**11.4 Staphylococcal scalded skin syndrome (SSSS)**

The SSSS is typically characterized by fever and rapid onset of diffuse, painful erythema progressing to widespread formation of thin-walled, easily ruptured, fluid-filled vesicles and bullae (**Figure 4**). Newborns and small infants tend to be most susceptible, though adults may certainly be affected. Nikolsky's sign is almost always present [216]. The clinical presentation of SSSS is the result of specific exotoxins that cleave desmoglein-1 (i.e., disrupt the connection between keratinocytes) and cause cellular detachment within the epidermis. While exotoxins are released by S. aureus, cultures to isolate these bacteria, however, are often negative. More helpful is a skin biopsy with frozen section that should demonstrate a very superficial epidermal split (in contrast to TEN where there is full-thickness epidermal necrosis). Differentiating SSSS from similar clinical presentations is critical because treatment typically involves the addition of medications (i.e., antibiotics) rather than the cessation of them. SSSS patients may require topical disinfection and careful placement on a burn bed covered with nonadherent sheeting. Attention to fluid replacement, pain management, electrolyte balance, and temperature and humidity control are paramount. Less urgent but just as important, the diagnosis of SSSS should prompt a search for staphylococcal "carriers" among close contacts of the affected patient. Healing is usually rapid with correct therapy and vigilant wound care [219].

### **11.5 Necrotizing fasciitis**

Necrotizing fasciitis refers to the severe and rapid destruction of skin, subcutaneous fat, and muscle caused by bacterial infection (e.g., group A streptococci,

community-based methicillin-resistant *Staphylococcus aureus*, Gram-negative bacteria, mixed infection, etc.) [220, 221]. It is characterized by widespread dermal necrosis, vessel thrombosis, and a massive, destructive inflammatory reaction. Mortality rate without surgical involvement may approach 100%. Similar to burn wounds, surgical management of this condition may include extensive debridement and management of the associated compartment syndrome. Also similar to burns, successful treatment depends on careful fluid replacement, broad-spectrum antibiotic coverage (including for Gram-negative organisms), specialized surgical dressings, and vigilant monitoring for signs of shock [222, 223]. Eventual skin grafting and/or tissue flaps may be required to cover large soft tissue defects.

Directly relevant to the theme of the current chapter, all three of the above dermatological conditions (and many others) are subject to the same general complications and considerations, and their final prognosis is directly proportional to the extent of their skin injuries and the level of expert care they urgently receive.
