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Dermatology

Stevens-Johnson Syndrome / Toxic Epidermal Necrolysis (SJS/TEN)

A life-threatening severe cutaneous adverse reaction with painful epidermal necrosis or detachment and prominent mucosal disease; treat it as a skin-failure emergency until specialist assessment excludes it.

In a nutshell

SJS/TEN is a life-threatening severe cutaneous adverse reaction: fever and a painful dusky eruption followed by blistering, epidermal detachment and prominent mucosal erosions. Stop the suspected culprit, transfer urgently to specialist skin-failure/burns/ICU care, calculate SCORTEN, involve ophthalmology and provide meticulous supportive care.

Classic presentation

A patient recently started on a high-risk medicine develops fever, painful dusky targetoid macules, blistering or peeling skin and painful oral, ocular or genital erosions.

Key points

  • Painful skin with mucosal erosions and epidermal detachment is the emergency pattern.
  • SJS is under 10% BSA detachment, SJS/TEN overlap 10% to 30% and TEN over 30%.
  • Stop the suspected culprit immediately when clinically safe and document the drug, timing, reaction and future avoidance clearly.
  • Transfer to a specialist skin-failure, burns or dermatology service with ICU capability; do not manage severe disease in a general ward without specialist input.
  • Ophthalmology review is urgent because ocular scarring can cause long-term visual loss.
  • Do not give routine prophylactic systemic antibiotics; use specialist-directed supportive care and treat clinical infection.

First-line investigation

ABCDE and full skin/mucosal assessment with BSA detachment estimate, medicine and infection timeline, baseline blood tests, urgent specialist biopsy and SCORTEN within 24 hours in adults.

Management

Stop culprit and transfer

  • Stop the suspected culprit when clinically safe, call dermatology and transfer urgently to an age-appropriate specialist skin-failure, burns or ICU service.4,1,6

Stabilise and stage severity

  • Perform ABCDE, estimate epidermal detachment, assess mucosal and organ involvement, obtain baseline investigations and calculate SCORTEN within 24 hours in adults.1,3

Support the skin-failure physiology

  • Provide careful fluids and electrolytes, temperature control, nutrition, analgesia, pressure relief, non-adherent wound care and specialist infection prevention.1,3

Protect eyes and mucosa

  • Arrange urgent ophthalmology review and ongoing eye care; protect oral, airway, genital and urinary function with the relevant specialist teams.1,2,3

Treat infection and specialist adjuncts selectively

  • Do not use routine prophylactic antibiotics or an unsupported universal immunomodulatory protocol; treat clinical infection and consider adjuncts only through the specialist MDT.1,7,5

Document lifelong drug safety

  • Record the suspected drug, timing, phenotype, severity and drug classes to avoid, refer for specialist drug-allergy assessment and provide written safety information and follow-up for ocular, mucosal, respiratory and psychological complications.4,2

Exam traps

  • SJS/TEN is usually painful, with mucosal disease; simple urticaria is itchy and does not cause epidermal detachment.
  • A biopsy supports diagnosis but must not delay culprit withdrawal, transfer or supportive treatment.
  • The percentage refers to epidermal detachment, not just the area of erythema.
  • Do not prescribe prophylactic antibiotics simply because the skin barrier is damaged.
  • A suspected culprit must be recorded with the reaction and future avoidance advice; do not rely on a vague 'allergy' label.
  • The eyes need early and repeated specialist review even when the skin findings appear limited.

Illustrations

Confluent epidermal necrosis in SJS/TENA skin-biopsy micrograph showing confluent full-thickness epidermal necrosis with separation at the dermoepidermal junction, the histological substrate of detachment in SJS/TEN.Nephron, Wikimedia Commons · CC-BY-SA-3.0

Key sources

  1. British Association of Dermatologists: UK guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults (UK multidisciplinary adult SJS/TEN guideline covering diagnosis, culprit withdrawal, SCORTEN, specialist care setting, skin, fluid, mucosal, infection and ophthalmic management; published 2016 and accessed 4 August 2026.)Updated 1 Jun 2016
  2. British Association of Dermatologists: SJS/TEN patient information (BAD patient information on SJS/TEN, triggers, multispecialty hospital care, mucosal complications and recovery; November 2023 leaflet accessed 4 August 2026.)Updated 1 Nov 2023
  3. NHS: Stevens-Johnson syndrome (Current NHS information on symptoms, emergency signs, medicine triggers, hospital treatment and complications; accessed 4 August 2026.)
  4. NICE CG183: Drug allergy: diagnosis and management (NICE guidance for recognition, culprit-drug withdrawal, structured documentation, avoidance information and referral after severe non-immediate cutaneous reactions including SJS/TEN; published 3 September 2014 and accessed 4 August 2026.)Updated 3 Sept 2014
  5. British National Formulary (BNF) (BNF online prescribing and adverse-reaction information for suspected culprit medicines, analgesia, fluids, ocular preparations and antimicrobials; current product-specific details must be checked at the point of care; accessed 4 August 2026.)
  6. British Association of Dermatologists: Highly specialised specifications (Current BAD specification stating that patients with SJS/TEN should be cared for in an age-appropriate burns centre or specialised dermatology centre co-located with age-appropriate intensive care; accessed 4 August 2026.)
  7. NICE NG15: Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use (NICE antimicrobial-stewardship principles for avoiding prophylactic or unnecessary antimicrobials, documenting indication and reviewing treatment; published 18 August 2015 and accessed 4 August 2026.)Updated 18 Aug 2015

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.