UK guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis 2016

Creamer D, Walsh SA , Dziewulski P, Exton LS, Lee HY, Dart JKG, Setterfield J, Bunker CB, Ardern-Jones MR, Watson KMT,
Wong GAE, Philippidou M, Vercueil A, Martin RV, Williams G, Shah M, Brown D, Williams P, Mohd Mustapa MF, Smith CH.
Br J Dermatol 2016; 174: 1194-1227 & J Plast Reconstr Aesthet Surg 2016; 69: e119-e153.
Initial assessment on · Take a detailed history from the patient and/or relatives
presentation · Perform a full physical examination, including baseline body weight and record the vital signs,
including oxygen saturation
· Order a set of investigations: FBC, U&E, LFT, glucose, magnesium, phosphate, bicarbonate,
mycoplasma serology, CXR, skin biopsy and baseline body weight
· Initiate a primary management plan:
1. establish peripheral venous access
2. if patient cannot maintain adequate nutrition orally, insert a nasogastric tube and institute
nasogastric feeding
3. insert a urinary catheter if urogenital involvement is causing significant dysuria/retention
(Strength of recommendation D (GPP))
Determination of drug · Identify causative agent and withdraw immediately
causality (Strength of recommendation D)
Prognostic scoring · Calculate SCORTEN within the first 24 hours
(Strength of recommendation C)
Care setting · A multi-disciplinary team should be convened, co-ordinated by a specialist in skin failure, usually
dermatology and/or plastic surgery, and including clinicians from intensive care, ophthalmology
and skin-care nursing
· Patients with greater than 10% BSA epidermal loss should be admitted without delay to a Burn
Centre or ICU with experience of treating patients with SJS/TEN and facilities to manage the
logistics of extensive skin loss wound care
· Patients must be barrier-nursed in a side room controlled for humidity, on a pressure-relieving
mattress with the ambient temperature raised to between 25° and 28°C
(Strength of recommendation D (GPP))
Skin management · Employ strict barrier nursing to reduce nosocomial infections
regimen 1 · Take swabs for bacterial and candidal culture from three areas of lesional skin, particularly
sloughy or crusted areas, on alternate days throughout the acute phase
Applicable to all patients · Administer systemic antibiotics only if there are clinical signs of infection
in all settings (Strength of recommendation D (GPP))
Skin management Institute a conservative approach in all patients as follows:
regimen 2 · Regularly cleanse wounds and intact skin by irrigating gently using warmed sterile water, saline
or an antimicrobial such as chlorhexidine (1/5000)
This may involve a · Apply a greasy emollient, such as 50% white soft paraffin with 50% liquid paraffin (50/50
conservative and/or WSP/LP), over the whole epidermis, including denuded areas
surgical approach based · Apply a topical antimicrobial agent to sloughy areas only (choice should be guided by local
on the specialist multi- microbiological advice). Consider Ag-containing products/dressings.
disciplinary team’s daily
· The detached, lesional epidermis may be left in situ to act as a biological dressing. Blisters
review of the individual should be decompressed by piercing and expression or aspiration of tissue fluid.
needs of the patient
· Apply non-adherent dressings to denuded dermis (suitable dressings include Mepitel™ or
Telfa™).
· A secondary foam or burn dressing should be used to collect exudate (suitable dressings include
Exu-Dry®).

Consider transfer to a Burn Centre in patients with TEN (>30% BSA epidermal loss) and
evidence of the following: clinical deterioration, extension of epidermal detachment, sub-
epidermal pus, local sepsis, wound conversion and/or delayed healing. In a Burn Centre
conservative measures may be supplemented with a surgical approach.
· Remove necrotic/loose infected epidermis and clean wounds using a topical antimicrobial agent
(e.g. betadine or chlorhexidine) under general anaesthetic
· Consider debridment with VersajetTM
· Physiological closure with Biobrane/ allograft /xenograft skin in patients with early presentation
involving non infected and large confluent areas
(Strength of recommendation D (GPP))
Fluid replacement · Site venous lines through non-lesional skin, whenever possible, and change peripheral venous
regimen cannulas every 48 hours
· Monitor fluid balance carefully: catheterize if appropriate/necessary
· Establish adequate intravenous fluid replacement initially. Fluid replacement can be guided by
urine output and other endpoint measurements. Individualized fluid management should be
adjusted on a daily basis.
· With improvement of SJS/TEN mouth involvement, oral administration of fluids should be
progressively increased
(Strength of recommendation D)
Nutrition regimen · Provide continuous enteral nutrition throughout the acute phase
· Deliver up to 20 to 25 kcal/kg/day during the early, catabolic phase and 25 to 30 kcal/kg/day
during the anabolic, recovery phase
(Strength of recommendation C)
Analgesia · Use a patient appropriate validated pain tool to assess pain in all conscious patients at least once
a day
· Patients should receive adequate analgesia to ensure comfort at rest, with the addition of
supplementary opiates, as required
· Additional analgesia may be needed to address increased pain associated with patient handling,
re-positioning and dressing changes
(Strength of recommendation D (GPP))
Supportive Therapeutic · Immobile patients should receive low molecular weight heparin
Measures · Patients in whom enteral nutrition cannot be established should receive a proton pump inhibitor
to reduce the risk of stress-related gastro-intestinal ulceration
· Neutropenic patients may benefit from recombinant human G-CSF
(Strength of recommendation C)
Treatment of eye · Daily ophthalmological review is necessary during the acute illness
involvement · Apply an ocular lubricant (e.g. non-preserved hyaluronate or carmellose eye drops) every two
hours through the acute illness
· Ocular hygiene must be carried out each day by an ophthalmologist or ophthalmic-trained nurse
· Application of topical corticosteroid drops (e.g. non-preserved dexamethasone 0.1% twice a day)
may reduce ocular surface damage
· Administer a broad-spectrum topical antibiotic as prophylaxis (e.g. moxifloxacin drops four times
a day) in the presence of corneal fluorescein staining or frank ulceration
· In the unconscious patient, prevention of corneal exposure is essential
(Strength of recommendation D (GPP))
Treatment of mouth · Daily oral review is necessary during the acute illness
involvement · Apply white soft paraffin ointment to the lips every two hours through the acute illness
· Clean the mouth daily with warm saline mouthwashes or an oral sponge
· Use an anti-inflammatory oral rinse or spray containing benzydamine hydrochloride every three
hours, particularly before eating
· Use an anti-septic oral rinse containing chlorhexidine twice a day
· Use a potent topical corticosteroid mouthwash (e.g. betamethasone sodium phosphate) four
times a day
(Strength of recommendation D (GPP))
Treatment of urogenital · Daily urogenital review is necessary during the acute illness
involvement · Apply white soft paraffin ointment to the urogenital skin and mucosae every four hours through
the acute illness
· Use a potent topical corticosteroid ointment once a day to the involved, but non-eroded, surfaces
· Use a silicone dressing (e.g. MepitelTM) to eroded areas
(Strength of recommendation D (GPP))
Treatment of airway · Respiratory symptoms and hypoxaemia on admission should prompt early discussion with an
involvement intensivist and rapid transfer to an ICU or Burn Centre, where fibre-optic bronchoscopy should be
undertaken
(Strength of recommendation D (GPP))
Active therapy · If active therapy is instituted it should be given, ideally, under the supervision of a specialist skin
failure MDT in the context of clinical research and/or case registry
(Strength of recommendation D)
Discharge and follow-up · Give the patient written information about drug(s) to avoid
· Encourage the patient to wear a MedicAlert bracelet
· Drug allergy should be documented in the patient’s notes; all doctors involved in the patient’s
care should be informed
· Report the episode to the national pharmacovigilance authorities
· Organize an out-patient clinic appointment, and if required an ophthalmology out-patient
appointment, within a few weeks of discharge
· Refer for review to unit with appropriate sub-speciality interest
(Strength of recommendation D (GPP))
Diagnostic testing · Routine drug hypersensitivity testing is not recommended following an episode of SJS/TEN.
· Seek specialist advice on hypersensitivity testing where:
1. the culprit drug is not known or
2. medication avoidance is detrimental to the individual or
3. accidental exposure is possible
(Strength of recommendation D (GPP))