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Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer. STAPHYLOCOCCAL SCALDED SKIN SYNDROME • • Clinical Features Management • • Nursing protocol References Clinical Features Certain strains of Staphylococcus aureus produce exfoliative toxins. In young infants, and in those with renal impairment, these can accumulate and result in widespread exfoliation of the skin known as Staphylococcal scalded skin syndrome (SSSS). The initial infection is often minor or undetected. Prodrome - malaise, irritability, fever, severe skin tenderness. Erythema usually begins on the head and spreads, particularly involving the skin folds. The skin is fragile and the superficial layers shear off easily with minor pressure. During this time the infant is at risk of significant fluid loss though the skin, secondary infection and may experience severe pain as with a burn. After several days the skin desquamates and then heals without scarring. Management Infants with SSSS should be admitted for appropriate fluid administration & monitoring, antibiotic and pain management. Fluids: IV, NG or oral fluids should be administered as needed to provide to maintenance requirements and allow for excess losses through the skin. Close attention should be paid to urine output and weight. Antibiotics: Swabs should be taken from areas of suspected infection. Anti-staphylococcal antibiotics (e.g. flucloxacillin) should be administered. It is unusual for these infants to have septicaemia. Analgesia: regular analgesia should be administered to maintain the infant in a comfortable state. This may include paracetamol, oral opiates or opiate infusions. Some infants require admission to intensive care for fluid and analgesia management. Caregivers should be asked about skin infections and be swabbed and treated as necessary to eradicate carriers of toxin-releasing Staph. Author: Editor: Dr Diana Purvis Dr Raewyn Gavin Staph Scalded Skin Syndrome Service: Date Issued: Paediatric Dermatology. March 2010 Page: 1 of 3 Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer. STAPHYLOCOCCAL SCALDED SKIN SYNDROME Nursing protocol protocol for SSSS Action On admission Nose, throat and skin swabs for culture and antibiotic sensitivities, include a specific request for an MRSA screen Baseline temperature, pulse, respiratory rate and blood pressure, increase frequency as indicated Height and weight Assess skin and record Skin care Daily bathing/washes; dependent on mobility and fragility of the skin Use an oily emollient in the water Use a soap substitute such as aqueous cream or emulsifying ointment Dress denuded areas with Vaseline Gauze soaked liberally in a 50:50 mixture of white soft paraffin/liquid paraffin. These are changed every 12-24hr Secure with a loose tubegauz suit Apply the 50:50 paraffin mix to all exposed areas, in particular the face and napkin area As the dressings dry out, reapply the 50:50 paraffin mix to the Vaseline gauze Eyes: at least 4-hourly eye care in the acute period; apply eye ointment/drops as prescribed Mouth: 2-hourly mouth care if limited oral intake and in the presence of mucosal and lip involvement Pressure area: nurse on a pressurerelieving mattress, monitor pressure areas and position patient appropriately Author: Editor: Dr Diana Purvis Dr Raewyn Gavin Staph Scalded Skin Syndrome Rationale For early detection of infection To obtain the normal range and detect deterioration of condition To assess fluid loss, monitor weight loss and calculate drug doses To assess extent of condition and monitor progress To clean the skin To prevent dryness Normal soap too astringent For comfort, to promote healing and to protect denuded areas from infection and further trauma To keep dressings in situ To protect these areas and prevent further trauma To maximize effectiveness of dressings To prevent damage, infection and longterm complications To prevent and/or improve mucosal and lip involvement To relieve pressure on the skin and alleviate pain Service: Date Issued: Paediatric Dermatology. March 2010 Page: 2 of 3 Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer. STAPHYLOCOCCAL SCALDED SKIN SYNDROME Action Fluid and electrolyte balance Administer IV replacement fluid as prescribed Secure cannula with non-adhesive tape/dressing and bandage well Careful fluid balance monitoring essential Consider urinary catheter for painful micturition and/or urine retention Nutrition Encourage/initiate enteral feeding If a nasogastric tube is required, secure with a tubular bandage or non-adhesive tape Involve dietician for assessment and guidance Pain relief Ensure adequate analgesia is administered, consider i.v. analgesics with extensive skin involvement General measures Minimal handling Provide constant environmental temperature where possible (30-32° is optimum) Monitor core temperature closely Nurse under strict infectious and protective precautions in a cubicle Give practical and emotional support to the child and family Discharge planning Teach the parents/carer the skin care regimen to be continued at home Rationale To correct fluid, electrolyte and protein loss and prevent dehydration, renal failure and shock Adhesive tapes/band-aid plasters will damage fragile skin To ensure correct fluid balance and to observe for urinary retention To normalise urine output and reduce pain on micturition To prevent weight loss, protein loss and promote wound healing Adhesive tape will damage fragile skin To ensure optimum dietary intake To ensure child is pain free, extensive skin loss causes high levels of pain that may be difficult to control with oral analgesics alone To prevent pain and damage to the skin Temperature regulation is compromised due to extensive skin loss Skin temperature is unreliable; at risk of hypothermia because of excess heat loss To protect against further sepsis Child and family may experience high levels of distress To sustain recovery References Textbook of Pediatric Dermatology, 2nd edition, Blackwell Science, 2006. Editors: JI Harper, A Oranje, N Prose. Author: Editor: Dr Diana Purvis Dr Raewyn Gavin Staph Scalded Skin Syndrome Service: Date Issued: Paediatric Dermatology. March 2010 Page: 3 of 3