent 
Dress denuded areas (where the top layer of skin has sheared off) with non-adhesive Mepitel soaked liberally with Duoleum (50:50 mixture of white soft paraffin and iquid paraffin). These are changed every 12-24hr or as needed For comfort, to promote healing and to protect denuded areas from infection and further trauma 
Nurse the child on an Exu-Dry Permeable Sheet without clothing. They can be covered with a hospital sheet. Duoleum is applied liberally to the whole body. This will keep the skin moisturised and ensure the non-adhesive Mepitel dressings are protecting the denuded skin areas. Use a patting motion - do not rub as this may cause further skin loss. To keep dressings in place. Adhesive tapes/band-aid plasters will damage fragile skin
Reapply Duoleum at least 4 hourly, more often as needed to the whole body to keep the skin moisturised and to prevent dressing adhering to denuded skin as this can be very painful to remove To maximize effectiveness of dressings
Apply Duoleum to all exposed areas, in particular the face and nappy area  To protect these areas and prevent further trauma 
Pressure area: nurse on a pressure-relieving mattress covered with Exu-Dry Permeable Sheet. Monitor pressure areas as per Glamorgan Score and position patient appropriately To relieve pressure on the skin and alleviate pain 
Eyes: at least 4-hourly eye care in the acute period; apply eye ointment/drops as prescribed  To prevent damage, infection and long-term complications 
Fluid and electrolyte balance  
Action Rationale
Administer IV replacement fluid as prescribed  To correct fluid, electrolyte and protein loss and prevent dehydration, renal failure and shock 
Secure cannula with non-adhesive tape/dressing and bandage well. If adhesive tapes have been used, then the tape should be left in place until the active process has subsided. Adhesive tapes/band-aid plasters will damage fragile skin 
Careful fluid balance monitoring essential  To ensure correct fluid balance and to observe for urinary retention 
Consider urinary catheter for painful micturition and/or urine retention  To normalise urine output and reduce pain on micturition
Nutrition  
Action Rationale 
Encourage/initiate enteral feeding  To prevent weight loss, protein loss and promote wound healing
If a nasogastric tube is required, secure with a tubular bandage or non-adhesive tape Adhesive tape will damage fragile skin 
Involve dietician for assessment and guidance To ensure optimum dietary intake 
Discharge planning  
Action Rationale
Teach the parents/carer the skin care regimen to be continued at home To sustain recovery 

References

Textbook of Pediatric Dermatology, 2nd edition, Blackwell Science, 2006. Editors: JI Harper, A Oranje, N Prose.

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Document Control

  • Date last published: 25 October 2018
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Dermatology, General Paediatrics
  • Author(s): Diana Purvis, Denise Gago
  • Owner: Diana Purvis
  • Editor: Greg Williams
  • Review frequency: 2 years

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