|Year : 2014 | Volume
| Issue : 2 | Page : 106-107
Brown, smooth, and shiny raw area: A unique additional finding in staphylococcal scalded skin syndrome
Chandra Sekhar Sirka
Department of Dermatology and Venereology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
|Date of Web Publication||29-Dec-2014|
Chandra Sekhar Sirka
Department of Dermatology and Venereology, All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sirka CS. Brown, smooth, and shiny raw area: A unique additional finding in staphylococcal scalded skin syndrome. Int J Adv Med Health Res 2014;1:106-7
A 24-year-old Indian male with Fitzpatrick skin type IV presented to skin OPD with history of left ear discharge for 8 days and fever, tenderness, and peeling of skin on the neck for 1 day. He was clinically suspected of bullous impetigo/staphylococcal scalded skin syndrome (SSSS) and was admitted to the skin ward. The tenderness and peeling of skin rapidly spread and involved the entire body over 3-4 h of admission. Patient was conscious and oriented. Clinical examination revealed a faint erythema and tenderness of skin with collection of fluid beneath the detached skin at places [Figure 1]. At a few places, the detached skin peeled off leaving a brown, smooth, and shiny raw area [Figure 2]. Mucosa was spared. The Nikolsky's sign was positive. Examinations of other systems were unremarkable. Blood and ear discharge were collected and sent for hematological investigations and culture sensitivity. Empirical Linezolid 600 mg BID orally for 7 days was started, and the raw area was cleaned with normal saline. No topical medications were used. Fever and skin tenderness improved within 3 and 5 h respectively, after the initiation of antibiotic. The hematology report revealed total leukocyte count (TLC) 14,500 cells/mm 3 and differential count (DC) neutrophils 80%, and culture from ear discharge and blood grew Staphylococcus aureus (MRSA positive) which was sensitive to Linezolid. The clinical examination, laboratory findings, and rapid response to treatment confirmed the diagnosis of SSSS. The blood investigation and swab taken from ear on day 10 revealed normal blood count and no growth from the blood and swab. The raw area re-epithelialized over a period of 14 days and there was no recurrence during the follow-up period of 1 month.
|Figure 2: SSSS: The detached skin peeled off in sheets leaving a brown, smooth, and shiny raw area|
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The occurrence of SSSS in adults is rare. The skin lesions of SSSS typically start as a patchy erythema with tenderness, which coalesce and spread rapidly to involve a larger area. Consequently, the skin gets detached in sheet and develops widespread blisters giving rise to a scalded appearance. The raw area looks shiny and varnish-like. ,
The present case had a faint erythema and skin tenderness followed by detachment of skin in sheets and collection of fluid beneath the detached skin at places. The peeled off skin left behind a brown, smooth, and shiny raw area. The brown, smooth and shiny raw area observed in the present case was similar to the previous reports on SSSS cases.  The brown color at the raw areas could be due to the reflection and absorption of light from the increased quantity and quality of melanin present in the epidermal cells of Fitzpatrick skin type IV. 
Based on the skin tenderness, widespread peeling of skin in sheets, and isolation of Staphylococcus aureus from the ear discharge the diagnosis of SSSS was made. Although performing biopsy and culture is ideal for the diagnosis. 
In the clinical setting, the SSSS skin lesions need to be differentiated from the non-infectious lesions of Stevens Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and immunobullous diseases. The commonly encountered finding in SJS, TEN, and immunobullous diseases is vesicles that rupture to give smooth, red, and shiny raw surface. The vesicles in SSSS are basically secondary to collection of exudates underneath the detached skin at the granular layer.
From the present case, it was concluded that a dermatologist must think toward the diagnosis of SSSS when the raw area appears brown, smooth, and shiny following the peeling of skin in an individual with any vesicobullous disease. However, these findings may be validated by carrying out studies on large number of patients.
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[Figure 1], [Figure 2]