Attention High-Risk Medications: Stevens–Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)

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Stevens–Johnson syndrome (SJS) and the related condition toxic epidermal necrolysis (TEN) are rare but life-threatening skin reactions, most often triggered by medications. They may be overlooked in clinical practice, which makes early recognition especially important, as these conditions can progress rapidly and require urgent medical care. 

It is therefore advisable for patients to carry an up-to-date list of their medications to help identify potential triggers quickly.

Medications Commonly Associated with SJS/TEN

Certain groups of active substances are particularly known to increase the risk of SJS and TEN, especially during the first 1–8 weeks after starting treatment.

High-Risk Medications

The following drugs are most frequently linked to SJS/TEN:

  • Allopurinol – the most common cause in Europe, often used to treat gout

  • Antiepileptic drugs – including lamotrigine, carbamazepine, phenytoin, and phenobarbital

  • Antibiotics

    • Co-trimoxazole and other sulfonamides

    • Aminopenicillins

    • Cephalosporins

    • Fluoroquinolones (e.g., ciprofloxacin)

  • NSAIDs (non-steroidal anti-inflammatory drugs)

    • Especially oxicam-type (e.g., piroxicam, meloxicam)

    • Also ibuprofen

  • Nevirapine – used in HIV treatment

Other Potential Triggers

Although less common, several other medications have been associated with SJS/TEN:

  • Other antibiotics – such as doxycycline and clarithromycin

  • Gout medication – allopurinol (also listed among high-risk drugs)

  • Other drugs – etoricoxib, fluconazole

  • Rarely reported cases

    • Hydroxychloroquine (recent updates to product information)

    • Human epoetin (associated with rare severe skin reactions)

Recognizing the Symptoms

SJS often begins subtly but can worsen quickly. Early symptoms may include:

  • Fever and flu-like symptoms

  • Fatigue and general malaise

These are followed by more severe signs:

  • A rapidly spreading, painful skin rash

  • Blistering of the skin and mucous membranes (e.g., mouth, eyes, genitals)

  • Skin detachment in severe cases (more typical of TEN)

Timeframe of Onset

  • Symptoms typically develop within 1 to 8 weeks after starting a new medication

  • The risk is highest during this early treatment period

What to Do in Case of Suspicion

If SJS or TEN is suspected:

  • Stop the suspected medication immediately

  • Seek urgent medical attention (this is a medical emergency)

Prompt discontinuation of the triggering drug is the most important first step and can significantly improve outcomes.

In addition:

Dietary management focuses on avoiding inflammatory foods like processed items, dairy, and spicy foods to minimize irritation to damaged skin and mucous membranes.

Foods to Avoid with SJS

    Dairy Products: Milk and cheese, which may exacerbate skin inflammation.

    Processed Foods: Packaged snacks, fast food, and foods with preservatives.

    Spicy Foods: Chili, peppers, and hot spices that irritate mouth and body mucous membranes.

    Acidic Foods: Citrus fruits (oranges, lemons, limes) and tomatoes can sting or worsen mouth ulcers.

    Gluten: Some individuals report worsened symptoms with wheat-based products.

    Potential Allergens: Eggs, soy, and shellfish, which can cause itching and lead to skin damage.

Key Takeaways Supported by References

  • Most cases are drug-induced, especially by antibiotics, anticonvulsants, NSAIDs, and allopurinol

SJS and TEN are rare but serious adverse drug reactions. Awareness of high-risk medications and early symptoms can be lifesaving. Patients and healthcare providers should remain especially vigilant during the first weeks of any new medication.

References:

Medication Use and the Risk of Stevens–Johnson Syndrome or Toxic Epidermal Necrolysis
https://www.nejm.org/doi/full/10.1056/NEJM199512143332404?utm_source=chatgpt.com

Culprit Medications and Risk Factors Associated with Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis: Population-Based Nested Case–Control Study
https://pmc.ncbi.nlm.nih.gov/articles/PMC8814784/?utm_source=chatgpt.com

Triggers for Stevens–Johnson syndrome / toxic epidermal necrolysis
https://dermnetnz.org/topics/sjsten-triggers

 

© 2000-2030 Sieglinde W. Alexander. All writings by Sieglinde W. Alexander have a fife year copy right. Library of Congress Card Number: LCN 00-192742 ISBN: 0-9703195-0-9   

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