# Staphylococcal scalded skin syndrome - Category: emergency - Review status: reviewed (every claim checked against a document named on this page) - Sources: Staphylococcal Scalded Skin Syndrome - StatPearls (NCBI Bookshelf NBK448135) - https://www.ncbi.nlm.nih.gov/books/NBK448135/ · Staphylococcal scalded skin syndrome - disease-level clinical article (staphylococcal-scalded-skin-syndrome-full.txt) · Staphylococcal scalded skin syndrome - disease-level clinical article (staphylococcal-scalded-skin-syndrome-clinical.txt) · Egyptian National Drug Formulary - Antimicrobial 2023 (cefazolin monograph, p216) · Egyptian National Drug Formulary - Antimicrobial 2023 (cephalexin monograph, p219) - Verified date: 2026-08 ## Verified against - Staphylococcal Scalded Skin Syndrome - StatPearls (NCBI Bookshelf NBK448135) - https://www.ncbi.nlm.nih.gov/books/NBK448135/ - Staphylococcal scalded skin syndrome - disease-level clinical article (staphylococcal-scalded-skin-syndrome-full.txt) - Staphylococcal scalded skin syndrome - disease-level clinical article (staphylococcal-scalded-skin-syndrome-clinical.txt) - Egyptian National Drug Formulary - Antimicrobial 2023 (cefazolin monograph, p216) - Egyptian National Drug Formulary - Antimicrobial 2023 (cephalexin monograph, p219) ## Treatment metadata - Cefazolin — 500 mg — injection - Referral & safety-netting (no drug therapy) - Cephalexin — 250 mg — oral.liquid ## Complete treatment card ```text STAPHYLOCOCCAL SCALDED SKIN SYNDROME Sources: Staphylococcal Scalded Skin Syndrome - StatPearls (NCBI Bookshelf NBK448135) - https://www.ncbi.nlm.nih.gov/books/NBK448135/ · Staphylococcal scalded skin syndrome - disease-level clinical article (staphylococcal-scalded-skin-syndrome-full.txt) · Staphylococcal scalded skin syndrome - disease-level clinical article (staphylococcal- scalded-skin-syndrome-clinical.txt) · Egyptian National Drug Formulary - Antimicrobial 2023 (cefazolin monograph, p216) · Egyptian National Drug Formulary - Antimicrobial 2023 (cephalexin monograph, p219) Review status: REVIEWED against 4 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (4) - A prodrome of malaise, fever, agitation, and tender skin often precedes the rash [fever · irritability · malaise · rash] - Purulent discharge from the nose or pink eye can reflect the underlying staph infection [pus · runny nose] - In an adult it usually goes with failing kidneys or a weakened immune system - In a child it can appear as early as 48 hours old, and becomes uncommon after age 6 SIGNS - what you find (7) - Redness starts on the head and around the face, often with facial swelling, then spreads elsewhere within 48 hours [facial swelling · redness] - The skin takes on a wrinkled appearance as flaccid, sterile blisters form within the superficial epidermis [blisters] - Nikolsky sign is positive - Skin folds are usually first to peel, leaving moist skin with a thin, varnish-like crust - Crusting and radial cracks around the mouth and eyes are a distinctive pattern, with the inside of the mouth spared [crusting] - Peeling lasts 3 to 5 days before the skin heals over without scarring - Red flag: afterwards watch for a falling temperature, an unstable circulation, and relapse [relapse] TESTS (7) - Diagnosis rests mainly on clinical appearance; lab work-up is reserved for cases where the picture is unclear - Blood cultures add little because it is the toxin, not the organism, that spreads through the blood - Blood and blister fluid cultures are usually negative but can turn positive in adults, especially with bacteremic sepsis - Even with negative blister cultures, the organism may still be recovered from the conjunctiva, nasopharynx, perianal area, or a skin focus of infection - White cell count can be raised or entirely normal - Frozen section analysis can confirm exactly where within the epidermis the blister split occurs - Latex agglutination, double immunodiffusion, or ELISA testing can identify the causative toxin IF NOT THIS - what else fits (5) - Bullous impetigo shares the same desmoglein-1 target but shows a dense dermal inflammatory infiltrate and a negative Nikolsky sign, and favors newborns - Stevens-Johnson syndrome and toxic epidermal necrolysis show dusky, necrotic-looking skin and usually follow a drug exposure in older children and adults - Acute generalized exanthematous pustulosis favors women and shows nonfollicular pustules in the flexures with subcorneal pustules on biopsy - Toxic shock syndrome presents with keratinocyte necrolysis, fever, low blood pressure, and multi-organ involvement - Scarlet fever tends to affect older children with flu-like symptoms followed by a sandpaper- textured rash Source Staphylococcal scalded skin syndrome - disease-level clinical article (staphylococcal- scalded-skin-syndrome-full.txt) Status traced to the source above Rx: Antibiotic | Main treatment ANTIBIOTIC - choose one 1. CEFAZOLIN [1st line] Adult 1-2 g every 8 hours intravenously x 10 days unless the clinical picture calls for longer Peds 50-100 mg/kg/day (50-100 mg/kg/day divided every 8 hours, intravenously. The article's alternatives, nafcillin or oxacillin at 100-150 mg/kg/day divided every 6 hours, are not stocked in Egypt.) 3kg -> 150-300 mg/day 4kg -> 200-400 mg/day 5kg -> 250-500 mg/day 6kg -> 300-600 mg/day 7kg -> 350-700 mg/day 8kg -> 400-800 mg/day 9kg -> 450-900 mg/day 10kg -> 500-1000 mg/day 11kg -> 550-1100 mg/day 12kg -> 600-1200 mg/day 13kg -> 650-1300 mg/day 14kg -> 700-1400 mg/day 15kg -> 750-1500 mg/day 16kg -> 800-1600 mg/day 17kg -> 850-1700 mg/day 18kg -> 900-1800 mg/day 19kg -> 950-1900 mg/day 20kg -> 1000-2000 mg/day 21kg -> 1050-2100 mg/day 22kg -> 1100-2200 mg/day 23kg -> 1150-2300 mg/day 24kg -> 1200-2400 mg/day 25kg -> 1250-2500 mg/day 26kg -> 1300-2600 mg/day 27kg -> 1350-2700 mg/day 28kg -> 1400-2800 mg/day 29kg -> 1450-2900 mg/day 30kg -> 1500-3000 mg/day 31kg -> 1550-3100 mg/day 32kg -> 1600-3200 mg/day 33kg -> 1650-3300 mg/day 34kg -> 1700-3400 mg/day 35kg -> 1750-3500 mg/day 36kg -> 1800-3600 mg/day 37kg -> 1850-3700 mg/day 38kg -> 1900-3800 mg/day 39kg -> 1950-3900 mg/day 40kg -> 2000-4000 mg/day 41kg -> 2050-4100 mg/day 42kg -> 2100-4200 mg/day 43kg -> 2150-4300 mg/day 44kg -> 2200-4400 mg/day 45kg -> 2250-4500 mg/day 46kg -> 2300-4600 mg/day 47kg -> 2350-4700 mg/day 48kg -> 2400-4800 mg/day 49kg -> 2450-4900 mg/day 50kg -> 2500-5000 mg/day Choice Alternatives. Cefazolin by injection is for the child sick enough to be admitted, which is most of them; oral cephalexin is for the milder case the article says can be treated by mouth for at least a week. Source Staphylococcal Scalded Skin Syndrome - StatPearls (NCBI Bookshelf NBK448135) - https://www.ncbi.nlm.nih.gov/books/NBK448135/ Why The cited article says an antibiotic active against methicillin-sensitive Staphylococcus aureus should be given promptly, and gives cefazolin at 50 to 100 mg/kg daily divided every 8 hours in children. The Egyptian formulary's cefazolin monograph names skin and soft tissue infection among its indications but carries no paediatric section, so the child's dose is cited to the article and the indication to the formulary. Nafcillin and oxacillin, the article's other two choices at 100-150 mg/kg daily, are not in the Egyptian formulary. Caution A CHILD WITH WIDESPREAD SKIN LOSS BELONGS IN HOSPITAL. The article says severe generalised disease needs admission and intravenous antibiotics, sometimes intensive care, for fluid loss and hypothermia through the raw skin - the same problem as a burn. IF MRSA IS SUSPECTED, THIS DRUG WILL NOT COVER IT. The article says give vancomycin instead where there has been recent healthcare contact, recent admission, nursing-home residence, or where local MRSA is common. DO NOT USE SILVER SULFADIAZINE ON THE SKIN. The article warns against it here: too much is absorbed through denuded skin and becomes toxic. AVOID IBUPROFEN AND THE OTHER NSAIDs for the pain - the article warns of kidney injury in this illness. Paracetamol, and an opioid if needed, are what it names. Clindamycin may reduce toxin production, but up to half of the strains behind this illness are clindamycin-resistant, so it is never the drug on its own. Egypt ZINOL 500 MG I.M./I.V. VIAL PHARCO B 31.00 EGP 2. CEPHALEXIN [2nd line] Adult 500 mg every 6 hours - At least one week Peds 25-50 mg/kg/day [child max 2000 mg] (Mild to moderate infection: 25-50 mg/kg/day divided every 6 or 12 hours, maximum 2,000 mg/day.) 3kg -> 75-150 mg/day 4kg -> 100-200 mg/day 5kg -> 125-250 mg/day 6kg -> 150-300 mg/day 7kg -> 175-350 mg/day 8kg -> 200-400 mg/day 9kg -> 225-450 mg/day 10kg -> 250-500 mg/day 11kg -> 275-550 mg/day 12kg -> 300-600 mg/day 13kg -> 325-650 mg/day 14kg -> 350-700 mg/day 15kg -> 375-750 mg/day 16kg -> 400-800 mg/day 17kg -> 425-850 mg/day 18kg -> 450-900 mg/day 19kg -> 475-950 mg/day 20kg -> 500-1000 mg/day 21kg -> 525-1050 mg/day 22kg -> 550-1100 mg/day 23kg -> 575-1150 mg/day 24kg -> 600-1200 mg/day 25kg -> 625-1250 mg/day 26kg -> 650-1300 mg/day 27kg -> 675-1350 mg/day 28kg -> 700-1400 mg/day 29kg -> 725-1450 mg/day 30kg -> 750-1500 mg/day 31kg -> 775-1550 mg/day 32kg -> 800-1600 mg/day 33kg -> 825-1650 mg/day 34kg -> 850-1700 mg/day 35kg -> 875-1750 mg/day 36kg -> 900-1800 mg/day 37kg -> 925-1850 mg/day 38kg -> 950-1900 mg/day 39kg -> 975-1950 mg/day 40kg -> 1000-2000 mg/day 41kg -> 1025-2000 mg/day (upper capped) 42kg -> 1050-2000 mg/day (upper capped) 43kg -> 1075-2000 mg/day (upper capped) 44kg -> 1100-2000 mg/day (upper capped) 45kg -> 1125-2000 mg/day (upper capped) 46kg -> 1150-2000 mg/day (upper capped) 47kg -> 1175-2000 mg/day (upper capped) 48kg -> 1200-2000 mg/day (upper capped) 49kg -> 1225-2000 mg/day (upper capped) 50kg -> 1250-2000 mg/day (upper capped) Source Egyptian National Drug Formulary - Antimicrobial 2023 (cephalexin monograph, p219) Why The cited article says an oral beta-lactamase-resistant penicillin or a first-generation cephalosporin for at least one week is usually enough for milder cases, and names cephalexin at 500 mg every 6 hours as one of the oral alternatives. The formulary's cephalexin monograph names skin and skin structure infection caused by Staphylococcus aureus and Streptococcus pyogenes as an indication and supplies the child's weight-based rule. Caution ORAL TREATMENT IS FOR THE MILD CASE ONLY. If the skin is peeling over a large area, if the child is dehydrated, febrile and miserable, or if there is any doubt, this is an admission, not a prescription. Tablets and oral suspension are not bioequivalent - the formulary says they must not be substituted milligram for milligram. Do not give to a child with a known allergy to cephalexin, another cephalosporin, or any component of the preparation. AVOID IBUPROFEN AND THE OTHER NSAIDs for the pain in this illness; the article warns of kidney injury. Use paracetamol. Egypt AMTHROST 250MG/5ML SUSP. 60ML SIGMA > SABAA 4.50 EGP CEPHOXIN 250MG/5ML DRY SUSP. 60 ML PHARCO B 6.50 EGP CEPHALEXIN 250MG/5ML SUSP. 60ML USP24 ARAB DRUG COMPANY (ADCO) 8.00 EGP CEPHLEX 250 MG/5 ML SUSP. 60ML KAHIRA 10.50 EGP MEDICEFLEXIN 250MG/5ML SUSP. 100ML T3A PHARMA > RIVA PHARMA S.A.E. 14.25 EGP KEFLEX 250MG/5ML PD. FOR ORAL SUSP. 60 ML HIKMA PHARMA 37.00 EGP AMTHROST 125MG/5ML SUSP. 60ML SIGMA > SABAA 4.00 EGP -> ? strength differs, ? different route - not oral liquid CEPHOXIN 125MG/5ML DRY SUSP. 60 ML PHARCO B 6.00 EGP -> ? strength differs, ? different route - not oral liquid MAIN TREATMENT 3. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Staphylococcal Scalded Skin Syndrome - StatPearls (NCBI Bookshelf NBK448135) - https://www.ncbi.nlm.nih.gov/books/NBK448135/ Why A febrile child whose skin is peeling in sheets is an admission for intravenous antibiotics and fluid. The article gives paediatric doses only for intravenous drugs, and its oral figures are adult amounts with no age band, so no prescribing row is offered - printing an oral antibiotic here would look like an alternative to hospital, and it is not. Caution SEVERE DISEASE MEANS ADMISSION, NOT AN ORAL SCRIPT - a child with severe, widespread SSSS has to go in for intravenous antibiotics, and intensive care may be needed, since the skin may want saline-soaked gauze and proper wound care. Start antibiotics promptly, aimed at methicillin-sensitive Staphylococcus aureus - cefazolin, nafcillin or oxacillin. WHY A CHILD DETERIORATES - the skin is behaving like a burn. Where a lot of it is involved the child loses heat and fluid through the lost epidermis, so hypothermia and a fluid deficit follow. Supportive care is the essential part: dehydration managed, temperature held, nutrition kept up, and intravenous fluid once there are signs of dehydration or of sepsis. DO NOT GIVE IBUPROFEN - paracetamol, and an opioid where the pain needs it, are the analgesics here. A non-steroidal anti-inflammatory such as ibuprofen must be AVOIDED, because of the risk to the kidneys. This matters because ibuprofen is the reflex antipyretic for a hot, miserable child, and here it is the wrong one. DO NOT PUT SILVER SULFADIAZINE ON IT - silver sulfadiazine must be AVOIDED here: more of it is absorbed through skin in this state, and toxicity follows. It is the standard burns cream and this looks like a burn; say so before someone reaches for it. TOPICAL ANTIBIOTICS ARE NOT TREATMENT HERE - a topical antimicrobial is generally ineffective in SSSS, though one may be used to decolonise the primary site of infection. The toxin is circulating; the skin that is peeling is not itself infected. CLINDAMYCIN ALONE IS NOT ENOUGH - clindamycin can damp down the toxin the bacteria make, but as many as 50% of the strains behind SSSS are resistant to it, so it must NOT be used on its own. SKIN CARE WHILE WAITING FOR TRANSPORT - put emollients and non-adherent dressings on the raw areas, to help them heal and to cut the heat lost. Keep the child warm and keep gauze off raw skin. A NEGATIVE SWAB PROVES NOTHING - a blood culture usually tells you little, because what spreads through the blood is the toxin, not the organism. And even where the fluid from an intact bulla grows nothing, S aureus may still be grown from the conjunctiva, the nasopharynx, the perianal skin, or a pus-filled focus elsewhere on the skin. Swab the nose, the eyes and the nappy area, not the blisters. The white cell count may be raised or may be perfectly normal. IT IS A CLINICAL DIAGNOSIS - SSSS is diagnosed chiefly on how it looks, with further tests reserved for the occasional case where the diagnosis is genuinely in doubt. Do not wait on a laboratory to start the referral. THE OUTLOOK IN A CHILD IS GOOD IF IT IS TREATED - treated properly, SSSS usually clears in 1 to 2 weeks and usually without complications, and a child is generally left with little or no scarring. Mortality in children is 4% or under; in adults it can reach 50%, on account of the illnesses they already carry. MILD CASES EXIST, AND THE DOSES FOR THEM ARE NOT PRINTED HERE - the article does say that a milder case is usually served by an oral beta-lactamase-resistant penicillin, or a first-generation cephalosporin, for a week at least. Its weight-based figures are for intravenous drugs, and its oral figures are flat adult amounts with no paediatric equivalent, so nothing here can be turned into a safe paediatric oral dose. Deciding that a child's SSSS is mild enough for oral treatment belongs to whoever admits them. PREVENT THE NEXT ONE - hygiene is the prevention, in children and adults alike: washing hands regularly, and looking after wounds properly. Parents and carers should keep the skin clean and watch for any sign of infection, particularly in a child who already has a skin disorder such as eczema. Where the infection was picked up in hospital, finding the S aureus carriers and decontaminating them matters especially. Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)