What is the recommended treatment for Mycoplasma pneumoniae‑associated rash and mucositis, ranging from mild erythema multiforme to severe Stevens‑Johnson syndrome or toxic epidermal necrolysis?

Treatment of Mycoplasma-Induced Rash and Mucositis

When Mycoplasma pneumoniae is confirmed or strongly suspected as the cause of severe mucositis with minimal skin involvement, treat the underlying infection with azithromycin and provide aggressive supportive care, particularly for mucosal surfaces; avoid unnecessary discontinuation of analgesics and do not use systemic immunomodulators. 1

Immediate Diagnostic and Therapeutic Steps

Confirm the Diagnosis

• Test all patients with severe mucositis for M. pneumoniae using respiratory PCR and/or serologic IgM assays 2, 1
• Consult infectious disease specialists to guide appropriate testing and antimicrobial selection 1
• Recognize the hallmark presentation: severe erosive and hemorrhagic mucositis affecting oral, ocular, and genital sites with minimal or absent skin involvement 1, 3

Antimicrobial Therapy (Essential Component)

• Administer targeted antibiotic therapy with azithromycin for confirmed or suspected M. pneumoniae infection 2, 1
• Unlike drug-induced SJS/TEN where drug withdrawal is paramount, MIRM requires active antimicrobial treatment of the underlying infection 1
• Do not delay antimicrobial treatment while awaiting confirmatory testing when the clinical picture is consistent with MIRM 1

Avoid Common Pitfalls in Drug Management

• Do not unnecessarily discontinue commonly used analgesics (paracetamol, ibuprofen) when infection is the likely cause rather than drug reaction 1
• Misclassifying MIRM as drug-induced SJS/TEN leads to missed antimicrobial therapy and unnecessary drug avoidance 1

Severity-Based Management Algorithm

Mild MIRM (Limited Mucosal Involvement, Stable Patient)

• Manage on an age-appropriate ward with focused mucosal support 1
• Obtain ophthalmology consultation within 24 hours to assess and manage ocular surface disease 2, 1
• Provide oral care with gentle debridement, topical anesthetic (lidocaine viscous), and nutritional support if oral intake is compromised 1
• Apply barrier ointments to genital lesions; consider topical high-potency corticosteroids for severe genital involvement 1

Severe MIRM (Extensive Mucositis, Systemic Involvement, or Any Skin Detachment)

• Transfer immediately to a specialized unit (dermatology-based PICU or pediatric burn center) 1
• Delayed transfer is associated with poorer outcomes and increased mortality 1
• Assemble a multidisciplinary team including dermatology, ophthalmology, infectious disease, and intensive-care specialists 1

Critical Supportive Care Measures

Ophthalmologic Management

• Aggressive ophthalmologic intervention is essential to prevent permanent visual impairment 1
• Early ophthalmology involvement (within 24 hours) is mandatory given the high rate of ocular involvement (82% of cases) 3

Nutritional Support

• Ensure adequate nutritional support, including enteral feeding when oral intake is limited due to severe oral mucositis 1
• Oral mucositis may require nasogastric tube feeding in severe cases 4

Wound and Infection Prevention

• Provide meticulous care of denuded skin and mucosa to prevent secondary bacterial infection and sepsis 1
• Monitor for signs of secondary infection in exposed dermis 1

Pain Management

• Implement effective pain control as a key component of care due to prominent mucocutaneous pain 1

Role of Immunomodulatory Therapy

Current evidence does NOT support the use of systemic immunomodulators (corticosteroids, IVIG, anti-TNF agents, ciclosporin) in MIRM or infection-associated SJS/TEN 1. This represents a critical distinction from drug-induced SJS/TEN and DRESS syndrome, where immunomodulation may have a role.

• If immunomodulatory treatment is considered, it must be administered only under a specialist skin-failure multidisciplinary team within a research or registry framework 1
• Some case reports describe short courses of corticosteroids (e.g., oral prednisolone) in conjunction with azithromycin, but this is not guideline-recommended 5

Prognosis and Long-Term Considerations

Expected Disease Course

• MIRM generally follows a more benign course than drug-induced SJS/TEN, with lower mortality (3% in case series) and less extensive skin involvement 3
• Complications include mucosal damage (10%), cutaneous scarring (5.6%), and recurrence (8%) 3

Long-Term Sequelae

• Ocular complications: dry eye, symblepharon, corneal scarring 1
• Oral issues: dental problems, strictures 1
• Urogenital stenosis 1
• Skin hyperpigmentation and scarring (typically milder than drug-induced SJS/TEN) 1

Follow-Up

• Recurrence may occur with future M. pneumoniae infections; counsel patients accordingly 1
• Arrange long-term ophthalmology follow-up for all patients with ocular involvement 1

Critical Pitfalls to Avoid

• Do not misclassify MIRM as drug-induced SJS/TEN, as this leads to missed antimicrobial therapy and unnecessary drug avoidance 1
• Do not underestimate isolated mucositis; extensive mucosal disease without significant skin loss still warrants specialized multidisciplinary care 1
• Do not delay ophthalmologic involvement to avert permanent visual loss 1
• Do not use systemic immunomodulators outside of specialized research protocols 1