What is the recommended dose of methylprednisolone (corticosteroid) in Stevens-Johnson syndrome?

Methylprednisolone Dosing in Stevens-Johnson Syndrome

For Stevens-Johnson syndrome, methylprednisolone should be dosed at 1-2 mg/kg/day (typically 40-80 mg daily for adults) or high-dose pulse therapy at 1000 mg IV daily for 3 days, initiated within 72 hours of presentation and tapered rapidly over 7-10 days. 1, 2

Evidence-Based Dosing Regimens

The 2016 U.K. guidelines for SJS/TEN management reviewed multiple dosing strategies, though they emphasize that no single intervention has conclusive superiority over supportive care 1:

Standard Dose Approach

• Methylprednisolone 40-80 mg daily (equivalent to prednisolone 1-2 mg/kg/day) for 7-14 days 1
• This cumulative dose equals prednisolone 10-25 mg/kg over the treatment course 1
• Rapid tapering within 7-10 days is recommended to minimize steroid-related complications 2

High-Dose Pulse Therapy

• Methylprednisolone 1000 mg IV daily for 3 days, with subsequent doses adjusted based on response 1
• This regimen showed 0% mortality in a Japanese case series of 6 SJS/TEN patients 1
• Methylprednisolone pulse therapy achieved 0% mortality (0/31) for SJS and 7.0% mortality (3/43) for TEN in a retrospective analysis of 132 cases 3

Alternative Dosing

• Some centers use methylprednisolone 40 mg/kg/day (approximately 750 mg daily for average adults) with documented success 4
• Lower doses of 40 mg/day have been used in combination with JAK inhibitors 5

Critical Timing Considerations

Early initiation is paramount—treatment should begin within 72 hours of presentation for optimal outcomes. 2

• Delayed treatment beyond 72 hours significantly reduces efficacy 2
• The dramatic reversal of disease progression observed with prompt corticosteroid therapy supports early aggressive treatment 4

Important Clinical Caveats

Evidence Quality Limitations

The U.K. guidelines explicitly state there is no conclusive evidence demonstrating benefit of any intervention over conservative management, and recommend that corticosteroid therapy be practiced under specialist supervision, ideally within clinical registries 1. The evidence base consists primarily of retrospective case series with significant ascertainment bias 1.

Combination Therapy Considerations

• When combined with IVIG (0.4 g/kg/day for 5 days), methylprednisolone showed 0% mortality (0/10) in TEN patients 3
• Cyclosporine 3-5 mg/kg/day for 10-14 days may be used alone or combined with corticosteroids 2
• Recent evidence supports JAK inhibitors (upadacitinib 15 mg/day) combined with lower-dose methylprednisolone (40 mg/day) for rapid disease control 5

Dose Equivalency

Understanding corticosteroid potency is essential to avoid underdosing 1:

• Methylprednisolone is 5 times more potent than hydrocortisone 1
• Methylprednisolone 48 mg = Prednisone 60 mg = Dexamethasone 10 mg 1

Practical Implementation Algorithm

1. Confirm diagnosis and withdraw culprit drug immediately 2
2. Initiate treatment within 72 hours of presentation 2
3. Choose dosing strategy based on disease severity:
   • Moderate SJS: Methylprednisolone 40-80 mg daily 1, 2
   • Severe SJS/TEN: Methylprednisolone 1000 mg IV daily for 3 days 1
4. Taper rapidly over 7-10 days once improvement begins 2
5. Monitor closely for disease progression and steroid complications 2

Common Pitfall to Avoid

Do not use standard methylprednisolone dose packs (which provide only 84 mg total over 6 days)—this represents significant underdosing compared to the recommended cumulative dose of 280-560 mg over 7-10 days 1. The most frequent error is inadequate initial dosing, which compromises treatment efficacy 1.