Management of Lacosamide‑Induced Stevens‑Johnson Syndrome / Toxic Epidermal Necrolysis

Immediate Reporting and Pharmacovigilance

The British Journal of Dermatology recommends stopping lamotrigine immediately upon suspicion of SJS, as lamotrigine is one of the most notorious causative agents for this life-threatening reaction 6, 7
Document all medications taken in the prior 2 months, including over-the-counter preparations, to identify potential causative agents 6
Calculate SCORTEN within the first 24 hours of admission to predict mortality risk, which uses 7 clinical parameters including age, BSA involvement, heart rate, serum glucose, bicarbonate, BUN, and presence of malignancy 6
Patients with >10% body surface area (BSA) epidermal loss must be transferred without delay to a burn center or ICU experienced in managing extensive skin loss 6, 7
Rapid admission to specialized centers is associated with improved survival, while delayed transfer increases mortality 6

Initiate fluid replacement using the formula: body weight (kg) × % BSA epidermal detachment = mL/hour, which is significantly less aggressive than burn formulas (Parkland) 7
Monitor for end-organ hypoperfusion while avoiding fluid overload 7
Cleanse wounds regularly with warmed sterile water, saline, or chlorhexidine (1:5000) 7
Apply greasy emollients (50% white soft paraffin with 50% liquid paraffin) over all skin, including denuded areas 7
Avoid prophylactic systemic antibiotics; only institute antimicrobial therapy if clinical signs of infection develop (confusion, hypotension, reduced urine output, oxygen desaturation, increased skin pain) 7
Provide continuous enteral nutrition via oral route or nasogastric tube if oral intake is precluded by buccal mucositis, delivering 20-25 kcal/kg daily during the early catabolic phase 8, 9
Use the WHO analgesic ladder approach for pain management, providing adequate background simple analgesia for comfort at rest 10, 8

For Grade 3-4 SJS/TEN, first-line systemic treatment is IV methylprednisolone 0.5-1 mg/kg for Grade 3, or 1-2 mg/kg for Grade 4, tapering when toxicity resolves 11
High-dose IVIG (2-3 g/kg over 3-5 days, typically 1 g/kg/day for 3 days) may be added in severe or steroid-unresponsive cases 11

74% of SJS/TEN patients develop acute ocular involvement (conjunctivitis, pseudomembrane formation, corneal/conjunctival epithelial defects) 12, 10, 8
Obtain ophthalmology consultation immediately, as 50-63% of patients with acute involvement develop chronic complications (severe dry eyes, trichiasis) 12, 10, 8

Do not delay transfer to specialized care, as this is associated with increased mortality 6
Do not use prophylactic antibiotics indiscriminately, as this increases Candida colonization and promotes resistant organisms 7
Do not underestimate fluid requirements but also avoid overaggressive resuscitation using burn formulas 7

SCORTEN score predicts mortality: score of 0-1 = 3.2% mortality, score of 5+ = 90% mortality 6
Re-epithelialization may occur within days or take weeks to complete 7