Staphylococcal scalded skin syndrome (SSSS) is a potentially serious acute skin condition caused by the exfoliative toxins of Staphylococcus aureus and typically affects infants and young children. It is usually preceded by a mucocutaneous staphylococcal infection, such as pharyngitis or bullous impetigo, though this preceding infection may go unnoticed by patients and other caregivers. Following systemic dissemination of toxins from the local infection, SSSS itself typically begins with skin tenderness, erythema, and fever. This is followed a day or two later by flaccid blisters and sloughing off of the superficial layer of skin to reveal moist, red tissue underneath, giving the area a scalded-looking appearance. Mucous membranes are spared. A presumptive diagnosis of SSSS is based on clinical findings. Biopsy is only performed in unclear cases and shows separation of the epidermis at the granular layer. Treatment involves the administration of antibiotics and potential intensive care monitoring. The prognosis is generally good, and blisters heal without significant scarring.
- Rare condition (∼ 8 per 1,000,000 children) 
- Primarily affects infants and young children between 6 months and 5 years of age (peak incidence: 2–3 years) 
- Rare in adults: may occur in adults with predisposing conditions (e.g., impaired renal function or immunosuppression) 
Epidemiological data refers to the US, unless otherwise specified.
- Route of infection: dissemination of toxins from a local infection
SSSS belongs to the spectrum of diseases mediated by specific staphylococcal toxins, which also includes bullous impetigo, toxic shock syndrome (TSS), and Staphylococcus aureus food poisoning. Unlike TSS, SSSS does not have systemic manifestations (involvement of, e.g., liver, kidney, bone marrow, CNS).
- Fever, malaise, and irritability
- Skin tenderness
- Diffuse or localized erythema, often beginning periorally
After 24–48 hours 
- Flaccid, easily ruptured blisters that break to reveal moist, red skin beneath (i.e., with a “scalded” appearance) → widespread sloughing of epidermal skin
- is positive
- No mucosal involvement
- Cracking, and crusting is common
- Signs of shock (hypotension, tachycardia)
The presumptive diagnosis of SSSS is made based on clinical findings. Cultures (e.g., blood or nasopharynx) are usually taken for confirming the diagnosis, and a biopsy may be performed to exclude suspected differential diagnoses but is usually not required.
- History: localized staphylococcal infection (e.g., pharyngitis, bullous impetigo)
- Laboratory tests: to confirm the diagnosis 
- Biopsy: indicated in unclear cases, especially when Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) are suspected
- Imaging: such as chest x-ray to rule out pneumonia as an original source of infection
|Differential diagnoses of severe exfoliative skin conditions|
|SSSS||Stevens-Johnson syndrome (SJS)||Toxic epidermal necrolysis (TEN)|
|Age of typical patient|| || || |
|Etiology|| || |
The differential diagnoses listed here are not exhaustive.
- Hospital admission 
- IV antibiotic
- Supportive care
Steroids are contraindicated, as the etiology of SSSS is infectious!
- Fluid and electrolyte imbalances
- Thermal dysregulation
- Secondary infections (e.g., pneumonia, sepsis)
We list the most important complications. The selection is not exhaustive.