An 8-month-old female with a history of eye discharge, presented with complaints of pustules on red tender skin, which ruptured to lead to erosions and peeling since 3 days. On examination, skin was tender with diffuse erythema. Whitish crusting and fissuring was seen in the perioral area and the neck (Fig. 1), with sparing of the mucosa. Flaccid pustules and blisters, few having ruptured to lead to erosions were seen on trunk, inner thighs and neck. Nikolsky sign was positive. Wrinkling of skin along with exfoliation was seen in the axillae. There was leucocytosis. Lesional pus for smear and culture sensitivity and blood culture were negative for Staphylococcus. Histopathology revealed focal loss of upper epidermis and presence of acantholytic cells in the subcorneal layer. A diagnosis of staphylococcal scalded skin syndrome (SSSS) was made. Patient had a complete recovery with peeling within 10 days on treatment with antistaphylococcal antibiotics.

Fig.1 Whitish crusting and fissuring in the perioral and perinasal areas with flaccid blisters in neck folds.

SSSS, caused by Staphylococcus aureus exfoliative toxins (ET) A and B, generally affects neonates, infants, and children less than 5 years of age, due to lack of protective antitoxin antibodies and immature renal function. Left untreated, large sheets of epidermis slough off to leave extensive areas of raw denuded skin that is sensitive and painful. The toxin is usually produced at a site distant from the lesions. ET acts as an atypical glutamate-specific serine protease that binds and cleaves desmoglein-1(found in the upper epidermis, absent in the mucosa) which explains the specific site of action in the superficial epidermis and the absence of mucous membranes affection in SSSS. Cultures from the skin lesions are negative for staphylococcus in almost all cases. It is important to send swabs from other areas such as the umbilicus, nasopharynx and conjunctivae. Anti-staphylococcal antibiotics, temperature regulation, maintaining fluid and electrolyte balance, nutritional management and skin care form the basis of treatment. The main differential diagnosis remains drug-induced toxic epidermal necrolysis (TEN) the differentiating factors in TEN being-adult onset, spared areas of the skin, mucosal involvement, presense of nikolsky sign only in involved skin (and not diffusely) and absence of perioral/perinasal crusting.