Steroid Duration and Tapering in Stevens-Johnson Syndrome
In Stevens-Johnson syndrome, systemic corticosteroids should be initiated early (within 72 hours) at moderate-to-high doses and tapered rapidly over 7-10 days, not prolonged courses. 1, 2
Recommended Steroid Regimens
High-Dose Pulse Therapy (Preferred for Severe Cases)
- Methylprednisolone 1000 mg IV daily for 3 consecutive days, followed by rapid taper over the subsequent 2-7 days 1, 3
- This regimen showed 0% mortality in Japanese case series despite predicted mortality rates 1, 3
- Alternative: IV dexamethasone 100 mg or 1.5 mg/kg daily for 3 days with subsequent taper 1
Moderate-Dose Oral/IV Therapy
- Prednisolone 1-2 mg/kg/day (typically 40-80 mg daily for adults) initiated within 72 hours 1, 4, 2
- Continue for 7-10 days total with rapid tapering 1, 4, 2
- Total cumulative dose equals approximately 10-25 mg/kg prednisolone over the treatment course 4
Critical Timing and Duration Principles
The key is early initiation and SHORT duration—not prolonged courses. 1, 2
- Start within 72 hours of presentation for maximum benefit 1, 2
- Taper rapidly within 7-10 days to minimize infection risk while suppressing disease progression 1, 4, 2
- Prolonged courses increase sepsis risk, which is the leading cause of mortality in SJS/TEN 1, 5
Tapering Schedule
For the moderate-dose regimen:
- After initial high-dose phase (3-5 days), reduce by approximately 50% every 2-3 days 1
- Complete taper by day 7-10 1, 4, 2
For pulse therapy:
- After 3 days of methylprednisolone 1000 mg IV, switch to oral prednisolone at half the IV dose for 2 additional days, then discontinue 1
Important Clinical Caveats
The evidence base is weak—no randomized controlled trials exist, only retrospective case series. 1 The 2016 U.K. guidelines explicitly state there is no conclusive evidence demonstrating benefit of any intervention over conservative management alone 1. However, multiple case series suggest benefit when steroids are used early and briefly 6, 3, 7.
Common Pitfalls to Avoid
- Do NOT use prolonged steroid courses (>10-14 days)—this dramatically increases infection risk without additional benefit 1, 2, 5
- Do NOT delay initiation—efficacy depends on starting within 72 hours 1, 2
- Do NOT use low doses—inadequate dosing (such as standard methylprednisolone dose packs providing only 84 mg total) represents significant underdosing 4
- Do NOT taper slowly—rapid taper over 7-10 days is essential 1, 4, 2
Alternative Agent: Cyclosporine
If steroids are contraindicated or as combination therapy:
- Cyclosporine 3-5 mg/kg/day for 10-14 days, then taper over additional 7 days 1, 2
- Can be used alone or combined with corticosteroids 2
- Showed 0% mortality in a French cohort of 29 patients 1
Multidisciplinary Supportive Care Priority
High-quality supportive care remains the cornerstone of management and takes priority over any specific immunomodulatory therapy. 1 The British guidelines emphasize that if corticosteroids are used, they should be administered under specialist supervision, ideally within clinical registries given the lack of definitive evidence 1, 4.