Stevens-Johnson syndrome

Trimethoprim sulfamethoxazole seems to be one of our bad boys in dermatology and has been associated with other hypersensitivity reactions.

Of course, we all know it as a cause of SJS-TEN.

It's also been associated with circulatory shock, aseptic meningitis, and respiratory failure.

Speaking of this respiratory failure thing, we discussed its association with ARDS, acute respiratory distress syndrome, back in episode 108.

I absolutely loved it, but I loved all the rotations going through.

And it actually wasn't until I came down here to Southwestern to give grand rounds, and I was actually interviewing to be an inpatient dermatologist, which is also, like, a rare thing that you never see, right? And I came down and I interviewed here, uh, to be an inpatient derm, like SJS, all the scary shit that people die from in the hospital on their skin, and during my grand rounds, three out of my six cases were actually genital cases.

And so they're like, "Oh, hey, we don't have a vulvar derm or a genital derm here.

We also don't have, like, acne or psoriasis." I was like, "Well, no." I was like, "I really like talking about uncomfortable things and making comfortable people uncomfortable." That is, like, one of my favorite things in the world.

Well, it is, but again, when, when my chairman was like, I think...

Again, I came here to interview for inpatient derm, and so he told me I was gonna have to have an area of focus.

I was like, "Well, inpatient." Like, he's like, "No, more focused." And so I think he thought SJS, calciphylaxis, something, right? But I was like, "Uh, vulvaderm." And so it did not exist.

I started with two half days a month, right? And then I went out for a couple maternity leaves, and now it's three half days a week with a crazy long waiting list.

So then it used to be like, well, what if there's, you know, what if I got a penicillin allergy? Now the algorithm is, was that reaction to a cephalosporin? Yes or no.

And was that, was it anaphylaxis or a severe reaction like SJS or DRESS? So if it's no, you do the cephalosporin.

So my reaction was penicillin and it wasn't DRESS or SJS or TEN, you still do the Catholic's.

So Keflex, and that's for skin.

If you really cannot do a cephalosporin, it's either Bactrim 160 to 800 milligrams, which is a pretty wide window, or doxycycline 100 milligrams once.

And those of us who look after them regularly will be very familiar with the physical, not only the physical, but also the psychological consequences of the disease.

So back in 2023, you and I, Saskia, were involved in the development of the consensus statement for via a Delphi exercise on the management of the post-acute and long-term sequelae of SJS-TEN.

And we emphasized in that consensus that of the physical sequelae, those affecting the mucosal sites were perhaps the most significant and impactful.

But we also emphasize the need to pay attention to psychological consequences, which can be highly significant, encompassing depression, anxiety, particularly health-related anxiety and post-traumatic stress disorder.

And Saskia, you described in a very nice JADV paper with your colleagues, the experience of following up a cohort of 27 patients, survivors of SJS-TEN at the centre in Kretai.

And perhaps you could tell the listeners about this patient cohort and what the results of your study showed, what was of importance to these patients?

Yes, I think it was important to report these patients because these patients, not a lot of patients, but 27 patients were those who joined us.

But when it comes to limbal stem cell deficiency, we did a lot of character limbal allografts where you take the cadaveric limbus and transplant it onto the onto a deficient surface.

And as we did these, there were certain groups that did really well and others did terrible, very, very badly, especially Stevens-Johnson syndrome.

And then we realized, when we started looking at it more carefully, after looking at the numbers, we realized, actually, if they had conjunctival inflammation, that was a problem.

And if they had lip problems, that was also a problem.

But if the process accelerates and the epidermis actually begins to slew.

If the total body surface area of epidermal detachment is less than ten percent, it is classified as Stevens-Johnson syndrome, or SJS.

Okay, and if it’s more?

If the slewing involves between ten and thirty percent of the body, we term it SJS/TEN overlap syndrome.

This presentation raises concern for Stevens-Johnson syndrome or toxic epidermal necrolysis.

Very good.

Skin pain, blistering, mucosal involvement, and systemic symptoms are all warning signs for SJS or TEN.

When epidermal detachment involves less than ten percent of the body surface area, we call it Stevens-Johnson syndrome, and if it's over thirty percent, then it's toxic epidermal necrolysis.

When identified, the suspected medication should be stopped immediately, and the patient needs urgent hospital care.

I will say that some of these stories have the most tantalizing final panels.

And this one where Dred learns that he's going to need a team for a suicide mission and that the only person who's best suited for that job is going to be an SJS judge who's currently in the Cubes.

And we get to see him in the final panel drawn by Nick Percival.

And I'll just say, I mean, well, it says the cosmic horror continues in Dark's mob next time.

But, as you say, that's an interesting character that could be just carried on in the magazine quite easily, it would seem, wouldn't it? Yeah.

Yeah, I mean, I don't see any reason why not.

I mean, if they brought Cursed Earth Coburn into the Red World, I don't really see any reason why they couldn't bring Dark in, either in the earlier incarnation as the brutal SJS judge or...

Give us more stories set on Dead World.