Retrospective Evaluation of Immunomodulating Therapies in the Management of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis at a Tertiary Burn ICU - European Medical Journal

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Retrospective Evaluation of Immunomodulating Therapies in the Management of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis at a Tertiary Burn ICU

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Dermatology
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Authors:
Kevin Chyung , 1 * Aaron Wang , 1 Nathaniel Bunnell , 1 Evan Mckee , 1 Nicole Case , 1 Caterina Prizio , 1 Sabrina Newman 1
  • 1. University of Colorado School of Medicine, Aurora, Colorado, USA
*Correspondence to [email protected]
Disclosure:

The authors have declared no conflicts of interest.

Acknowledgements:

Chyung and Wang are co-first authors.

Keywords:
Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis, drug hypersensitivity, severe cutaneous adverse reaction.
Citation:
Dermatol AMJ. ;3[1]:59-60. https://doi.org/10.33590/dermatolamj/15561AQ0.

Each article is made available under the terms of the Creative Commons Attribution-Non Commercial 4.0 License.

BACKGROUND AND AIMS

Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are rare, life-threatening cutaneous adverse drug reactions characterized by epidermal detachment and mucosal involvement, with estimated mortality rates ranging from 5% for SJS to 30–50% for TEN.1,2 SJS/TEN is most often triggered by medications such as sulfonamides, antiepileptics, and non-steroidal anti-inflammatory drugs. These conditions are managed primarily through immediate withdrawal of the causative agent and intensive supportive care, yet controversy remains around the role of systemic immunomodulating therapies.3,4

METHODS

To generate risk-adjusted estimates, the authors used Day-1 Score of Toxic Epidermal Necrolysis (SCORTEN) to derive expected mortality rate and calculated the standardized mortality ratio while tracking acute complications in a single-center retrospective cohort admitted to the Burn ICU, University of Colorado Hospital, Aurora, USA, from January 2000–August 2025.5 The authors compared outcomes between supportive care and supportive care with systemic immunomodulation.

RESULTS

Among the 75 patients evaluated (38 immunomodulated; 37 supportive care), there were 6/38 (15.79%) versus 6/37 (16.22%) in-hospital deaths. Based on SCORTEN, expected mortality rates were 7.28 (immunomodulated) and 6.73 (supportive care), yielding standardized mortality ratios (SMR) of 0.82 (95% CI: 0.30–1.79) and 0.89 (95% CI: 0.33–1.94), respectively. The SMR ratio (immunomodulated/supportive) was 0.92 (95% CI: 0.30–2.86; p=0.89). Among immunomodulated patients versus supportive care, sepsis occurred in 9/38 (23.7%) versus 10/37 (27.0%; p=0.79), acute kidney injury in 12/38 (31.6%) versus 12/37 (32.4%; p=1.00), and secondary infection in 14/38 (36.8%) versus 7/37 (18.9%; p=0.12). Among cyclosporine-treated patients (n=14), there was one death, with SMR 0.35 (95% CI: 0.01–1.94). Sepsis occurred in 2/14 (14.3%; cyclosporine-treated) versus 10/37 (27.0%; supportive; p=0.471), acute kidney injury in 5/14 (35.7%) versus 12/37 (32.4%; p=1.000), and secondary infection in 7/14 (50.0%) versus 7/37 (18.9%; p=0.038).

CONCLUSION

The findings highlight the need for careful patient selection when considering systemic immunomodulation in SJS/TEN, particularly given the potential risk of secondary infection. In the future, larger, prospective studies may be required in order to clarify whether cyclosporine may offer a mortality benefit and to better define its safety profile in this high-risk population. These data suggest there is no significant difference in mortality between care plans, but an increase in secondary infection rates with immunomodulation. Cyclosporine remains a viable option, with a moderate reduction in SMR, but more investigation is required to confirm this trend.6,7

References
Shah H et al. Update on Stevens-Johnson syndrome and toxic epidermal necrolysis: diagnosis and management. Am J Clin Dermatol. 2024;25(6):891-908. Micheletti RG et al. Stevens-Johnson syndrome/toxic epidermal necrolysis: a multicenter retrospective study of 377 adult patients from the United States. J Invest Dermatol. 2018;138(11):2315-21. Zimmermann S et al. Systemic immunomodulating therapies for Stevens-Johnson syndrome and toxic epidermal necrolysis: a systematic review and meta-analysis. JAMA Dermatol. 2017;153(6):514-22. Ye L et al. The effect of intravenous immunoglobulin combined with corticosteroid on the progression of Stevens-Johnson syndrome and toxic epidermal necrolysis: a meta-analysis. PLoS One. 2016;11(11):e0167120. Chyung K et al. Retrospective evaluation of immunomodulating therapies in the management of Stevens-Johnson syndrome and toxic epidermal necrolysis at a tertiary burn ICU. Poster 73834. AAD Annual Meeting, March 27-31, 2026. Paradisi A et al. Etanercept therapy for toxic epidermal necrolysis. J Am Acad Dermatol. 2014;71(2):278-83 St John J et al. Successful use of cyclosporin A for Stevens–Johnson syndrome and toxic epidermal necrolysis in three children. Pediatr Dermatol. 2017;34(5):540-46.

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