Selective serotonin reuptake inhibitor–associated Stevens–Johnson syndrome
Stevens–Johnson syndrome (SJS) is a severe mucocutaneous drug reaction that has been reported with selective serotonin reuptake inhibitors, including fluoxetine. [2] Rapid recognition and immediate withdrawal of the suspected offending drug are required to reduce progression. [1]
Causality with SSRIs
- Fluoxetine has been reported to cause biopsy-confirmed SJS after recent initiation, with improvement after discontinuation. [2]
Immediate Actions and Drug Withdrawal
- The suspected causative agent should be identified and withdrawn immediately. [1]
- Multidisciplinary care should be convened and coordinated by a specialist in skin failure, usually dermatology and/or plastic surgery, with involvement of intensive care, ophthalmology, and skin-care nursing. [1]
- SCORTEN should be calculated within the first 24 hours for prognostication. [1]
Treatment Setting and Referral
- Patients with greater than 10% BSA epidermal loss should be admitted without delay to a Burn Centre or ICU with experience managing SJS/TEN. [1]
- Barrier nursing in a side room should be used with humidity control and an ambient temperature target of 25°C to 28°C. [1]
Supportive Skin, Fluid, and Nutrition Management
- Strict barrier nursing should be used to reduce nosocomial infections. [1]
- Bacterial and candidal cultures should be taken from three areas of lesional skin on alternate days during the acute phase. [1]
- Systemic antibiotics should be administered only if clinical signs of infection are present. [1]
- Wounds and intact skin should be cleansed with warmed sterile water, saline, or an antimicrobial such as chlorhexidine 1/5000. [1]
- A greasy emollient should be applied over the whole epidermis, including denuded areas. [1]
- Detached lesional epidermis may be left in situ as a biological dressing, with decompression of blisters by piercing and expression or aspiration of tissue fluid. [1]
- Detached denuded dermis should be covered with non-adherent dressings. [1]
- Enteral nutrition should be provided continuously throughout the acute phase. [1]
- Nutrition targets should be 20 to 25 kcal/kg/day during the early catabolic phase and 25 to 30 kcal/kg/day during the anabolic recovery phase. [1]
- Adequate intravenous fluid replacement should be established initially, with daily individualized adjustment guided by urine output and other endpoints. [1]
Symptom Control and Complication Prevention
- Patient-appropriate validated pain tools should be used in conscious patients at least once daily. [1]
- Adequate analgesia should be provided for comfort at rest, with supplemental opioids as required. [1]
- Immobile patients should receive low molecular weight heparin. [1]
- A proton pump inhibitor should be used when enteral nutrition cannot be established to reduce stress-related gastrointestinal ulceration risk. [1]
- Neutropenic patients may benefit from recombinant human G-CSF. [1]
Organ-Specific Supportive Care
Eye involvement
- Daily ophthalmological review is required during the acute illness. [1]
- Ocular lubricant should be applied every two hours during the acute illness. [1]
- Ocular hygiene should be performed daily by an ophthalmologist or ophthalmic-trained nurse. [1]
- Topical corticosteroid drops (for example, non-preserved dexamethasone 0.1% twice daily) may reduce ocular surface damage. [1]
- Broad-spectrum topical antibiotic prophylaxis should be used in the presence of corneal fluorescein staining or frank ulceration (for example, moxifloxacin drops four times daily). [1]
Mouth involvement
- Daily oral review is required during the acute illness. [1]
- White soft paraffin should be applied to the lips every two hours through the acute illness. [1]
- Mouth should be cleaned daily with warm saline mouthwashes or an oral sponge. [1]
- An anti-inflammatory oral rinse or spray containing benzydamine hydrochloride should be used every three hours, particularly before eating. [1]
- An antiseptic oral rinse containing chlorhexidine should be used twice daily. [1]
- Potent topical corticosteroid mouthwash (for example, betamethasone sodium phosphate four times daily) should be used. [1]
Urogenital involvement
- Daily urogenital review is required during the acute illness. [1]
- White soft paraffin should be applied every four hours to urogenital skin and mucosae. [1]
- Potent topical corticosteroid ointment should be used once daily to involved but non-eroded surfaces. [1]
- A silicone dressing (for example, Mepitel) should be used to eroded areas. [1]
Airway involvement
- Respiratory symptoms and hypoxaemia on admission should prompt early discussion with an intensivist and rapid transfer to an ICU or Burn Centre, where fibre-optic bronchoscopy should be undertaken. [1]
Ongoing Drug Allergy Documentation and Follow-Up
- Written information should be provided about the drug(s) to avoid. [1]
- Drug allergy should be documented in the medical record, and all clinicians involved should be informed. [1]
- The episode should be reported to national pharmacovigilance authorities. [1]
- Outpatient clinic follow-up should be organized within a few weeks of discharge, with ophthalmology follow-up if required. [1]
Diagnostic Testing for Future Risk
- Routine drug hypersensitivity testing is not recommended after an episode of SJS/TEN. [1]
- Specialist advice for hypersensitivity testing should be sought if the culprit drug is unknown, avoidance is detrimental to the individual, or accidental exposure is possible. [1]