What is the Johnson treatment?

Johnson Treatment in Stevens-Johnson Syndrome

The "Johnson treatment" does not refer to a medical intervention for Stevens-Johnson Syndrome (SJS)—this appears to be a misunderstanding of terminology. The term "Johnson" in Stevens-Johnson Syndrome refers to the physicians who first described this severe mucocutaneous reaction (Stevens and Johnson, 1922), not to any specific treatment protocol. 1

What Stevens-Johnson Syndrome Actually Is

Stevens-Johnson Syndrome is a rare, life-threatening drug reaction characterized by widespread skin detachment and mucosal involvement, requiring immediate drug discontinuation and intensive supportive care. 1, 2

• SJS involves <10% body surface area skin detachment, while toxic epidermal necrolysis (TEN) involves >30% 3, 4
• Mortality rates range from 10-30% depending on severity 1
• Most commonly triggered by sulfonamides, anti-epileptics, allopurinol, and NSAIDs 3, 4

Evidence-Based Treatment Approach

Immediate Actions (First 24 Hours)

Stop all potential culprit medications immediately—this is the single most critical intervention that directly impacts survival. 1, 2

Transfer patients with >10% body surface area involvement to a specialized burn unit or ICU with SJS/TEN experience within 24 hours. 1, 2

• Calculate SCORTEN score on admission to predict mortality risk 2, 3
• Barrier nursing in temperature-controlled room (25-28°C) on pressure-relieving mattress 1, 2

Supportive Care Framework

High-quality multidisciplinary supportive care is the cornerstone of treatment and takes priority over any specific pharmacologic intervention. 1

Fluid Management

• Careful IV fluid resuscitation guided by urine output (target 0.5-1 mL/kg/hr) and serial lactate measurements 1, 2
• Avoid fluid overload which causes pulmonary and intestinal edema 1, 2
• Monitor electrolytes daily, particularly sodium levels 1, 2

Skin Care

• Handle skin gently to minimize shearing forces 1, 2
• Leave detached epidermis in place as biological dressing 2
• Apply bland emollients frequently to all skin surfaces 1, 2
• Use non-adherent dressings on denuded areas 2
• Avoid adhesive tapes, blood pressure cuffs directly on skin, and adhesive ECG leads 1

Infection Prevention

• Do NOT use prophylactic antibiotics—this increases colonization with resistant organisms 2, 5
• Obtain skin swabs for culture from sloughy or crusted areas throughout acute phase 1, 2
• Use targeted antimicrobial therapy only when clinical infection is documented 2

Critical Organ-Specific Management

Ophthalmology (Highest Priority for Long-Term Morbidity)

Obtain ophthalmology consultation within 24 hours of diagnosis with daily examinations throughout the acute phase—early intervention prevents permanent blindness. 1, 2

• Apply preservative-free lubricant drops every 2 hours 2
• Daily lysis of conjunctival adhesions by ophthalmologist to prevent symblepharon formation 2
• Topical antibiotics when corneal staining or ulceration present 2
• Consider topical corticosteroids under ophthalmologist supervision 2

Oral Care

• Benzydamine hydrochloride oral rinse every 3 hours, especially before eating 2
• Antiseptic oral rinse twice daily 2
• Viscous lidocaine 2% or cocaine mouthwash 2-5% for severe pain 2

Urogenital Care

• Catheterize when dysuria causes retention or for output monitoring 2
• Apply white soft paraffin to urogenital mucosa every 4 hours 2
• Consider vaginal dilators or tampons wrapped in non-adherent dressing to prevent vaginal synechiae 2

Pharmacologic Treatment Options

There is no conclusive evidence that any systemic pharmacologic intervention improves mortality over high-quality supportive care alone. 1

However, based on available evidence:

Cyclosporine (Strongest Evidence)

Cyclosporine 3 mg/kg daily for 10 days, then tapered over 1 month, has shown the most consistent mortality benefit in observational studies. 1, 2, 3

• One prospective study showed 0/29 deaths versus 2.75/29 predicted by SCORTEN 1
• Should be considered if started early in disease course 1, 2

Systemic Corticosteroids (Controversial)

If corticosteroids are used, they must be started within 72 hours of symptom onset as high-dose IV methylprednisolone pulse therapy. 2, 3

• Evidence is mixed—some studies show benefit, others show harm 1
• Late administration appears ineffective or harmful 1

Intravenous Immunoglobulin (IVIG)

IVIG shows no mortality benefit in meta-analysis (pooled OR 1.00,95% CI 0.58-1.75, P=0.99) and should not be considered standard therapy. 1

• High-dose IVIG (≥2 g/kg total) had lower mortality than low-dose in subgroup analysis, but this did not reach significance on multivariate analysis 1
• Pediatric patients had better outcomes than adults (0% vs 21.6% mortality) 1
• Costly and in limited supply 1

Nutritional Support

Provide continuous enteral nutrition at 20-25 kcal/kg daily during acute phase, increasing to 25-30 kcal/kg during recovery. 2

• Use nasogastric feeding when oral intake precluded by mucositis 2

Common Pitfalls to Avoid

Delayed recognition and continued administration of culprit drug dramatically increases mortality. 2, 5

Prophylactic antibiotics increase resistant organism colonization without reducing infection rates. 2

Failure to obtain ophthalmology consultation within 24 hours leads to preventable blindness. 1, 2

Overaggressive fluid resuscitation causes pulmonary edema and worsens outcomes. 1, 2

Using adhesive products on skin causes further epidermal detachment. 1

Discharge Planning

Provide written documentation of culprit drug(s) to avoid, including cross-reactive medications, and recommend MedicAlert bracelet. 2

• Report adverse drug reaction to pharmacovigilance authorities (MHRA in UK, FDA MedWatch in US) 1, 2
• Counsel patients about expected fatigue lasting weeks to months 1
• Arrange ophthalmology follow-up even if no acute ocular symptoms 1, 2
• Document drug allergy prominently in all medical records 2

---

Note on "Johnson Intervention": If the question refers to the "Johnson Intervention" in substance abuse treatment (a confrontational technique where family members confront someone about addiction), this is completely unrelated to Stevens-Johnson Syndrome and involves structured family intervention to encourage treatment entry. 6, 7