Toxic Epidermal Necrolysis 

Nursing Knowledge

Toxic Epidermal Necrolysis 

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are variants of the same rare, severe, and potentially fatal skin condition involving sheet-like loss of epidermal and mucosal tissue, accompanied by other systemic symptoms. Over 80% of cases are the result of an adverse drug reaction.
Last updated: December 4, 2023

Table of contents

What is Stevens-Johnson Syndrome? 

Stevens-Johnson syndrome (SJS) is a rare, severe skin reaction, often caused by medications or infection. 

Common medication triggers include: 

  • Anticonvulsants
  • Alopurinol
  • Sulfonamides
  • Antibiotics
  • NSAIDs

Genetic factors may also increase the risk of SJS reaction. Family members of clients with SJS should be counseled regarding their risk and the associated medications.

What is toxic epidermal necrolysis? 

Toxic epidermal necrolysis (TEN) is the term for the most severe form of Stevens-Johnson syndrome. 

Disease progression of SJS and TEN

Early stages

Stevens-Johnson syndrome at first can present with non-specific symptoms like: 

  • Fever
  • Malaise
  • Cough
  • Rhinitis
  • Myalgia

Appearance of skin lesions

As the disease progresses, skin lesions appear (mostly on the upper body): 

  • Targetoid rash
  • Mucosal ulcerations 

Further spreading and progression to toxic epidermal necrolysis symptoms

In the later stages, sloughing lesions and blistering spreads over the body: 

  • Large, painful erosions
  • Easy sloughing of skin
  • Compromised skin and mucosal barriers 
Drug induced toxic epidermal necrolysis two case reports

Drug-induced toxic epidermal necrolysis with peeled skin over the back and buttocks.

Image: “Drug induced toxic epidermal necrolysis: two case reports” by Qadir SN, Raza N, Qadir F. License: CC BY 3.0


Classification is based on the percentage of affected body surface area. 

Affected %Classification
> 10 %Stevens-Johnson syndrome 
10–30 %Overlap SJS and TEN
> 30%Toxic epidermal necrolysis

Complications and long-term effects

The loss of a protective skin barrier may lead to extreme dehydration, infection, sepsis, shock.

Mucosal damage affecting the airway may lead to the client requiring mechanical ventilation. Damage to ocular tissue can cause blindness.

Acute organ dysfunction can affect pulmonary, cardiovascular, gastrointestinal, renal, and hematologic systems and may lead to multiple organ failure.

Treatment of toxic epidermal necrolysis

If a medication trigger is suspected, discontinue the medication as soon as possible. 

Supportive care measures include: 

  • Fluid replacement
  • Pain relief
  • Nutritional support
  • Supplemental O2 or ventilation
  • Infection prevention

High-dose systemic corticosteroid therapy may be considered. 

Red man syndrome vs Stevens-Johnson syndrome 

Red man syndrome (RMS) and Stevens-Johnson syndrome (SJS) are both adverse reactions presenting with rashes, they are very distinct in terms of severity, risks, and treatment. 

Red man syndrome is often due to rapid infusion of the antibiotic vancomycin. Slowing the infusion rate or pre-treatment with antihistamines are usually the only required treatment measures. Other than the relatively benign red man syndrome, Stevens-Johnson syndrome’s symptoms can progress to skin shedding and permanent damage, and can be life-threatening in its most severe form of epidermal necrolysis. Often, hospitalization in a burn unit or ICU is necessary.


Toxic Epidermal Necrolysis 

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Overview of Stevens-Johnson syndrome/toxic epidermal necrolysis; disease progression, common medication triggers, genetic factors, complications, and treatment.

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