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Staphylococcal scalded skin syndrome

A staph toxin, not the bacteria themselves, makes a young child's skin redden, blister and peel as though it has been scalded. It looks alarming, needs hospital treatment, and usually heals completely.

Written by David Roberts, editor · Updated

Checked against current CDC and IDSA guidance. Not medically reviewed. How we source this

What it is

Staphylococcal scalded skin syndrome (SSSS, sometimes called Ritter disease) happens when certain strains of Staphylococcus aureus release exfoliative toxins into the bloodstream. Those toxins target a protein that holds the outermost skin layer together, so the top layer separates over wide areas — far from wherever the actual bacteria are sitting.

The original infection is often trivial and easy to miss: a crusted nostril, sticky eye, infected umbilical stump, nappy-area sore or a small wound.

What it looks like

  • Fever, irritability and a child who is clearly unwell and sore to touch
  • Widespread redness, often starting around the mouth, eyes, nose and in skin folds
  • Wrinkled-looking skin, then fragile blisters that burst easily
  • Peeling in sheets, leaving raw, moist, red areas like a scald
  • Crusting and radiating cracks around the mouth, though the inside of the mouth is spared
  • Nikolsky sign — gentle sideways pressure on normal-looking skin makes it slide away

How it differs from other rashes

ConditionHow it differs
Bullous impetigoSame toxins, but the blisters form only where the bacteria are. The child is usually otherwise well.
Toxic epidermal necrolysisUsually drug-triggered, affects the mouth and eye membranes, and splits the skin at a deeper level. More dangerous.
Burn or scaldFollows a clear injury with a matching pattern, rather than starting in folds and around the face with fever.
MRSA rashMRSA usually causes discrete lumps, abscesses or spreading cellulitis rather than widespread peeling.

Diagnosis

Diagnosis is largely clinical, based on the appearance and the age of the child. Swabs are taken from likely sources — nose, eyes, umbilicus, throat, any wound — rather than from the peeling skin itself, which is usually sterile. Blood cultures are taken in babies and anyone very unwell. A skin biopsy is occasionally used to separate SSSS from toxic epidermal necrolysis.

Treatment

  • Admission to hospital for most children, and for all babies
  • Intravenous anti-staphylococcal antibiotics, switched to oral once improving
  • An antibiotic that covers MRSA — such as vancomycin or clindamycin — where MRSA is suspected or locally common
  • Fluids, because raw skin loses water and heat quickly
  • Pain relief and gentle, non-adherent dressings; skin care like burn care
  • Emollients as the skin re-forms

Steroids are not used, and antibiotics are not stopped early even once the peeling settles.

Recovery

Most children start improving within one to three days of antibiotics, and the skin heals in one to two weeks. Because the split is in the outermost layer, healing is usually scar-free. Adults with SSSS — rare, and mostly people with kidney failure or immunosuppression — do considerably worse and need intensive care more often.

Related reading

See also MRSA in children and babies, MRSA skin infection and staph infections explained.

Frequently asked questions

What is staphylococcal scalded skin syndrome?
It is a reaction to a toxin made by certain strains of Staphylococcus aureus. The toxin travels in the bloodstream from a small, often unnoticed staph infection and splits the outer layer of skin, so large areas redden, blister and peel as though scalded. It mostly affects babies and children under five.
What causes scalded skin syndrome?
Exfoliative toxins A and B, produced by some Staphylococcus aureus strains. The original infection can be tiny — a crusted nose, a conjunctivitis, an infected umbilical stump or a small skin lesion. The rash itself is caused by the toxin, not by bacteria in the peeling skin.
What does scalded skin syndrome look like?
It usually starts with fever, irritability and a tender, red rash that often begins around the mouth, eyes, nose and skin folds. Within a day or two the skin wrinkles, forms fragile fluid-filled blisters and peels in sheets, leaving raw, moist, painful areas. Gentle rubbing of normal-looking skin can make it slide away — the Nikolsky sign.
Is scalded skin syndrome contagious?
The rash itself is not, because it is a toxin effect rather than an infection of the peeling skin. The underlying staph bacteria can be passed on by contact, which is why hand hygiene matters and why nursery or hospital outbreaks occasionally happen.
How is scalded skin syndrome treated?
In hospital, with intravenous anti-staphylococcal antibiotics, fluids, pain relief and careful wound and skin care similar to burn care. If MRSA is suspected or confirmed the antibiotic is changed to one that covers it, such as vancomycin or clindamycin. Steroids are not used.
How is it different from impetigo?
Bullous impetigo is caused by the same toxins but stays local — blisters form where the bacteria are. In scalded skin syndrome the toxin spreads through the bloodstream, so skin peels in places far from the original infection, and the child is systemically unwell.
Do children recover from scalded skin syndrome?
Almost always, when treated. Children usually improve within a few days and the skin heals in one to two weeks without scarring, because the split is in the outermost layer only. Mortality in children is low; it is higher in adults, who usually have kidney disease or a weakened immune system.
Can adults get scalded skin syndrome?
It is rare in adults and mostly occurs in those with kidney failure or significant immunosuppression, because healthy adult kidneys clear the toxin efficiently and most adults have antibodies against it. Adult cases are more serious than paediatric ones.
References
  1. NHS. Staphylococcal scalded skin syndrome (2023)
  2. CDC. Staphylococcus aureus infections (2024)
  3. Handler M.Z. & Schwartz R.A., Journal of the European Academy of Dermatology and Venereology. Staphylococcal scalded skin syndrome: diagnosis and management in children and adults (2014)
  4. DermNet NZ. Staphylococcal scalded skin syndrome (2023)

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