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By Stephen M. Schleicher, MD, and Brian Irwin, DO
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CASE:
This two-year-old boy presents with an erythematous rash and bullae that developed within 24 hours. There was no antecedent inguinal or perianal dermatitis, but the rash was preceded by two days of low-grade fever, slightly decreased oral intake, and irritability. He takes no oral medications. Examination reveals mild inguinal lymphadenopathy, normal vital signs, and no evidence of dehydration. Mucous membranes are unaffected. Exquisite tenderness of the perineal skin is elicited. Nikolsky’s sign is positive on both bullae and surrounding skin. Ruptured bullae reveal moist skin with shallow erosions. A culture of aspirated fluid from intact bullae revealed no growth.
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This patient has localized staphylococcal scalded skin syndrome (SSSS). The condition is caused by toxigenic strains of Staphylococcus aureus and most commonly afflicts infants and young children. Its presention ranges from isolated bullae to generalized erythroderma. In the latter, toxin released during the inflammatory process leads to widespread desquamation of the epidermis. Toxic epidermal necrolysis (TEN) is included in the differential diagnosis. This is because both TEN and SSSS may exhibit a positive Nikolsky’s sign, in which gentle stroking of the skin leads to epidermal separation. However, TEN is often drug induced and uncommon in this age group. Localized SSSS responds to oral antibiotics such as dicloxacillin. More generalized cases require admission, intravenous antibiotics, and adequate hydration. |
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Dr. Schleicher is director of DermDx Centers
and a clinical instructor of dermatology at the Philadelphia
College of Osteopathic Medicine, at Kings College in Wilkes-Barre,
Pennsylvania, and at Arcadia University in Glenside, Pennsylvania.
He is also a member of the EMERGENCY MEDICINE editorial board.
Dr. Irwin is a family physician in the Tamworth and Ossipee Family Medicine divisions of Huggins Hospital in Wolfeboro, New Hampshire.
Emerg Med 39(5):51-2, 2007
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