When appearances deceive: a comparative analysis of acute skin failure in pediatric patients

Acute skin failure in children encompasses several life-threatening conditions that can present with strikingly similar, extensive skin detachment despite fundamentally different causes. Staphylococcal scalded skin syndrome (SSSS), toxic epidermal necrolysis (TEN), and severe cutaneous bacterial infections may look almost identical at the bedside, yet differ profoundly in mechanism, treatment, and prognosis. The objective of this study is to describe four consecutive pediatric cases of acute skin failure and to derive a practical, bedside diagnostic approach that helps distinguish infectious from immune-mediated causes early, when therapeutic decisions must be made. We performed a retrospective analysis of four children managed in our Pediatric Intensive Care Unit between 2023 and 2024, comparing clinical presentation, diagnostic work-up, treatment, and outcome. The report follows the CARE (CAse REport) guidelines. Three children with SSSS or severe cutaneous bacterial infection recovered completely with antibiotic therapy within 4-7 days. One child with lamotrigine-induced TEN required 42 days of intensive care and multimodal immunomodulation before complete recovery. All four children survived and recovered fully.

The extent of skin detachment alone cannot establish the diagnosis. Careful assessment of mucosal involvement, a detailed medication history, and microbiological findings-together with the treatment response at 48-72 h-were the most useful discriminators, determining whether antibiotic therapy or immunomodulation was required.

• SSSS, TEN, and severe cutaneous bacterial infections can all cause extensive skin detachment in children and may be difficult to distinguish at first presentation. • The treatments for these conditions differ fundamentally, and inappropriate therapy can worsen the outcome.

• In a comparative series of four children, the extent of skin involvement did not discriminate between causes: two children with 90% body-surface involvement required opposite treatments. • We propose a pragmatic, time-anchored bedside approach-systematic mucosal examination, a structured medication history, and reassessment of treatment response at 48-72 h-to help distinguish infectious from immune-mediated acute skin failure.