Report

Stevens-Johnson syndrome and toxic epidermal necrolysis: a

retrospective descriptive study
Osward Y. Carrasquillo, MD, MPH, Marely Santiago-Vazquez, MD, Rocio Cardona, MD,
Mariana Cruz-Manzano, MD and Luz D. Figueroa, MD

Department of Dermatology, University of Abstract

Puerto Rico School of Medicine, San Juan, Background Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are
Puerto Rico
rare and potentially life-threatening mucocutaneous reactions. Given their rarity, limited
Correspondence
cohort studies have been done. The aim of this study is to evaluate and compare the
Osward Y. Carrasquillo, MD, MPH demographics, etiology, management, clinical and laboratory characteristics, complications,
PO Box 365067 and outcome of SJS/TEN patients seen by the inpatient dermatology service at the
San Juan PR 00936-5067 University of Puerto Rico.
Puerto Rico
Methods A retrospective review of 30 cases with identified diagnosis of SJS, overlap SJS/
E-mail: ocarrasquillo5@gmail.com
TEN, or TEN who were consulted to the Dermatology Department of the University of
Conflict of interest: The authors have no
Puerto Rico from 2006 to 2017.
conflict of interest to disclose. Results A total of 24 adult and six pediatric cases were reviewed. Females were
predominant with a female to male ratio of 1.3 : 1. The most frequent offending drugs
doi: 10.1111/ijd.14493 identified were antibiotics (56.7%), anticonvulsants (23.3%), and nonsteroidal anti-
inflammatory drugs (NSAIDs) (16.7%) with the most frequent antibiotic identified being
trimethoprim/sulfamethoxazole (23.3%). Seventy percent of patients experienced at least
one complication, most often of infectious etiology (80.1%). During hospital course, 73%
received pharmacologic therapy (23% received IVIG alone, 17% received steroids alone,
and 33% both) versus 27% which received only supportive care. Mortality rate in this study
was 13.8%. When comparing SCORTEN at day one of admission, deceased cases had a
mean SCORTEN at day 1 of 4.0, while survivors had an average of 1.54 (P < 0.001).
Conclusion Antibiotics followed by anticonvulsants were the most frequently offending
drugs identified within this study.

partial to full thickness epidermal necrosis. Subepidermal bulla

Introduction
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis
(TEN) are acute, potentially fatal forms of drug-induced hypersen-
1,2
sitivity reactions. Most cases are preceded by a prodromal of
upper respiratory tract symptoms, fever, and malaise for 1–
3 days followed by manifestation of painful, erythematous,
dusky-red, or purpuric amorphous macules that may progress to
flaccid blisters, hemorrhagic erosions, and associated mucosal
involvement.1,3 Once considered separate clinical entities, these
are now considered different variants within the same disease
spectrum differing only by the extent of skin detachment.
Whereas less than 10% of body surface area (BSA) involvement
classifies under SJS, SJS/TEN overlap falls under 10–30% BSA
involvement while more than 30% BSA involvement defines
TEN.4 Although there are no accepted diagnostic criteria for SJS/
TEN, diagnosis is usually based on clinical assessment as well
as histopathological findings. Histopathologically, the hallmark of
SJS/TEN is the presence of apoptotic keratinocytes resulting in
and minimal dermal inflammatory infiltrate may also be seen.1,2,5
SJS/TEN can occur in patients at any age yet it is more com-
monly observed in women with a female to male ratio of 1.5 : 1.3
The overall combined incidence of SJS, SJS/TEN overlap and
TEN is estimated at 2–7 per million cases annually worldwide.6–9
Medications such as antibiotics, allopurinol, NSAIDs, and aro-
matic anticonvulsants are the most frequently incriminated trig-
gers with the highest risk of onset occurring within the initial
weeks of treatment, ranging from 7 to 21 days.3 For anticonvul-
sants, risk is greatest within the first 2 months of treatment.10
Other causes reported are infections, such as Mycoplasma pneu-
monia and Herpes simplex virus, immunizations, and contrast
medium.3,11 Given the rarity of SJS/TEN, there is a lack of large-
scale epidemiological studies in the United States, particularly
within the hispanic population. This hospital-based retrospective
study aims to study the demography, offending drugs, treatment,
complications, and outcome in patients with SJS/TEN within the
Puerto Rican population. 1

ª 2019 The International Society of Dermatology International Journal of Dermatology 2019

2 Report Stevens-Johnson syndrome and toxic epidermal necrolysis
Material and methods
We retrospectively reviewed the medical records of cases of
SJS, overlap SJS/TEN, and TEN that were treated in our two
university hospitals, University of Puerto Rico Pediatric Hospital
and University of Puerto Rico District Hospital, from January
2006 to December 2017. Data collected from medical records
included: age at the time of the admission, gender, allergies,
possible causative agents, diagnosis (SJS, overlap SJS/TEN, or
TEN), comorbidities, skin lesions onset, mortality probability
(determined by the SCORTEN scale on days 1 and 3 of admis-
sion), management, complications, and services consulted,
among others. Data collection and statistical analysis were done
using Statistical Package for the Social Sciences (SPSS)
version 25. Descriptive statistics were performed; ANOVA and
v2 tests were used as statistical tests for comparison between
variables, and P < 0.05 was considered to indicate a statistically
significant difference. The University of Puerto Rico Institutional
Review Board granted approval for the study.
Results
A total of thirty cases including three (10%) of SJS, 10 (33%) of
SJS/TEN overlap, and 17 (57%) of TEN were assigned to the der-
matology inpatient consult service from January 2006 to Decem-
ber 2017. The average age of patients was 35.9  21.7 years,
with a range from 2 to 81 years. Of the thirty cases, 56.7% were
female and 43.3% were male, with a female to male ratio of
1.3 : 1. All patients had workup done to rule out other uncommon
but possible etiologies of SJS/TEN such as infections (including
Herpes simplex and Mycoplasma pneumoniae, among others),
immunizations, and contrast media. Clinically, all patients pre-
sented with erythematous areas with bullae formation and ero-
sions. Extension of the lesions ranged from 5% to 90% of body
surface area. A Nikolsky’s sign was positive in 100% of cases.
Fifty percent of the patients had a previous history of drug allergy
to one or more medications, most commonly to trimethoprim/sul-
famethoxazole (23.3%), followed by ciprofloxacin (16.7%). Two
cases caused by trimethoprim/sulfamethoxazole and one case
caused by piperacillin/tazobactam already had history of allergy
to the culprit medication. The majority of the patients (26; 86.7%)
had at least one comorbidity. The most common conditions were
hypertension (33.3%), asthma (23.3%), type II diabetes mellitus
(13.3%), and epilepsy (10%).
Possible causative agents were administered for an average of
13.1 (ranging from 1 to 42) days prior to the onset of symptoms.
The mean time that implicated drugs were stopped was
1.05 days after the onset of skin symptoms. The most probable
culprit drugs were antibiotics, anticonvulsants, and nonsteroidal
anti-inflammatory drugs (NSAIDs) with 56.7%, 23.3%, and
16.7%, respectively. To confirm drug causality, ALDEN score
was calculated (Table 1). In one case (3.3%), the cause was not
identified. Of the 17 cases caused by antibiotics, seven (41.1%)
International Journal of Dermatology 2019
Carrasquillo et al.
were because of trimethoprim/sulfamethoxazole. Among the
seven cases caused by anticonvulsants, lamotrigine was the
most common (n = 4; 57.1%). When the culprit drug was anticon-
vulsants, the patients developed skin lesions an average of
32.9 days after initiating the medication, whereas NSAIDs and
antibiotics caused skin lesions 1.8 days (P = 0.009) and 8.6 days
(P = 0.001) after starting the causative drug, respectively.
Twenty-five patients (83.3%) arrived to the emergency room
(ER) within 5 days of the onset of skin lesions. Two patients
(6.7%) were already admitted because of other causes when
skin lesions appeared. Upon arrival to the ER, 44% of patients
had greater than 30% of BSA involvement, meeting diagnostic
criteria for TEN. All patients were admitted to the hospital. The
majority of them (70%) had an average hospital stay of 6 days
or more. SCORTEN was calculated on day one and day three
of hospital admission to determine prognosis. On day one of
admission, the average of SCORTEN was 1.9  1.3. SCOR-
TEN on day 3 was calculated in 20 patients with an average of
1.7  0.9. In 10 cases, SCORTEN at day 3 was not calculated
either because the patient was discharged home due to mild
disease and arrest of progression or due to death. A total of
43.3% patients were transferred to the intensive care unit (ICU)
during the hospitalization. All patients were found to have muco-
sal involvement, most commonly oral and ocular mucosa in
86.7% and 63.3% of cases, respectively. Genital, nasal, and
anal mucosa involvement was identified in fewer cases. All
patients were admitted by the internal medicine or pediatrics
service depending on the age. In 80% of cases, more than one
service was consulted. The most consulted service was oph-
thalmology (73.3%). Other commonly consulted services were
infectious disease, general surgery, obstetrics/gynecology, and
wound care with 30%, 26.7%, 26.7%, and 23.3%, respectively.
Twenty-one patients had at least one complication during the
admission (Table 2). The most common complication was of
infectious etiology (81%). Among the patients who were compli-
cated by an infection bacteremia, sepsis or septic shock was
seen in 47.1% and urinary tract infection in 23.5%. Other com-
plications included elevated transaminases (19%) and acute
kidney injury (14.3%). With regards to pathology, all cases had
a biopsy done with SJS/TEN stated as the most likely diagno-
sis. Twenty-four detailed pathology reports were available. Infil-
trate was described in the biopsies of 21 cases as sparse
(n = 19) or moderate (n = 2) while epidermal necrosis was
described as confluent/extensive (n = 11), moderate (n = 10),
or minor (n = 3); type of infiltrate was not specified.
The major systemic treatments used in addition to supportive
therapy included either corticosteroids or IVIG. Ninety percent
of patients required local wound care, which included vaseli-
nated gauzes, mupirocin ointment to periorificial areas, mouth
wash (mixture of diphenhydramine, viscous lidocaine, and cal-
cium carbonate), and silver sulfadiazine. Nearly all of the
patients were not debrided (96.7%). Prior to dermatologic evalu-
ation, 46.7% of patients were administered methylprednisolone
ª 2019 The International Society of Dermatology
Carrasquillo et al. Stevens-Johnson syndrome and toxic epidermal necrolysis Report 3

Table 1 Description of cases based on most probable culprit drug

Skin lesions
Possible causative agent Number of cases ALDEN scorea Agec Gender onset (days)c Diagnosis

Antibiotics
Trimethoprim/sulfamethoxazole 7 Very probable (7) 39.6 4 M, 3 F 9 4 TEN, 2 overlap, 1 SJS
Amoxicillin and amoxicillin/clavulanate 4 Probable (2) 39.5 1 M, 3 F 15.7b 1 TEN, 3 overlap
Possible (2)
Ciprofloxacin 2 Very probable (1) 74 2F 2 1 TEN, 1 SJS
Probable (1)
Ceftriaxone 1 Very probable 26 F 1 TEN
Piperacillin/tazobactam 1 Probable 74 M 4 TEN
d
Azithromycin 1 2 M N/A Overlap
Moxifloxacin 1 Probable 63 F 10 TEN
Anticonvulsants
Lamotrigine 4 Very probable (3) 17.3 3 M, 1 F 41 2 TEN, 1 overlap, 1 SJS
Possible (1)
Phenytoin 2 Very probable (1) 19 1 M, 1 F 28.5 1 TEN, 1 overlap
Probable (1)
Phenobarbital 1 Very probable 2 M 9 TEN
NSAIDs
Naproxen 2 Probable (1) 40 2F 1 2 TEN
Possible (1)
Nabumetone 2 Very probable (1) 38 1M, 1 F 2.5 1 TEN, 1 overlap
Probable (1)
Ibuprofen 1 Possible 39 F 2 Overlap
e
Not determined 1 24 F N/A TEN

ALDEN, algorithm of drug causality in epidermal necrolysis; M, male; F, female; TEN, toxic epidermal necrolysis; SJS, Stevens-Johnson syn-
drome; NSAIDs, nonsteroidal anti-inflammatory drugs.
a
According to criteria by Sassolas et al.45
b
Based on three patients.
c
Average: cases where more than one patient was affected.
d
Could not be calculated accurately as index day was not available. Other causes of SJS/TEN such as infections and immunizations were
excluded.
e
Could not be calculated as patient had multiple suspicious medications as possible causes of her condition.

Table 2 Complications in patients with SJS, overlap SJS/ administration and outcome was found (P = 0.708). After initia-
TEN, and TEN tion of treatment, most of the patients (83.3%) had arrest in pro-
gression within 1–10 days.
Type of SJS Overlap SJS/ Total A total of 25 patients were discharged home, and four cases
complication (%) TEN (%) TEN (%) (%) ended in death of the patient. We were not able to find the out-
come of one patient upon revision of the medical record. All
Renal 1 (3.3) 0 (0) 2 (6.7) 3 (10)
Pulmonary 0 (0) 2 (6.7) 6 (20) 8 (26.7) patients discharged home were completely recovered and were
Intubated 0 (0) 1 (3.3) 3 (10) 4 (13.3) not on any medication at the time of the discharge. During hos-
Hepatic 1 (3.3) 1 (3.3) 3 (10) 5 (16.7) pital course, 60% received IVIG, 48% received steroids, 44%
Infectious 2 (6.7) 2 (6.7) 13 (43.3) 17 (56.7) were admitted to the ICU and more than half (64%) experienced
Hematologic 1 (3.3) 3 (10) 13 (43.3) 17 (56.7)
complications. When comparing SCORTEN at day one of
Cardiac 0 (0) 0 (0) 1 (3.3) 1 (3.3)
admission, deceased cases had a mean SCORTEN at day 1 of
SJS, Stevens-Johnson syndrome; TEN, toxic epidermal necrolysis. 4.0, while survivors had an average of 1.5 (P < 0.001). Mortality
rate in this study was 13.8% (4/29) and included one case of
sodium succinate 60–125 mg IV every 6–8 hours for 1 day. No SJS/TEN overlap and three cases of TEN. Detailed description
association between steroid use and outcome was observed of fatal cases is illustrated on Table 3.
(P = 0.941). A total of 17 cases received intravenous
immunoglobulin (IVIG). In one case, we were unable to deter-
Discussion
mine if a patient was treated with IVIGs, as the information was
missing. The dosage of IVIG was 3–4 g/kg total by continuous SJS and TEN are rare and serious dermatologic emergencies
infusion over 3–5 days. No association between IVIG most often secondary to drug reactions.1,2 To our knowledge,

ª 2019 The International Society of Dermatology International Journal of Dermatology 2019

4 Report Stevens-Johnson syndrome and toxic epidermal necrolysis Carrasquillo et al.

Table 3 Description of fatal cases

SCORTEN
day 1/day
Gender Age Culprit drug 3 Comorbidities Complications Treatment for SJS/TEN

F 24 Not 4/–b Asthma, malignancy Anemia, hypoalbuminemia, sepsis Supportive carec

determineda (Aspergillus fumigatus), pulmonary
aspergillosis, renal failure
M 65 Amoxicillin/ 3/–b Type II diabetes mellitus, Anemia, sepsis, respiratory distress IV steroids, IVIG,
clavulanate hypertension, malignancy requiring mechanical ventilation supportive carec
M 74 Piperacillin/ 3/3 Type II diabetes mellitus, Anemia, hypoalbuminemia, pulmonary IV steroids, supportive carec
tazobactam hypertension edema, sepsis (Morganella
morgana)
F 67 Ciprofloxacin 3/3 Type II diabetes mellitus, Sepsis (Pseudomonas aeruginosa), IVIG, supportive carec
hypertension, asthma dysphagia, hypoalbuminemia

SCORTEN, severity-of-illness scale for toxic epidermal necrolysis; SJS, Stevens-Johnson syndrome; TEN, toxic epidermal necrolysis; F,
female; M, male; IV, intravenous; IVIG, intravenous immunoglobulin.
All patients had diagnosis of TEN (BSA > 30%).
a
Patient with multiple suspicious medications and other possible causes for SJS/TEN.
b
Both patients died at day three.
c
Supportive treatment included wound care, IV fluids, pain control, and nutritional support.

there is a lack of epidemiological studies that have described
the clinical characteristics of Latin Americans/Hispanic patients
with SJS/TEN. In this hospital-based retrospective study, we
present the clinical characteristics, treatment, and outcome of
SJS and TEN in 30 patients treated in our two university-based
hospitals from January 2006 to December 2017 within the
Puerto Rican population.
In our study, the age of patients with SJS/TEN was widely
distributed with a female predominance, consistent with previ-
ous studies.3 Although SJS/TEN represent different spectrums
within the same clinical entity, SJS is reported to be more com-
mon than TEN with an annual incidence of 1.2–6 and 0.4–1.9
per million people worldwide annually, respectively.3 However,
we found that cases of TEN (57%) were more frequently
reported than those of SJS (10%). This could be explained by
the fact that our study was done on tertiary level institutions.
The most common cause of SJS/TEN are medications. As
seen in large multinational case–control studies, the most com-
monly implicated medications for SJS and TEN are allopurinol,
anticonvulsants (including lamotrigine), antibacterial sulfon-
amides, nevirapine, and oxicam.12 Other possible nondrug-re-
lated causes reported are infections, such as Mycoplasma
pneumonia and Herpes simplex virus, immunizations, and con-
trast medium.3,11 Several clinical risk factors have been
described including older age,13 genetic susceptibility associated
to specific HLA alleles, and immunocompromised states such as
HIV infection14 and hematologic malignancy.12,15,16 Given that
genetic susceptibility associated with specific HLA alleles has
been demonstrated in East Asian populations,17–19 race/ethnicity
are also thought to play an important role in the pathogenesis of
the disease. Although the exact pathogenesis that induces skin
damage is not fully understood, it is suggested that upon
exposure to certain types of drugs or drug metabolites, predis-
posed individuals mount an immune response to a neoantigenic
drug tissue complex that results in massive keratinocyte apopto-
sis.10,20 The secretion of granulysin by cytotoxic CD8 T-cells and
natural killer cells as well as increased interaction between FAS
ligand and FAS death receptor on keratinocytes are thought to
play a major role on keratinocyte apoptosis.3,20–24 Antibiotics
(56.7%), especially trimethoprim/sulfamethoxazole, were the
most commonly identified drugs in our patients. This was followed
by anticonvulsants (23.3%), most commonly lamotrigine. This dif-
fers from other studies where anticonvulsants, especially carba-
mazepine, represent the drug most commonly associated with
SJS/TEN.1,25 Additionally, in contrast to large multinational case–
control studies, allopurinol was not identified as a causative
agent.12 This might be related to our small sample size and the
study being from only one institution.
Skin manifestations begin approximately 7–21 days after initia-
tion of the causative drug in first exposure cases while re-expo-
sure to a drug that previously caused SJS or TEN can produce
skin changes within 2 days of initiating; therefore, prompt identifi-
cation of the offending drug is an important and difficult task.
Delayed withdrawal of the causative drug increases mortality.26
An average of 13.1 (1–42) treatment days prior to symptom onset
was described in our study. In addition to mucocutaneous mani-
festations, systemic involvement was commonly seen in multiple
cases including sepsis, septic shock, hepatitis, renal dysfunction,
and respiratory failure. Sepsis, respiratory failure, and multiple
organ failure are the most common causes of in-hospital death,
which is consistent with our findings.27
The severity and mortality risk of patients with SJS/TEN
depend mainly on the amount of skin detachment. Several pre-
dictors of mortality have been described which include:

International Journal of Dermatology 2019 ª 2019 The International Society of Dermatology

Carrasquillo et al.
increasing age, increasing number of chronic conditions, infec-
tion, hematologic malignancy, and renal failure.27 Given mas-
sive transdermal fluid loss and hypercatabolic state,
hypoalbuminemia, anemia, and electrolyte imbalances may also
be observed. The prognosis of individual patients can be evalu-
ated by applying SCORTEN.1,28,29 SCORTEN is an SJS/TEN-
specific severity of illness score that has been validated for use
on days one and three of hospitalization that can help deter-
mine the clinical setting for management of patients as well as
survival prognosis.29,30 It is based on seven independent risk
factors that include: age >40, tachychardia (>120 bpm), malig-
nancy, initial presentation of skin detachment >10%, serum urea
>10 mM, serum glucose >14 mM, and serum bicarbonate
<20 mM. In a survival analysis cohort, the average mortality rate
at 1 year reported is 24% for SJS, 43% for SJS/TEN overlap,
and 49% for TEN, with infections (S. aureus and P. aeruginosa)
recognized as the most common cause of death.31
During hospitalization, calculation of SCORTEN on day one
and day three was performed to evaluate prognosis and to aid
in the decision of referral to an intensive care unit. Highly spe-
cialized dermatology units are the preferable treatment units for
patients with SJS/TEN, but if not available, transfer to a burn
unit or intensive care ward with daily dermatologic consultation
is the next preferred form of management.11 In our study, 43%
of patients were admitted to the ICU in the absence of a burn
unit. There were four fatal cases, SCORTEN scores on day one
of admission for all cases were ≥3. This implies a 35.8% or
greater risk of mortality.29 As seen in our study, higher scores
were seen to correlate with mortality.
Considering the potentially fatal outcomes associated with
SJS/TEN, optimal medical management consists of early diag-
nosis alongside immediate discontinuation of the causative drug
and rapid initiation of supportive care.1 Beyond supportive care,
there is no established therapy for SJS/TEN. Fluid and elec-
trolyte replacement, wound care, nutritional support, pain con-
trol, and monitoring for superinfections are examples of
supportive care that should be considered when dealing with
these patients. A consensus regarding a specific therapy for
SJS and TEN is yet to be determined due in part to the low
prevalence of cases and, therefore, limited literature.1,3
Immunosuppressive and immunomodulating therapies sug-
gested for the management include systemic corticosteroids,
intravenous immune globulins, and cyclosporine.32 However,
their use is controversial, and none have been adequately stud-
ied in prospective, controlled clinical studies mainly due to the
low incidence and high mortality rate of SJS/TEN. Some studies
have associated the use of corticosteroids with increased mor-
tality, infection, and duration of hospital stay.33,34 On the other
hand, some studies have reported a beneficial role with early
administration of corticosteroids in high doses or in combination
with IVIG to produce a synergistic effect that will arrest disease
progression and shorten healing time.35 However, two subse-
quent studies did not confirm the survival benefit of systemic
ª 2019 The International Society of Dermatology
Stevens-Johnson syndrome and toxic epidermal necrolysis Report 5
corticosteroid use.31,36 The role of intravenous immunoglobulins
for the management of SJS/TEN is also controversial.29,37,38
Some studies suggest the use of high dose (1–2 g/kg) IVIG as
an alternative treatment to reduce mortality rate.39–41 However,
subsequent studies have not been able to demonstrate consis-
tently a significant reduction in mortality rate compared to other
treatment modalities mainly because of variations between
treatment modalities (low vs. high dose) and timing of adminis-
tration between the different cases reported.42,43 In our study,
56.7% of cases received IVIG, and we did not find a statistical
significance between IVIG and outcome. By blocking ker-
atinocyte apoptosis, treatment with IVIG has shown significant
potential for treating SJS and TEN.41,44 Most studies suggest
IVIG be administered at a total dose of >2 g/kg administered
over 3–4 days to reduce TEN associated mortality. At our insti-
tution, we use IVIG 3–4 g/kg total by continuous infusion over
3–5 days for SJS/TEN. Other beneficial effects include short-
ened healing time, minimal side effects, and increased dosage
associated with increased survival rate.41,44 Few studies have
managed to demonstrate, while taking into account gender and
comorbidities, whether a positive outcome in SJS and TEN
patients can be attributed to clinical characteristics and early
treatment.
Our study was limited by its retrospective nature, which
impeded patient follow-up for further complications and hindered
the consideration of patient comorbidities potentially influencing
patient outcome. Another limitation is that the study was from a
tertiary center only. Although SJS and TEN are associated with
a low prevalence rate, our small sample size limited the breadth
of our analysis. Additionally, data retrieval also represents a
possible limitation in our study as in some cases information
was not included on medical chart.
In conclusion, Stevens-Johnson Syndrome (SJS) and toxic
epidermal necrolysis (TEN) are rare and potentially fatal cuta-
neous eruptions most commonly attributed to adverse drug
reactions. In our study, antibiotics were the most common
impugned drugs followed by anticonvulsants. Immediate identifi-
cation and removal of the possible causative agents is a key
part of management, which gives way to expedited therapy.
The calculation of a SCORTEN on day 1 and 3 is an accurate
measure for prognosis and mortality rate, whereas SCORTEN
score ≥3 demonstrates an increased risk of mortality. Due to
the low prevalence of SJS and TEN cases, no consensus has
been made regarding a specific form of therapy, although
immediate elimination of the suspected drug, admission to a
specialized dermatologic or burn unit (ICU in cases where the
aforementioned locations are unavailable), expedited supportive
care, and vigilance for complications are conventional recom-
mendations. In our study, 86.2% (25/29) of patients survived of
which more than half received IVIG, which is considered to be
an adequate and immediate form of management associated
with a high survival rate while corticosteroid use remains contro-
versial.
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6 Report Stevens-Johnson syndrome and toxic epidermal necrolysis Carrasquillo et al.

Johnson syndrome and toxic epidermal necrolysis.

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