eMedicine Specialties > Emergency Medicine > Allergy & Immunology

Stevens-Johnson Syndrome: Follow-up

Author: Steven J Parrillo, DO, FACEP, FACOEP, Associate Professor, Emergency Medicine, Jefferson Medical College and Philadelphia College of Osteopathic Medicine; Medical Director, Department of Emergency Medicine, Einstein Elkins Park; Chair, Emergency Management Committee, Albert Einstein Healthcare Network; Medical Director, Disaster Medicine and Management Masters Program, Philadelphia University
Coauthor(s): Catherine V Parrillo, DO, FACOP, FAAP, Clinical Assistant Professor, Department of Pediatrics, Philadelphia College of Osteopathic Medicine
Contributor Information and Disclosures

Updated: Jun 1, 2009

Follow-up

Further Inpatient Care

  • Saline compresses may be applied to the eyelids, lips, and nose.
  • Careful daily inspection is necessary to monitor for secondary superinfections.
  • Prophylactic systemic antibiotics are not useful, especially in the current era of multiple-drug resistance.
  • Antimicrobials are indicated in cases of urinary tract or cutaneous infections, either of which may lead to bacteremia.

Further Outpatient Care

  • Although patients with erythema multiforme minor may be treated as outpatients with topical steroids, those with erythema multiforme major (ie, Stevens-Johnson syndrome) must be hospitalized.
  • Cases of erythema multiforme minor must be followed closely. Some authors recommend daily follow-up.

Transfer

  • Patients with Stevens-Johnson syndrome (SJS) are often critically ill; therefore, they must be admitted to hospitals capable of delivering critical care.
  • Some patients may require the services of a burn unit.
  • Transfer criteria would be the same as for patients with thermal burns.

Deterrence/Prevention

  • Patients must avoid any future exposure to agent(s) implicated in the occurrence of Stevens-Johnson syndrome (SJS). Recurrences are possible.

Complications

  • Ophthalmologic - Corneal ulceration, anterior uveitis, panophthalmitis, blindness
  • Gastroenterologic - Esophageal strictures
  • Genitourinary - Renal tubular necrosis, renal failure, penile scarring, vaginal stenosis
  • Pulmonary - Tracheobronchial shedding with resultant respiratory failure
  • Cutaneous - Scarring and cosmetic deformity, recurrences of infection through slow-healing ulcerations

Prognosis

  • Individual lesions typically should heal within 1-2 weeks, unless secondary infection occurs. Most patients recover without sequelae.
  • Development of serious sequelae, such as respiratory failure, renal failure, and blindness, determines prognosis in those affected.
  • Up to 15% of all patients with Stevens-Johnson syndrome (SJS) die as a result of the condition.
  • The SCORTEN score looks at a number of variables and uses them to prognosticate risk factors for death in both SJS and TEN. The variables include the following:
    • Age >40 years
    • Malignancy
    • Heart rate >120
    • Initial percentage of epidermal detachment >10%
    • BUN level >10 mmol/L
    • Serum glucose level >14 mmol/L
    • Bicarbonate level <20 mmol/L
  • Mortality rates are as follows:
    • SCORTEN 0-1 >3.2%
    • SCORTEN 2 >12.1%
    • SCORTEN 3 >35.3%
    • SCORTEN 4 >58.3%
    • SCORTEN 5 or more >90%

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • The gravity of the diagnosis must be recognized. Because patients with Stevens-Johnson syndrome (SJS) who present early in the development of the disease may not yet be critically ill, the clinician may misdiagnose and discharge. SJS should be considered in all patients with target lesions and mucous membrane involvement.
  • Provide close follow-up and clear instructions.
  • When discharging a patient home, clearly document the degree (%) of skin involvement, the absence of mucous membrane lesions, and any clinical signs of toxicity.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous editor, Charles V Pollack, Jr, MD, to the development and writing of this article.



More on Stevens-Johnson Syndrome

Overview: Stevens-Johnson Syndrome
Differential Diagnoses & Workup: Stevens-Johnson Syndrome
Treatment & Medication: Stevens-Johnson Syndrome
Follow-up: Stevens-Johnson Syndrome
Multimedia: Stevens-Johnson Syndrome
References
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References

  1. French LE. Toxic epidermal necrolysis and Stevens Johnson syndrome: our current understanding. Allergol Int. Mar 2006;55(1):9-16. [Medline].

  2. Bastuji-Garin S, Fouchard N, Bertocchi M, et al. SCORTEN: a severity-of-illness score for toxic epidermal necrolysis. J Invest Dermatol. Aug 2000;115(2):149-53. [Medline].

  3. Hillebrand-Haverkort ME, Budding AE, bij de Vaate LA, van Agtmael MA. Mycoplasma pneumoniae infection with incomplete Stevens-Johnson syndrome. Lancet Infect Dis. Oct 2008;8(10):586-7. [Medline].

  4. Hallgren J, Tengvall-Linder M, Persson M, et al. Stevens-Johnson syndrome associated with ciprofloxacin: a review of adverse cutaneous events reported in Sweden as associated with this drug. J Am Acad Dermatol. Nov 2003;49(5 Suppl):S267-9. [Medline].

  5. Metry DW, Lahart CJ, Farmer KL, Herbert AA. Stevens-Johnson syndrome caused by the antiretroviral drug nevirapine. J Am Acad Dermatol. Feb 2001;44(2 Suppl):354-7. [Medline].

  6. Mockenhaupt M, Messenheimer J, Tennis P, et al. Risk of Stevens-Johnson syndrome and toxic epidermal necrolysis in new users of antiepileptics. Neurology. Apr 12 2005;64(7):1134-8. [Medline].

  7. Halevy S, Ghislain PD, Mockenhaupt M, Fagot JP, Bouwes Bavinck JN, Sidoroff A, et al. Allopurinol is the most common cause of Stevens-Johnson syndrome and toxic epidermal necrolysis in Europe and Israel. J Am Acad Dermatol. Jan 2008;58(1):25-32. [Medline].

  8. Schneck J, Fagot JP, Sekula P et al. Effects of treatments on the mortality of Stevens-Johnson syndrome and toxic epidemal necrolysis: A retrospective study on patients included in the prospective EuroSCAR Study. J Am Acad Dermatol. Jan 2008;58(1):33-40. [Medline].

  9. Hebert AA, Bogle MA. Intravenous immunoglobulin prophylaxis for recurrent Stevens-Johnson syndrome. J Am Acad Dermatol. Feb 2004;50(2):286-8. [Medline].

  10. Ball R, Ball LK, Wise RP, et al. Stevens-Johnson syndrome and toxic epidermal necrolysis after vaccination: reports to the vaccine adverse event reporting system. Pediatr Infect Dis J. Feb 2001;20(2):219-23. [Medline].

  11. Brett AS, Philips D, Lynn AW. Intravenous immunoglobulin therapy for Stevens-Johnson syndrome. South Med J. Mar 2001;94(3):342-3. [Medline].

  12. Cunha BA. Antibiotic side effects. Med Clin North Am. Jan 2001;85(1):149-85. [Medline].

  13. French LE, Trent JT, Kerdel FA. Use of intravenous immunoglobulin in toxic epidermal necrolysis and Stevens-Johnson syndrome: our current understanding. Int Immunopharmacol. Apr 2006;6(4):543-9. [Medline].

  14. Garcia-Doval I, LeCleach L, Bocquet H, et al. Toxic epidermal necrolysis and Stevens-Johnson syndrome: does early withdrawal of causative drugs decrease the risk of death?. Arch Dermatol. Mar 2000;136(3):323-7. [Medline].

  15. Hofbauer GF, Burg G, Nestle FO. Cocaine-related Stevens-Johnson syndrome. Dermatology. 2000;201(3):258-60. [Medline].

  16. Lonjou C, Thomas L, Borot N, Ledger N, de Toma C, LeLouet H. A marker for Stevens-Johnson syndrome ...: ethnicity matters. Pharmacogenomics J. Jul-Aug 2006;6(4):265-8. [Medline].

  17. Parrillo SJ. Stevens-Johnson syndrome and toxic epidermal necrolysis. Curr Allergy Asthma Rep. Jul 2007;7(4):243-7. [Medline].

  18. Prais D, Grisuru-Soen G, Barzilai A, Amir J. Varicella zoster virus infection associated with erythema multiforme in children. Infection. Jan-Feb 2001;29(1):37-9. [Medline].

  19. Revuz J. New advances in severe adverse drug reactions. Dermatol Clin. Oct 2001;19(4):697-709, ix. [Medline].

  20. Schalock PC, Dinulos JG. Mycoplasma pneumoniae-induced Stevens-Johnson syndrome without skin lesions: fact or fiction?. J Am Acad Dermatol. Feb 2005;52(2):312-5. [Medline].

  21. Stevens AM, Johnson FC. A new eruptive fever associated with stomatitis and opthalmitis. Report of two cases in children. Am J Dis Child. 1922;526-533.

  22. Todd G. Adverse cutaneous drug eruptions and HIV: a clinician's global perspective. Dermatol Clin. Oct 2006;24(4):459-72, vi. [Medline].

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Further Reading

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Keywords

Stevens-Johnson syndrome, SJS, erythema multiforme major, immune-complex–mediated hypersensitivity complex, mucosal scarring, esophageal strictures, corneal ulceration, anterior uveitis, keratitis, panophthalmitis, vaginal stenosis, penile scarring, SCORTEN score, upper respiratory tract infection,mucocutaneous lesions, rash, urticarial lesions, vulvovaginitis, balanitis, toxic epidermal necrolysis, TEN

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Contributor Information and Disclosures

Author

Steven J Parrillo, DO, FACEP, FACOEP, Associate Professor, Emergency Medicine, Jefferson Medical College and Philadelphia College of Osteopathic Medicine; Medical Director, Department of Emergency Medicine, Einstein Elkins Park; Chair, Emergency Management Committee, Albert Einstein Healthcare Network; Medical Director, Disaster Medicine and Management Masters Program, Philadelphia University
Steven J Parrillo, DO, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Osteopathic Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Catherine V Parrillo, DO, FACOP, FAAP, Clinical Assistant Professor, Department of Pediatrics, Philadelphia College of Osteopathic Medicine
Catherine V Parrillo, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Medical Editor

Daniel J Dire, MD, FACEP, FAAP, FAAEM, Clinical Associate Professor, Department of Emergency Medicine, University of Texas-Houston
Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, and Association of Military Surgeons of the US
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Matthew M Rice, MD, JD, FACEP, Senior Vice President, Chief Medical Officer, Northwest Emergency Physicians; Assistant Clinical Professor of Medicine, University of Washington at Seattle
Matthew M Rice, MD, JD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Washington State Medical Association
Disclosure: Team Health  Salary Employment

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

 
 
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