What is the recommended oral care and pain management for a patient with Stevens‑Johnson syndrome involving the oral mucosa?

Stevens-Johnson Syndrome Oral Care

Immediately apply white soft paraffin ointment to the lips every 2 hours and initiate a structured regimen of mucoprotectant mouthwashes, antiseptic rinses, and topical analgesics to prevent scarring and manage severe oral pain. 1

Initial Assessment and Monitoring

• Examine the mouth as part of the initial assessment, looking specifically for mucosal erythema, blistering, ulceration, and hemorrhagic crusting of the lips 1
• Perform daily oral reviews throughout the acute illness to monitor for progression, secondary infection, and healing 1
• Take oral and lip swabs regularly if bacterial or candidal infection is suspected 1

Lip Protection Protocol

• Apply white soft paraffin ointment to the lips immediately upon diagnosis, then every 2 hours throughout the acute illness 1, 2, 3
• This frequent application is critical to prevent hemorrhagic sloughing and subsequent labial scarring that can restrict mouth opening 1

Mucosal Protection and Cleansing

• Use a mucoprotectant mouthwash (e.g., Gelclair) three times daily to protect ulcerated mucosal surfaces 1, 4
• Clean the mouth daily with warm saline mouthwashes or an oral sponge, sweeping gently in the labial and buccal sulci to reduce the risk of fibrotic scars 1, 4, 3
• Avoid alcohol-containing mouthwashes as they cause additional pain and impair healing 3

Pain Management Algorithm

First-Line: Anti-inflammatory Rinse

• Use benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating 1, 4
• This provides both anti-inflammatory and analgesic effects 4

Second-Line: Topical Anesthetics (if benzydamine inadequate)

• Apply viscous lidocaine 2%, 15 mL per application, as needed 1, 4, 5
• Use not more than 3 to 4 times daily per FDA labeling 5
• Have patient hold in mouth for 1-2 minutes before expectorating 4
• Avoid eating or drinking for 30 minutes after application to maximize effectiveness 4
• Be aware that topical anesthetics can temporarily impair swallowing reflexes and airway protection 4

Third-Line: For Severe Oral Discomfort

• Cocaine mouthwashes 2%-5% can be used three times daily for severe cases 1

Antiseptic Protocol

• Use antiseptic oral rinse twice daily to reduce bacterial colonization 1, 4, 3
• Options include:
  • 1.5% hydrogen peroxide mouthwash (Peroxyl), 10 mL twice daily 1
  • 0.2% chlorhexidine digluconate mouthwash (Corsodyl), 10 mL twice daily 1, 3
• Dilute 0.2% chlorhexidine by up to 50% to reduce soreness that accompanies this treatment 1

Anti-inflammatory Therapy

• Consider topical corticosteroid (e.g., betamethasone sodium phosphate 0.5 mg in 10 mL water) as a 3-minute rinse-and-spit preparation four times daily 1, 2
• While evidence is limited, topical corticosteroids have been shown to reduce oral inflammation in blistering conditions including SJS/TEN 1

Management of Secondary Infections

Candidal Infection

• Treat with nystatin oral suspension 100,000 units four times daily for 1 week 1, 2
• Alternative: miconazole oral gel (Daktarin) 5-10 mL held in the mouth after food four times daily for 1 week 1, 2

Bacterial or HSV Infection

• Slow healing may reflect secondary bacterial infection or HSV reactivation 1
• Obtain cultures and treat appropriately based on results 1

Nutritional Support

• If tolerated, provide soft, moist, low-acidity foods 1, 3
• Eliminate irritating foods including tomatoes, citrus fruits, hot drinks, spicy foods, and crusty foods 3
• Most patients require intravenous fluids and nutrition via soft, fine-bore nasogastric tube due to severe oral pain 1
• Drinking and eating are usually severely compromised by oral involvement 1, 6

Critical Pitfalls to Avoid

• Do not delay lip protection—immediate and frequent application of white soft paraffin is essential to prevent scarring 1
• Do not use petroleum-based products chronically as they promote mucosal dehydration and create an occlusive environment increasing infection risk 3
• Do not exceed maximum doses of topical anesthetics to avoid systemic toxicity (seizures, methemoglobinemia) 4
• Do not underestimate the severity of mucosal involvement—up to 40% of patients develop chronic sicca syndrome from minor salivary gland damage 1

Long-Term Complications to Monitor

• Labial and intraoral scarring may restrict mouth opening and cause difficulty with eating or speaking 1
• Sicca syndrome develops as a chronic problem in up to 40% of patients due to minor salivary gland damage 1
• Mucosal involvement may extend to oropharynx, larynx, respiratory tract, and esophagus in severe cases 1