In an adult with Stevens‑Johnson syndrome/toxic epidermal necrolysis already receiving cyclosporine, should systemic corticosteroids be added?

Adding Steroids to Cyclosporine in SJS-TEN: Not Recommended

No, adding systemic corticosteroids to cyclosporine in a patient already receiving cyclosporine for SJS-TEN is not supported by current evidence and may increase infection risk without proven additional benefit. 1, 2

Why This Practice Should Be Avoided

Cyclosporine Monotherapy Has Strong Evidence

• Cyclosporine at 3 mg/kg daily for 10 days demonstrated zero deaths in a landmark prospective study of 29 patients, whereas SCORTEN predicted 2.75 deaths—representing substantial mortality reduction as monotherapy 1
• The standard cyclosporine regimen (3 mg/kg/day divided into two doses for 7-10 days, followed by a 7-day taper) targets the core pathophysiology by directly inhibiting CD8+ T-cell signaling that drives keratinocyte apoptosis 1
• Meta-analysis data show cyclosporine has a significant beneficial effect compared with supportive care alone, with no deaths reported 1

Corticosteroids Lack Definitive Evidence and Carry Significant Risk

• The British Association of Dermatologists explicitly states there is no conclusive evidence that corticosteroids improve outcomes over conservative management (strength of recommendation D, level of evidence 4) 1, 2
• The primary concern is increased infection risk in patients who already have compromised skin barrier function, potentially increasing sepsis risk in this vulnerable population 1, 2
• Two deaths were specifically reported in patients treated with prednisolone in retrospective case series 1, 2

Evidence for Corticosteroids Is Inconsistent and Low Quality

• Retrospective EuroSCAR data showed lower mortality in German patients treated with corticosteroids but not in French patients, highlighting geographic and methodological inconsistencies 1, 2
• A meta-analysis suggested potential survival benefit with glucocorticosteroids, but this was significant in only one of three statistical analyses 1, 3
• No randomized controlled trials exist—all available data derive from retrospective case series with major ascertainment bias, small sample sizes, and heterogeneity in timing and dosing 1, 4

The Clinical Algorithm: What to Do Instead

If Already on Cyclosporine

• Continue cyclosporine monotherapy at 3 mg/kg/day divided into two doses for the full 7-10 day course, then taper over 7 days 1
• Do not add corticosteroids unless cyclosporine is failing and disease progression continues despite adequate dosing 1, 2
• Prioritize high-quality multidisciplinary supportive care including fluid/electrolyte management, meticulous wound care, infection prevention, and ophthalmology consultation 1, 2

If Considering Combination Therapy

• There is no evidence supporting the combination of cyclosporine plus corticosteroids over cyclosporine alone 1, 5, 6
• The infection risk from corticosteroids may negate any theoretical additive immunosuppressive benefit 1, 2
• If disease progression continues on cyclosporine, consider switching to TNF-α inhibitors (etanercept showed 0% mortality in one case series with SCORTEN-predicted mortality of 50%) rather than adding steroids 1

Critical Pitfalls to Avoid

The Infection Risk Cannot Be Overstated

• Corticosteroids blunt the febrile response, making infection detection more difficult in patients who already require daily smears of skin and mucous membranes for infection monitoring 2
• Septicemia is a leading cause of morbidity and fatality in the acute phase of SJS-TEN 6
• The compromised skin barrier in SJS-TEN patients makes them particularly vulnerable to the immunosuppressive effects of corticosteroids 1, 2

If Steroids Are Already Being Given

• Taper and discontinue as rapidly as possible once you recognize cyclosporine is the evidence-based monotherapy 2, 7
• If you must continue steroids temporarily during transition, use the shortest possible duration (7-10 days maximum) with rapid tapering once disease progression arrests 2
• Monitor aggressively for infections with daily cultures and maintain a low threshold for empiric antibiotics 2, 7

The Bottom Line on Current Practice

The practice of adding corticosteroids to cyclosporine reflects outdated treatment patterns rather than evidence-based medicine. Cyclosporine has demonstrated mortality reduction as monotherapy, while corticosteroids carry infection risk without proven benefit when added to cyclosporine. 1, 2, 5