Severe cutaneous adverse reactions and burn-centre care — Rapid

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.

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.

Acute skin failure

Hypothermia, tachycardia, hypotension, oliguria, confusion, severe pain, expanding detachment or hypoxia indicates barrier and organ failure regardless of the named SCAR.

Investigation priorities

Medicine chronology and causality assessmentFirst step

Identify the likely culprit quickly enough to reduce ongoing injury.

Management branches

First-line emergency sequenceStop culprit and transfer early

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.

Key medicines

White soft paraffin and liquid paraffin 50:50 ointmentApply gently over intact and denuded epidermis after warmed cleansing and whenever the surface dries, generally at least every 4 hours during acute specialist care.

Weight-adjusted LMWH thromboprophylaxisGive the hospital protocol's prophylactic subcutaneous dose once daily, adjusted for body weight and renal function, while mobility is substantially reduced unless contraindicated.

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