The disease

Staphylococcal scalded skin syndrome (SSSS) is the clinical term used for a spectrum of blistering skin diseases induced by the exfoliative (epidermolytic) toxins (ET) of Staphylococcus aureus.1 Current synonyms include Ritter’s disease, bullous impetigo, pemphigus neonatorum, and staphylococcal scarlatiniform rash. It is a disease primarily affecting infants and young children,2 but cases have been reported in adults.3 It seems that the location of lesions depends on age. In neonates, the lesions are mostly found on the perineum or periumbilically, or both, while the extremities are more commonly affected in older children.2 The disease begins with erythema and fever, followed by formation of large fluid filled bullae which quickly rupture on slightest pressure (Nikolsky sign) to leave extensive areas of denuded skin.

The form and severity of SSSS will vary with the route of delivery of the toxin to the skin, ranging from the localised bullous impetigo to generalised SSSS involving the entire skin surface.2-4 In the latter, patients are susceptible to poor temperature control, extensive fluid losses, and secondary infections. They may also develop sepsis and present with hypotension, neutropenia, and respiratory distress.5 Antibiotic treatment with β-lactamase resistant semisynthetic penicillins such as flucloxacillin is usually effective.3 6 Outbreaks of SSSS involving a large number of babies in neonatal wards are not uncommon and may persist for a long time if carriers of toxin producing S aureus are not rapidly identified and treated.6-9

Considering the severity of the disease and the amount of published work, it is surprising how little progress has been made in understanding the mode of action of the toxin and the epidemiology of the disease. Much work over the years on SSSS has been uneventful and repetitive—a large outbreak or a fatal outcome usually results in a surge …