Stevens-Johnson / Toxic Epidermal Necrolysis (TEN)

These rare but horrible skin conditions may begin with a 1-2 days of fever and discomfort.  Unusual skin pain, or muscle pain out of proportion to the aches of a virus, should alert us.  There may be early signs of painful rash: blisters or sunburn-like reddening (not itching).  Blisters may occur inside the mouth and eyes; women may have vaginal burning.  One key sign may be present: rubbing apparently-normal skin makes it peel off (Nikolsky’s sign).

Stevens-Johnson & TEN are pretty much the same disease.ย  The cause is often a medication: maybe for Gout (allopurinol), Seizures (phenobarbitol, Dilantinยฎ, carbamazepine, lamotrigine), or sulfa antibiotics.ย  Viruses or Mycoplasma (“walking pneumonia”) can also be triggers.

Fever plus widespread skin pain and/or sunburn-like rash is very concerning, especially if there are any blisters (and the patient hadn’t been anywhere to get a real sunburn).  Blisters in eyes, mouth, or vagina make the diagnosis definite.  Patients often need treatment in specialty ICUs that handle burns.  Mortality can be up to 30%.  If you can handle disturbing pictures, Google-image the diseases.

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