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STAPHYLOCOCCAL SCALDED SKIN SYNDROME - A #dermatology/#dermtwitter #tweetorial!
Let's start with a question: You are seeing a new patient with a rash you suspect of being SSSS, but aren't sure if it might be bullous impetigo.
What test will help you differentiate the two?
STAPHYLOCOCCAL SCALDED SKIN SYNDROME - A #dermatology/#dermtwitter #tweetorial!
Let's start with a question: You are seeing a new patient with a rash you suspect of being SSSS, but aren't sure if it might be bullous impetigo.
What test will help you differentiate the two?
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The correct answer is wound culture! SSSS should be sterile or skin flora; bullous impetigo will have lots of staph grow out. Keep reading to find out why! 👇
But before we get there, let's talk about the SSSS exam. The pic is a good example of "sad facies." pc:@dermnetnz
The correct answer is wound culture! SSSS should be sterile or skin flora; bullous impetigo will have lots of staph grow out. Keep reading to find out why! 👇
But before we get there, let's talk about the SSSS exam. The pic is a good example of "sad facies." pc:@dermnetnz
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The other great clue you are dealing with SSSS is the predilection for skin folds. This eruption can cause a high BSA of erythema --> desquamation.
SSSS is more common in the #pediatrics population, especially in kids <5 years of age (for all the #tweetiatricians out there!)
The other great clue you are dealing with SSSS is the predilection for skin folds. This eruption can cause a high BSA of erythema --> desquamation.
SSSS is more common in the #pediatrics population, especially in kids <5 years of age (for all the #tweetiatricians out there!)
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So what's the pathophys? The exfoliative toxin from Staph cleaves Desmoglein 1 (Dsg 1 in the figure), which holds keratinocytes together. Notice how the split is really high up in the epidermis, since there is Dsg3 to hold the lower level together?
pc:mdpi.com/2072-6651/2/5/…
So what's the pathophys? The exfoliative toxin from Staph cleaves Desmoglein 1 (Dsg 1 in the figure), which holds keratinocytes together. Notice how the split is really high up in the epidermis, since there is Dsg3 to hold the lower level together?
pc:mdpi.com/2072-6651/2/5/…
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This split being high means a couple things -
- The eruption will be nikolsky positive (rubbing next to a blister will cause a new one to form).
- Any bullae you see will be flaccid (but usually they've already popped)
What other non-infx disease has this same pathophys?
This split being high means a couple things -
- The eruption will be nikolsky positive (rubbing next to a blister will cause a new one to form).
- Any bullae you see will be flaccid (but usually they've already popped)
What other non-infx disease has this same pathophys?
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Pemphigus foliaceous is similar, but instead of a toxin, an auto-antibody cleaves Dsg 1!
Importantly, Dsg1 being the antigen in question for these diseases means that the mucosal sites should NOT be involved.
So what about bullous impetigo? Why does the swab help?
Pemphigus foliaceous is similar, but instead of a toxin, an auto-antibody cleaves Dsg 1!
Importantly, Dsg1 being the antigen in question for these diseases means that the mucosal sites should NOT be involved.
So what about bullous impetigo? Why does the swab help?
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Bullous impetigo is a local effect of staph at the site with toxin cleaving Dsg 1 leading to bullae.
SSSS is a staph infection somewhere that releases this toxin into the blood. This is why a) the swab would be negative for staph and b) why these patients are usually sicker!
Bullous impetigo is a local effect of staph at the site with toxin cleaving Dsg 1 leading to bullae.
SSSS is a staph infection somewhere that releases this toxin into the blood. This is why a) the swab would be negative for staph and b) why these patients are usually sicker!
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Given these facts, we often treat bullous impetigo with just topical antibiotics, but SSSS will usually require systemic antibiotics (and making sure we find the original source of the staph infection).
But wait, you say. Why does this happen more in young kids??
Given these facts, we often treat bullous impetigo with just topical antibiotics, but SSSS will usually require systemic antibiotics (and making sure we find the original source of the staph infection).
But wait, you say. Why does this happen more in young kids??
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2 reasons! Young kids haven't yet developed protective antibodies, AND their kidneys aren't quite able to filter the toxins out.
This latter reason is why in adults, we usually see SSSS in patients who have renal insufficiency!!
My face when I learned this 👇
2 reasons! Young kids haven't yet developed protective antibodies, AND their kidneys aren't quite able to filter the toxins out.
This latter reason is why in adults, we usually see SSSS in patients who have renal insufficiency!!
My face when I learned this 👇
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So one last ? you might asking: If these pts have a widespread blistering rash & look sick, how am I supposed to differentiate from SJS/TEN?!
It all comes down to level of the split! Remember that SSSS won't have mucosal involvement (SJS does).
So one last ? you might asking: If these pts have a widespread blistering rash & look sick, how am I supposed to differentiate from SJS/TEN?!
It all comes down to level of the split! Remember that SSSS won't have mucosal involvement (SJS does).
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But what about biopsy? Yes, it will tell you the level of the split, but #dermatologists usually don't need it and rely on the exam.
One cool test we can do is a "jelly roll." We roll desquamated skin around a qtip, & send for frozens. Full thickness ➡️ SJS, partial ➡️SSSS!
But what about biopsy? Yes, it will tell you the level of the split, but #dermatologists usually don't need it and rely on the exam.
One cool test we can do is a "jelly roll." We roll desquamated skin around a qtip, & send for frozens. Full thickness ➡️ SJS, partial ➡️SSSS!
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Luckily, with appropriate antibiotic treatment, almost all of our SSSS patients do well. Another nice point of having such a high up split is that there is no scarring!
The key is early diagnosis, and hopefully this #medthread will help someone out there in the future!
Luckily, with appropriate antibiotic treatment, almost all of our SSSS patients do well. Another nice point of having such a high up split is that there is no scarring!
The key is early diagnosis, and hopefully this #medthread will help someone out there in the future!
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RECAP!
- SSSS is from exfoliative toxin cleaving Dsg 1.
- Exam is superficial nikolsky positive desquamation, accentuated in skin folds.
- Young kids are the most likely patient, but adults with AKI/CKD can get it too!
- No mucosal involvement & partial thickness (vs SJS)!
RECAP!
- SSSS is from exfoliative toxin cleaving Dsg 1.
- Exam is superficial nikolsky positive desquamation, accentuated in skin folds.
- Young kids are the most likely patient, but adults with AKI/CKD can get it too!
- No mucosal involvement & partial thickness (vs SJS)!
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Thanks for tuning in. Add any questions/comments below, and happy jelly roll-ing! Until next time!
#meded #FOAMEd #medtwitter #dermatologia #IDtwitter
Thanks for tuning in. Add any questions/comments below, and happy jelly roll-ing! Until next time!
#meded #FOAMEd #medtwitter #dermatologia #IDtwitter
