Why is prophylactic anticoagulation given to patients with Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (SJS-TEN)?

Prophylactic Anticoagulation in SJS-TEN Patients

Prophylactic anticoagulation with low molecular weight heparin is necessary for SJS-TEN patients who are immobile in bed to prevent venous thromboembolism, unless contraindicated. 1

Rationale for Prophylactic Anticoagulation

SJS-TEN patients are at increased risk of venous thromboembolism (VTE) due to several factors:

1. Immobility: Patients with SJS-TEN are often immobilized in bed due to:

   • Extensive skin detachment and pain
   • Critical illness requiring intensive care management
   • Need to minimize shearing forces on damaged skin

2. Hypercoagulable state: SJS-TEN creates a pro-inflammatory state with:

   • Systemic inflammatory response
   • Potential dehydration
   • Increased risk of sepsis

3. Critical illness: Similar to other ICU patients, SJS-TEN patients face:

   • Increased thrombotic risk due to critical illness
   • Extended hospital stays
   • Multiple invasive procedures

Implementation Guidelines

The British Association of Dermatologists specifically recommends:

• Low molecular weight heparin as the preferred prophylactic anticoagulant 1
• Administration throughout the period of immobility
• Standard prophylactic dosing based on weight and renal function
• Careful administration through non-lesional skin

Special Considerations

• Contraindications: Withhold anticoagulation in cases of:

  • Active bleeding
  • Severe thrombocytopenia
  • Coagulopathy
  • Recent intracranial hemorrhage

• Monitoring: Regular assessment of:

  • Bleeding risk
  • Platelet counts
  • Signs of VTE despite prophylaxis

• Administration:

  • Administer subcutaneous injections through non-lesional skin
  • Minimize trauma to damaged skin areas

Comprehensive Care Context

Prophylactic anticoagulation is part of a broader supportive care approach for SJS-TEN patients that also includes:

• Admission to burn centers or ICUs for patients with >10% body surface area involvement 2
• Careful wound care with non-adherent dressings 2
• Maintenance of ambient temperature between 25-28°C 2
• Continuous enteral nutrition throughout the acute phase 1
• Gastric protection with proton pump inhibitors when enteral nutrition cannot be established 1

Evidence Quality

The recommendation for prophylactic anticoagulation in SJS-TEN is based on:

• British Association of Dermatologists guidelines (2016) with strength of recommendation C and level of evidence 3 1
• Standard critical care practices for immobilized patients
• Recognition of SJS-TEN as a medical emergency with mortality rates of 1-5% for SJS and 25-35% for TEN 3

While specific studies on anticoagulation in SJS-TEN are limited, the recommendation follows established principles for VTE prophylaxis in critically ill, immobilized patients, with the goal of reducing morbidity and mortality in this vulnerable population.