STAPHYLOCOCCAL SCALDED SKIN SYNDROME (SSSS) Staphylococcal scalded skin syndrome is a generalized, confluent, superficially exfoliative disease, occurring

most commonly in neonates and young children. It was known in the past as Ritter's disease or dermatitis exfoliativa neonatorum. It has been reported to occur rarely in adults, as in Richard et al's patient, an immunosuppressed homosexual. When it does occur in an adult, usually either renal compromise or immunosuppression is a predisposing factor. It is a febrile, rapidly evolving, generalized, desquamative infectious disease, in which the skin ex-foliates in sheets. It does not separate at the dermo-epidermal junction, as in toxic (drug-induced) epidermal necrolysis (TEN), but immediately below the granular layer. The lesions are thus much more superficial and less severe than in TEN, and healing is much more rapid. They also extend far beyond areas of actual staphylococcal infection, by action of the epidermolytic toxin, exfoliatin, elaborated by the staphylococcus in remote sites. Usually the staphylococci are present at a distal focus such as the pharynx, nose, ear, or conjunctiva. Septicemia or cutaneous infection may also be the causative focus. Its clinical manifestations begin abruptly with fever, skin tenderness, and erythema involving the neck, groins, and axillae. There is sparing of the palms, soles, and mucous membranes. Nikolsky's sign is positive. Generalized exfoliation follows within the next hours to days, with large sheets of epidermis separating. Staphylococcus aureus of Group 2, most commonly phage type 71, has been the causative agent in most cases. If cultures are taken (which is not necessary) they should be obtained from the mucous membranes because the skin erythema and desquamation is due to the distant effects of the exfoliative toxin, unlike the situation in bullous impetigo, where S. aureus is present in the lesions. Rapid diagnosis can be made by examining frozen sections of a blister roof and observing that the full thickness of the epidermis is not necrotic as in TEN but rather is cleaved below the granular layer. Treatment of choice is a penicillinase-resistant penicillin such as cloxacillin or dicloxacillin, or erythromycin, combined with fluid therapy and general supportive measures. The prognosis is good, and corticosteroids are contraindicated.