Infant with tender skin, diffuse erythema, sand-paper skin followed by large bullae and sloughing; positive Nikolsky sign.

Infant with tender skin, diffuse erythema, sand-paper skin followed by large bullae and sloughing; positive Nikolsky sign.

• A. TEN
• B. Exfoliative Erythroderma
• C. SSSS
• D. Pemphigus Vulgaris

Answer: (C)

The key idea is recognizing a toxin-mediated superficial skin destruction that causes widespread detachment in an infant. Staphylococcal Scalded Skin Syndrome results from exfoliative toxins produced by Staphylococcus aureus, which cleave desmoglein-1 in the superficial epidermis. This produces tender, diffuse erythema with a sand-paper feel, followed by large flaccid bullae and brisk sloughing of the skin, and a positive Nikolsky sign where gentle pressure causes the outer layer to separate. The process is restricted to the epidermis and typically spares mucous membranes, which helps distinguish it from other conditions. In TEN, there is full-thickness epidermal detachment and mucosal involvement, usually drug-related and more common in older patients. Pemphigus vulgaris also involves mucous membranes and autoimmune desmoglein antibodies, not the toxin-mediated pattern seen here. Exfoliative erythroderma presents with diffuse redness and scaling rather than the focal bullae and superficial sloughing described. Thus this presentation in an infant best fits Staphylococcal Scalded Skin Syndrome.

The key idea is recognizing a toxin-mediated superficial skin destruction that causes widespread detachment in an infant. Staphylococcal Scalded Skin Syndrome results from exfoliative toxins produced by Staphylococcus aureus, which cleave desmoglein-1 in the superficial epidermis. This produces tender, diffuse erythema with a sand-paper feel, followed by large flaccid bullae and brisk sloughing of the skin, and a positive Nikolsky sign where gentle pressure causes the outer layer to separate. The process is restricted to the epidermis and typically spares mucous membranes, which helps distinguish it from other conditions. In TEN, there is full-thickness epidermal detachment and mucosal involvement, usually drug-related and more common in older patients. Pemphigus vulgaris also involves mucous membranes and autoimmune desmoglein antibodies, not the toxin-mediated pattern seen here. Exfoliative erythroderma presents with diffuse redness and scaling rather than the focal bullae and superficial sloughing described. Thus this presentation in an infant best fits Staphylococcal Scalded Skin Syndrome.