Background Staphylococcal Scalded Skin Syndrome (SSSS) is a rare exfoliative skin disorder caused by exfoliative toxins from Staphylococcus aureus. While classically associated with pediatric patients, SSSS in adults is rare, with an annual incidence of 0.98 per million. Adult presentations are often severe, particularly in immunocompromised individuals or those with renal insufficiency, due to reduced clearance of circulating toxins. This case highlights an atypical adult presentation of SSSS in a patient with end-stage renal disease (ESRD) on hemodialysis.

Case Presentation A 62-year-old male with a medical history of ESRD on hemodialysis, diabetes mellitus, and peripheral arterial disease presented to the emergency department for dialysis. He was admitted for bacteremia and peri-incisional erythema at a right lower extremity surgical site. Over several days, the patient developed a widespread rash with blistering and skin sloughing across the back, extremities, and face. He underwent an above-the-knee amputation on day 4 of admission for infection control. Dermatology was consulted on day 6. Examination revealed a Nikolsky-positive, Asboe-Hansen–negative desquamating rash with superficial epidermal sloughing and pigment retention. Mucosal involvement was minimal, and blood cultures were negative. Histopathologic diagnosis was not pursued due to clear clinical presentation, retained pigment, and classic distribution of sloughing. The patient remained afebrile and hemodynamically stable. Treatment included completing a 6-day course of vancomycin, wound care with non-adherent dressings, and emollient therapy.

Discussion This case demonstrates a rare adult presentation of SSSS in a hemodialysis-dependent patient. The diagnosis was made clinically based on desquamation pattern, superficial split level (retained pigment), lack of mucosal involvement, and negative cultures—differentiating it from Stevens-Johnson Syndrome, pemphigus vulgaris, and TEN-like dermatoses. Adult SSSS often presents without bacteremia, particularly in patients with impaired renal function who lack the capacity to clear exfoliative toxins. Recognition of this rare clinical entity in adults is critical, especially in vulnerable populations. Prompt infection control, supportive care, and wound management are central to recovery. This case reinforces the importance of maintaining a broad differential when approaching positive Nikolsky sign presentations and underscores that SSSS is not limited to pediatric populations.