What is the recommended acute management for Stevens‑Johnson syndrome/toxic epidermal necrolysis?

Acute Management of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

Patients with SJS/TEN and >10% body surface area (BSA) epidermal loss must be transferred immediately to a burn center or intensive care unit with specialized experience in managing extensive skin loss, as delayed transfer significantly increases mortality. 1

Immediate Actions

Stop the Culprit Drug

• List all medications (including over-the-counter preparations) taken in the 2 months prior to symptom onset 1
• Immediately discontinue all suspected causative agents—most commonly allopurinol, carbamazepine, lamotrigine, nevirapine, oxicam NSAIDs, phenobarbital, phenytoin, sulfamethoxazole, and sulfasalazine 1

Calculate SCORTEN Within 24 Hours

SCORTEN should be calculated within the first 24 hours of admission to predict mortality and guide intensity of care 1. This validated prognostic tool uses seven parameters (age >40, malignancy, tachycardia >120, initial BSA detachment >10%, serum urea >10 mmol/L, serum glucose >14 mmol/L, serum bicarbonate <20 mmol/L).

Care Setting and Environment

Transfer patients with >10% BSA epidermal loss without delay to a burn center or ICU experienced in SJS/TEN management 1. Three studies and a systematic review demonstrate that rapid admission to a burn center improves survival, while delayed transfer increases mortality 1.

Specialized Environment Requirements

• Barrier nursing in a side room with controlled humidity 1
• Pressure-relieving mattress 1
• Ambient temperature raised to 25-28°C 1
• Multidisciplinary team coordinated by dermatology/plastic surgery, including intensive care, ophthalmology, specialist nursing, and consultants from respiratory medicine, gastroenterology, gynecology, urology, oral medicine, microbiology, pain team, dietetics, physiotherapy, and pharmacy 1

Skin Management

Conservative Approach (All Patients)

Employ strict barrier nursing and avoid systemic antibiotics unless clinical signs of infection are present 1. Indiscriminate prophylactic antibiotics increase colonization with Candida albicans 1.

Wound Care Protocol

• Take bacterial and candidal swabs from three lesional areas on alternate days throughout the acute phase 1
• Regularly cleanse wounds using warmed sterile water, saline, or chlorhexidine (1:5000) 1
• Apply greasy emollient (50% white soft paraffin with 50% liquid paraffin) over entire epidermis including denuded areas 1
• Apply topical antimicrobial agents (consider silver-containing products) to sloughy areas only, guided by local microbiology 1
• Leave detached lesional epidermis in situ as biological dressing; decompress blisters by piercing and expressing fluid 1
• Apply nonadherent dressings (e.g., Mepitel, Telfa) to denuded dermis 1
• Use secondary foam or burn dressing to collect exudate 1

Surgical Approach (Burn Centers)

Consider transfer to a burn center for patients with TEN (>30% BSA) showing clinical deterioration, extension of detachment, subepidermal pus, local sepsis, wound conversion, or delayed healing 1. Surgical management includes:

• Removal of necrotic/loose infected epidermis under general anesthesia 1
• Cleaning with topical antimicrobial agents (betadine or chlorhexidine) 1
• Consider debridement with Versajet 1
• Physiological closure with Biobrane/allograft/xenograft for early presentation with noninfected large confluent areas 1

Fluid and Nutritional Management

Fluid Replacement

• Site venous lines through nonlesional skin when possible; change peripheral cannulas every 48 hours 1
• Monitor fluid balance carefully with catheterization if appropriate 1
• Establish adequate IV fluid replacement initially, guided by urine output and other endpoints 1
• Progressively increase oral fluids as mouth involvement improves 1

Nutrition

• Provide continuous enteral nutrition throughout the acute phase 1
• Deliver 20-25 kcal/kg daily during early catabolic phase 1
• Increase to 25-30 kcal/kg daily during anabolic recovery phase 1

Mucosal Management

Ocular Care (Critical for Long-term Outcomes)

• Daily ophthalmology review during acute illness 1
• Administer broad-spectrum topical antibiotic prophylaxis (e.g., moxifloxacin drops four times daily) with corneal fluorescein staining or ulceration 1
• Prevent corneal exposure in unconscious patients 1

Oral Care

• Daily oral review 1
• Apply white soft paraffin ointment to lips every 2 hours 1
• Clean mouth daily with warm saline mouthwashes or oral sponge 1
• Use benzydamine hydrochloride anti-inflammatory rinse/spray every 3 hours, particularly before eating 1
• Use chlorhexidine antiseptic oral rinse twice daily 1
• Use potent topical corticosteroid mouthwash (e.g., betamethasone sodium phosphate) four times daily 1

Urogenital Care

• Daily urogenital review 1
• Apply white soft paraffin ointment to urogenital skin and mucosae every 4 hours 1
• Use potent topical corticosteroid ointment once daily to involved but noneroded surfaces 1
• Apply silicone dressing (e.g., Mepitel) to eroded areas 1

Airway Management

Respiratory symptoms and hypoxemia on admission require immediate discussion with an intensivist and rapid ICU/burn center transfer for fiberoptic bronchoscopy 1.

Pain Management

• Assess pain using validated pain tools at least once daily in conscious patients 1
• Provide adequate analgesia to ensure comfort at rest 1
• Add supplementary opiates as required 1
• Provide additional analgesia for dressing changes and procedures 1

Active Immunomodulatory Therapy

If active therapy is instituted, it should be given under supervision of a specialist skin failure multidisciplinary team in the context of clinical research and/or case registry 1. The evidence for systemic corticosteroids, intravenous immunoglobulin, cyclosporine, and TNF-alpha blockers remains controversial and lacks high-quality prospective data demonstrating clear mortality benefit 1, 2, 3, 4, 5. The 2016 U.K. guidelines emphasize that supportive care is the cornerstone of treatment, with immunomodulatory agents reserved for research settings 1.

Critical Pitfalls to Avoid

• Delayed transfer: Rapid admission to specialized centers is associated with improved survival; delayed transfer increases mortality 1
• Prophylactic antibiotics: Only administer systemic antibiotics with clinical signs of infection to avoid increased Candida colonization 1
• Rough handling: Minimize shearing forces on fragile skin during patient movement and positioning 1
• Missing mucosal complications: Daily ophthalmology review is essential as ocular damage is the most disabling long-term complication 1