Steroid Dosing for Toxic Epidermal Necrolysis
The UK guidelines recommend against routine use of systemic corticosteroids in toxic epidermal necrolysis due to conflicting evidence on efficacy and significant concerns about increased infection risk. 1, 2
Evidence Assessment for Corticosteroid Use
The evidence for systemic corticosteroids in TEN remains highly controversial and insufficient to support routine use:
No randomized controlled trials exist - all available evidence comes from retrospective case series with significant methodological limitations 1
The British Journal of Dermatology guidelines emphasize that there is no active therapeutic regimen with unequivocal benefit for TEN, with only level 3-4 evidence supporting any intervention 2, 3
A meta-analysis showed potential survival benefit with glucocorticosteroids, but this was significant in only one of three statistical analyses 2
Retrospective EuroSCAR data showed lower mortality in German patients (but not French patients) treated with corticosteroids compared to supportive care alone, highlighting geographic and methodological inconsistencies 1, 2
Infection Risk Concerns
The primary concern with systemic corticosteroids is increased infection risk, which is particularly dangerous in TEN patients who already have compromised skin barrier function:
The UK guidelines specifically cite infection risk as a major reason for recommending against routine corticosteroid use 1, 2
Historical case series reported deaths in patients treated with prednisolone 2
Comparative studies showed that cyclosporin (3 mg/kg/day) was associated with significantly fewer infections and lower mortality compared to cyclophosphamide plus corticosteroids 4
If Corticosteroids Are Used Despite Guidelines
When clinicians choose to use corticosteroids despite guideline recommendations, the reported dosing regimens from case series include:
Methylprednisolone 40-80 mg daily (approximately 0.8-1.5 mg/kg/day for average adult) with rapid tapering over 7-10 days once disease progression arrests 1, 5
IV dexamethasone 100 mg once daily for 3 days in combination with cyclophosphamide (though this regimen showed inferior outcomes to cyclosporin) 1
Methylprednisolone 1-1.5 mg/kg/day in combination with other agents 1
One recent case report used methylprednisolone 40 mg/day (approximately 0.8 mg/kg) combined with upadacitinib (JAK inhibitor) with rapid disease control 6
Recommended Alternative Approaches
High-quality multidisciplinary supportive care remains the priority in TEN management regardless of specific pharmacologic interventions 2, 3
Ciclosporin 3 mg/kg/day for 10 days then tapered has shown more promising results than corticosteroids, with one study showing no deaths despite SCORTEN-predicted mortality of 2.75/29 2
High-dose IVIG (2-3 g/kg total dose over 3-5 days) has shown better outcomes than low-dose regimens in some studies, though meta-analysis shows no overall survival benefit compared to supportive care alone 3
Combination therapy of IVIG plus corticosteroids showed trends toward lower mortality (45% reduction, though not statistically significant) and significantly lower infection rates compared to corticosteroids alone in a propensity-matched study 7
Critical Clinical Pitfalls
Do not use corticosteroids as monotherapy without considering alternatives like cyclosporin or IVIG, given the infection risk and lack of proven benefit 1, 2
If corticosteroids are initiated, use the shortest possible duration with rapid tapering once disease progression arrests (typically 7-10 days total) 1, 5
Immediately discontinue the culprit drug - this is more important than any pharmacologic intervention 5
Monitor closely for infections with daily smears of skin and mucous membranes, as corticosteroids blunt the febrile response 1, 5
Maintain strict supportive care measures: isolation at adequate room temperature to prevent hypothermia, strict monitoring of vital signs and laboratory parameters, and high-calorie diet due to catabolic state 5