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Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis:
Update In Therapeutic Approach
Dr Oh Choon Chiat Associate Consultant
Department of Dermatology Singapore General Hospital
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Adverse drug reactions
• Exanthematous
• Fixed drug eruption
• Drug-induced hypersensitivity syndrome (DIHS)/ Drug-related eosinophilia with systemic symptoms (DRESS)
• Epidermal necrolysis: Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN)
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What type of drug reaction is this?
a. Drug-Induced Hypersensitivity Reaction b. Exanthematous c. Fixed Drug Eruption d. Stevens-Johnson Syndrome e. Vasculitis
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Exanthematous eruptions
• Most common of all cutaneous drug eruptions (~90%) • Limited to the skin • Lesions initially appear on the trunk and spread centrifugally to the
extremities in a symmetric fashion • Erythematous macules and infiltrated papules • Pruritus and mild fever may be present • Skin lesions usually appear more than 2 days after the drug has been
started, mainly around day 8-11, and occasionally persists several days after having stopped the drug
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What’s the likely diagnosis?
1. Bullous pemphigoid
2. Erythema migrans
3. Fixed drug eruption
4. Spider bite
5. Vasculitis
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Fixed Drug Eruption
• Adverse drug reaction characterized by the formation of a solitary erythematous patch or plaque that will recur at the same site with re-exposure to the drug
• This distinguishing feature is why it’s called “fixed”
• Commonly involved drugs include: phenolphthalein (laxatives) /barbiturates / tetracyclines/ metronidazole/ sulfonamides/ NSAIDs
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What is the next best step in management? 1. Consult dermatology
2. Discontinue all non-life-sustaining medications
3. Request a tissue biopsy to confirm suspected diagnosis
4. Consider transfer to burn unit
5. All of the above
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HOW TO BREAK BAD NEWS TO A DERMATOLOGIST
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Summary
• A detailed medication history is essential in suspected drug reactions
• Document the drug reaction in the patient’s chart with the medication and description of the reaction
• Exanthematous eruptions are the most common of all cutaneous drug eruptions and tend to resolve without sequelae
• Fixed drug eruptions will recur at the same with re- exposure to the drug
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Summary
• SJS and TEN are acute life-threatening mucocutaneous reactions characterized by extensive necrosis and detachment of the epidermis and mucosal surfaces
• Consult dermatology at the earliest moment of concern for SJS/TEN
• Cessation of culprit drug/ supportive care of skin and affected organs/ IVIG vs Ciclosporin
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