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  • Presentation

Management of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: Emergency Treatment, Supportive Care, and Silver Nitrate

Description

The talk emphasized that Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are true dermatologic emergencies requiring immediate recognition and treatment without waiting for biopsy results. It reviewed epidemiology, common triggers such as allopurinol, anticonvulsants, lamotrigine, abacavir, nevirapine, and mycoplasma in children, along with pathogenesis involving cytotoxic T-cell activation, Fas ligand, granulysin, and keratinocyte apoptosis. Key red flags include mucositis, blistering, skin detachment, Nikolsky sign, fever, dyspnea, hypotension, leukopenia, and worsening labs such as elevated CRP, LDH, or sodium. Management centers on stopping the culprit drug, hospitalizing the patient, assessing comorbidities especially renal function, and providing aggressive supportive care: fluid and electrolyte replacement, nutrition, airway protection, pain control, anticoagulation, gastric prophylaxis, and careful care of eyes, mucosa, and genitalia. Systemic treatments discussed included corticosteroids, IVIG, cyclosporine, anti-TNF therapy such as etanercept, and plasmapheresis in refractory cases. A major focus was skin care using silver nitrate spray and nonadherent dressings, with the speaker describing favorable experiences using silver nitrate directly on denuded skin and reporting no signs of toxicity when monitored appropriately. Ocular management was highlighted as crucial, including ophthalmology consultation and amniotic membrane transplantation to reduce inflammation and prevent blindness. The presentation concluded with an algorithm: suspect the diagnosis, stop the drug, calculate severity scores, transfer severe cases to ICU or a burn center, begin early clinical treatment, and tailor therapy to comorbidities and available resources.

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Conclusions

  • Stevens-Johnson syndrome and toxic epidermal necrolysis are true dermatologic emergencies that require immediate recognition and treatment based on clinical suspicion rather than waiting for biopsy results.
  • The first and most important intervention is prompt discontinuation of the culprit drug, followed by early specialist dermatology assessment and transfer to higher-level care when body surface area involvement is extensive.
  • Supportive care remains the foundation of management, including fluid and electrolyte replacement, nutrition, pain control, airway/renal monitoring, and protection of eyes, mucosa, and genital sites.
  • Systemic corticosteroids are presented as the most widely used and effective initial therapy, especially when given early in pulse regimens.
  • Cyclosporine appears to be a useful treatment option that may reduce progression, systemic complications, and mortality, particularly when combined with steroids.
  • Etanercept is suggested to be a promising anti-TNF therapy with rapid clinical improvement and favorable survival outcomes, especially as part of combination treatment with corticosteroids.
  • IVIG may help in some cases by blocking Fas-mediated apoptosis, but its overall effectiveness is described as controversial and it does not reliably prevent ocular damage.
  • For severe or refractory cases, plasmapheresis is proposed as an option that can lower inflammatory mediators such as IL-6, IL-8, and TNF-alpha.
  • Topical silver nitrate spray is presented as an innovative wound-care strategy that may reduce pain and simplify skin management without the need for frequent dressing changes.
  • Early ophthalmologic intervention, including amniotic membrane transplantation in selected patients, is important for preventing long-term ocular sequelae such as blindness.
  • Severity scoring and laboratory markers, especially SCORTEN, CRP, LDH, and sodium, help predict prognosis and identify patients at risk of deterioration.
  • Overall, the talk concludes that best outcomes depend on rapid diagnosis, drug withdrawal, risk stratification, aggressive supportive care, and selective use of innovative therapies such as etanercept and topical silver nitrate.
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