Derm Cases · Dermatology / Emergency Medicine / Critical Care
OSCE — suspected SJS/TEN: drug stop, SCORTEN, BSA and emergency care
An 8-minute OSCE station on recognition of SJS/TEN, immediate drug withdrawal, BSA classification, SCORTEN prognostication, fluid strategy, and multidisciplinary supportive care including eyes and mucosa.
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Study tools
Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station on recognition of SJS/TEN, immediate drug withdrawal, BSA classification, SCORTEN prognostication, fluid strategy, and multidisciplinary supportive care including eyes and mucosa.
Brief (to candidate)
A 45-year-old woman develops painful dusky macules, blistering and sheet-like epidermal detachment involving about 25% BSA five days after starting allopurinol and a course of co-trimoxazole. She has oral erosions, photophobia and fever. You have 8 minutes for emergency assessment, classification, prognostication and initial management.
[1]Candidate instructions
- Recognise SJS/TEN spectrum and grade by % BSA detachment.
- Stop all suspected culprit drugs immediately; list high-risk drug classes.
- Calculate or list SCORTEN variables.
- Outline ABC / fluid / wound / infection supportive care (and fluid pitfall vs burns).
- Arrange eyes, mucosa, urology/gynaecology and ICU/burn-unit disposition.
- Mention HLA risk context where relevant (e.g. carbamazepine/allopurinol ancestry).
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Recognition | Severe mucocutaneous reaction with full-thickness necrosis and ≥2 mucosal sites; positive Nikolsky concept; not simple drug rash[1] |
| BSA classification | SJS <10%, overlap 10–30%, TEN >30% detached/detachable epidermis — this case ~25% = SJS–TEN overlap[1] |
| Immediate action | STOP all suspected drugs now (allopurinol, co-trimoxazole); do not wait for biopsy to stop culprit |
| SCORTEN | Lists variables: age >40, malignancy, HR >120, initial BSA >10%, urea >10 mmol/L, glucose >14 mmol/L, bicarbonate <20 mmol/L; score predicts mortality; recalculate at 72 h[2] |
| Supportive care | Airway/haemodynamics; reduced (not full Parkland) fluid vs burns; sterile wound care; early sepsis vigilance; analgesia; nutrition; stop unnecessary lines |
| Organ-specific | Urgent ophthalmology (chronic eye morbidity); oral/genital care; avoid silver sulfadiazine if sulphonamide culprit suspected |
| Genetics / communication | Notes HLA-B*1502 (carbamazepine, SE Asian ancestry) and HLA-B*5801 (allopurinol) risk context; documents drug allergy permanently; MDT/ICU transfer[3][4] |
Model key actions
- Diagnose SJS–TEN overlap (~25% BSA) with multi-site mucositis; stop culprit drugs immediately.[1]
- Apply SCORTEN, escalate to high-dependency/burn-capable unit, prioritise eyes and sepsis prevention.[2][4]
- Avoid fluid over-resuscitation; no delay for unproven systemic immunomodulation before supportive stabilisation.
Common errors
- Continuing the culprit drug.
- Giving full burn-formula (Parkland) fluids.
- Missing ocular emergency review.
- Labelling as “viral exanthem” or mild SJS without BSA/SCORTEN.
- Delaying transfer while awaiting biopsy or experimental therapies.
References4ShowHide
- [1]Frantz R, Huang S, Are A, Motaparthi K. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Review of Diagnosis and Management. Medicina (Kaunas), 2021.PMID 34577817
- [2]Bastuji-Garin S, Fouchard N, Bertocchi M, Roujeau JC, Revuz J, Wolkenstein P. SCORTEN: a severity-of-illness score for toxic epidermal necrolysis. Journal of Investigative Dermatology, 2000.PMID 10951229
- [3]Chung WH, Hung SI, Hong HS, et al. Medical genetics: a marker for Stevens-Johnson syndrome (HLA-B*1502). Nature, 2004.PMID 15057820
- [4]Meledathu S, Gordon M, Thornton M, Ashinoff R. Management of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: A Comprehensive Review. Journal of Drugs in Dermatology, 2023.PMID 37943271