Dermatological emergencies in children encompass a diverse group of disorders that require prompt recognition and timely intervention to prevent significant morbidity and, occasionally, mortality. Although these conditions account for a relatively small proportion of pediatric hospital admissions, they often necessitate urgent multidisciplinary care because of extensive skin involvement, systemic manifestations, and the potential for rapid clinical deterioration (Inamdar & Raghunatha, 2013).

Among these, infectious dermatological emergencies constitute an important subgroup. Bacterial and viral dermatoses such as staphylococcal scalded skin syndrome (SSSS), neonatal varicella, rickettsial fever, and herpes zoster may present with widespread cutaneous involvement, fever, fluid and electrolyte imbalance, secondary infections, and systemic complications. Early clinical recognition and prompt management are essential to reduce morbidity and improve clinical outcomes (Raghunatha & Inamdar, 2013).

The spectrum of infectious dermatological emergencies varies according to geographic region, socioeconomic conditions, immunization status, and healthcare accessibility. Despite their clinical significance, published data describing the epidemiological and clinical profile of infectious dermatological emergencies in the pediatric population remain limited, particularly from India. Most available studies have evaluated pediatric dermatological emergencies as a whole, with relatively little emphasis on infectious etiologies (Inamdar & Palit, 2005; Raghunatha & Inamdar, 2013).

The present study was therefore undertaken to evaluate the clinico-epidemiological profile and spectrum of infectious dermatological emergencies in children presenting to a tertiary care centre in South India. A better understanding of their clinical presentation and distribution may facilitate early diagnosis, prompt treatment, and improved patient care.

MATERIALS AND METHODS

Study Design and Setting

This hospital-based cross-sectional study was conducted in the Departments of Dermatology and Pediatrics at Bapuji Hospital and Chigateri General Hospital, Davangere, Karnataka, over a period of 22 months from November 2014 to August 2016.

Study Population

Children aged ≤15 years presenting with infectious dermatological emergencies during the study period were included in the study.

Inclusion Criteria

• Children aged ≤15 years presenting with infectious dermatological emergencies.
• Patients admitted to the Departments of Dermatology or Pediatrics during the study period.

Exclusion Criteria

• Children with non-infectious dermatological emergencies.
• Patients aged >15 years.

Data Collection

A detailed clinical history was obtained from the parents or caregivers, followed by a thorough general and dermatological examination. Demographic details, clinical presentation, and examination findings were recorded using a predesigned proforma. Relevant laboratory investigations were performed wherever indicated to confirm the diagnosis.

Study Variables

The following parameters were recorded:

• Age
• Sex
• Type of infectious dermatological emergency
• Cutaneous manifestations
• Mucosal involvement
• Nail involvement
• Palmar and plantar involvement

Statistical Analysis

Data were entered into Microsoft Excel and analyzed using the Statistical Package for the Social Sciences (SPSS). Categorical variables were expressed as frequencies and percentages.

RESULTS

A total of 64 children with dermatological emergencies were evaluated during the study period. Infectious dermatological emergencies constituted the largest subgroup, accounting for 18 (28.1%) cases. These 18 patients formed the study population for the present analysis

.

Staphylococcal scalded skin syndrome (SSSS) was the most common infectious dermatological emergency, accounting for 61.1% (11/18) of cases. Neonatal varicella and rickettsial fever each accounted for 16.7% (3/18) of cases, while herpes zoster was the least common diagnosis, accounting for 5.6% (1/18) (Table 1).

Table 1. Distribution of infectious dermatological emergencies (n = 18)

The clinicodemographic characteristics of the infectious dermatological emergencies are summarized in Table 2. Staphylococcal scalded skin syndrome predominantly affected neonates and infants and was characterized by diffuse erythema, flaccid bullae, and exfoliation. Blood cultures were positive for Staphylococcus aureus in 54.5% of patients with SSSS. Neonatal varicella occurred exclusively in neonates, with all mothers reporting a history of varicella during the last trimester of pregnancy. One neonate developed fulminant varicella pneumonia and succumbed to the illness. All three patients with rickettsial fever were male children who presented with a generalized macular rash involving the palms and soles, and all had positive Weil–Felix test results. A single case of herpes zoster was observed in a 5-month-old immunocompetent male infant with lesions confined to the L3 dermatome (Table 2).

Table 2. Clinicodemographic characteristics of individual infectious dermatological emergencies

Investigations were performed based on the clinical diagnosis and suspected etiology. Among patients with staphylococcal scalded skin syndrome, blood cultures yielded Staphylococcus aureus in 54.5% of cases. All three patients with rickettsial fever demonstrated positive Weil–Felix test results, supporting the clinical diagnosis. In cases of neonatal varicella, the diagnosis was established based on the characteristic clinical presentation along with a maternal history of varicella during the last trimester of pregnancy. The diagnosis of herpes zoster was made clinically based on the presence of a unilateral dermatomal vesicular eruption.

The majority of patients responded well to appropriate treatment and recovered without significant sequelae. However, one neonate with neonatal varicella developed fulminant varicella pneumonia and succumbed to the illness despite supportive management. All patients with staphylococcal scalded skin syndrome, rickettsial fever, and herpes zoster recovered following appropriate medical management.

Table 3 Diagnostic investigations and outcomes of infectious dermatological emergencies

DISCUSSION

In this prospective observational study, infectious dermatoses constituted 28.1% of all pediatric dermatological emergencies presenting to a tertiary care referral centre, with Staphylococcal Scalded Skin Syndrome (SSSS) accounting for nearly two-thirds of infectious cases. Neonatal varicella and rickettsial fever each contributed 16.7% of cases, while herpes zoster was uncommon. Although SSSS represented the most frequent infectious emergency, neonatal varicella was associated with the greatest mortality, underscoring that the frequency of presentation does not necessarily reflect disease severity. These findings highlight the continued burden of severe bacterial skin infections in young children while emphasizing the potentially catastrophic outcomes of vertically transmitted viral infections.

Table 4. Comparison of the Present Study with Selected Published Studies on Pediatric Infectious Dermatological Emergencies

Abbreviation: NR = Not reported.

The predominance of SSSS in our cohort is consistent with the epidemiology of pediatric dermatological emergencies reported from several tertiary care centres, where toxin-mediated staphylococcal infections remain an important cause of hospitalization among infants and young children (Gray et al., 2025; Leung et al., 2018). In the present study, SSSS accounted for 61.1% of infectious dermatological emergencies, making it the single most common infectious diagnosis. Similar observations have been reported in Indian studies evaluating pediatric cutaneous emergencies, where SSSS consistently constitutes one of the leading causes of emergency dermatological admissions (Sarkar et al., 2024). The predominance of SSSS in referral hospitals may partly reflect delayed presentation from peripheral healthcare facilities, the need for inpatient supportive care, and the referral of more severe cases requiring multidisciplinary management.

The higher incidence of SSSS among younger children observed in our study is biologically plausible. Neonates and infants possess immature renal mechanisms for clearing circulating exfoliative toxins produced by Staphylococcus aureus, rendering them particularly susceptible to widespread epidermal cleavage. In addition, immature humoral immunity and limited neutralizing antibodies against exfoliative toxins contribute to disease susceptibility during early childhood (Leung et al., 2018). These factors likely explain why SSSS remains predominantly a disease of infancy despite the widespread prevalence of S. aureus colonization across all age groups.

Clinically, all patients with SSSS in our study demonstrated generalized erythema followed by superficial blistering and exfoliation, findings that closely mirror the classical presentation described in the literature. Prompt recognition of the characteristic morphology is particularly important because early lesions may resemble viral exanthems, drug eruptions, or immunobullous disorders, potentially delaying definitive therapy. The diagnosis of SSSS remains primarily clinical, with histopathology and skin biopsy reserved for diagnostically challenging cases. Current evidence also suggests that extensive laboratory investigations are often unnecessary in uncomplicated presentations, and emphasis should instead be placed on early clinical diagnosis, initiation of appropriate anti-staphylococcal antibiotics, meticulous wound care, fluid management, and prevention of secondary infection (Gray et al., 2025).

Blood cultures were positive in four of the eleven children with SSSS in our series, a proportion somewhat higher than that reported in many published studies, where bacteremia is relatively uncommon because exfoliative toxins are frequently produced at distant sites of localized infection rather than within the skin itself (Leung et al., 2018; Gray et al., 2025). This finding may reflect referral bias toward more severe disease in our tertiary care setting or differences in the timing of specimen collection before initiation of antibiotic therapy. Regardless, positive blood cultures reinforce the importance of microbiological evaluation in hospitalized children with systemic features, as culture results facilitate targeted antimicrobial therapy and local antimicrobial stewardship.

Importantly, all children with SSSS recovered completely without mortality. This favourable outcome aligns with contemporary evidence demonstrating that, when recognized early and managed aggressively with appropriate intravenous antibiotics and supportive care, pediatric SSSS carries an excellent prognosis despite its dramatic clinical presentation (Gray et al., 2025). Advances in supportive management, improved fluid and electrolyte correction, earlier referral, and greater clinician awareness have collectively contributed to the marked reduction in mortality observed over recent decades.

Although viral infections were less frequent than bacterial infections, they contributed disproportionately to disease severity. Neonatal varicella represented only three cases in our cohort but accounted for all infection-related deaths, highlighting the devastating consequences of perinatally acquired varicella-zoster virus infection. Neonatal varicella remains an uncommon but potentially life-threatening condition, particularly when maternal primary varicella develops between five days before delivery and two days after childbirth, a period during which insufficient maternal antibodies are transferred trans-placentally to the newborn (Longbottom & Lyall, 2024). This critical window has consistently been associated with the highest neonatal mortality in both historical and contemporary studies.

All neonates in the present study developed widespread vesiculobullous eruptions shortly after birth, with maternal varicella documented during the peripartum period. Despite intensive supportive care, two neonates succumbed to complications of disseminated disease, while one recovered following antiviral therapy. Although the number of cases was small, the observed mortality emphasizes that neonatal varicella continues to pose a significant therapeutic challenge in resource-limited settings. Comparable reports from India have similarly documented severe neonatal disease associated with maternal peripartum infection, particularly where delayed referral or limited access to varicella-zoster immunoglobulin (VZIG) influences outcomes.

Current recommendations emphasize that prevention remains the cornerstone of management. Administration of VZIG to exposed neonates whenever available, prompt initiation of intravenous acyclovir in symptomatic infants, and careful maternal screening during late pregnancy have substantially improved neonatal survival in contemporary practice (Longbottom & Lyall, 2024). Unfortunately, VZIG remains inconsistently available in many low- and middle-income countries, including parts of India, making early recognition and timely antiviral therapy even more critical. Our findings reinforce the need for heightened awareness among obstetricians, pediatricians, and dermatologists regarding maternal varicella during the peripartum period to facilitate rapid neonatal assessment and intervention.

Taken together, the findings from SSSS and neonatal varicella illustrate two contrasting yet equally important facets of pediatric infectious dermatological emergencies. While SSSS was the most frequent diagnosis and demonstrated an excellent prognosis with early recognition and appropriate therapy, neonatal varicella, despite its rarity, accounted for the highest mortality in the cohort. This distinction underscores that clinicians should prioritize not only common conditions requiring prompt treatment but also uncommon infections with disproportionately severe outcomes, particularly in neonates and other vulnerable pediatric populations.

Beyond bacterial and viral infections, rickettsial fever constituted an important proportion (16.7%) of infectious dermatological emergencies in our cohort. Although only three children were diagnosed, all presented with high-grade fever accompanied by a characteristic maculopapular rash involving the palms and soles, clinical features that strongly suggested a rickettsial etiology. The diagnosis was supported by positive Weil–Felix testing in all cases. While the Weil–Felix test has historically served as an inexpensive diagnostic tool in resource-constrained settings, its limited sensitivity and specificity are well recognized. Contemporary guidelines advocate the use of indirect immunofluorescence assay (IFA) or polymerase chain reaction (PCR) wherever available; however, these modalities remain inaccessible in many parts of India. Consequently, clinicians practicing in endemic regions continue to rely predominantly on clinical suspicion supported by basic serological tests to initiate early treatment (Mahajan et al., 2024).

The occurrence of rickettsial infections in our study reflects the re-emergence of these zoonotic diseases across southern India during the past decade. Several reports from Karnataka, Tamil Nadu, Kerala, and Andhra Pradesh have documented increasing numbers of pediatric scrub typhus and spotted fever group rickettsioses, often presenting with fever and rash that closely mimic viral exanthems, meningococcemia, dengue, or drug eruptions (Mahajan et al., 2024). This diagnostic overlap contributes to delayed recognition and inappropriate initial management, thereby increasing the risk of severe complications such as meningoencephalitis, myocarditis, acute respiratory distress syndrome, and multiorgan dysfunction.

Fortunately, all children in our series responded promptly to doxycycline therapy without residual sequelae. This favourable outcome highlights one of the defining characteristics of rickettsial infections—the dramatic clinical response following timely initiation of appropriate antimicrobial therapy. Numerous studies have demonstrated that defervescence within 48–72 hours of doxycycline initiation is highly suggestive of rickettsial disease and supports the continued recommendation that empirical doxycycline should not be delayed while awaiting confirmatory investigations when clinical suspicion is high (Mahajan et al., 2024). Our findings therefore reinforce the importance of maintaining a high index of suspicion for rickettsial infections in children presenting with acute febrile illness and rash in endemic regions.

Herpes zoster was the least common infectious emergency, with only a single case observed during the study period. Although herpes zoster is generally considered uncommon in immunocompetent children, its occurrence is increasingly recognized following either primary varicella infection during infancy or intrauterine exposure to varicella-zoster virus. The affected child in our study demonstrated a classical unilateral dermatomal vesicular eruption and responded well to antiviral therapy without complications. This presentation is consistent with published literature indicating that uncomplicated pediatric herpes zoster usually follows a benign clinical course when recognized early (Zhang et al., 2025).

Historically, herpes zoster in children was frequently considered a marker of underlying immunodeficiency or malignancy. However, contemporary evidence suggests that isolated, uncomplicated herpes zoster in an otherwise healthy child should not automatically prompt extensive investigations for occult immune dysfunction (Zhang et al., 2025). Instead, clinical assessment should focus on identifying features suggestive of immunosuppression, recurrent infections, multi-dermatomal involvement, or disseminated disease before pursuing exhaustive immunological evaluation. Our observation of complete recovery without recurrence supports this evolving understanding of pediatric herpes zoster.

Collectively, the infectious dermatological emergencies encountered in this study illustrate the wide spectrum of disease severity encountered in pediatric dermatology. SSSS emerged as the predominant bacterial emergency requiring hospitalization but demonstrated excellent outcomes with timely antibiotic therapy and supportive care. In contrast, neonatal varicella, despite its lower frequency, accounted for the highest mortality, emphasizing the devastating consequences of delayed maternal diagnosis and vertical transmission. Rickettsial fever represented an important regional differential diagnosis of acute febrile rash illness and highlighted the importance of early empirical therapy in endemic areas, whereas herpes zoster remained an uncommon but generally self-limited condition. These observations emphasize that prompt clinical recognition remains the single most important determinant of outcome across the diverse spectrum of pediatric infectious dermatological emergencies.

The findings of this study have important implications for clinical practice, particularly in tertiary referral centres serving large pediatric populations. First, dermatological emergencies should be considered in the differential diagnosis of every child presenting with fever and rash, especially when associated with blistering, exfoliation, or systemic toxicity. Second, early involvement of dermatologists in multidisciplinary care can facilitate rapid diagnosis, minimize unnecessary investigations, and expedite appropriate therapy. Third, strengthening referral pathways between primary healthcare centres and tertiary hospitals may reduce delays in diagnosis, particularly for conditions such as neonatal varicella and rickettsial fever, where timely intervention directly influences survival. Finally, continued clinician education regarding regional epidemiological trends and evolving diagnostic recommendations is essential for improving outcomes in pediatric infectious dermatoses.

The present study possesses several strengths. It prospectively evaluated pediatric dermatological emergencies over the study period using standardized clinical assessment and included a spectrum of uncommon but clinically significant infectious disorders encountered in routine tertiary care practice. Furthermore, the study provides contemporary data from South India, where published literature focusing exclusively on infectious pediatric dermatological emergencies remains limited. By documenting the clinical profile, investigations, management, and outcomes of these conditions, the study contributes valuable regional evidence that may assist clinicians managing similar patient populations.

Nevertheless, certain limitations should be acknowledged. The study was conducted at a single tertiary referral centre with a relatively small sample of infectious cases, which may limit the generalizability of the findings to community settings. Referral bias may have contributed to the higher proportion of severe cases requiring hospitalization, particularly SSSS and neonatal varicella. In addition, advanced diagnostic modalities such as PCR, indirect immunofluorescence assays for rickettsial infections, and molecular characterization of Staphylococcus aureus strains were not routinely available, necessitating reliance on conventional diagnostic methods. Finally, the observational design precludes assessment of long-term outcomes or predictors of disease severity.

In conclusion, infectious dermatoses continue to represent a significant proportion of pediatric dermatological emergencies in tertiary care practice. Staphylococcal Scalded Skin Syndrome was the predominant infectious emergency and demonstrated excellent outcomes with prompt recognition and appropriate management, whereas neonatal varicella, although infrequent, remained associated with substantial mortality. Rickettsial fever should be considered an important differential diagnosis in endemic regions owing to its characteristic clinical presentation and excellent response to early doxycycline therapy, while uncomplicated pediatric herpes zoster generally follows a favourable course. Strengthening early recognition, facilitating timely referral, improving access to advanced diagnostics, and promoting multidisciplinary management are likely to further reduce morbidity and mortality associated with pediatric infectious dermatological emergencies.

REFERENCES

1. Gray, M. P., et al. (2025). Staphylococcal scalded skin syndrome in children: A systematic review. Pediatric Dermatology.
2. Leung, A. K. C., Barankin, B., & Leong, K. F. (2018). Staphylococcal-scalded skin syndrome: Evaluation, diagnosis, and management. World Journal of Pediatrics, 14(2), 116–120.
3. Longbottom, L., & Lyall, H. (2024). Congenital and neonatal varicella: Prevention and management. Archives of Disease in Childhood, 109(8), 610–615.
4. Mahajan, S. K., et al. (2024). Human rickettsial infections in India: Current epidemiology, diagnosis and management. Indian Journal of Medical Research.
5. Sarkar, R., et al. (2024). Fever with rash in a child: Revisited. Indian Journal of Dermatology.
6. Zhang, X., et al. (2025). Pediatric herpes zoster: Current concepts in epidemiology, diagnosis and management. Frontiers in Pediatrics.
7. Ladhani, S. (2001). Recent developments in staphylococcal scalded skin syndrome. Clinical Microbiology and Infection, 7(6), 301–307.
8. Handler, M. Z., & Schwartz, R. A. (2014). Staphylococcal scalded skin syndrome: Diagnosis and management in children and adults. Journal of the European Academy of Dermatology and Venereology, 28(11), 1418–1423.
9. Liy-Wong, C., et al. (2021). Staphylococcal scalded skin syndrome: Clinical features, diagnosis and treatment. Cutis.
10. Indian Academy of Pediatrics. Red Book/Recommendations on varicella and neonatal infections.
11. Indian Council of Medical Research. Guidelines for diagnosis and management of rickettsial diseases in India.