a 51-year - old male developed a rash 2 weeks after receiving vincristine for continuation therapy of his b - cell acute lymphoblastic leukemia . the patient reported an initially developing  pimple in the right axilla , which subsequently expanded into a large area of redness involving the right flank and right arm . this rash was noted to be extremely painful , and he developed similar , smaller lesions elsewhere . in addition to his chemotherapy , he was receiving 6-mercaptopurine as well as acyclovir and dapsone for prophylaxis . physical examination revealed a large , round , geographic erosion with superficial sloughing within the right axilla ( fig . there were multiple additional tender , circular , erythematous erosions on the distal right arm and contralateral axilla , and multiple , small resolving erythematous , crusted erosions on his left nare ( fig . a sample from the axillary erosion was sent for microbiologic culture , and a biopsy of one of the circular erythematous lesions on the arm was performed . histopathologic examination revealed complete subcorneal splitting of the epidermis with detachment of the stratum corneum ( fig . multiple detached fragments of normal - appearing stratum corneum with attached acantholytic granular keratinocytes were present ( fig . the epidermis showed subtle irregular orientation of the stratum basale and loss of normal , gradual keratinocyte flattening towards the surface , consistent with mild epidermal dysmaturation and suggestive of a chemotherapy effect ( fig . , closer examination of the superficial layer of granular and spinous keratinocytes underlying the detached fragments of stratum corneum revealed a cytomorphology similar to that of the basal keratinocytes . the histologic differential diagnoses included toxic epidermal necrolysis , bullous impetigo , pemphigus foliaceus , staphylococcal scalded skin syndrome ( ssss , or staphylococcal epidermolytic toxin syndrome ) , and toxic erythema of chemotherapy ( tec ) . toxic epidermal necrolysis was less favored given the absence of mucosal involvement clinically and the lack of epidermal necrosis histologically . secondly , bullous impetigo was thought to be less likely given the absence of organisms on gram stain , paucity of inflammation , and absence of a neutrophilic infiltrate . pemphigus foliaceus was also less favored given the acantholytic keratinocytes attached to the detached stratum corneum as well as the paucity of inflammation . finally , while the mild epidermal dysmaturation present was suggestive of a chemotherapy effect , this finding alone was insufficient for a diagnosis of tec . characteristic diagnostic features of tec , such as vacuolar change at the dermal - epidermal junction , eccrine ducts , and/or hair follicles as well as syringosquamous metaplasia , were not identified . taken together , the histologic findings were most consistent with ssss on a background of a chemotherapy effect . based on these findings , the patient was started on oral cephalexin as well as topical mupirocin and clobetasol . the patient 's skin lesions and pain significantly improved over the course of 1 week ( fig . ssss is a toxin - mediated , epidermolytic condition caused by the remote production and hematogenous circulation of exfoliative toxins ( exfoliatoxin ) that bind and cleave desmoglein 1 in the superficial epidermis . ssss is a condition that predominantly affects young children and neonates ( ritter 's disease ) , in whom the prognosis is quite favorable . ssss much less commonly affects adults , who typically have underlying renal dysfunction , malignancy , or immunosuppression and are thought to have a reduced ability to excrete the toxin . there has been one prior report of ssss occurring in a patient shortly after receiving chemotherapy for a peripheral neuroectodermal tumor . several cases of ssss caused by methicillin - resistant s. aureus in adults have been reported . the prognosis of ssss is much less favorable in adults than it is in children , and mortality rates between 40 and 50% have been reported . ssss is a relatively uncommon condition , with epidemiologic studies estimating a yearly incidence of less than one case ( 0.09 - 0.56 ) per one million inhabitants per year in developed countries . ssss as well as localized and generalized bullous impetigo belong to the  staphylococcal epidermolytic toxin syndromes . while localized and generalized bullous impetigo are the result of local production of exfoliative toxins within the skin , toxin production in ssss is classically thought to occur at a distant site . clinically , patients with ssss develop a tender , erythematous , scarlatiniform eruption followed by the development of flaccid , easily ruptured bullae involving the periorificial face , neck , axillae , trunk , and groins with sparing of the mucous membranes . the bullae typically exhibit a positive nikolsky sign , leaving behind moist , red erosions . the superficial dermis typically contains a sparse mixed inflammatory infiltrate , in contrast to bullous impetigo and pemphigus foliaceus , wherein the infiltrate is typically heavier . in addition , the subcorneal blister of bullous impetigo typically contains a heavier neutrophilic infiltrate as well as multiple gram - positive cocci . the diagnosis of ssss is typically rendered based on the clinical , histologic , and microbiologic data . systemic and topical antibiotics targeting gram - positive cocci in addition to appropriate wound care of erosions are the mainstay of therapy . the histologic findings of mild epidermal dysmaturation in our patient are consistent with those seen secondary to chemotherapy . the entity tec has recently been proposed to unify a broad , heterogeneous disorder encompassing the clinical and histopathologic findings seen in chemotherapy - associated acral erythema , neutrophilic eccrine hidradenitis , and syringosquamous metaplasia . clinically , patients with tec develop painful , pruritic erythematous or edematous patches or plaques on the hands and feet , intertriginous areas , elbows , knees , and/or ears that appear days to weeks after the administration of a number of chemotherapeutic agents . these lesions may develop a dusky hue , petechiae , or bullae , and desquamate and spontaneously resolve without specific therapy . pain - epithelial toxic disorder characterized by vacuolar change at the dermal - epidermal junction , eccrine ducts , and/or hair follicles with epidermal dysmaturation and syringosquamous metaplasia . acantholysis and follicular hyperkeratosis may also be seen . while clear vacuolar changes were rare in our patient , taken together , our patient represents an uncommon case of ssss in an adult occurring on a background of chemotherapy - related changes .
staphylococcal scalded skin syndrome is a toxin - mediated , epidermolytic condition that uncommonly affects adults . 
 a 51-year - old man receiving chemotherapy for leukemia presented with a large geographic erosion with superficial sloughing and multiple smaller lesions elsewhere . 
 biopsy revealed complete subcorneal splitting with multiple detached fragments of normal - appearing stratum corneum with fragments of attached acantholytic granular keratinocytes . 
 mild epidermal dysmaturation was also noted . 
 based on these findings , the patient was started on oral cephalexin , topical mupirocin , and topical clobetasol . 
 his lesions improved significantly over the course of 1 week .