What is the appropriate management for a previously healthy adult patient with no known comorbidities (co-existing health conditions), who presents with multiple painful oral and genital ulcers and lesions, along with a very painful throat, following a recent episode of fever and sore throat treated with unknown medications?

Suspected Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) - Immediate Management Required

This patient most likely has Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) triggered by the unknown medications taken for fever, and requires immediate hospitalization with aggressive supportive care including topical steroids, pain control, antiseptic measures, and consideration of systemic immunosuppression. 1

Critical First Steps

Immediate Assessment and Diagnosis

• Stop all potentially causative medications immediately - the "unknown medications" taken 8 days ago are the most likely trigger, as SJS/TEN typically presents 1-3 weeks after drug exposure 1
• Examine the entire skin surface for blistering, detachment, or targetoid lesions that would confirm SJS/TEN 1
• Document the percentage of body surface area involved, as this determines severity and prognosis 1
• Rule out herpes simplex virus infection with PCR testing from ulcer swabs, though the combination of oral AND genital ulcers with severe throat involvement after drug exposure makes SJS/TEN far more likely than primary HSV infection 2, 3

Why SJS/TEN is the Primary Concern

The clinical presentation of multiple painful oral and genital ulcers with severe throat pain following recent medication exposure for a febrile illness is classic for drug-induced SJS/TEN rather than:

• Not herpes simplex virus - HSV typically causes either oral OR genital lesions, not both simultaneously in an immunocompetent patient, and the medication history is key 1, 3
• Not Behçet's disease - while Behçet's can cause oral and genital ulcers, it doesn't present acutely after medication exposure and typically has a relapsing-remitting course 1, 4
• Not simple aphthous ulcers - the severity, acute onset after medications, and involvement of throat make this unlikely 5

Immediate Oral and Throat Management

Topical Therapy (Start Immediately)

• Apply white soft paraffin ointment to lips every 2 hours to prevent adhesions and reduce pain 1, 5
• Use mucoprotectant mouthwash (e.g., Gelclair) three times daily to protect ulcerated surfaces 1, 5
• Apply betamethasone sodium phosphate 0.5 mg in 10 mL water as a rinse-and-spit preparation four times daily for anti-inflammatory effect 1, 5
• For severe localized ulcers, apply clobetasol propionate 0.05% mixed with Orabase directly to affected areas daily 1, 5

Pain Control (Essential for Oral Intake)

• Benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating 1, 5
• Viscous lidocaine 2%, 15 mL per application as needed for breakthrough pain 1, 5
• For severe pain unresponsive to topical measures, cocaine mouthwashes 2-5% three times daily may be necessary 1

Oral Hygiene and Infection Prevention

• Clean mouth daily with warm saline mouthwashes, gently sweeping in labial and buccal sulci to prevent fibrotic adhesions 1, 5
• Use antiseptic oral rinse twice daily - either 1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate (dilute chlorhexidine by 50% to reduce stinging) 1, 5
• Take oral and lip swabs regularly to monitor for secondary bacterial or candidal infection 1
• If candidal infection develops, treat with nystatin oral suspension 100,000 units four times daily for 1 week 1

Genital Ulcer Management

Immediate Genital Care

• Examine the urogenital tract immediately and document extent of involvement 1
• Apply white soft paraffin ointment to urogenital skin and mucosae every 4 hours 1, 5
• Use Mepitel dressings to eroded areas to reduce pain and prevent adhesions 1
• Consider potent topical corticosteroid ointment once daily to non-eroded genital surfaces 1
• Catheterize to prevent urethral strictures if there is significant urethral involvement 1

Special Considerations for Female Patients

• Early assessment by a vulval specialist is recommended to consider vaginal dilators to prevent vaginal synechiae 1
• Insert a dilator or tampon wrapped in Mepitel into the vagina to prevent adhesion formation 1

Systemic Therapy Considerations

When to Consider Systemic Immunosuppression

While the evidence for systemic therapy in SJS/TEN remains controversial, systemic corticosteroids or other immunosuppressive agents should be considered in consultation with dermatology for extensive mucosal involvement that threatens airway compromise or nutritional intake 1

The key distinction here is that if this is SJS/TEN (most likely), systemic steroids are controversial but may be needed. However, if testing reveals this is actually severe HSV infection (less likely given the presentation), then oral acyclovir 400 mg five times daily should be started immediately 6

Critical Pitfalls to Avoid

• Do not restart any of the "unknown medications" - these are the likely culprits and re-exposure can be fatal 1
• Do not delay topical therapy while waiting for diagnostic confirmation - mucosal care should begin immediately 1, 5
• Do not use topical antivirals alone - if HSV is confirmed, systemic therapy is required for severe disease 1
• Do not assume this is a sexually transmitted infection - the acute presentation after medication exposure and involvement of throat makes drug reaction far more likely 7, 8
• Do not neglect nutritional support - severe oral pain may prevent adequate oral intake, requiring IV hydration and nutrition 1

Monitoring and Follow-up

• Daily examination of oral, genital, and skin surfaces to assess progression and response to therapy 1
• Monitor for secondary infections with regular swabs 1
• Assess ability to maintain oral intake and provide IV support if needed 1
• Multidisciplinary consultation with dermatology, ophthalmology (to check for ocular involvement), and gynecology/urology as appropriate 1