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abrasion, surgical site) an underlying dermatosis (pitted keratolysis, tinea, or stasis dermatitis/ulcer), or
through the middle ear or nasal mucosa in children. Risk factors include prior surgery resulting in lymph-
edema, diabetes mellitus, hematologic malignancies and other immunocompromised states.
Subjective: Symptoms
Prodrome of malaise, anorexia, fever and chills is occasionally observed. More common is the rapid
development of high fever and chills.
Objective: Signs
Using Basic Tools: The primary lesion is a bright erythematous, edematous, raised, warm, tender plaque
with sharp, palpable leading margins (see Color Plates Picture 5). The distribution of lesion varies from the
face to the lower extremities. Usually seen with an associated regional lymphadenopathy.
Using Advanced Tools: Lab: WBC count for infection
Assessment:
Diagnose based on clinical findings.
Differential Diagnosis: Early allergic or irritant contact dermatitis; fixed drug eruption; deep venous
thrombosis; thrombophlebitis; rapidly progressive necrotizing fasciitis (a well-demarcated dusky purpuric lesion
that is caused by thrombosis of the vessels, which is usually palpable). See related topics in this book.
Plan:
Treatment:
Primary: Dicloxacillin 500 mg po q 6 hrs for early mild cases
Or nafcillin or oxacillin 2.0 grams IV q 4 hrs for more severe cases
Alternative: Erythromycin 500mg po q 6 hrs
Patient Education
Prevention: Keep wounds clean, dry and protected.
Follow-up Actions
Evacuation/Consultation Criteria: Evacuate urgently. Consult dermatology or infectious disease if possible.
Skin: Staphylococcal Scalded Skin Syndrome
MAJ Daniel Schissel, MC, USAIntroduction: Staphylococcal scalded skin syndrome is a fairly distinctive pediatric dermatosis caused by an
epidermolytic (epidermis-destroying) toxin. The reason for the association with children appears to be related
to the fact that most adults and children over the age of 10 can localize, metabolize, and excrete the toxin
more efciently. They may develop bolus impetigo instead, but will limit the hematogenous dissemination of the
toxin. This condition is most common in children 5 years of age and younger.
Subjective: Symptoms
Prodrome: Fever, malaise, extreme irritability, and anorexia; irritable child with low-grade fever.
Objective: Signs
Using Basic Tools: Generalized macular erythema, with ne, stippled, “sandpaper” appearance, rapidly
progressing to a tender scarlatiniform phase over 24-48 hrs; spreads from the intertriginous and perioral facial
areas to the rest of the body. The exfoliative phase is heralded by a characteristic perioral crusting that often
cracks in a radial fashion. Within 48-72 hours, the upper epidermis may become wrinkled or slough off with
light stroking of the skin (Nikolsky’s sign). Shortly thereafter, accid bullae and desquamation of the upper
layers of the epidermis are noted (see Color Plates Picture 12). Unless subsequent infective processes are
present, the entire skin will re-epithelialize with scarring with in 2 weeks.
Using Advanced Tools: Lab: Staph aureus cultured only from colonized site of infection; umbilical stump,