LAPORAN KASUS

SSSS
Oleh:
Dinah Intan Rasari

Pembimbing: dr. Nandya Satyaguna

Mei - 2023
 01 02
Skenario kasus Tinjauan Pustaka

OUTLINE
03 04
Pembahasan Simpulan
SKENARIO
KASUS
IDENTITAS
PASIEN
• Nama : An. K
• Usia : 10 Bulan
• TTL : 1/7/2022
• Jenis Kelamin : Perempuan
• NRM : R00307667
• Alamat : Sukabumi
• Agama : Islam
• Pembayaran : Tunai
• Waktu masuk RS : Minggu, 30 April 2023
• Tempat perawatan : Tanjung VIP
• DPJP : dr. SpA
• Raber : dr. SpKK
 KELUHAN
UTAMA

KULIT MERAH MELEPUH

Riwayat Penyakit Sekarang
(Alloanamnesa ibu)

Pasien dibawa oleh orangtua ke IGD dengan keluhan kulit daerah wajah kemerahan dan melepuh sejak 1 hari
SMRS. Keluhan diawali dengan kulit kemerahan dan kering di seluruh tubuh sejak 4 hari SMRS. Keluhan
kemerahan awalnya di daerah wajah lalu meluas keseluruh tubuh. Orang tua pasien mengatakan anaknya
demam dan pilek sejak 5 hari smrs dan kedua kelopak matanya bengkak.

Keluhan batuk (-). Benjolan di tubuh (-). Riwayat terpapar zat panas (-).

3 hari SMRS pasien sempat dibawa berobat ke dokter umum dan mendapatkan cetirizine obat sirup, gentamisin
salep, dan hidrokortison asetat 1% salep namun keluhan tidak membaik.

Nafsu makan pasien menjadi berkurang.

Riwayat Penyakit Dahulu
• Riwayat keluhan serupa sebelumnya disangkal
• Riwayat alergi disangkal

Riwayat Penyakit Keluarga

• Riwayat keluhan serupa di keluarga disangkal
• Riwayat alergi disangkal
PEMERIKSAAN FISIK (30/04/2023)

Kesadaran Compos Mentis

Suhu 37oC

Tekanan Darah Tidak dikaji

Nadi 110 x/m

Respirasi 40 x/m

SpO2 98% room air

BB 8 kg
PEMERIKSAAN FISIK (30/04/2023)

Kepala Normocephal
Konjungtiva anemis -/- sclera ikterik -/-
Mata
edema palpebral +/+
Jantung BJ I & II reguler, murmur (-), gallop (-)

Pulmo VBS +/+ ronkhi -/- wheezing -/-

Abdomen Datar, BU (+), soepel (+) NT (-)

Ekstremitas Akral hangat, CRT <2s

PEMERIKSAAN FISIK (30/04/2023)
PEMERIKSAAN FISIK (30/04/2023)
PEMERIKSAAN FISIK (30/04/2023)
28/04/2023 29/04/2023
 STATUS DERMATOLOGIKUS

Distribusi Generalisata

Ad Regio Seluruh regio tubuh, pada beberapa regio kulit sehat lebih sedikit daripada kulit sakit.

Multipel, sebagian diskret sebagian konfluens, bentuk sebagian teratur sebagian tidak
Lesi teratur, ukuran milier sampai dengan plakat, lesi menimbul dari permukaan, batas
sebagian tegas sebagian tidak tegas, sebagian basah sebagian kering.

Efloresensi Diatas dasar yang eritem terdapat krusta serosa, vesikel, disertai erosi.
PEMERIKSAAN PENUNJANG (30/04/2023)
PEMERIKSAAN PENUNJANG (30/04/2023)
1. SSSS (Staphylococcal Scalded Skin Syndrome) —DAFTAR
2. ISPA
MASALAH
TATALAKSANA DPJP (30/04/2023)

Konsul dr. SpA, advis: Konsul dr. SpKK, advis:

• Rawat Tanjung • Mupirocin Cream 3x1 ue
• Raber Kulit
• IVFD 2A 500cc/24 jam
• Inj Ceftriaxone 1 x 500mg
• Cetirizine drops 2 x 0.25 ml
• Paracetamol 100mg prn
FOLLOW UP
1/5/2023 2/5/2023 3/5/2023

Visite dr. SpA & SpKK

S Kulit melepuh mulai mengering
Ruam (+) demam (-)

TTV: N: 100x/m, S: 36.8, R: TTV: N: 100x/m, S: 36, R:

O 30x/m, SpO2: 98% room air 30x/m, SpO2: 98% room air
Krusta serosa (+) Erosi (+) deskuamasi (+)

A SSSS SSSS

dr. SpA advis:

• IVFD 2A 500cc/24 jam
• Inj. Amikacin 3 x 60mg
• Inj. Ceftriaxone 1 x 500mg
• Terapi lain lanjut
P • Cetirizine drops 2 x 0.25 ml
• Paracetamol 100mg prn
dr. SpKK advis:
• Mupirocin cream
• Terapi lanjut
TINJAUAN
PUSTAKA
 SSSS
(Staphylococcal Scalded Skin Syndrome)
DEFINISI
Infeksi kulit oleh Staphylococcus aureus tipe tertentu
dengan ciri khas adanya epidermolisis.

Djuanda. A. Ilmu Penyakit Kulit dan Kelamin. Edisi keenam. Jakarta: FKUI. 2011
 The incidence of SSSS is relatively low.
A study in the Czech Republic showed an

incidence of approximately 25 cases per 100,000

children younger than one year of age.
Most cases occur in children younger than two
EPIDEMIOLOGI years old.

SSSS can occur in outbreaks, particularly in nurseries.

It is far less common in adults. When they do occur, cases in adults typically
involve those with immunosuppression such as HIV/AIDS, severe renal
impairment or renal failure, or in those with malignancy.

Lamand V, Dauwalder O, Tristan A, Casalegno JS, Meugnier H, Bes M, Dumitrescu O, Croze M, Vandenesch F, Etienne J, Lina G. Epidemiological data of staphylococcal scalded skin syndrome in France from 1997 to 2007 and
microbiological characteristics of Staphylococcus aureus associated strains. Clin Microbiol Infect. 2012 Dec;18(12):E514-21.
 Staphylococcus aureus
grup II faga 52, 55 dan atau faga 71

ETIOLOGI Staphylococcus aureus (S. aureus) bakteri gram positif, bersifat

anaerob fakultatif, umumnya tumbuh berpasangan maupun berkelompok.

S. aureus merupakan mikroflora normal manusia.

Biasanya terdapat pada saluran pernapasan atas dan kulit.

Infeksi serius akan terjadi ketika resistensi inang melemah dan dapat
menimbulkan penyakit melalui kemampuannya tersebar luas dalam
jaringan dan melalui pembentukan zat yang berperan sebagai faktor
virulensi dapat berupa protein, termasuk enzim dan toksin.

Prescott LM, Harley JP, Klein DA. 2002. Microbiology. 5th Ed. Boston: McGraw-Hill.
BASIC
SCIENCE
BASIC
SCIENCE
 Infeksi

Eksotoksin  epidermolitik
(epidermolin, eksofoliatin)

PATOGENESIS Terdistribusi secara sistemik

Kerusakan epidermis

Epidermolisis
 • Irritable
• Fever
• Malaise
• Within 24 to 48 hours, a very tender rash develops. The rash
typically starts on the face and flexures (groin, axillae, neck).
• Soon after this, large thin blisters form. The characteristic flaccid,

GEJALA blisters and bullae contain anything from thin, sterile cloudy fluid to
frank yellow pus underneath.
KLINIS • The disease may present with only localized blisters. However, in
its classic form, the disease progresses to a diffuse, markedly
erythematous rash with significant tenderness.
• Further progression transitions to flaccid blisters and
desquamation.
• Nikolsky’s sign positive.

Ladhani S, Joannou CL, Lochrie DP, Evans RW, Poston SM. Clinical, microbial, and biochemical aspects of the exfoliative toxins causing staphylococcal scalded-skin syndrome. Clin Microbiol Rev. 1999 Apr;12(2):224-42.
 • Dehydration
• Secondary infections
KOMPLIKASI • Electrolyte imbalance
• Sepsis
• Scarring

Haggerty J, Grimaldo F. A Desquamating Skin Rash in a Pediatric Patient. Clin Pract Cases Emerg Med. 2019 May;3(2):112-114
 • Biopsy
• Cultures from areas of suspected primary infection
• Diagnosis of staphylococcal scalded skin syndrome is suspected

PEMERIKSAAN clinically, but confirmation may require biopsy. Specimens show no

inflammatory superficial splitting of the epidermis.
TAMBAHAN • Cultures should be taken from the conjunctiva, nasopharynx, blood,
urine, and areas of possible primary infection, such as the umbilicus
in a neonate or suspect skin lesions. Cultures should not be taken from
bullae because they are sterile.
HISTOPATOLOGI

TATALAKSANA
SSSS is considered a
dermatological emergency
which requires hospitalization
and prompt treatment.
• Antibiotics (IV)
First-line: a penicillinase-resistant, anti-staphylococcal antibiotic such as flucloxacillin.
Other options include: ceftriaxone, clarithromycin (for penicillin-allergy), cefazolin, nafcillin, or
oxacillin.
Methicillin resistance (MRSA) infection: vancomycin.
• Topical antibiotics (mupirocin cream) alone are not effective and even localized SSSS
should be treated with systemic antibiotics.
• Intravenous (IV) fluids should be administered in those with signs of dehydration or
and/or sepsis.
• Emollients and non-adherent dressings should be applied to the skin and denuded
areas to promote healing and reduce heat loss.
• The application of silver sulfadiazine should be avoided given the potential for increased
systemic absorption and resultant toxicity.
• Hand hygiene with contact isolation and proper cleaning of objects such as
stethoscopes are important in preventing additional outbreaks in hospitals.
Baartmans MG, Dokter J, den Hollander JC, Kroon AA, Oranje AP. Use of skin substitute dressings in the treatment of staphylococcal scalded skin syndrome in neonates and young infants. Neonatology. 2011;100(1):9-13
Braunstein I, Wanat KA, Abuabara K, McGowan KL, Yan AC, Treat JR. Antibiotic sensitivity and resistance patterns in pediatric staphylococcal scalded skin syndrome. Pediatr Dermatol. 2014 May-Jun;31(3):305-8.
 Recognized early and treated appropriately overall have a very good prognosis.
The mortality rate in children is less than 5%.

PROGNOSIS Within a few days of treatment, fevers subside, and the rash begins to improve.
Skin desquamation usually occurs within five days with complete resolution
within two weeks, typically without any permanent sequel.

Jordan KS. Staphylococcal Scalded Skin Syndrome: A Pediatric Dermatological Emergency. Adv Emerg Nurs J. 2019 Apr/Jun;41(2):129-134
PEMBAHASAN
Incidence
Younger than one year of age.
Most cases occur in children younger than two years old.

Symptoms dan Literatures

• Kulit daerah wajah melepuh  Loss of the epidermal layer and associated blistering occurs.
• Kulit kemerahan dan kering di seluruh tubuh  The bacteria release poison (toxins) that cause the skin
to blister and peel.
• Diawali wajah lalu meluas keseluruh tubuh  The rash typically starts on the face and flexures (groin,
axillae, neck).
• Demam dan pilek  The initial localized infection often.
DIFERENSIAL
DIAGNOSIS
DIFERENSIAL
DIAGNOSIS

Murphy-Lavoie H, Le Gros TL. Emergent Diagnosis of the Unknown Rash. Emergency Medicine. 2010 March.
SIMPULAN
 Generalized desquamation and systemic illness are most often in staphylococcal scalded skin

syndrome (SSSS) in infants and young children (and occasionally in immunocompromised adults) and

toxic epidermal necrolysis in older patients.

 Do a biopsy and culture the conjunctiva, nasopharynx, blood, urine, and areas of possible primary

infection, such as the umbilicus and suspect skin lesions.

 Treat patients with antistaphylococcal antibiotics and, if disease is widespread, in a burn unit if

possible.

 Monitor and treat for complications similar to those that occur with burns (eg, fluid and electrolyte

imbalance, sepsis).
Terima
Kasih
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