What is the management for a patient with a burning sensation in the mouth, blisters throughout the buccal mucosa, and conjunctival injection after starting lamotrigine (lamotrigine) a few months ago?

Management of Lamotrigine-Induced Stevens-Johnson Syndrome

Immediately discontinue lamotrigine and admit this patient to a burn unit or intensive care unit, as this presentation is consistent with Stevens-Johnson syndrome (SJS), a severe cutaneous adverse reaction requiring urgent multidisciplinary care. 1, 2

Immediate Actions

Drug Discontinuation

• Stop lamotrigine immediately and permanently – this is the single most critical intervention, as continued exposure worsens outcomes 1, 2, 3
• Lamotrigine is contraindicated for life after SJS development 4
• Document this as a severe drug allergy in all medical records 1

Admission and Consultation

• Admit to burn unit or ICU for patients with mucosal involvement and blistering, even if body surface area (BSA) involvement appears limited initially 1
• Convene a multidisciplinary team including:
  • Dermatology (urgent consultation) 1
  • Ophthalmology (for conjunctival injection and potential ocular sequelae) 1
  • Wound care services 1
  • Pain/palliative care if needed 1

Prognostic Assessment

• Calculate SCORTEN within 24 hours to assess mortality risk and guide intensity of care 1, 3
• Monitor for progression – SJS can evolve to toxic epidermal necrolysis (TEN) with >10% BSA involvement 1

Pharmacologic Management

Corticosteroids

• Initiate IV methylprednisolone 0.5-1 mg/kg (or equivalent) immediately 1
• Unlike traditional teaching that avoided steroids in SJS, current evidence supports their use when the mechanism is T-cell immune-mediated (as with drug reactions) 1
• Taper over at least 4 weeks once clinical improvement occurs 1
• For severe or steroid-unresponsive cases, consider IVIG or cyclosporine 1

Supportive Medications

• Oral antihistamines for pruritus 1, 2
• Topical emollients and petrolatum-based products for skin 1
• High-strength topical corticosteroids to affected areas 1
• For oral lesions: mouthwash containing diphenhydramine, viscous lidocaine, and sodium bicarbonate 2
• Viscous lidocaine and petroleum jelly for lip lesions 2

Supportive Care

Fluid and Wound Management

• Establish IV access and maintain fluid/electrolyte balance 1
• Minimize insensible water losses 1
• Prevent secondary infection with appropriate wound care 1
• Apply topical emollients regularly 1

Nutrition

• If oral intake is inadequate due to mucosal involvement, insert nasogastric tube for feeding 1
• Maintain adequate nutrition to support healing 1

Urogenital Care

• Insert urinary catheter if urogenital involvement causes dysuria or retention 1

Ophthalmologic Management

• Daily ophthalmology evaluation is essential given the conjunctival injection 1
• Early intervention prevents scarring and vision loss 1
• Topical treatments and lubrication as directed by ophthalmology 1

Critical Pitfalls to Avoid

Timing and Recognition

• SJS typically develops 2-6 weeks after drug initiation (average 3 weeks), which matches this patient's timeline of "a few months ago" 2, 5, 6, 3
• Do not rechallenge with lamotrigine – even appropriate dosing does not prevent SJS 2
• The reaction can occur despite proper dose escalation protocols 2, 3

Concomitant Medications

• Valproic acid increases lamotrigine-induced SJS risk through pharmacokinetic interactions 5, 7
• Review all medications, but lamotrigine remains the most likely culprit given the clinical presentation and timeline 2, 5

Monitoring After Discharge

• Symptoms may persist for weeks after drug discontinuation 6
• Post-inflammatory hyperpigmentation is common 3
• Long-term ophthalmologic follow-up is necessary to monitor for delayed ocular complications 1

Prognosis

• With early recognition and appropriate management, most patients recover within 2-3 weeks 2, 3
• Mortality risk is stratified by SCORTEN score 1, 3
• Permanent discontinuation of lamotrigine is mandatory 1, 4