Staph Scalded Skin Management

7/28/2019 Staph Scalded Skin Management

1/17

Melissa Kleschen, MD, PGY3

Morning Report


2/17

17 mo boy with rash. Rash started 7 days ago. Started as a small crusting yellow

papule on his lip. He then developed lesions on his right dorsal

hand and thumb that were vesicular in nature and fluid-filled.

3 days PTA he developed a macular papular rash that began in

his groin area and traveled up to his neck. Not itchy.

1-2 days PTA he developed a puffy" face and neck

Reported tactile fever x7 days, but no documented temperatures

Good po intake. No URI symptoms, nausea, vomiting, or

diarrhea. No joint pain or swelling.

Tried Bactroban 4 days ago (for hand/lip lesions) withimprovement in lip lesion only.


3/17

PMH/ PSH: Full term birth without complications, nomajor or chronic illnesses

MEDICATIONS: Motrin and Tylenol for discomfort.ALLERGIES: NKDA

IMMUNIZATIONS: Up to date, including flu shot.

DEVELOPMENT: Normal for age.

FAMILY HISTORY: No FH of any respiratory,cardiac, or childhood illnesses. 10 year old brotherwith impetigo 1 month ago.

SOCIAL HISTORY: Lives in Utah with parents and 2

siblings. No recent travel or contact with unusualanimals. No new medications or exposure tomedications. No known injections.


4/17

Exam Vitals: T 38.4. HR 128. RR 32. SaO2 97% on RA.

WEIGHT - 12.8 Kg, (85%ile); HEIGHT - 82.5 cm, (66%ile)

GENERAL: Sitting in mother's lap, tears present, unhappy but

cooperative

HEAD: normocephalic, atraumatic. EYES: normal red reflex bilaterally, conjunctiva normal without

injection.

EARS: tympanic membranes gray bilaterally, normal light reflex

and landmarks, no effusion or perforation.

NOSE: no discharge or obstruction.

OROPHARYNX: moist mucus membranes, no cleft palate, tonsils

2+ without exudate, no pharyngeal erythema or lesions.

NECK: supple, no lymphadenopathy. Mild edema present inferior

to each ear. No masses felt.


5/17

CV: normal rate, rhythm, and S1/S2, without murmur. Pulsesappropriate. Capillary refill time 2 seconds.

LUNGS: clear to auscultation bilaterally, good air flow, noretractions.

ABDOMEN: soft, non-tender, non-distended with active bowelsounds and no masses or hepatosplenomegaly.

EXTREMITIES: warm and well perfused. No cyanosis,

clubbing, or edema. GU: Tanner stage I, diffuse erythema present without any

lesions or desquamation.

NEUROLOGIC: awake and alert, arousable, cranial nerves II-XII grossly intact, grossly normal strength, normal tone.

SKIN: Diffuse erythematous blanching macular papular rashextending from mid-thigh to neck and face. Multiple peelingand crusted lesions on right hand, neck, and throughout trunk.2-3 bullae present on neck, surrounding skin non-fluctant orerythematous. No mottling, no jaundice, no unusualbirthmarks.


6/17

The rash


7/17

17 mo male with 7 days of macular papular rash, vesicular lesions,

bullae, desquamation, possible tactile fever, and irritability.

Differential??


8/17

Differential Impetigo, bullous impetigo Staph scalded skin syndrome

Toxic shock syndrome

HSV, VZV

Erythema multiforme

Stevens Johnson Syndrome/TEN

Acute generalized exanthematous pustulosis (AGEP,pustulardrug eruption)

Drug reaction with eosinophilia and systemic symptoms(DRESS syndrome)

Pustular psoriasis/von ZumBusch variant (acute phase) Kawasaki's Disease

Bullous SLE


9/17

Blisters form from

Disruption of cellular or extracellular adhesionmolecules (eg, autoimmune blistering disorders,

congenital epidermolysis bullosa)

Epidermal cell injury or death (eg, toxic epidermal

necrolysis, erythema multiforme)

Accumulation of excessive edema (spongiosis)

within the epidermis (eg, contact dermatitis, acute

and chronic vesicular palmoplantar dermatitis)

Traumatic injury (eg, friction blisters)

Vessicles 1cm


10/17

LABS CBC:

WBC 10 (59% neutr, 0% bands, 27% lymph, 6%monos, 6% eos), Hgb 5, Hct 13.6, Plt 356.

CMP:

Na 135, K 4.7, Cl 103, CO2 23, BUN 12, Cr 0.23,Glucose 92, Ca 9.7, Protein 6.2, Albumin 3.8,Bilirubin


11/17

More rash pictures


12/17

Hospital Course Started IV clindamycin, wound care, and pain

control

Derm consult:

Biopsy: subcorneal pustules consistent with

staph scaled skin vs bullous impetigo. Afterdiscussion of clinical presentation, favorStaph Scaled Skin Syndrome

Continued on clindamycin for SSS (transitioned to

oral at discharge). His rash worsened with moredesquamation for 1-2 days, then started toimprove


13/17

Staph Scaled Skin Syndrome Most severe skin manifestation of Staphlococcus

aureus exotoxin-mediated disease Usually due to exotoxin A

Typically not invasive outside skin disease

Intact bullae of SSSS usually sterile. Staph recoveredfrom a distant site (nose, throat, local skin infection,blood, urine)

12-14 hours after systemic toxin exposure, theattachment between stratum conrneum and

underlying epidermis weakens causing vessicles,bullae, and desquamation

Nikolsky sign: shearing force applied to skin produces ablister


14/17

Staph Scalded Skin


15/17

Staph Scalded Skin


16/17

Eradicate the staph infectionAntibiotics: MSSA vs. MRSA coverage

IV antibiotics suggested until resolution of fever x72hours or improvement in condition if afebrile

Hydration and electrolyte management due todiffuse skin breakdown/fluid loss

Treat skin like a burn Bland emollients on the skin and non-adherent

dressings Re-epithelialization can occur within 1-2 weeks

with minimal scarring or skin damage

Consider MRSA eradication

Staph Scalded Skin Management


17/17

References

Pollack S. Staphylococcal Scalded SkinSyndrome. Pediatrics in Review 1996;17:18.

Todd JK. Staphylococcal Infections. Pediatrics in

Review 2005; 26:444.

Gupta A, Jacobs N. Visual Diagnosis : 2-week-

old Has a Red, Peeling Rash. Pediatrics in

Review 2013; 34:e9

Hull, et. al. Approach to the patient withcutaneous blisters. UpToDate. Feb 2013.

Staph Scalded Skin Management

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