Severe Cutaneous Adverse Reactions in Hospitalized Patients: Diagnosis, Mimickers, and Management

The talk reviewed severe cutaneous adverse reactions (SCARs) in hospitalized patients, focusing on DRESS and SJS-TEN, their triggers, clinical features, pathology, mimickers, and treatment. DRESS is a delayed T-cell–mediated reaction often triggered by anticonvulsants, antibiotics, or allopurinol, typically presenting 2 to 6 weeks after exposure with morbilliform rash, facial edema, fever, lymphadenopathy, eosinophilia or atypical lymphocytosis, and organ involvement most commonly affecting the liver. A case illustrated how DRESS can initially resemble SJS-TEN; the patient had mucosal pain, rash, and initially negative eosinophilia after steroid treatment, but later developed eosinophilia and transaminitis, meeting RegiSCAR criteria for definite DRESS. The speaker emphasized that DRESS can present as erythema multiforme-like or targetoid disease and that biopsy can help with prognosis and excluding mimics. Management includes stopping the culprit drug, supportive care, and systemic corticosteroids for severe disease; IVIG is not supported as monotherapy and is better considered adjunctive or reserved for refractory cases. Steroid-sparing therapies such as cyclosporine and JAK inhibitors may eventually replace steroids, while others like IL-5, IL-4/13 inhibition, and IVIG are more adjunctive. The second major topic was SJS-TEN, a related SCAR with shorter latency, dusky macules, epidermal detachment, mucosal involvement, and characteristic histology of subepidermal blistering with confluent epidermal necrosis. A GBFDE case highlighted key clinical distinctions from SJS-TEN: sharply demarcated recurrent lesions in the same sites, preserved oral mucosa, and classic “dinner plate” plaques. For SJS-TEN, the speaker discussed etanercept as a promising therapy with evidence for faster re-epithelialization and possible mortality benefit, though certainty remains low; newer investigational options include JAK inhibition and other targeted therapies. The talk concluded by calling for randomized controlled trials, standardized outcomes, and precision-medicine approaches to guide future SCAR management.