especially on the hands and feet, but the peeling occurs at least 10 to 14 days after the initial febrile episode, while the exfoliation in SSSS occurs within the first few days of the onset of the illness FIGURE 66.4 Staphylococcal-scalded skin syndrome Note the scalded appearance of the skin under the ruptured bullae of the chest and axilla in this child with staphylococcal-scalded skin syndrome (Reprinted with permission from Lippincott Nursing Assessment Philadelphia, PA: Wolters Kluwer; 2014.) The primary site of the staphylococcal infection is often unknown but recent surgeries (umbilical cord or circumcision in neonates) or other breaks in the skin should be evaluated and cultured If no clear source of infection can be found, the nares and anus and most heavily crusted areas should be cultured in order to establish antibiotic sensitivities of the SA that is colonizing the child Therapy for SSSS is with systemic antistaphylococcal antibiotics, typically oxacillin or other beta lactamase–resistant antibiotics Clindamycin is often added because it inhibits bacterial ribosomal function, thus decreasing toxin formation In critically ill patients vancomycin should be considered in case the infection is being caused by a resistant staphylococcal strain Ecthyma