Synopsis
Recognise SJS/TEN, DRESS and AGEP early, stop the most likely culprit safely, distinguish epidermal loss from mimics, and deliver multidisciplinary skin-failure, mucosal, ocular and organ care through the appropriate specialist centre.
- SJS/TEN typically causes prodrome, disproportionate skin pain, dusky macules or atypical targets, flaccid blisters, epidermal detachment and prominent ocular, oral or genital erosions.
- Classify by detached or detachable surface: SJS below 10%, overlap 10% to 30%, and TEN above 30%; extent can evolve after presentation and must be remapped.
- DRESS usually emerges two to eight weeks after starting a culprit with fever, widespread eruption, facial oedema, nodes, eosinophilia or atypical lymphocytes and liver, kidney, lung or cardiac injury.
- Build a calendar of every medicine started, increased, intermittently taken or stopped in the previous two months, including antimicrobials, anticonvulsants, allopurinol, analgesics and non-prescription products.
- Withdraw likely culprit treatment immediately but do not create avoidable harm by indiscriminately stopping physiological corticosteroid, antiseizure cover or another essential medicine without a safe substitute.
- SJS/TEN care prioritises culprit withdrawal and meticulous multidisciplinary support; no single systemic immunomodulator has conclusive superiority over high-quality conservative care in the UK guideline.
- Early ophthalmology, daily eye, mouth and urogenital review, respiratory surveillance, individualised fluids, enteral nutrition, pain control and non-traumatic wound care prevent lifelong disability as well as death.
- Do not give routine prophylactic systemic antibiotics; culture strategically and treat clinical infection, because indiscriminate exposure selects Candida and resistant colonisation.
- Document the exact culprit and drugs to avoid, notify every care setting and report through MHRA Yellow Card; specialist allergy input is needed when causality remains uncertain or broad avoidance compromises care.
Key red flags
Skin pain, epidermal tenderness, dusky or blistering targets, positive shearing, any mucosal erosion, facial oedema with fever, eosinophilia or organ injury, pustules with systemic illness, hypotension, hypoxia, oliguria, confusion, rising transaminases, myocarditis symptoms or a rapidly spreading eruption requires same-day hospital and dermatology assessment.
Hypothermia, tachycardia, hypotension, oliguria, confusion, severe pain, expanding detachment or hypoxia indicates barrier and organ failure regardless of the named SCAR.
Investigation priorities
Identify the likely culprit quickly enough to reduce ongoing injury.
Management branches
Painful blistering, epidermal loss or severe mucositis raises SJS/TEN or another SCAR.
- Stop the likely culprit immediately, preserve essential treatment with safe alternatives, assess ABCDE and airway, weigh the patient and map skin and every mucosal site.
- Contact dermatology, critical care and the regional specialised service early; arrange care in an age-specific Burns Centre or dermatology centre co-located with intensive care.
- Obtain histology and immunofluorescence biopsies, FBC, metabolic and organ profiles, cultures and imaging without delaying transfer or supportive treatment.
- Calculate SCORTEN within 24 hours, record causality reasoning and notify ophthalmology immediately so the first formal eye examination occurs within 24 hours.