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Presentation

Inpatient Dermatology Cases: Toxic Epidermal Necrolysis, Fixed Drug Eruption, and DRESS Syndrome

Description

This talk reviewed inpatient dermatology consult cases focusing on severe drug reactions that can mimic one another. The first case was a man initially thought to have toxic epidermal necrolysis because of widespread targetoid plaques, skin detachment, and full-thickness epidermal necrosis on biopsy, but the atypical five-month prodrome, minimal mucosal involvement, interface dermatitis with eosinophils, and recurrence of new lesions after acetaminophen exposure led to a final diagnosis of generalized bullous fixed drug eruption. The speaker emphasized careful medication history, the characteristic rapid onset after exposure, recurrence at the same sites, and the danger of re-challenge. The second case was a woman with fever, erythroderma, facial edema, conjunctival injection, eosinophilia, and hepatitis after leflunomide exposure, consistent with DRESS syndrome. She improved with systemic corticosteroids but relapsed when tapered too quickly, and her course was complicated by a perforated duodenal ulcer, severe infection, and death from septic shock. The presentation highlighted that severe DRESS is especially concerning with long half-life drugs, that early recognition lowers mortality, and that management may require prolonged steroid tapers, topical or systemic therapy depending on severity, and occasionally steroid-sparing agents such as mycophenolate, cyclosporine, IVIG, or newer targeted therapies.

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Conclusions

Generalized bullous fixed drug eruption can closely mimic Stevens-Johnson syndrome or toxic epidermal necrolysis, so careful attention to lesion morphology, mucosal involvement, and medication timing is essential.
In patients with widespread bullous eruptions and minimal mucositis, recurrent round violaceous plaques with burning pain and rapid reactivation after re-exposure strongly support fixed drug eruption over TEN.
Acetaminophen and NSAIDs are important triggers to consider in suspected generalized bullous fixed drug eruption, and a positive rechallenge can confirm the diagnosis when it is safe to observe.
Early recognition of generalized bullous fixed drug eruption matters because it is a dangerous condition with substantial ICU use, prolonged recovery, and nontrivial mortality.
Drug-induced hypersensitivity syndrome/DRESS should be suspected when rash is accompanied by eosinophilia, hepatitis, fever, and recurrence during steroid taper.
Severe DIHS can be prolonged and worse when caused by drugs with long half-lives, making prompt discontinuation and sustained immunosuppression especially important.
Systemic corticosteroids remain a mainstay for significant DRESS/DIHS, but tapering too quickly can lead to relapse and requires close follow-up.
More severe or persistent DIHS may benefit from adjunct steroid-sparing therapies such as mycophenolate or other immunomodulators when inflammation cannot be controlled with steroids alone.
Academic inpatient dermatology teams improve outcomes by integrating clinical pattern recognition with pathology and medication review to avoid anchoring on an initial diagnosis.
Overall, the cases highlight that many severe inpatient eruptions are diagnostically deceptive, and repeated reassessment over time is often necessary to reach the correct conclusion.

Paumann M, Reinkemeier F, Lehnhardt M, Mockenhaupt M. Case report: Generalized bullous fixed drug eruption mimicking epidermal necrolysis. Front Med (Lausanne). 2023 Aug 14;10:1125754.#10.3389/fmed.2023.1125754
Chen et al. (as cited on the DIHS Mortality slide).
Kridin et al. (as cited on the DIHS Mortality slide).