Severe Cutaneous

Adverse Drug
Reactions
(SCARs)

Epidemiology

SCARs
SJS

TEN

DRESS

AGEP

SJS/TEN


% BSA

Steven Johnson Syndrome (SJS)

<10% BSA

5%

50

- ex.Herpes, Mycoplasma
pneumoniae
-
- Graft versus host disease
6

Toxic Epidermal Necrolysis (TEN)

SJS

80-95 %
>30% BSA

 SJS TEN

SJS

10%

Overlap
SJS/TEN

10%
- 30%

SJS

TEN

30%

SJS

SJS/TEN
Symptom
- 50 (prodrome) 1-14

-

- 1-14 > 2
5
- Onset 1-6
- Nikolsky' sign = positive

SJS/TEN
Mucous membrane involvement
- : conjunctivitis , corneal ulcer,
keratitis,
- : hemorrhagic crusts
, gray-white
membranes
- : vagina
, urethra
- :

10

 SJS/TEN

11

 SJS/TEN

Stevens-Johnson syndrome (SJS) Toxic

Epidermal Necrolysis (TEN)

12

 SJS/TEN
allopurinol

carbamazepine, phenobarbital, phenytoin lamotrigine

NSAIDs ibuprofen, meloxicam, piroxicam tenoxicam

HIV non-nucleoside reverse transcriptase inhibitor nevirapine

containing products
13

 SJS/TEN
co-trimoxazole, sulfadiazine, sulfadoxine, sulfafurazole,
sulfamethoxazole sulfasalazine

amoxicillin

rifampicin

Dapsone
14

Stevens- Johnson syndrome

15

** score > 3
admit ICU**

16

Specific Treatment

SJS / TEN Care Map

of Chiangrai Prachanukroh Hospital
17

Specific Treatment

18

Specific Treatment

19

Specific Treatment

20

Specific Treatment

21

DRESS syndrome

22

DRESS syndrome
Drug hypersensitivity syndrome :DHS

Drug Rash with Eosinophilia and Systemic Syndrome

:DRESS syndrome

Anticonvulsant Hypersensitivity Syndrome (AHS)

23

DRESS syndrome

Skin Rash

Blood count
abnormality

Internal organ
involvement
24

DRESS syndrome
Internal organ
involvement

>> Hepatitis: ()
transaminase, alkaline phosphatase,
bilirubin
>> Nephritis: ()
hematuria, acute renal injury,
granulomatous interstitial nephritis
>> Lymphadenopathy
>> Myocarditis
>> Pericarditis
>> Pneumonitis

25

26

Diagnosis
At least 3 of these
criteria should be
present for DRESS.
27

Diagnosis

28

Diagnosis
DHS/DRESS 3 (level of evidence:
IV)
1. (macule/
patch) (papule/ plaque)
2. Complete blood count eosinophil 1,500 /..
atypical lymphocyte
3. 1
a. 2 .
b. transaminase 2
c. Interstitial nephropathy
d. Interstitial lung disease
e. Myocardial involvement
DHS/DRESS
1 3
29

Treatment
1. (grade of
recommendation: A)
2.
paracetamol
antihistamines hydroxyzine, chlorpheniramine
fluid and electrolyte imbalance

30

Treatment
3. Systemic corticosteroids therapy
(level of evidence: IV, grade of recommendation: B)
prednisolone
1-2 ././

internal
organ
involvement

2-4

cyclosporine, N-acetylcysteine
(level of evidence: IV,grade of recommendation: C)
31

Acute Generalized
Exanthematous
Pustulosis
(AGEP)
32

(AGEP)

Neutrophil

7 x 109

33

 AGEP
amoxicillin, clindamycin, erythromycin, metronidazole, cotrimoxazole

carbamazepine

nonsteroidal antiinflamatory agents

1-5

34

(AGEP) : Diagnosis

Score interpretation
0 = no
1-4 = possible
5-7 = probable
8-12 = definitive acute generalized
exanthematous pustulosis.

35

Treatment
The main treatment is removal of the causative drug, which
leads to improvement in symptoms within several days.
Moist dressings and antiseptic solutions are appropriate during
the pustular phase to help prevent infection.
Antibiotics should be avoided, unless a superinfection of the
pustules occurs.
Topical corticosteroids may be appropriate for treatment of
pruritus and inammation in prolonged cases.
Treatment with potent topical corticosteroids has been
correlated with decreased duration of hospitalization.
Patients have been treated with systemic corticosteroids;
however, evidence that systemic corticosteroids reduce disease duration
is unclear.
36

37