What is the recommended steroid treatment for Stevens-Johnson syndrome?

Steroid Treatment for Stevens-Johnson Syndrome

Topical corticosteroids are recommended for localized treatment of Stevens-Johnson syndrome, while systemic corticosteroids may be beneficial when initiated early in the disease course for more severe cases. 1

Topical Corticosteroid Recommendations

Oral Mucosal Involvement

• Apply topical corticosteroids four times daily:
  • Betamethasone sodium phosphate 0.5 mg in 10 mL water as a 3-minute rinse-and-spit preparation
  • For more severe cases: Clobetasol propionate 0.05% mixed in equal amounts with Orabase, applied directly to the sulci, labial or buccal mucosae daily during the acute phase 1

Urogenital Involvement

• Apply potent topical corticosteroid ointment once daily to involved, non-eroded urogenital surfaces 1
• This helps reduce inflammation and prevent adhesions

Ocular Involvement

• Topical corticosteroid drops (e.g., nonpreserved dexamethasone 0.1%), supervised by an ophthalmologist 1
• Caution: Topical corticosteroids can mask signs of corneal infection

Systemic Corticosteroid Therapy

Indications

• More extensive disease involvement
• Significant mucosal involvement
• Early disease stage (preferably within 72 hours of onset) 2

Dosing Recommendations

• Moderate to high doses:
  • Prednisolone 1-2 mg/kg/day (or equivalent) 2
  • Methylprednisolone (40-80 mg daily) 1
  • For severe cases: Pulse therapy with IV methylprednisolone (1000 mg) for 3 consecutive days has shown benefit 1

Duration

• Short course with rapid tapering within 7-10 days 2
• Prolonged therapy increases infection risk

Important Considerations

Timing of Treatment

• Early initiation (within 72 hours) appears most beneficial 2
• Delayed treatment may have less impact on disease progression

Monitoring

• Daily examination of affected mucosal surfaces
• Monitor for signs of secondary infection
• For patients on prolonged corticosteroids:
  • Monitor blood pressure, glycemic control, and serum potassium 1
  • Consider osteoporosis prevention measures 1

Potential Complications

• Increased risk of infection
• Adrenal suppression with prolonged use
• Withdrawal syndrome with abrupt discontinuation (weakness, nausea, arthralgia) 1

Alternative Treatments

• Cyclosporine (3-5 mg/kg/day for 10-14 days) may be used alone or in combination with corticosteroids 2, 3
• Emerging evidence suggests TNF-α inhibitors like etanercept may accelerate recovery and reduce steroid requirements 4

Treatment Approach Based on Disease Severity

1. Mild disease (limited skin involvement):

   • Topical corticosteroids to affected areas
   • Supportive care

2. Moderate disease:

   • Oral prednisolone 1-2 mg/kg/day with rapid taper
   • Topical corticosteroids to mucosal surfaces

3. Severe disease (extensive involvement):

   • Consider IV methylprednisolone pulse therapy
   • Consider adjunctive cyclosporine
   • Intensive supportive care in specialized unit

Cautions

• Stevens-Johnson syndrome can be life-threatening with mortality rates increasing with extent of epidermal detachment
• Treatment should be initiated promptly upon diagnosis
• A multidisciplinary approach involving dermatology, ophthalmology, and critical care is essential for severe cases
• Careful monitoring for secondary infection is crucial when using systemic corticosteroids