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Exfoliative skin diseases are rare in neonates. When caused by coagulase-positive Staphylococcus aureus, scalded-skin diseases such as staphylococcal scalded-skin syndrome (SSSS), bullous impetigo, and staphylococcal scarlet fever may develop. These diseases might cause significant complications and mortality. SSSS is caused by staphylococcal exfoliative toxins A or B, which split the granular layer of the skin, induce proteolysis, and might exhibit superantigen activities, such as epidermolysis and lymphocyte mitogenicity. We describe a 1378-g premature male infant who was born at 29 weeks' gestation and developed SSSS on day 3 of life, with no clinical signs of neonatal sepsis. After cultures from the lesion and bloodstream were obtained, intravenous cloxacillin therapy was started. Infection control measures were implemented instantly and included isolation of the infected infant, personnel handwashing with hexachlorophene, and placement of exposed neonates into a cohort. The initial lesion expanded and additional lesions appeared, but 12 hours after initiation of antibacterial therapy, the lesions ceased to proliferate. Cultures from scalded-skin lesions grew coagulase-positiveStaphylococcus aureus, whereas the bloodstream culture was sterile. The lesions resolved completely within 6 days, and the infant's subsequent course was uneventful. No similar skin lesions were noticed in other infants in the neonatal intensive care unit. We discuss recent advances in understanding the pathogenesis of neonatal SSSS, highlight the importance of early diagnosis and treatment, and stress the need for new adjunctive therapies for this disease.

To the Editor. — We read with interest the article by Janssen et al.1 After reviewing the literature regarding umbilical cord care,2,3 our hospital began instituting the natural drying technique in December 2000. Within several months, three healthy newborns, of ∼3000 deliveries per year, were noted to have bullous impetigo around the umbilical area, all culture-positive for Staphylococcus aureus. After these infections, we surveyed local general pediatricians to determine their experiences with dry cord care and parents’ acceptance of this change. Thirty-seven pediatricians responded to our survey. Eighty percent of the respondents noted that some or most of their parents continued with the natural drying process after discharge. …

A massive outbreak of the staphylococcal scalded skin syndrome due to an organism with an unusual phage pattern, occurred during a 115-day period and involved 68 newborns. Generalized exfoliative dermatitis was seen in 24 babies, and Staphylococcus aureus was isolated from 23. Fourteen isolates were phage typed, with 13 reported as the epidemic strain 29/79/80/3A/3C/54/75. Eight babies had generalized scarlatiniform eruption without exfoliation (staphylococcal scarlet fever). Cultural data were available from six, all positive for S aureus. Four organisms were typed and reported as the epidemic strain. Of 34 infants with bullous impetigo 20 had cultures that were positive for S aureus, and four were phage typed, revealing the epidemic strain. Illness was mild in all patients; there were no deaths and no invasive forms of staphylococcal infection. The male to female ratio of generalized exfoliative disease was 5:1. The concept of a neonatal staphylococcal scalded skin syndrome, comprised of a triad of skin disorders induced by an exotoxin elaborated by certain strains of coagulase positive S aureus, is confirmed.

An epidemic of discrete exfoliative skin lesions associated with group II staphylococci was recognized in infants recently discharged from a newborn nursery unit. Bacteriologic surveillance of infants discharged from the nursery indicated a recent increase in colonization of infants with this organism. Nasal cultures from personnel and environmental cultures failed to reveal the source of the epidemic. Isolation of the organism from two infants discharged home directly from the admission-observation nursery suggested that the epidemic was being perpetuated by a reservoir of infection among infants in this central nursery. Following a change in the location of this nursery, with physical separation of all new admissions from previously colonized infants, there was an immediate and significant decrease in colonization with the epidemic strain of staphylococcus. Closing of the entire admitting nursery and converting to a cohort system was associated with a total disappearance of the epidemic strain.

A full-term male infant delivered by caesarean section following a prolonged rupture of the amniotic membranes of 30 hours' duration manifested peculiar skin lesions at the time of birth consistent with the healing phase of bullous impetigo. He was colonized with β-hemolytic Streptococcus group B that was also cultured from the mother's cervix. It is possible this infant became infected in utero since the healing stage of the lesions suggest that they were present sometime before birth.