Staphylococcal scalded skin syndrome (SSSS)

In most skin infections the bacteria invade the area that becomes red and sore. SSSS is different. The infection can be small and remote, such as in the nose, throat, umbilical stump or a minor skin lesion, but certain strains of Staphylococcus aureus release exfoliative toxins into the bloodstream. DermNet explains that these toxins attack a protein, desmoglein-1, that holds cells of the outer skin layer together, so the skin cells become loose and unstuck.

Because the damage comes from circulating toxin, skin far from the original infection can blister, and cultures from the blisters themselves are often negative.

DermNet reports that SSSS mostly affects children under five, peaking at ages two to three. The immune and kidney systems of young children are immature, so they are less able to neutralise and clear the toxin. Rare cases occur in adults who are immunosuppressed or have severe kidney disease, in whom the illness tends to be more dangerous.

The illness often begins with fever, irritability and a tender, red rash. Within 24 to 48 hours the redness spreads and fragile fluid-filled blisters appear, often starting around the face, nappy area and skin folds. The skin may look wrinkled or paper-thin. Gentle rubbing causes the surface to slide away, a finding doctors call the Nikolsky sign, which helps to separate SSSS from other blistering conditions.

Children are usually miserable, may feed or drink poorly and lose fluid through the damaged skin. Mouth lining is typically spared, which is another feature that helps in diagnosis.

• Fever and unusual irritability.

• Widespread red and painful skin.

• Blisters that burst easily and leave raw areas.

• Crusting around the eyes, nose and mouth.

Diagnosis is mainly clinical, based on the look and feel of the skin. Supporting tests include swabs from the nose, throat, eyes or any obvious site of infection, blood cultures, and sometimes a skin biopsy, which shows splitting high in the epidermis without much inflammation. Doctors also consider conditions such as toxic epidermal necrolysis, burns and other blistering diseases, which need different treatment.

DermNet describes SSSS as a dermatological emergency needing admission and intravenous penicillinase-resistant antibiotics such as flucloxacillin, plus supportive care. That care includes pain relief, replacement of fluids, and gentle skin care with emollients, avoiding anything that rubs or peels the skin. The NHS notes in its impetigo guidance that babies and people with weakened immunity may need antibiotic tablets to stop a staphylococcal skin infection from causing more serious problems, which is why young children with blistering skin should be seen early.

Nursing is similar to burns care: keeping the child warm, avoiding adhesive dressings, watching fluid balance and protecting raw areas from infection.

DermNet reports that children recover completely within about two weeks with prompt treatment, and scarring is not usual because only the surface layer is lost. Deaths are uncommon in children but substantially higher in adults with other illnesses. Complications such as dehydration, secondary skin infection and sepsis are the main risks, which is why early recognition counts.

A child with fever and a spreading red, tender or blistering rash should be seen the same day. Call 999 or go to A&E if the child is floppy, very drowsy, breathing fast, refusing to drink, passing very little urine or has a rash that does not fade when pressed. NHS 111 can advise if you are unsure. People with impetigo-type sores should see a GP, particularly if the child is under twelve months.