What is the next step in management for a patient with a positive Nikolsky (Nikolsky's sign) sign, fever, and genital lesions after antibiotic treatment?

Immediate Hospitalization and Discontinuation of All Antibiotics

This patient has Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN), a life-threatening drug reaction requiring immediate cessation of the causative antibiotic and urgent transfer to a specialized burn unit or intensive care setting. 1

Clinical Recognition

The triad of positive Nikolsky sign, fever, and mucosal (genital) lesions following antibiotic exposure is pathognomonic for SJS/TEN:

• Positive Nikolsky sign indicates epidermal necrolysis where lateral pressure causes normal epidermis to dislodge and blister to extend 1, 2
• Fever and systemic symptoms typically precede cutaneous manifestations by several days 1
• Genital lesions represent the erosive and hemorrhagic mucositis affecting mucous membranes (eyes, mouth, nose, genitalia) that is an early and prominent feature 1
• Cutaneous pain is a prominent early feature that should alert clinicians to incipient epidermal necrolysis 1

Immediate Management Steps

1. Stop All Potential Causative Drugs

• Immediately discontinue all antibiotics and any other medications started within the past 8 weeks, as drug-induced immune responses trigger keratinocyte apoptosis via granulysin-mediated pathways 1

2. Urgent Transfer

• Transfer to burn unit or intensive care unit for specialized management of extensive epidermal loss 1
• SJS/TEN behaves like a severe burn injury with massive fluid losses, infection risk, and potential for multi-organ failure 1

3. Assess Disease Severity

Calculate body surface area (BSA) involvement to classify phenotype:

• SJS: <10% BSA detachment with purpuric macules or flat atypical targets 1
• Overlap SJS-TEN: 10-30% BSA detachment 1
• TEN: >30% BSA detachment 1

4. Supportive Care Priorities

• Fluid resuscitation similar to burn protocols for denuded dermis that exudes serum 1
• Wound care with sterile dressings to prevent secondary infection of exposed dermis 1, 3
• Pain management as lesional skin is extremely tender 1
• Nutritional support for hypermetabolic state 1

5. Monitor for Complications

• Ocular involvement requires urgent ophthalmology consultation to prevent permanent sequelae 1
• Secondary bacterial infection of denuded areas that readily bleed 1
• Respiratory compromise if oropharyngeal mucositis is severe 1

Critical Pitfalls to Avoid

• Do NOT rechallenge with the suspected antibiotic - this can be fatal 1
• Do NOT delay transfer - mortality increases with delayed specialized care 1
• Do NOT confuse with staphylococcal scalded skin syndrome - though both have positive Nikolsky sign, SSSS lacks mucosal involvement and occurs primarily in neonates/young children 3
• Do NOT treat as a simple drug rash - SJS/TEN progresses rapidly with maximum involvement at 5-7 days 1

Disease Progression Timeline

• Prodrome: Fever, malaise, upper respiratory symptoms precede eruption by several days 1
• Early lesions: Atypical targets and purpuric macules on upper torso, proximal limbs, face 1
• Progression: Lesions spread, coalesce, and reach maximum extent 5-7 days after onset 1
• Blistering phase: Flaccid bullae form as necrotic epidermis separates, leaving sheets of exposed dermis 1