Dermatological emergencies in ICU: SJS, TEN, and DRESS

Also known as Stevens-Johnson syndrome · Toxic epidermal necrolysis · Drug reaction with eosinophilia and systemic symptoms · Drug-induced hypersensitivity syndrome · Lyell syndrome

Severe cutaneous adverse reactions (SCAR) in ICU. SJS/TEN: epidermal necrolysis, 65-75% drug-induced; SJS under 10% BSA detachment, overlap 10-30%, TEN over 30%; SCAR mortality 10% to over 30%. DRESS (DIHS): delayed drug hypersensitivity (median 22 days) with exanthema, eosinophilia, fever, lymphadenopathy and visceral involvement. Management: stop the culprit drug, expert-centre supportive care (fluids titrated to urine output, nutrition, analgesia, infection prevention, early ophthalmology), SCORTEN on admission and day 3; corticosteroids for DRESS with visceral involvement; AGEP and pharmacogenomics.

high43 referencesUpdated 2 Oct 202632 min readSource-verified · Oct 2026

Checked against its sources on 2 Oct 2026

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8 MCQs

The one-line answer

SJS and TEN are severe cutaneous adverse reactions, 65 to 75 per cent induced by drugs; granulysin from cytotoxic T lymphocytes and NK cells is the key mediator of disseminated keratinocyte death.^[28]^[27] SJS is detachment below 10 per cent of body surface area, SJS-TEN overlap 10 to 30 per cent, TEN above 30 per cent (the 1993 consensus classification).^[41] SCAR mortality ranges from 10 per cent to over 30 per cent; in RegiSCAR, SJS/TEN mortality was 23 per cent at 6 weeks and 34 per cent at 1 year.^[25]^[42] DRESS is a separate delayed hypersensitivity (median onset 22 days after the culprit drug), with eosinophilia in 95 per cent, fever in 90 per cent, lymphadenopathy in 54 per cent and visceral involvement in 91 per cent. Treatment for all three begins the same way: stop the culprit drug — then expert-centre supportive care for SJS/TEN, corticosteroids for DRESS with visceral involvement.^[13]^[14]^[19]^[25]^[28]

Meet the patient

A 68-year-old Han Chinese man started allopurinol three weeks ago for gout. He now has fever, painful oral and ocular mucositis, atypical target lesions, and sheet-like epidermal detachment of 35 per cent body surface area with a positive Nikolsky sign. SCORTEN at 24 hours is 4.^[38]

Two questions decide his survival: what drug did he start in the last month? (withdraw it and everything non-essential now) and is this TEN — does he need burn-unit-level care? (over 30 per cent detachment says yes, and so does the SCORTEN of 4). The clock is already running on his eyes.^[41]^[13]^[17]

SJS vs SJS-TEN overlap vs TEN vs DRESS

Feature	SJS	SJS-TEN overlap	TEN	DRESS (DIHS)
Detached BSA	under 10%	10-30%	over 30% (or over 10% with large sheets and no spots)	Not defined by detachment
Lesions	Widespread erythematous or purpuric macules or flat atypical targets	Widespread purpuric macules or flat atypical targets	With spots, or large epidermal sheets without spots	Exanthema (ubiquitous)
Timing	Risk concentrated in the first few weeks of drug intake	Same	Same	Median 22 days (IQR 17-31)
Mucosa	Involved	Involved	Involved	Mild (56%)
Eosinophilia	—	—	—	95%
Mortality	4.8% (US adults, adjusted)	19.4%	14.8%	2 acute-phase deaths in 117 RegiSCAR cases

^[41] ^[37] ^[19] ^[43]

Acute management of suspected SJS/TEN

STOP all suspected drugs — the strongly implicated culprits are allopurinol (the most common single cause), anti-infective sulphonamides, carbamazepine, phenytoin, phenobarbital, lamotrigine, nevirapine and oxicam NSAIDs. Withdraw ALL non-essential drugs^[37]^[38]
Assess severity — %BSA detached, mucosal sites, organ function. Calculate SCORTEN on admission AND again on day 3 (day-3 score performs best)^[1]^[2]
Burn centre/ICU — transfer as soon as respiratory symptoms and hypoxaemia appear; up to 38% need mechanical ventilation in the acute phase^[13]
Fluid resuscitation — TEN is not a burn: a burn-centre series found mean day-0 crystalloid of 2.2 mL/kg/%TBSA (falling to 1.4 mL/kg/%TBSA by day 2) gave adequate resuscitation — start around 2 mL/kg/%TBSA and titrate to urine output (1.3-1.8 mL/kg/h achieved); a guideline, not a formula^[16]
Nutrition — a large subset need nasogastric feeding because of oral mucosal pain and difficulty swallowing; low threshold for an NG tube; parenteral nutrition if neither oral nor enteral is possible^[13]
Analgesia — acute-phase patients often cannot use PCA and may need opioid infusions^[13]
Infection prevention — a core part of best supportive care; one in two ventilated patients develops VAP^[14]^[15]
Urgent ophthalmology review — ocular involvement threatens sight; early amniotic membrane transplantation in the acute stage suppresses inflammation and averts cicatricial complications^[17]^[18]
Skin care — conservative (aspirate blister fluid, leave detached epidermis to protect the dermis) or surgical (debride, then synthetic dressings, allograft or xenograft); little evidence favours either^[13]
Respiratory — supplemental oxygen, bronchodilators, bronchial aspiration and physical therapy; mechanical ventilation in adult TEN is associated with higher mortality^[13]^[15]

^[13] ^[14] ^[1] ^[2] ^[3]

References43Show

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