FIGURE 66.3 Bullous impetigo (Reprinted with permission from Goodheart HP Goodheart’s Photoguide of Common Skin Disorders 2nd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2003.) Staphylococcal-Scalded Skin Syndrome Staphylococcal-scalded skin syndrome (SSSS) is a severe infection resulting from dissemination of the exfoliative toxin produced by SA SSSS is most common in children under years of age and can present in neonates The clinical appearance is diffuse redness that parents commonly liken to a sunburn The skin then peels most characteristically around the mouth, nose, and eyes Although the crusting and peeling is most prominent in these periorificial areas and can be exuberant, the actual conjunctiva and oral mucosa are not affected Peeling is also typically prominent in the neck, axillary, and inguinal folds ( Fig 66.4 ) If the red skin is rubbed, a blister can often be induced (Nikolsky sign) The main clinical differential is Stevens–Johnson syndrome (SJS), which by definition must affect two mucous membranes In the mucosa, desmoglein (DSG3) is more important in keratinocyte cell–cell adhesion than DSG1 The exfoliative toxin only targets DSG1 and so the mucosa is spared in SSSS Therefore, the most reliable way of differentiating SSSS from SJS is the lack of mucosal involvement in SSSS Kawasaki can also cause peeling skin,