Stevens-Johnson Syndrome Research Articles

002 National clinical audit on the management of Stevens–Johnson syndrome/toxic epidermal necrolysis in adults

Abstract UK guidelines for the management of Stevens–Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) in adults, published by the British Association of Dermatologists (BAD) in 2016, outline a set of audit standards (Creamer D, Walsh SA, Dziewulski P et al. U.K. guidelines for the management of Stevens–Johnson syndrome/toxic epidermal necrolysis in adults 2016. Br J Dermatol 2016; 174:1194–227). Our aim was to audit the current management of SJS/TEN in adults against audit standards in the BAD guidelines. BAD members were invited to submit data on five consecutive adults with SJS/TEN per department over an 8-week period in 2022. All data were obtained from respondents using a Microsoft Excel spreadsheet proforma returned to the BAD by email. No patient-identifiable data were requested. Initial data extraction was conducted using a novel and reproducible program written in the R statistical language (V3.7 and the readxl, ggplot2 and ggthemes packages). The data analysis was also performed using Microsoft Excel. Thirty-nine (29%) dermatology centres in the UK participated and data for 147 adults with SJS/TEN were collected. Within 24 h of a diagnosis being made or suspected, the following were documented: Severity-of-Illness Score for TEN (SCORTEN) for 52% (n = 76/147) of submitted cases, list of medications for 77% (n = 113) and timelines for commencement/alterations of medications for 71% (n = 104). Initial assessment was of the eyes (by an ophthalmologist) for 48% (n = 71) of cases, the mouth in 88% (n = 130), the genital skin in 70% (n = 103) and the urinary tract in 63% (n = 93). In the first 10 days after a suspected or confirmed diagnosis of SJS/TEN, daily assessments of the mouth were documented in 18% (n = 26) of cases, the eyes in 8% (n = 12) and the urinary tract and genital skin in 10% (n = 14). Documentation regarding advice on (i) avoidance of the culprit drug was present for 58% (n = 76/130) of cases and (ii) request for a medic alert bracelet/amulet in 6% (n = 9/147). In adults with SJS/TEN, drug causality assessment was documented adequately. Initial assessment of the mouth, eyes, urinary tract and genital skin was good to fair; however, daily assessments were poor. Other audit standards that require improving include documentation of SCORTEN and advice to avoid the culprit drug and request a medic alert bracelet/amulet. In adults with SJS/TEN, there are multiple points in the assessment pathway that require careful documentation and regular review. These are a challenge for many clinical inpatient environments. Care within a burns unit or similar may not be possible for all. This audit suggests that some form of assessment and clinical review checklist might enable colleagues to maintain standards outlined in the guideline. Among these, use of SCORTEN, advice to avoid the culprit drug and requests for a Medic Alert bracelet/amulet are key.

Stevens-Johnson syndrome in an 18-year-old Nigerian female: A case report

Purpose: This is a Stevens-Johnson syndrome (SJS) case with an atypical presentation. Stevens-Johnson syndrome is a hypersensitivity reaction distinguished by necrosis of skin tissue and mucosal linings including the genitals and eyes. It usually occurs as a reaction to certain medications. The condition is regarded as a medical emergency and management is tailored according to presenting symptoms with emphasis on airway and hemodynamic stability, lesion treatment, and prevention of opportunistic infection. While the condition is not hereditary, genetic codes passed on may increase the risk of similar immune-mediated hypersensitivity responses among progenies of affected individuals. Cyclosporine and other immunomodulatory therapeutics have shown promise in managing this condition.
 Case Report: This patient presented with severely reduced vision. The patient also had a recent history of bilateral ocular adnexal surgery and a family (father) history of kidney disease. An extensive case history, ocular workup, and microbial sensitivity testing were carried out to reach a diagnosis. The patient was initially placed doxycycline, Vitamin C, Moxifloxacin and Fluconazole. These were later adjusted when culture results returned. Unfortunately, due to the delay in presentation, the condition had progressed significantly, and management was palliative rather than restorative.
 Conclusion: A knowledge of SJS and quick intervention is key to minimizing morbidity and possible mortality from this condition. Management of this condition is multi-disciplinary and eye care providers should examine sufferers for ocular involvement so as to mitigate visual morbidity.

Ocular surface complications following biological therapy for cancer.

Novel and highly effective biological agents developed to treat cancer over the past two decades have also been linked to multiple adverse outcomes, including unanticipated consequences for the cornea. This review provides an overview of adverse corneal complications of biological agents currently in use for the treatment of cancer. Epidermal growth factor receptor inhibitors and immune checkpoint inhibitors are the two classes of biological agents most frequently associated with corneal adverse events. Dry eye, Stevens-Johnson syndrome, and corneal transplant rejection have all been reported following the use of immune checkpoint inhibitors. The management of these adverse events requires close collaboration between ophthalmologists, dermatologists, and oncologists. This review focuses in depth on the epidemiology, pathophysiology, and management of ocular surface complications of biological therapies against cancer.

Severe ocular complications of SJS/TEN and associations among pre-onset, acute, and chronic factors: a report from the international ophthalmology collaborative group.

We formed an international research collaboration that included Japan, South Korea, Brazil, Thailand, Taiwan, the UK, and the US (682 patients from 13 hospitals between 2005 and 2020), to better evaluate the role of race, ethnicity, and other risk factors in the pathophysiology of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Ophthalmologists often see SJS/TEN patients with severe ocular complications (SOC; frequency 50% SJS/TEN patients) when the patients are referred to them in the chronic stage after the acute stage has passed. Global data were collected using a Clinical Report Form, capturing pre-onset factors, as well as acute and chronic ocular findings. Key conclusions of this retrospective observational cohort study were as follows: (1) Ingestion of cold medications [acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs)] was significantly and positively correlated with trichiasis, symblepharon, and/or conjunctivalization of the cornea in the chronic stage; (2) common cold symptoms prior to onset of SJS/TEN were significantly and positively correlated with acute conjunctivitis and ocular surface erosions in the acute stage and with trichiasis and symblepharon and/or conjunctivalization of the cornea in the chronic stage; (3) patients with SJS/TEN who presented with SOC tended to be female; (4) patients less than 30 years of age are more likely to develop SOC in the acute and chronic stages of SJS/TEN; (5) patients with acute severe conjunctivitis with ocular surface erosion and pseudomembrane formation in the acute stage are more likely to develop ocular sequelae in the chronic stage; and (6) onychopathy in the acute stage was positively correlated with ocular sequelae in the chronic stage. Our findings show that the ingestion of cold medications, common cold symptoms prior to the onset of SJS/TEN, and a young age might strongly contribute to developing the SOC of SJS/TEN.

Aripiprazole-Induced Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: A Case Study.

The use of medications in management of disease is an integral part of treatment to patients in both the inpatient and outpatient setting; however, these medications often have risk of adverse effects associated with their benefits of use. Adverse cutaneous reactions are one of the most frequent types of adverse drug reactions. Two major phenotypes of cutaneous adverse drug reactions are toxic epidermal necrolysis (TEN), and Stevens-Johnson syndrome (SJS). Aripiprazole is an antipsychotic drug with a well-documented profile of adverse effects for physicians to be aware of; however, SJS/TEN is not known to be included in that profile. The authors encountered a case of aripiprazole-induced SJS/TEN and used the electronic medical records from this encounter to summarize this novel case in detail. Existing literature was reviewed using public databases for evaluation of similar cases. We present a case of SJS/TEN induced by aripiprazole use for bipolar disorder, type 1, which is not an adverse effect of the drug that has been documented in the literature. We include patient history, hospital course, images, and treatment of disease throughout admission as well as a thorough discussion of the topic. We present a case of an adverse drug reaction that has not previously been documented in the literature with the goal of informing readers of the potential for this life-threatening atypical effect and the severity of disease it may cause.

#5781 DRUG-INDUCED ACUTE INTERSTITIAL NEPHRITIS (D-AIN): HOW TO IDENTIFY THE RESPONSIBLE DRUG?

Abstract Background and Aims The mainstay of D-AIN treatment is the removal of the responsible drug. However, it is not always easy to identify the culprit drug as this entity mainly affects elderly patients on multiple medications, they rarely associate systemic symptoms (rash, fever), and the timeline regarding the diagnosis and the associated drug is not always clear. Therefore, the diagnosis and treatment are delayed, making full renal function recovery less likely. The lymphocyte transformation test (LTT) has demonstrated to be useful in the identification of the involved drug in other hypersensitivity-mediated lymphocyte T diseases such as Stevens-Johnson Syndrome or Dress Syndrome. For this reason, we wonder if this test could be relevant in identifying the responsible drug in D-AIN. The aim of this study is to test LTT in patients with clinical and histological diagnosis of D-AIN. Method We have conducted a retrospective observational study in which we have collected data from 2019 to 2022 from our electronic databases. Results: We have registered 9 cases of D-AIN diagnosed with histological confirmation in whom the LTT had been performed. 22.2% of these patients were men. The mean age was 48.1 years (standard deviation of 15.8). None of them had previous chronic kidney disease (CKD). Mean peak creatinine at diagnosis was 4.66 mg/dl (standard deviation of 1.95). Regarding the typical symptoms of the D-AIN, three patients (33%) presented with fever and none of them suffered from rash. 6 patients had sterile pyuria (66%). All of them received steroid treatment. Concerning the LTT results, 7 cases were positive for one of the drugs the patient was taking, and 2 were negative. Among the positive cases, the identified drugs were 1 case of beta lactams (piperacillin), 1 case of PPIs (omeprazole), 1 case of metamizole, 1 case of paracetamol, 1 case of eslicarbazepine and 2 cases of NSAIDs (dexketoprofen), while the negative cases have not been suspected of taking any culprit drug. Conclusion LTT may be a useful test to identify the responsible drug for D-AIN, especially in patients taking multiple medications in which may be included some of great importance like immunotherapy (typical cause of D-AIN) in oncological treatments. In negative cases, it could be expected that the patient had taken medications difficult to be identified in the clinical history or, in some situations, the drug hapten responsible for kidney damage might be a drug metabolite and not the drug itself, which cannot be detected by the test.

Stevens-Johnson Syndrome Secondary to Herpetic Infection: A Case Report

Stevens-Johnson syndrome (SJS) is a rare but serious drug reaction characterized by extensive necrosis of the skin and mucous membranes. It is considered a medical emergency and requires immediate medical intervention, with a high mortality rate, especially during the acute phase.
 Symptoms of Stevens-Johnson syndrome include a rash, blisters, and lesions in the oral mucosa, throat, genitals, and eyes. Before the rash appears, symptoms such as fever, headache, muscle pain, and flu-like signs may occur.
 While the causes of Stevens-Johnson syndrome are not fully understood, it is often associated with an allergic reaction to medication. In children, it can also have an infectious origin.
 Survivors of Stevens-Johnson syndrome may experience long-term sequelae, including cutaneous, ophthalmological, genital, oral-dental, and psychological issues. Therefore, monitoring and early detection are crucial.
 The severity of this pathology makes the reported case particularly compelling. It highlights the importance of medical personnel having knowledge and mastery of this condition in order to improve management and prognosis.
 We report the case of an 8-year-old child who presented with a pseudogripal syndrome that rapidly progressed in 24 hours to an exanthem characterized by macules in pseudo-rings. The condition was complicated by a severe, diffuse enanthem and resulted in detachment with a positive Nikolsky sign. The clinical and biological evolution was favorable under symptomatic treatment, antiviral medication and intravenous immunoglobulin infusion.Top of Form

Investigation of Four Cases of Stevens-Johnson Syndrome among Participants in a Mass Drug Administration Campaign with Sulfadoxine-Pyrimethamine and Primaquine in Haiti, 2020.

In 2018, a mass drug administration (MDA) campaign for malaria elimination was piloted in Haiti. The pilot treated 36,338 people with sulfadoxine-pyrimethamine (SP) and primaquine; no severe adverse events were detected. In 2020, another MDA campaign using the same medications was implemented to mitigate an upsurge in malaria cases during the COVID-19 pandemic. Four cases of Stevens-Johnson syndrome (SJS) were identified among the 42,249 people who took the medications. Three of these individuals required hospitalization; all survived. In addition to SP ingestion, an investigation of potential causes for increased SJS cases identified that all four cases had human leukocyte antigens A*29 and/or B*44:03, another known risk factor for SJS. Additionally, three of the four case individuals had antibodies to SARS-CoV-2, and the fourth may have been exposed around the same time. These findings raise the possibility that recent SARS-CoV-2 infection may have contributed to the increased risk for SJS associated with SP exposure during the 2020 campaign.

Selected cutaneous adverse events in patients treated with ICI monotherapy and combination therapy: a retrospective pharmacovigilance study and meta-analysis.

Introduction: Cutaneous adverse events are commonly reported immune-related adverse events (irAEs), some of which are serious or even life-threatening, and it is essential to study these specific cutaneous AEs to understand their characteristics and risk. Methods: We performed a meta-analysis of published clinical trials for immune checkpoint inhibitors (ICIs) to evaluate the incidence of cutaneous adverse events, using data from PubMed, Embase, and the Cochrane Library databases. Results: A total of 232 trials with 45,472 patients were involved. Results showed that anti-PD-1 and targeted therapy combinations were associated with higher risk for most of the selected cutaneous adverse events. In addition, a retrospective pharmacovigilance study was conducted using the Food and Drug Administration (FDA) Adverse Events System database. Reporting odds ratio (ROR) and Bayesian information components (IC) were used to perform the disproportionality analysis. Cases were extracted from January 2011 to September 2020. We identified 381 (20.24%) maculopapular rash, 213 (11.32%) vitiligo, 215 (11.42%) Stevens-Johnson syndrome (SJS), and 165 (8.77%) toxic epidermal necrolysis (TEN) cases. For vitiligo, anti-PD-1/L1 combined with anti-CTLA-4 therapy showed the strongest signal (ROR: 55.89; 95% CI: 42.34-73.78; IC025: 4.73). Palmar-plantar erythrodysesthesia (PPE) was reported with the most significant association with combined anti-PD-1/L1 and VEGF (R)-TKIs (ROR: 18.67; 95% CI: 14.77-23.60; IC025: 3.67). For SJS/TEN, antiPD-1 inhibitors showed the strongest signal (ROR: 3.07; 95% CI: 2.68-3.52; IC025: 1.39). The median onset time of vitiligo and SJS/TEN was 83 and 24 days, respectively. Conclusion: Overall, in selected cutaneous AEs, each of them showed specific characteristics. It is necessary to realize their differences and take appropriate interventions in patients with different regimens.

Drug-induced Stevens Johnson syndrome and toxic epidermal necrolysis: Interpreting the systematic reviews on immunomodulatory therapies.

Drug-induced Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are non-immunoglobulin E-mediated severe cutaneous adverse reactions with a high risk of morbidity, mortality, and physical and mental health impact. These are associated with certain high-risk drugs, human leukocyte antigen (HLA)-specific genotypes and ethnicities. HLA class I-restricted oligoclonal CD8 cytotoxic T-cell responses occur at the tissue level in SJS/TEN. Cytotoxic T cells are the T effector cells that result in keratinocyte apoptosis (cell death) mediated by T effector molecules granzyme B, perforin, granulysin, gamma interferon, tumor necrosis factor-alpha, and lipocalin-2. The clinical hallmarks of SJS/TEN include fever, ≥2 mucosal involvements (ocular, oral, and genital), and positive Nikolsky sign with epidermal detachment. Systematic reviews on immunomodulatory treatments remain limited by the paucity of randomized controlled trials, heterogeneity of studies, and non-standardization of outcome measures. Preventive HLA genotype screening before the prescription of carbamazepine and allopurinol may further reduce the incidence of SJS/TEN. The role of immunomodulatory treatments in SJS/TEN is at present not supported by robust evidence from systematic reviews given the lack of randomized controlled trials. The evidence for improved survival with off-label use of corticosteroids plus intravenous immunoglobulins, ciclosporin plus intravenous immunoglobulins, and ciclosporin alone has not been demonstrated by network meta-analyses and meta-regression. In the real-world clinical setting, systemic corticosteroids (in SJS and overlap SJS/TEN), ciclosporin, and etanercept (in TEN) appear to be the off-label treatments currently most widely used.

Case Reports of Stevens Johnson Syndrome (SJS) Induced by Chemically Unrelated Drugs

Stevens-Johnson syndrome (SJS) is considered as serious mucocutaneous autoimmune disease which is potentially fatal. It may be initiated by medical treatment or infection and sometimes both may be triggering factors. Skin reactions involving loss of skin and mucus membrane and in severe cases, systemic symptoms may be appeared in SJS. In most of the cases medication is the causative factor. Toxic Epidermal Necrolysis (TEN) is a severe form of SJS, as it involves more than 30% of the skin surface with extensive damage to the mucous membranes. SJS and TEN are distinguished based on the extent of the detached skin surface area. It starts with flu-like symptoms, rashes with pain; the upper layer of affected skin dies, sheds and begins to heal after several days. In severe cases, it may leads to life threatening condition. Here we are presenting drug induced SJS in three different cases with different drugs. In first case, a 40-years male treated with Phenytoin 400mg for epilepsy, in second case, a 50-years male was given Amoxicillin + clavulanic acid-625 for some skin lesions and in third case, 50-years old female was given Methotrexate 7.5mg for Rheumatoid arthritis. In all the three cases, SJS symptoms were started within a period of 5-10days. All the symptoms and reactions were noticed and assessed for the confirmations of SJS.

Clinical, diagnostic, and treatment comparisons between Stevens-Johnson syndrome and toxic epidermal necrolysis: review of the literature

Stevens-Johnson syndrome is a rare but serious medical condition, which is classified within the blistering diseases of the skin and mucous membranes. It is characterized by a severe and generalized immune-mediated inflammatory reaction, predominantly affecting the skin and mucous membranes, such as the eyes, mouth and genitalia.

Suspected cutaneous adverse drug reactions reported with traditional medicines: analysis of data for United Nations Asia region from WHO VigiBase.

Background: Data on traditional medicine-induced cutaneous adverse drug reactions (ADRs) is very scarce. The current secondary analysis based on the WHO database (VigiBase) of individual case safety reports (ICSRs) focuses on the suspected cutaneous ADRs linked to traditional medicines (TMs). Methods: All the ICSRs reported between 1st January 2016 and 30th June 2021 from the UN Asia region in VigiBase where at least one TM was suspected to cause cutaneous ADRs were included in the study. Data regarding demographic details, suspected drug, adverse reaction as per MedDRA term, the seriousness of the reaction, de-challenge, re-challenge, and clinical outcome for suspected cutaneous ADRs associated with TM were obtained from VigiBase and analyzed for frequency of reported events and suspected medicines. Findings: Total 3,523 ICSRs with 5,761 ADRs related to "skin and subcutaneous tissue disorders" were included in the analysis. Amongst these, 6.8% of ICSRs were reported as serious. Pruritus (29.6%), rash (20.3%), urticaria (18.9%), and hyperhidrosis (3.3%) were commonly reported ADRs. Artemisia argyi H.Lév. and Vaniot. (14.9%), Ginkgo biloba L. (5.1%), Vitis vinifera L. (4%), Vitex agnus-castus L. (3.8%), Silybum marianum (L.), Gaertn (3.5%), and Viscus album L. (2.7%) were some commonly suspected TMs for cutaneous ADRs. There were 46 cases of Stevens-Johnson syndrome and toxic epidermal necrolysis reported with TMs during the study period. Death was reported in 5 ICSRs. Interpretation: TMs are linked with various cutaneous ADRS ranging from pruritus to toxic epidermal necrolysis which may have serious consequences. TMs listed as suspected offending agents in this analysis, should be kept in mind while dealing with suspected cutaneous ADRs. Clinicians should be more vigilant in detecting and reporting events associated with TMs.

Key factors predicting the in-hospital mortality of patients with severe cutaneous adverse reactions in Thailand.

At present, no predictive models are available to determine the probability of in-hospital mortality rates (HMRs) in all phenotypes of severe cutaneous adverse reactions (SCARs). Our study explored whether simple clinical and laboratory assessments could help predict the HMRs in any phenotypes of SCAR patients. Factors influencing HMRs in 195 adults diagnosed with different SCAR phenotypes were identified, and their optimal cut-offs were determined by Youden's index. Predictive equations for HMRs for all SCAR patients and Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) patients were determined using the exact logistic regression models. Acute generalized exanthematous pustulosis (AGEP) patients were significantly older, with a short time from drug exposure to reaction, and higher neutrophil count compared to SJS/TEN and drug reaction with eosinophilia and systemic symptoms (DRESS, p < 0.001). Peripheral blood eosinophilia, atypical lymphocytosis and elevated liver transaminase enzymes were significantly higher in DRESS. SJS/TEN phenotype, age ≥ 71.5 years, neutrophil-to-lymphocyte ratio ≥ 4.08 (high NLR) and systemic infection were factors predicting in-hospital mortality in all SCAR subjects. The ALLSCAR model developed from these factors demonstrated high-diagnostic accuracy for predicting HMRs in all SCAR phenotypes (area under the receiver-operator curve (AUC) = 0.95). The risk of in-hospital death was significantly increased in SCAR patients with high NLR after adjusting for systemic infection. The model derived from high NLR, systemic infection and age yielded higher accuracy than SCORTEN (AUC = 0.77) for predicting the HMRs in SJS/TEN patients (AUC = 0.97). Being older, having systemic infection, having a high NLR and SJS/TEN phenotype increases ALLSCAR scores, which in turn increases the risk of in-hospital mortality. These basic clinical and laboratory parameters can easily be obtained in any hospital setting. Despite its simple approach, further validation of the model is warranted.

Clinical, diagnostic, and treatment comparisons between Stevens-Johnson syndrome and toxic epidermal necrolysis: review of the literature

Clinical, diagnostic, and treatment comparisons between Stevens-Johnson syndrome and toxic epidermal necrolysis: review of the literature

Anti-Monkeypox Infection Approaches: From Prevention to Therapeutic Lines.

Anti-Monkeypox Infection Approaches: From Prevention to Therapeutic Lines.

Lip Synechia: An Unusual Complication in Stevens–Johnson Syndrome Amenable to Surgical Correction

Lip Synechia: An Unusual Complication in Stevens–Johnson Syndrome Amenable to Surgical Correction

A case of Stevens-Johnson syndrome without skin lesions

A case of Stevens-Johnson syndrome without skin lesions

Adverse cutaneous reactions to psychotropic drugs

IntroductionPsychotropic drugs are not devoid of side effects, especially cutaneous reactions, some of which are severe, and can jeopardize functional and life prognosis. The Aim of this study is to highlight the epidemiological and clinical features of severe cutaneous adverse reactions (SCARs) due to psychotropic drugs. Materials and methodsWe carried out a retrospective study over a period of 10years, It concerned all patients hospitalized in our dermatology department for SCARs induced by psychotropic drugs. The imputability was confirmed by the French methodology of Bégaud et al. ResultsWe identified 41 cases, of which 18 patients (43.9%) were being treated with psychotropic drugs for the first time. The most incriminated psychotropic drugs were: carbamazepine (n=16), phenobarbital (n=8), lamotrigine (n=5). Clinical forms were: drug reaction with eosinophilia and systemic symptoms syndrome (n=30), Stevens–Johnson syndrome (n=4), overlap syndrome (n=1), drug-induced vasculitis (n=4), symmetrical drug-related intertriginous and flexural exanthema syndrome (n=1), photosensitivity (n=1). Complications were as follows: hepatic cytolysis (75%), cholestasis (60%), functional renal failure (43%). Carbamazepine was statistically correlated with renal damage and cholestasis (P=0.013) and phenobarbital was associated with a risk of hepatic cytolysis (P=0.027). ConclusionCutaneous side effects to psychotropic drugs remain rare<2%. In our study, we found that rapid or recent increase in dose of anticonvulsants, or the combination of several psychotropic drugs is the most common cause of SCARs. We also found that carbamazepine was more likely to cause renal damage and cholestasis, whereas chlorpromazine was statistically correlated with hepatic cytolysis.

A Case Report of Phenytoin-Induced Stevens-Johnson Syndrome

Stevens-Johnson syndrome and Toxic epidermal necrosis are acute, self-limited diseases, rare but life-threatening adverse drug reactions. Anti-epileptic drug-induced Steven-Johnson syndrome is a severe cutaneous adverse reaction, among anti-epileptic drugs carbamazepine and phenytoin are the major culprit. We report here a case of Steven-Johnson syndrome due to phenytoin. A 22-year-old female reported the chief complaint of fever and multiple rashes all over the body with skin peeling, gradual onset, and progressive in nature. The reaction was evoked after intake of T. Phenytoin for 1 ½ months. She started heavy skin eruption all over the body for 15 days. She was treated with corticosteroids, anti-microbial, and anti-fungal agents. Healthcare providers must carefully regard the adverse effect of the drug, especially the one that is Steven-Johnson syndrome which is a potentially fatal condition. The most commonly prescribed drug regimen should also be used and continuously monitored to prevent adverse drug reactions. Keywords: Steven-Johnson syndrome, Adverse drug reaction, Phenytoin, Skin eruption