An Overview of Scalded Skin Syndrome (SSS)

Medically Reviewed By William C. Lloyd III, MD, FACS
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Scalded skin syndrome, or SSS, is a serious skin condition that occurs as a reaction to a bacterial toxin. It causes the outer layer of the skin to peel, blister, or both. The affected skin can resemble a burn wound, giving the condition its name.  SSS develops when Staphylococcus aureus bacteria infects the skin and produces a harmful toxin. As a result, healthcare professionals usually refer to the condition as staphylococcal scalded skin syndrome (SSSS). It is also known as Ritter’s disease.

According to the National Organization for Rare Disorders (NORD), hospitalization data indicates that the prevalence of the condition has doubled over the last 10 years. Despite this, the condition is still relatively rare, with NORD suggesting that up to 0.56 people per 1,000,000 of the general population experience the condition.

Infants and children are more susceptible to the condition, but older people can also develop it.

This article will explain SSS, including its symptoms, causes, and risk factors. It will also discuss the transmission and prevention of the condition, as well as its treatment and outlook.

Symptoms 

A young child talks to a doctor in a clinic, wearing face masks.
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Initial indications of SSS can include a low fever, generalized redness or discoloration of the skin, and skin tenderness. This skin irritation can develop into a tender rash. It may also cause other non-skin-related symptoms such as a sore throat or conjunctivitis, the inflammation of the eyelids. 

The principal symptoms of SSS are the effects it has on the skin. SSS may cause skin symptoms, including:

  • skin that feels rough and later becomes discolored and wrinkled
  • large areas of skin that exfoliate or peel off, revealing moist, red tissue
  • skin peeling that occurs when applying pressure to the skin — Nikolsky sign
  • red or discolored blisters filled with fluid
  • sores
  • scaling skin that has the appearance of a burn
  • rapidly spreading rash

It is common for the symptoms to appear on areas of the skin that are prone to movement or creasing, such as around the joints. In children, it often affects the skin around the eyes, mouth, and ears. Babies may also commonly experience it around the diaper area and belly button.

In newborns with scaled skin syndrome, symptoms usually appear 48 hours after birth. 

Other symptoms can also include:

  • chills
  • weakness
  • joint and muscle aching or pain
  • fluid loss from the affected skin
  • a general feeling of being unwell

Causes and risk factors

S. aureus is commonly present on human skin, including in areas such as the nose and armpit. Typically, it causes no harm. However, some strains of S. aureus carry a toxin. When these bacteria are able to break through the skin, for example, due to a scrape or bite, they can quickly multiply at that site. This releases the toxin that causes the symptoms of SSS.

For example, people are at a higher risk of experiencing a Staphylococcal or “staph” infection due to factors including:

  • having surgery
  • staying in a healthcare facility
  • having medical devices in their body
  • injecting medication or drugs
  • coming in to close contact with someone who has a Staphylococcal infection

NORD notes that younger children and infants may be more susceptible to the condition as they may have fewer antibodies to the toxin. Additionally, as younger children’s kidneys are still developing, their kidneys may be slower at clearing the toxin. As a result, infants have a higher risk of developing SSS, while the condition is rare in people older than 6 years. In fact, the condition is most common around 48 hours from birth.

Although it is less common, older children and adults can also develop the condition, especially people with compromised immune systems or impaired kidney function. This can include people taking immunosuppressant drugs or chemotherapy.

Transmission and contagiousness 

SSS is contagious and can develop with the spread of the S. aureus bacteria. This includes direct contact or touching an item where the bacteria is present. For example, transmission may occur after sharing towels, skin-to-skin contact, or contact with droplets after a person coughs.

Transmission is possible even when the person carrying the bacteria has no symptoms of infection.

However, as the skin peeling and blisters result from the toxin — not the bacteria itself — the wounds may not always contain contagious material themselves.

People with SSS should still, however, isolate from others to prevent spreading the condition if possible. Caregivers of children and babies should take extra precautions to avoid passing on the infection. This includes following proper hand hygiene and disinfecting items that a person with the infection makes contact with. Additionally, they should undergo nasal swab testing. 

If you cannot isolate, try to keep the skin covered and maintain distance from others, making sure to wash your hands regularly.

Prevention 

According to the Centers for Disease Control and Prevention (CDC), you can prevent skin infections such as SSS by washing your hands frequently and properly with soap and water.

Other measures to prevent infection include:

  • avoiding sharing personal items, such as razors, towels, or clothing
  • keeping any cuts or wounds clean by washing with soap and water and covering with bandages until they heal
  • cleaning your hands and body regularly with soap and water, and especially after:
    • exercising
    • changing a bandage or touching a wound
    • touching worn clothes
  • avoiding picking at any wounds

Diagnosis 

Diagnosis may first involve ruling out other conditions which cause skin symptoms.

Doctors may begin the diagnostic process by examining the affected skin for the characteristics of SSS. They will also ask for details about your symptoms and medical history. Some cases may require a skin biopsy, which involves taking a small skin sample and examining it with a microscope. This is because certain characteristics that are noticeable during a skin biopsy can differentiate SSS from other conditions.

Clinicians may also take cultures from parts of the body that often harbor Staphylococcus bacteria, such as the corners of the eyes and nasal passages.

Treatment 

Treatment for SSS typically involves alleviating the specific symptoms a person experiences.

Doctors can also prescribe a combination of topical and injected or oral antibiotics. 

Antibiotics for SSS can include: 

  • cefazolin
  • nafcillin
  • oxacillin for methicillin-sensitive S. aureus (MSSA)
  • vancomycin for methicillin-resistant S. aureus (MRSA) 

The impacted skin may also require treatment such as soothing moisturizers and nonstick dressing. This promotes wound healing and prevents heat loss. Severe cases may require a hospital stay to monitor dehydration, nutrition, and temperature regulation. 

At-home care 

It is not advisable to attempt to treat SSS at home without first seeking professional medical treatment.

Some cases can be treatable with outpatient care after a doctor has examined your symptoms and condition. Such cases generally require follow-up appointments with a primary care doctor.

However, at-home care can support your recovery. This may involve taking the prescribed medications and managing pain with over-the-counter nonsteroidal anti-inflammatory drugs such as ibuprofen. Additionally, you may need to reapply sterile bandages over any open wounds.

Affected adults and children should make sure to increase their fluid intake to counteract potential fluid loss. Consult with the child’s pediatrician before changing their fluid intake. 

Your doctor can help advise on what you can do to safely care for yourself or others at home.

Complications and outlook 

The severity of SSS ranges from mild to severe. Since symptoms progress quickly, the condition requires immediate medical attention. Severe cases can cause life threatening complications.

For children, mild cases of SSS typically clear up within 2 weeks with effective treatment. Additionally, there may be minimal or even no scarring.  

There is also a low mortality rate for the condition in children, with a rate of less than 5%. However, the condition can be more serious in adults, as they have a mortality rate of up to 60%.

The top layer of skin acts as a protective barrier. Since SSS causes this layer to separate from the bottom layers, people with SSS risk developing sepsis, which is a life threatening blood and tissue infection. Children with healthy immune systems who develop SSS are unlikely to experience sepsis.

Other possible complications include:

Some strains of S. aureus are resistant to the medication methicillin, as well as some other antibiotics. Clinicians may refer to these as MRSA. While this may be more difficult to manage, other antibiotics can act against MRSA and it is usually treatable.

Contact your doctor for a more personal outlook of what to expect from your treatment and condition.

Learn more about MRSA, including its symptoms, complications, and treatment.

Summary

SSS is a type of skin infection that causes peeling skin or blistering. It occurs due to infection with S. aureus bacteria, which produce a toxin that causes the protective top layer of skin to separate from the bottom layer.

The condition is most common in infants, and rare in people older than 6 years. While mild cases typically resolve with outpatient care, the condition can cause serious complications and is particularly life threatening to adults.

As a result, SSS requires immediate medical care and monitoring to prevent complications. Contact your doctor immediately for any symptoms of SSS, such as peeling skin, low fever, or tender rash.

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Medical Reviewer: William C. Lloyd III, MD, FACS
Last Review Date: 2022 Sep 29
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