World Journal of Pediatrics

, Volume 14, Issue 2, pp 116–120 | Cite as

Staphylococcal-scalded skin syndrome: evaluation, diagnosis, and management

  • Alexander K. C. LeungEmail author
  • Benjamin Barankin
  • Kin Fon Leong
Review Article



Staphylococcal-scalded skin syndrome (SSSS), also known as Ritter disease, is a potentially life-threatening disorder and a pediatric emergency. Early diagnosis and treatment is imperative to reduce the morbidity and mortality of this condition. The purpose of this article is to familiarize physicians with the evaluation, diagnosis, and treatment of SSSS.

Data sources

A PubMed search was completed in Clinical Queries using the key terms “Staphylococcal scalded skin syndrome” and “Ritter disease”.


SSSS is caused by toxigenic strains of Staphylococcus aureus. Hydrolysis of the amino-terminal extracellular domain of desmoglein 1 by staphylococcal exfoliative toxins results in disruption of keratinocytes adhesion and cleavage within the stratum granulosum which leads to bulla formation. The diagnosis is mainly clinical, based on the findings of tender erythroderma, bullae, and desquamation with a scalded appearance especially in friction zones, periorificial scabs/crusting, positive Nikolsky sign, and absence of mucosal involvement. Prompt empiric treatment with intravenous anti-staphylococcal antibiotic such as nafcillin, oxacillin, or flucloxacillin is essential until cultures are available to guide therapy. Clarithromycin or cefuroxime may be used should the patient have penicillin allergy. If the patient is not improving, critically ill, or in communities where the prevalence of methicillin-resistant S. aureus is high, vancomycin should be used.


A high index of suspicion is essential for an accurate diagnosis to be made and treatment promptly initiated.


Blisters Desquamation Erythroderma Exfoliative toxins Staphylococcus aureus 


Author contributions

AKCL wrote the first draft of the manuscript, as well as a statement of whether an honorarium, grant, or other form of payment was given to anyone to produce the manuscript. AKCL, BB, and KFL contributed to drafting and revising the manuscript. We have seen and approved the final version submitted for publication and take full responsibility for the manuscript.


None. There is no honorarium, grant, or other form of payment given to any of the author/coauthor.

Compliance with ethical standards

Ethical approval

Not applicable.

Conflict of interest

No financial or non-financial benefits have been received or will be received from any party related directly or indirectly to the subject of this article.


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Copyright information

© Children's Hospital, Zhejiang University School of Medicine 2018

Authors and Affiliations

  • Alexander K. C. Leung
    • 1
    Email author
  • Benjamin Barankin
    • 2
  • Kin Fon Leong
    • 3
  1. 1.Department of Pediatrics, The Alberta Children’s HospitalThe University of CalgaryCalgaryCanada
  2. 2.Toronto Dermatology CentreTorontoCanada
  3. 3.The Pediatric Institute, Kuala Lumpur General HospitalKuala LumpurMalaysia

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