Management of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

Classification and Assessment

The management of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) is based on the extent of epidermal detachment rather than the affected surface area, as this figure has greater prognostic value 1, 2
SJS is defined as epidermal detachment of <10% body surface area (BSA) plus widespread purpuric macules or flat atypical targets 3
Overlap SJS-TEN is defined as detachment of 10-30% BSA plus widespread purpuric macules or flat atypical targets 3, 4
TEN is defined as detachment of >30% BSA with or without widespread purpuric macules or target lesions 3, 5
When assessing patients with suspected SJS/TEN, both the extent of erythema AND the extent of epidermal detachment should be recorded separately on a body map 1, 6
Epidermal detachment includes both: already detached epidermis (visible erosions and blisters) and detachable epidermis (areas with positive Nikolsky sign) 1, 2

The percentage of epidermal detachment is used in the SCORTEN scoring system to predict mortality 8
Patients with >10% BSA epidermal detachment should be admitted without delay to a burn center or ICU with experience in treating SJS/TEN 8
The approach to wound management differs based on the extent of epidermal detachment: conservative approach for limited detachment and surgical approach for detachment >30% BSA with clinical deterioration 8

Use the Lund and Browder chart to estimate the percentage of BSA involved 1, 2
Document both erythema and epidermal detachment separately, as they represent different aspects of the disease 1, 2
Monitor for progression of detachment, as this indicates worsening disease 8

Staphylococcal scalded skin syndrome has a more superficial level of skin cleavage and can be differentiated on skin biopsy 4
The Nikolsky sign is demonstrated when gentle lateral pressure causes lesional, detachable epidermis to slide over the dermis 7