A previously healthy 4-year-old child pictured below presents to the emergency room (ER) with a 2-day history of a brightly erythematous rash and temperature of 40°C (104°F). The exquisitely tender, generalized rash is worse in the flexural and perioral areas. The child is admitted and over the next day develops crusting and fissuring around the eyes, mouth, and nose. The desquamation of skin shown in the photograph occurs with gentle traction. Which of the following is the most likely diagnosis?
- Epidermolysis bullosa
- Staphylococcal scalded skin syndrome
- Erythema multiforme
- Drug eruption
- Scarlet fever
Also known as Ritter disease, staphylococcal scalded skin disease is seen most commonly in children less than 5 years of age. The rash is preceded by fever, irritability, erythema, and extraordinary tenderness of the skin. Circumoral erythema; crusting of the eyes, mouth, and nose; and blisters on the skin can develop. Intraoral mucosal surfaces are not affected. Peeling of the epidermis in response to mild shearing forces (Nikolsky sign) leaves the patient susceptible to problems similar to those of a burn injury, including infection and fluid and electrolyte imbalance. Cultures of the bullae are negative, but the source site or blood often may be positive. Treatment includes antibiotics (to cover resistant S aureus) and localized skin care.