A rapidly worsening rash in a paediatric patient
A 4-year-old healthy female presented to the ED with a rapidly worsening rash. Two days before, she had seen her primary care physician for bumps on her cheek, which were diagnosed as hand-foot-and-mouth disease, or HFMD.

The patient developed more bumps on her face and body, with increasing pain and discomfort. On the morning of presentation, her eyes seemed slightly swollen, and her mother noticed the appearance of “water blisters” on her skin. This prompted her to bring the patient to the ED.

The patient was afebrile and drinking well, although she was not eating much. No topical products were applied to the skin. The only medication she received was two doses of ibuprofen for pain after the rash began. No one else at home had any rashes, although HFMD was going around her preschool class.
On exam, the patient was nontoxic but uncomfortable and lying still.

She had broad areas of erythema over much of her body with accentuation in the skin folds. She had significant yellowish crusting with underlying erythema on her face, concentrated around the mouth and eye. There were no intraoral, conjunctival or urethral lesions noted.

Multiple crusted erosions were seen on the trunk. Examination of the axillae, groin and neck revealed flaccid vesicles with clear fluid and thin desquamation. A complete blood count and comprehensive metabolic panel were normal.
She was diagnosed with Staphylococcal scalded skin syndrome (SSSS).

Key takeaways:-
• The rash begins rapidly, often with the onset of sunburn-like erythema that is tender. This erythema rapidly gives way to flaccid, fluid-filled vesicles or bullae that easily rupture and form large erosions and areas of thin desquamation with the presence of Nikolsky’s sign.

• These skin findings are accentuated in the skin folds, including the neck, axillae and groin. Additionally, patients with SSSS have a classic appearance known as “sad man facies,” with significant periorbital and periocular erythema causing thick yellow-colored crusting.

• Although skin findings and edema may be impressive around the eyes, mouth and genitalia, the mucosal surfaces themselves are characteristically spared. The diagnosis is typically made on a clinical basis, and biopsy is not usually needed.


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