June 2021 ORIGINAL ARTICLES

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order in toddlers in pediatric primary care. PloS One 2020;15:e0232335.
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50 Years Ago in THE JOURNAL OF PEDIATRICS

The Baptism of Staphylococcal Scalded Skin Syndrome: Old is Gold
Melish ME, Glasgow LA. Staphylococcal scalded skin syndrome: the expanded clinical syndrome. J Pediatr 1971;78:958-67.

M ellish and Glasgow, in this landmark paper, coined the term staphylococcal scalded skin syndrome (SSSS) in
children and evaluated its treatment options in an animal model. These 28 patients had presented with gener-
alized erythema followed by variable degrees of exfoliation and were classified as having either toxic epidermal nec-
rolysis, staphylococcal scarlatiniform eruption, or bullous impetigo. On the basis of similar clinical profile and
identical isolation of phage group II Staphylococcus, these heterogenic manifestations were proposed to be regarded
as a single expanded clinical syndrome, SSSS. The authors further demonstrated, in neonatal mice models, that initi-
ation of methicillin before the exfoliative phase was effective in ameliorating the course of the disease, whereas cor-
ticosteroids lacked a beneficial effect.
The authors’ observations on pathogenesis of disease, methicillin therapy, and role of steroids have proven correct.
It is established that phage group II staphylococci, particularly strain 55 and 71, lead to clinical manifestations of SSSS
by hematogenous release of exotoxins A or B from a distant primary site. These toxins bind and cleave desmoglein-1,
leading to splitting of epidermis at granular layer.1 The proposed spectrum of SSSS by authors also stands true except
that it is now known that toxic epidermal necrolysis is caused by hypersensitivity phenomenon, a noninfectious eti-
ology, and has different histology.
The theory of methicillin therapy postulated in the original report has formed the basis of management of the SSSS.
Milder and localized forms of SSSS are treated with oral penicillinase-resistant penicillins. Vancomycin should be
considered in areas having high prevalence of methicillin-resistant strains or as a second-line therapy. Clindamycin
is also commonly added to decrease toxin production by the organism. Topical antibiotics are not recommended,
and use of steroids is contraindicated.1,2 Children with SSSS must be isolated to prevent further outbreaks and pro-
vided with optimum supportive therapy for best results and least complications.
The baptism of SSSS by Melish and Glasgow has stood the test of time!

Shashi Kant Dhir, MD, DM

Department of Pediatrics
GGS Medical College
Faridkot, Punjab, India

Piyush Gupta, MD, FAMS

Department of Pediatrics
University College of Medical Sciences
Delhi, India

References

1. Ladhani S, Joannou CL, Lochrie DP, Evans RW, Poston SM. Clinical, microbial, and biochemical aspects of the exfoliative toxins causing staph-
ylococcal scalded-skin syndrome. Clin Microbiol Rev 1999;12:224-42.
2. Liy-Wong C, Pope E, Weinstein M, Lara-Corrales I. Staphylococcal scalded skin syndrome: an epidemiological and clinical review of 84 cases.
Pediatr Dermatol 2021.

Associations Among Referral Concerns, Screening Results, and Diagnostic Outcomes of Young Children Assessed in a 81
Statewide Early Autism Evaluation Network