Cutaneous Drug Reactions Research Articles

Stevens Johnson Syndrome and Toxic Epidermal Necrolysis: Maternal and Foetal Outcomes in Twenty-Two Consecutive Pregnant HIV Infected Women.

IntroductionStevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) form a spectrum of a rare and life-threatening cutaneous drug reaction. SJS/TEN in pregnancy poses largely unknown risk factors and outcomes for both the mother and foetus compared to the general population.MethodsWe conducted a study of consecutive pregnant women admitted to single tertiary referral centre in South Africa with SJS/TEN over a 3 year period. They were all managed by the same medical team using the same protocols. We evaluated their underlying illnesses, offending drugs and the course of pregnancy and outcomes to determine factors influencing maternal and foetal outcomes.ResultsWe identified twenty-two women who developed SJS/TEN while pregnant, all of them HIV-infected. Their median age was 29 years. The majority 16/22 (73%) had SJS, the milder variant of the disease affecting < 10% body surface area. Nevirapine was the offending drug in 21/22 (95%) cases. All 22 of the mothers survived with 3/22 (14%) developing postpartum sepsis. Pregnancy outcomes were known in 18/22 women and 9/18 (50%) babies were delivered by caesarean section. There were 2 foetal deaths at 21 and 31 weeks respectively and both were associated with post-partum sepsis. Postnatal complications occurred in 5 cases, 3 involving the respiratory system and the other two being low birth weight deliveries. Eight placentae and one foetus were sent for histology and none showed macroscopic or microscopic features of SJS/TEN. On follow-up, only 12/20 children were tested for HIV at 6 weeks post-delivery and none of them were HIV-infected. All had received prophylactic ARVs including nevirapine.ConclusionsTEN, the severe form of the disease, was associated with poorer foetal outcomes. SJS/TEN-associated mortality is not increased in HIV-infected pregnant women. Maternal SJS/TEN does not seem to commonly manifest in the foetus.

Evaluation of cytokine profile and HLA association in benznidazole related cutaneous reactions in patients with Chagas disease.

Benznidazole is the drug of choice for Chagas disease. The major drawback of this drug is the high adverse events rate, being cutaneous reactions the most frequent one, leading to definitive withdrawal of treatment in 15%-30% of patients. Prospective observational study where adult Chagas disease patients accepting to receive benznidazole (100 mg/8 hours for 60 days) were included. The objective was to characterize the skin toxicity of benznidazole in patients with Chagas disease, determine the serum cytokine profile, and evaluate the potential association with specific HLA alleles and benznidazole concentration. Serum cytokine levels were measured at day 0, 15, and 60 of treatment. Class I and II HLA alleles were determined. When cutaneous reaction was detected, a skin biopsy was performed. Serum benznidazole concentration was determined at the time of cutaneous reaction, or at day 15 of treatment. Fifty-two patients were included, 20(38.5%) had cutaneous reaction, and median time of appearance was 9 days. Skin biopsies showed histopathological findings consistent with drug eruption. Patients with cutaneous drug-reaction had higher proportion of eosinophilia during treatment, and higher interleukin (IL)-5 and IL-10 serum concentrations at day 15 of treatment than those without cutaneous reaction. Treatment interruption (that included moderate-severe cutaneous reactions) was more frequent in patients carrying HLA-B*3505 allele (45.5% vs 15.4%, P = .033). No differences in benznidazole serum concentration were found. Benznidazole related cutaneous reaction rate is high, and it was produced by a delayed hypersensitivity reaction with a Th2 response. Carrying HLA-B*3505 allele could be associated with moderate-severe cutaneous reaction.

Incidence of adverse cutaneous drug reactions in 22,866 Chinese inpatients: a prospective study.

Cutaneous adverse drug reactions (ADRs) are common. However, no prospective study assessing cutaneous ADRs is available for Chinese populations. This study aimed to assess the incidence, manifestations, causative drugs, and other factors related to cutaneous ADRs. A total of 22,866 inpatients were surveyed prospectively from January to April 2012 at the Peking Union Medical College Hospital. Only cutaneous ADRs induced by systemic drugs were considered. Fifty cases were confirmed as cutaneous ADRs, for an estimated incidence of 2.2 per 1000 during this period (95 % confidence interval 1.6-2.8). Cases of cutaneous ADRs comprised 69 % females, while 63 % of all inpatients were female (χ (2) = 0.641, P = 0.427). The department of infectious diseases was the most frequently involved department. Morbilliform exanthema (40 %) was the most frequent cutaneous ADR, followed by urticaria (23.1 %). Anti-infection drugs (36.9 %) caused most cases of cutaneous ADRs, followed by iodinated contrast media (ICM, 18.5 %) and non-steroidal anti-inflammatory drugs (NSAIDs, 18.5 %). The most frequently associated disorders were cancer (24 %), infection (22 %), cardiovascular and cerebrovascular diseases (20 %), and autoimmune diseases (18 %). In this first prospective study assessing the incidence of cutaneous ADRs in China, anti-infection drugs were the most commonly involved drugs, followed by ICM and NSAIDs. No evidence of increased cutaneous ADR incidence in AIDS or SLE patients was observed. Our findings indicate that cancer and its treatments were often related to cutaneous ADRs in China.

Common adverse cutaneous drug reaction patterns and the causative drugs in Malaysia

Background: Patients with adverse cutaneous drug reactions (ACDRs) are frequently referred from primary care to tertiary centres for further management. This causes a loss of information regarding ACDRs as these patients discontinue primary care follow-up upon referral to tertiary care. The aim of this study is to determine the prevalence and characteristics of ACDR, and to use this valuable information to enhance awareness of primary care physicians regarding this condition.Method: A retrospective cross-sectional study on ACDR was done at the Dermatology Clinic, Kuala Lumpur General Hospital from January 2009 to December 2010.Results: The prevalence of ACDR was 0.2%. The majority of patients (71.6%) were below 59 years of age. ACDR commonly (55.2%) occurs within hours to days of drug ingestion and is of mild to moderate severity (74.6%). About 27.6% of affected patients took 1 to 5 drugs concurrently. Common cutaneous manifestation of ACDR includes maculopapular rash (22.4%) and Stevens–Johnson syndrome (SJS, 9.7%). Antibiotics (36.6%), traditional and complementary medicine (TCM, 17.9%) and analgesics (13.4%) were the most frequent agents responsible for ACDR.Conclusion: The prevalence of ACDR in this study is low and the majority were of mild to moderate severity. The most common cutaneous manifestation was a maculopapular reaction and Stevens–Johnson syndrome. Antibiotics were the commonest causative agent for ACDR followed by traditional and complementary medicine and analgesics. Patients presenting with cutaneous disorders in primary care should be assessed for possible ACDR. A detailed drug history, time of initiation and duration of drug consumption are all valuable information required for an accurate diagnosis and proper evaluation of ACDR. It is hoped that the findings of this study will facilitate early recognition of ACDR followed by identification and elimination of any possible offending drugs that may be prescribed in primary care practice.

A Retrospective Study of Spectrum of Nevirapine Induced Cutaneous Drug Reactions in HIV Positive Patients

A Retrospective Study of Spectrum of Nevirapine Induced Cutaneous Drug Reactions in HIV Positive Patients

Dress syndrome à la sulfasalazine au cours de la maladie de Crohn

The drug-induced hypersensitivity syndrome (DRESS syndrome) is a severe cutaneous drug reaction which can be life-threatening. We report a 23-year-old woman suffering from a DRESS syndrome 3 weeks after sulfasalazine exposure. She had a skin eruption, liver involvement and hypereosinophilia. She fully recovered after drug withdrawal.

A retrospective study of cutaneous drug reactions in an outpatient population.

Adverse cutaneous drug reactions (ACDR) are unexpected cutaneous changes occurring at drug dosages that are normally used for disease prophylaxis, diagnosis or treatment. The aim of the study was to determine the clinical types of ACDR, the causative agents, the latency time between drug intake and onset of ACDR and the recovery time in an outpatient population. Ninety-five patients diagnosed with ACDR at the Department of Dermatology of the University of Genoa between 2003 and 2012 were retrospectively studied. Antimicrobials, especially cephalosporins, were the most responsible for ACDR, followed by non-steroidal anti-inflammatory drugs and antihypertensives. The most common clinical manifestations were exanthema (42.1%), erythema multiforme (10.53%) and vasculitis (9.53%). Patients with peripheral eosinophilia showed a more severe clinical manifestation, they were treated with systemic therapies and their recovery time was longer. It is important to have an appropriate clinical approach according to the ACDR severity degree. We think that eosinophilia may characterise severe cutaneous eruptions and that it should always be investigated when ACDR is suspected in order to manage the patient with the appropriate treatment.

Common adverse cutaneous drug reaction patterns and the causative drugs in Malaysia

Background: Patients with adverse cutaneous drug reactions (ACDRs) are frequently referred from primary care to tertiary centres for further management. This causes a loss of information regarding ACDRs as these patients discontinue primary care follow-up upon referral to tertiary care. The aim of this study is to determine the prevalence and characteristics of ACDR, and to use this valuable information to enhance awareness of primary care physicians regarding this condition.Method: A retrospective cross-sectional study on ACDR was done at the Dermatology Clinic, Kuala Lumpur General Hospital from January 2009 to December 2010.Results: The prevalence of ACDR was 0.2%. The majority of patients (71.6%) were below 59 years of age. ACDR commonly (55.2%) occurs within hours to days of drug ingestion and is of mild to moderate severity (74.6%). About 27.6% of affected patients took 1 to 5 drugs concurrently. Common cutaneous manifestation of ACDR includes maculopapular rash (22.4%) and Stevens–Johnson syndrome ...

Challenges in Diagnosis, Management, and Treatment of Allopurinol-Induced DRESS Syndrome

We describe the presentation, diagnosis, management, and treatment of a 62-year-old woman with a medical history of gout who presented with a maculopapular rash, facial and tongue edema. Her initial presentation, coupled with a history of recent allopurinol use for systematic relief, led to the diagnosis of allopurinol-induced drug rash with eosinophilia and systemic symptoms (DRESS) syndrome, further confirmed by the RegiSCAR scoring criteria including a skin biopsy. The patient was initially treated conservatively but required systemic corticosteroid therapy as she developed severe multi-organ dysfunction. This article will highlight the challenges involved in diagnosing DRESS syndrome from other adverse cutaneous drug reactions, delayed systemic complications, and the need for evidence-based treatment modalities and regimens using the most recent published literature and analysis of case reports. Among treatment modalities, pulsed parenteral steroids show promise in a few case reports. We also discuss the newer alternative gout therapies since the mainstay of gout treatment, allopurinol, is potentially associated with morbidity and mortality risks as manifested in our patient with DRESS.

Adverse cutaneous drug reactions--a clinico-demographic study in a tertiary care teaching hospital of the Kashmir Valley, India.

Adverse cutaneous drug reactions (ACDRs) are caused by a wide variety of agents. The aim was to study the incidence and clinico-demographic profile of ACDRs to identify any potential risk factors and compare the results with other studies. A cross-sectional observational study was conducted over a period of one year from October 2012 to October 2013 in the outpatient department (OPD) of a tertiary care teaching hospital of the Kashmir valley in India and various ACDRs were recorded. The incidence of ACDRs was 0.16%. The mean age of patients was 39.36 ± 16.77 years. The male: female ratio was 0.97:1. The most frequently reported cutaneous reactions were with antimicrobials (57.33%) followed by NSAIDs (21.33%) and antiepileptic drugs (17.33%). Less common groups involved were steroids, antipsychotics and bisphosphonates (1.33% each). Fixed drug eruptions (FDEs) were the commonest (45.33%) followed by maculopapular (17.33%), photoallergic (8%), erythema multiforme (6.66%), Stevens-Johnson syndrome (5.33%) and lichenoid eruptions (4%). Less common patterns were urticaria, Drug Reaction with Eosinophilia and systemic symptoms (DRESS syndrome) and acneform eruptions (2.66% each) followed by angioedema, acute generalized exanthematous pustulosis (AGEP), exfoliative dermatitis and toxic epidermal necrolysis (1.33% each). Physicians should have adequate knowledge of adverse drug reactions, especially of newer drugs which are increasing every year in order to minimize such events.

Role of dermatology in pharmacogenomics: drug-induced skin injury.

Different individuals may respond diversely to the same drug, in terms of efficacy and toxicity. Adverse drug reactions cause about 6% of all hospital admissions and account for up to 9% of hospitalization costs. Drug-induced skin injury (DISI) is the most common presentation of adverse drug reactions, ranging from maculopapular eruptions to severe adverse cutaneous drug reactions (SCARs) with mortality of up to 40%. Specific genetic polymorphisms confer susceptibility to different types of DISI. Identifying patients genetically at risk for SCARs is one of the goals of pharmacogenomics. In this article, the aspects of clinical dermatology relevant to the pharmacogenetics of DISI are reviewed. Many SCARs are now preventable, with consequent reduction of morbidity, mortality and healthcare costs.

Drug-induced skin reactions: a 2-year study.

BackgroundThe aim of this study was to analyze the clinical characteristics of patients with adverse cutaneous drug reactions, which occur when a medicinal product results in cutaneous morbidity.MethodsThe study included 308 patients who were diagnosed as having an adverse cutaneous drug reaction during the study period (2007–2009). In 84 cases, histopathologic examination of skin biopsies were also performed.ResultsPatients with drug reactions were found to be more commonly female (63%) than male (37%). Beta-lactam antibiotics were found to be the most frequent cause of adverse cutaneous drug reactions (42.7%), followed by non-steroidal anti-inflammatory drugs (16.5%). Acute urticaria was the most common clinical presentation (59.2%) followed by fixed drug eruptions (18.5%), and maculopapular eruptions (14.9%).ConclusionAdverse cutaneous drug reactions in our study population were mainly induced by beta-lactam antibiotics and non-steroidal anti-inflammatory drugs. The most common forms of cutaneous adverse drug reactions were found to be acute urticaria, fixed drug eruptions, and maculopapular rashes.

EMPACT Syndrome - Erythema Multiform Due to Phenytoin Associated to Cranial Radio Therapy: Case Report and Review of the Literature

Erythema multiforme, Stevens - Johnson syndrome and toxic epidermal necrolysis are rare and severe cutaneous syndrome that are usually drug related. Aromatic oral anticonvulsants (e.g.: phenobarbital, phenytoin, carbamazepine) are recognized as the most common cause of these disorders. Cranial irradiation in patients receiving anticonvulsants might act as a precipitating factor in the development of these severe cutaneous drug reactions for reasons not yet elucid ated. The most common presentation is an erythematous macular eruption on the scalp within the radiation field that extends to the trunk, eventually disseminating to involve mucus membranes and Case Study

Cefaclor-Induced Generalized Fixed Drug Eruption.

Dear Editor: Fixed drug eruption (FDE) is characterized by the site-specific recurrence of dusky-red to brownish macules or patches that recur with re-administration of the causative drug1. Although FDE usually presents as a solitary lesion, the lesions can be generalized in rare instances. Although cephalosporins are some of the widely prescribed antibiotics worldwide, FDE due to cephalosporins is rarely reported. Here, we report a case of generalized FDE due to cefaclor confirmed by rechallenge. A 64-year-old man presented with generalized brownish patches (Fig. 1A). He had been diagnosed with macular degeneration approximately 2 months earlier, and received 3 injections of bevacizumab. After each injection, he took cefaclor, loxoprofen, and streptokinase/streptodornase at 4-week intervals to reduce pain and prevent secondary infection. Erythematous patches developed 6 hours after he took the oral medicines for the first time. The skin lesions resolved spontaneously, leaving hyperpigmentation. Whenever he took the medicines, new erythematous patches developed and previous hyperpigmented patches darkened. Skin biopsy results were concordant with a clinical diagnosis of FDE (Fig. 2). We explained to him the probable diagnosis, causative drugs, and methods for definite diagnosis. After 3 months, he volunteered to take the 3 abovementioned drugs to identify the causative drug. After he took cefaclor, existing skin lesions became reddish and new lesions developed within 24 hours (Fig. 1B). No skin lesions developed after taking the other drugs. Considering this and his clinical history, he was diagnosed with cefaclor-induced generalized FDE. No skin lesions developed after cefaclor was changed to ofloxacin. However, patch tests performed 8 months later on normal and hyperpigmented areas with 10%, 20%, and 30% pet. cefaclor powder were negative on days 2 and 4. Fig. 1 (A) Generalized brownish hyperpigmented annular patches over the whole body after taking cefaclor, ioxoprofen, and streptokinase/streptodornase. (B) Development of new lesions and darkening of existing lesions after taking cefaclor 250 mg. Fig. 2 Skin biopsy specimen showing edematous degeneration of the basal membrane of the epidermis, pigment incontinence, and superficial perivascular lymphocytic infiltration (H&E, ×200). Cefaclor is a second-generation cephalosporin. Adverse cutaneous drug reactions due to cephalosporin generally cause a morbiliform rash but rarely lead to FDE. There are several tests for identifying the causative drug, including the patch test, prick test, and intradermal skin test. However, the patch test at the site of a previous lesion shows a positive response in up to only 43% of cases2, and the positivity rate of patch test results using drugs other than nonsteroidal anti-inflammatory drug is very low3. Prick and intradermal skin test results are positive 24% and 67%, respectively. An oral challenge test with the suspected drug may be the best method, but it cannot often be performed because of its high risk. In the present case, the patient's voluntary provocation test aided the diagnosis of FDE. Only 5 cases of localized FDE due to cephalosporins including cefazolin, cephalexin, cefaclor, ceftazidime, and ceftriaxone have been reported. All cases were diagnosed by provocation tests and not by patch or intradermal test. To our knowledge, this is the first case report of cefaclor-induced generalized FDE. As cefaclor rarely causes FDE, patients as well as clinicians tend to ignore any skin lesions due to FDE. Furthermore, it is often difficult to identify the causative drug when patient is taking multiple medications. In summary, we report a case of cefaclor-induced generalized FDE proven by a self-rechallenge test.

Assessment of the causality of drug induced cutaneous manifestations

Background: A wide spectrum of cutaneous manifestations ranging from Maculopapular rash to severe Toxic Epidermal Necrolysis (TEN) can be produced by different classes of drugs. Some severe ACDRs may result in serious morbidity and even death. Objective: To assess the causality and identify the offending drug. Methods: The present hospital based study was carried out for a period of one year at Mahatma Gandhi Memorial Hospital, Warangal. The study subjects were those who had adverse cutaneous drug reactions. Patients willing to participate in the study with ACDR were included. Any cases with doubtful drug reaction were excluded. Complete history was taken and detailed clinical examination was done. Regular follow up of cases was done. Data was entered in the Microsoft Excel Worksheet and analyzed. Results: Maculopapular rash and FDE were commonly caused by Antibiotics, while urticaria was due to NSAIDs and Acneiform eruptions was caused by Steroids. Severe Cutaneous Adverse Reactions (SCARs) was seen in 7 patients. Amongst SCARs, SJS followed by TEN and AGEP was seen in 4, 2 and 1 case respectively. Antibiotics were the commonest offending agent for SCARs. Antimicrobials were the commonest offending group of drugs responsible for the adverse cutaneous drug reactions; however when individual drugs were considered, Diclofenac was leading drug followed by Amoxicillin and Phenytoin. Commonest reaction caused by NSAIDs was Urticaria followed by Maculopapular rash. Antiepileptics and Antipsychotics commonly caused Maculopapular rash whereas FDE was commonly seen with Antibiotics. Acneiform eruption was commonly caused by Systemic Steroids followed by SSRIs. Conclusion: Antimicrobials as a group were the most common offending agents. However, when individual drugs were taken into considerations then Diclofenac (15%) followed by Amoxicillin (9%) and Phenytoin (8%) in the order were the offending drugs.

Effect of antiretroviral therapy on mucocutaneous manifestations among Human Immunodeficiency Virus-infected patients in a tertiary care centre in South India

Background:Human Immunodeficiency Virus (HIV) infection produces a wide range of infectious and noninfectious dermatoses which correlate with the degree of immunodeficiency. Since the introduction of highly active antiretroviral therapy (HAART), there has been a dramatic decrease in the incidence of HIV-associated dermatoses. However, HAART itself causes various cutaneous adverse drug reactions.Aims:To assess the various mucocutaneous manifestations in HIV-infected individuals and its association with CD4 count and to assess the effect of HAART on mucocutaneous manifestations.Materials and Methods:Of the 170 patients recruited, 110 patients were previously diagnosed with HIV and were on follow-up. The rest 60 patients were newly diagnosed cases at recruitment, and these patients were followed up every month for mucocutaneous manifestations for a period of 6 months.Results:Of the 170 patients screened, 69.41% patients had at least one mucocutaneous lesion at presentation. Fungal, viral, and bacterial infections were observed present in 17.6%, 10.6%, and 9.4% patients, respectively. There was a significant difference in the occurrence of candidal infections in the HAART versus non-HAART group (P = 0.0002). Candidiasis (P ≤ 0.0001) and human papillomavirus infection (P = 0.0475) occurred more commonly with CD4 count <200 cells/mm 3 . Among the noninfectious dermatoses, inflammatory dermatoses (17.6%) were more commonly observed at recruitment followed by adverse cutaneous drug reactions (16.5%) and neoplasms (5.3%).Conclusion:HAART has significantly altered the patterns of mucocutaneous manifestations. The prevalence of both infectious and inflammatory dermatoses has come down. However, there is an increase in the incidence of adverse cutaneous drug reactions.

特発性皮膚薬物有害反応が疑われた猫の29例

特発性皮膚薬物有害反応が疑われた猫の29例

Onychomadesis with Lichen Planus: An Under-Recognized Manifestation.

Onychomadesis or proximal separation of the nail pate usually results from severe, generalized dermatoses like bullous diseases, hand foot and mouth disease, varicella or severe cutaneous drug reactions. Although lichen planus (LP) produces varied nail manifestations (longitudinal onychorrhexis, onychoschizia, nail pigmentation, pterygium etc.), to the best of our knowledge, onychomadesis as a manifestation of nail LP is not recorded. This report presents two children with onychomadesis arising with generalized eruptive LP.

Effect of antiretroviral therapy on mucocutaneous manifestations among Human Immunodeficiency Virus-infected patients in a tertiary care centre in South India.

Human Immunodeficiency Virus (HIV) infection produces a wide range of infectious and noninfectious dermatoses which correlate with the degree of immunodeficiency. Since the introduction of highly active antiretroviral therapy (HAART), there has been a dramatic decrease in the incidence of HIV-associated dermatoses. However, HAART itself causes various cutaneous adverse drug reactions. To assess the various mucocutaneous manifestations in HIV-infected individuals and its association with CD4 count and to assess the effect of HAART on mucocutaneous manifestations. Of the 170 patients recruited, 110 patients were previously diagnosed with HIV and were on follow-up. The rest 60 patients were newly diagnosed cases at recruitment, and these patients were followed up every month for mucocutaneous manifestations for a period of 6 months. Of the 170 patients screened, 69.41% patients had at least one mucocutaneous lesion at presentation. Fungal, viral, and bacterial infections were observed present in 17.6%, 10.6%, and 9.4% patients, respectively. There was a significant difference in the occurrence of candidal infections in the HAART versus non-HAART group (P = 0.0002). Candidiasis (P ≤ 0.0001) and human papillomavirus infection (P = 0.0475) occurred more commonly with CD4 count <200 cells/mm (3) . Among the noninfectious dermatoses, inflammatory dermatoses (17.6%) were more commonly observed at recruitment followed by adverse cutaneous drug reactions (16.5%) and neoplasms (5.3%). HAART has significantly altered the patterns of mucocutaneous manifestations. The prevalence of both infectious and inflammatory dermatoses has come down. However, there is an increase in the incidence of adverse cutaneous drug reactions.

Steven johnsons syndrome and toxic epidermal necrolysis: A review

Toxic epidermal necrolysis (TEN) and Stevens Johnson Syndrome (SJS) are severe adverse cutaneous drug reactions that predominantly involve the skin and mucous membranes. They are characterized by mucocutaneous tenderness and typically hemorrhagic erosions, erythema and more or less severe epidermal detachment presenting as blisters and areas of denuded skin. Drugs are assumed or identified as the main cause of SJS/TEN in most cases, but Mycoplasma pneumoniae and Herpes simplex virus infections are well documented causes alongside rare cases in which the etiology remains unknown. Several drugs are at risk of inducing TEN/SJS including: Allopurinol, Trimethoprim-sulfamethoxazole and other sulfonamide-antibiotics, aminopenicillins, cephalosporins, quinolones, carbamazepine, phenytoin, phenobarbital and NSAID's of the oxicam-type. Differential diagnosis includes linear IgA dermatosis and paraneoplastic pemphigus, pemphigus vulgaris and bullous pemphigoid, acute generalized exanthematous pustulosis (AGEP), disseminated fixed bullous drug eruption and staphyloccocal scalded skin syndrome (SSSS). Due to the high risk of mortality, management of patients with SJS/TEN requires rapid diagnosis, identification and interruption of the culprit drug, specialized supportive care ideally in an intensive care unit, and consideration of immunomodulating agents such as high-dose intravenous immunoglobulin therapy.