see also: [[Rash]] See: [Systemic drug reactions with skin involvement: Stevens-Johnson syndrome, toxic epidermal necrolysis, and DRESS.](bookends://sonnysoftware.com/ref/DL/205925) [SJS presenting with ocular symptoms malpractice case](https://expertwitness.substack.com/p/stevens-johnson-syndrome-presenting) > [!key points] > - Key to diagnosis of SJS-TEN is recognising involvement of **2 or more mucosal surfaces** > - eyes and lips/mouth most common > - Look for acute conjunctivitis occurring *before* or simultaneously with skin eruptions accompanied by extremely high fever and oral and nail involvement; in [one study](https://pubmed.ncbi.nlm.nih.gov/19243825/), acute conjunctivitis occurred before the skin eruptions in 42/94 patients! > - supportive care: > - fluid and electrolyte losses > - hypothermia > - secondary bacterial infection > - loss of albumin > - high output cardiac failure in elderly > - secondary ARDS, multiple organ failure most common causes of death ## DDx - erythema multiforme (affects < 10% BSA) - staph scalded skin (more superficial, less sick, usually an infant) - scarlet fever (streptococcal origin, no blistering) - toxic shock syndrome (less severe rash ,superficial peeling rather than full thickness denudation) - acute graft vs host disease - severe bullous drug eruption (patient less sick) - drug hypersensitivity syndrome (no blistering) - exfoliative dermatitis (erythroderma) - bullous pemphigoid and pemphigus vulgaris - HSV/ zoster ![[Rash#SJS / TEN]] ## Nikolsky sign test for epidermal involvement finger pressure over a blistering lesion results in lateral extension of the lesion and ready separation off the epidermis off of the underlying dermis due to sheering forces ## Rash example ![[Pasted image 20241102164403.png]] widespread erythematous rash with mucosal involvement bullous detachment of the epidermis on the face involves > 30% TBSA → TENs