Paediatric Acute care Guidelines PMH Emergency Department


  • This condition generally affects children < 5 years of age, and can be a severe and potentially life threatening illness, particularly in neonates.
  • It is caused by dissemination of Staphylococcus aureus exfoliative toxins which causes lysis within the superficial layers of the skin, resulting in large thin-walled bullae which quickly break down, leaving raw denuded areas.
    • These lesions resemble scalds from hot liquid, hence the name of the condition.

The primary site of staphylococcal infection:

  • Neonates – periumbilical infection, conjunctivitis, bullous impetigo and “septic spots” are common sites
  • Infants – infected eczema, paronychia, boils, impetigo and skin trauma are common causes


  • Initial signs and symptoms
    • +/- Fever
    • Irritability
    • Generalised erythroderma (blanching) which may be scarletiniform (sandpaper-like) or tender on palpation
  • Erythroderma progresses to the formation of large, thin walled, fluid-filled bullae which typically occur in areas of mechanical stress (flexural areas, buttocks, hands & feet)
  • Gentle pressure to the skin results in separation of the upper epidermis and wrinkling of skin (Nikolsky sign)

Differential Diagnosis

  • Bullous impetigo
  • Toxic epidermal necrolysis
  • Stevens Johnson syndrome
  • Scarlet fever
  • Kawasaki disease


  • Children should be hospitalised for intravenous antibiotics
  • Blood culture
  • Swabs taken from the nose and any infected sites
  • Antibiotics:
    • Flucloxacillin – refer to Antibiotics
      • ≤ 1 month: 25 mg/kg IV refer to Neonatal Clinical Care Unit – Drug Protocols
      • ≥ 1 month: 50mg/kg IV (maximum of 2 grams) 6 hourly
        • Prior MRSA colonisation or failure to respond despite Flucloxacillin should prompt consideration for MRSA. Discuss with Infectious Diseases or Clinical Microbiology services.
    • Consider Clindamycin (discuss with Infectious Diseases or Clinical Microbiology services)

If large areas of skin are involved:

  • Fluid and electrolyte management
  • Pain control (consider referral to Pain Management) 
  • Wound care is important (refer to Dermatology)
    • Principles of burn wound management may apply


  • With early recognition and treatment, children should recover fully
  • Permanent scarring is unlikely to occur


External review: Infectious Diseases Team July 2015

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