Introduction
Methods
Data sources and searches
Study selection
Reference numbers | Suggestive SJS/TEN-like LE rule-out | Definitive SJS/TEN-like LE rule-out |
---|---|---|
[28] | N/A | N/A |
[22] | N/A | Negative direct immunofluorescence for immunoglobulins and complement |
[29] | Normal complement concentrations (C3, C4) | Negative antinuclear antibody |
[30] | Normal complement concentrations (C3, C4) Previously diagnoses of seronegative symmetrical polyarthritis | N/A |
[31] | N/A | N/A |
[32] | Diagnosed with Sjogren’s syndrome 7 years prior, confirmed with serology and a labial biopsy No history of sensitivity to sunlight | Negative direct immunofluorescence for immunoglobulins and complement Negative antibodies to double-stranded DNA. (Positive antinuclear antigen at a dilution of 1: 4000 with speckled pattern and positive anti-Ro and anti-La antibodies.) |
[33] | Multi-specialty workup: included dermatology, infectious disease, and plastic surgery | N/A |
[34] | Multi-specialty workup: Evaluated and treated in burn unit and dermatology, ophthalmology and gynecology services were consulted | N/A |
[35] | N/A | N/A |
[36] | N/A | Negative direct immunofluorescence Negative antinuclear antibodies |
[37] | N/A | N/A |
[38] | N/A | Negative direct immunofluorescence |
[39] | N/A | Negative antinuclear antibody Negative anti-Smith antibody Negative anti-DNA antibody |
Data extraction and quality assessment
Reference to case | [28] | [22] | [29] | [30] | [31] | [32] | [33] | [34] | [35] | [36] | [37] | [38] | [39] |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Study year | 1989 | 1996 | 2000 | 2003 | 2005 | 2008 | 2010 | 2011 | 2014 | 2016 | 2018 | 2021 | 2021 |
Study type: case report (C), abstract (A) | C | C | C | C | C | C | C | C | C | C | A (poster abstract) | C | C |
Demographics (age, gender) | 12, M | 23, F | 16, F | 34, M | 66, M | 29, F | 30, M | 22, F | 19, F | 48, F | 65, F | 22, F | 18, F |
SJS or SJS/TEN or TEN | SJS | TEN | SJS | SJS | TEN | TEN | TEN | TEN | SJS | SJS | SJS | TEN | SJS |
Causal drug | 3 weeks chloroquine and sulfadoxine-pyrimethamine | 14 days clobazam | 3 weeks of carbamazepine, increased doses from 200 mg/day to 600 mg/day | 2 months sulfasalazine | One dose Naproxen Sodium (Rash not present until 3 days after drug exposure. Experienced similar eruption three times after intake of naproxen, in the last 5 years | 3 years of hydroxychloroquine (Also used gabapentin for 2 years for postherpetic neuralgia) | 19 days of lamotrigine and increased dose of chlorpromazine after 10 years of use (Also used alprazolam, zolpidem, lithium) | One dose (200 mg) of Ibuprofen, not first-time use (1 day after drug use, rash started, stable 2 days, then sever rash after tanning bed) | 10 days ciprofloxacin/ 1-day fluconazole (Rash presented day after drug course) | 3 days itraconazole (Rash presented day after drug course) | Lamotrigine (duration of use not specified) | 10 days of lamotrigine | One dose of tramadol (Only drug taken 7–10 prior to rash onset) |
Diagnosis associated with drug | Prophylactic malaria | Alopecia areata on the scalp | Epilepsy (Additional history of allergic rhino-conjunctivitis) | Seronegative symmetrical polyarthritis | Keratitis of the right eye | Sjogren’s syndrome | Bipolar 1 | Menstrual discomfort | Vaginal infection | Vaginal yeast infection | Epilepsy | Bipolar disorder | Hip pain |
UVR exposure place and amount | Rash presented after first day of sun exposure at the seashore in Thailand | 1 day at beach | 45 min of sunlight, explained as an intense exposure | N/A | N/A | Sunburnt on Mediterranean cruise | 19 days in psychiatric ward, often lay in sun during day | Eight-minute exposure in tanning bed | 1 day at beach | Several hours of sun exposure all three days of itraconazole use | N/A | Daily tanning bed use all 10 days of lamotrigine use | 1 day at a lake |
Reported photodistributed rash (Y/N) | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
Rash extension to clothing covered skin (Y/N) (lack of linear demarcation, satellite lesions) | Y Lack of linear demarcation, satellite lesions | Y Lack of linear demarcation, satellite lesions | N/A | N/A | Y Lack of linear demarcation, satellite lesions | Y Lack of linear demarcation, satellite lesions | Y Lack of linear demarcation, satellite lesions | Y Lack of linear demarcation, satellite lesions | Y Lack of linear demarcation, satellite lesions | Y Satellite lesions under areola | N/A | Y Lack of linear demarcation, satellite lesions | Y Lack of linear demarcation, satellite lesions |
Time from UVR exposure to rash onset | N/A | 36 h | 1 day | 3 days | N/A | N/A | N/A | 1 day (to change from baseline rash) | 2 days | 1 day | N/A | N/a | 1 day |
Timeline of progression/ worsening of rash | Reported worsening rash at 3 days | 4 days until progression of rash stopped | Progressed past 48 h | On day 12 of hospitalization, skin lesions were improving | Eruption of new lesions ceased on 12th day of admission | 14 days (7 days to hospital admission, then 7 days later, skin detachment extended to involve at least 60% of the body surface area) | 5 days of gradual progression to painful bullous eruptions and 30% total body surface area | N/A | N/A | Reported worsening rash at 48 h, Presented to ED 5 days | N/A | N/A – Hospitalized for 12 days | Day 5 of rash presented to hospital from continued worsening symptoms |
Mucus membrane involvement | Conjunctivitis, erosions of the buccal mucosa and lips, and erosive balanitis | Bilateral conjunctival, oral, and genital mucosa | Oral, ocular, and genital mucosa | Oral and genital mucosa | Buccal and palatal mucosa | Hemorrhagic crusting of the lips, buccal mucosa and tongue. Eyelids were eroded with intense conjunctival Injection. Vulvar and vaginal lesions | Oral mucosa, conjunctivitis | Oral, ocular, and vaginal mucosa | White vesicles and erosions on the lips. Ulcers of the oral mucosa. Erythematous patches within the labia | Irritation and redness of the conjunctivas. Necrotic crusts on the lips. Oral mucosal inflammation and ulcerations | N/A | Conjunctival injection. Bullae involving the vermillion and mucosal lips, buccal mucosa, and tongue. Swelling of genitalia | Cheilitis, bleeding oral ulcers, and bilateral conjunctival hyperemia with purulent discharge |
Palmar and plantar rash (Y/N) | Y Iris lesions on palms and soles | N/A | N/A | Y Annular iris lesions on palms of the hands and the soles of the feet | N/A | N/A | N/A | N/A | N | Y After 48 h the palms and soles were erythematous and painful with some blisters between the toes | N/A | Y Pruritic eruption including palms and soles | Y Maculopapular rash of palms of hands and soles of feet |
Nikolsky sign ( ±) | N/A | + | N/A | + | + | + | N/A | N/A | N/A | - | N/A | N/A | + |
Skin biopsy | N/A | Hydropic and vacuolar degeneration of the basal cells, with exocytosis of mono-nuclear cells in the epidermis and a subepidermal bulla with festooning of the underlying papillary dermis Direct immunofluorescence for immunoglobulins and complement was negative | Presence of a subepidermal blister with necrosis of the epidermal keratinocytes and intense chronic inflammatory infiltrate with some eosinophils around the vessels and hair follicles in the dermisa | Full-thickness epidermal necrosis. The cytoplasmic limits of the cells had been lost | Extensive epidermal necrosis; areas around the necrosis showed vacuolar degeneration of the basal layer, edema of the superficial dermis, melanophages and a mild perivascular lymphocytic infiltration | Subepidermal, cell-poor bulla formation with full thickness epidermal necrosis, consistent with TEN Direct immunofluorescence for immunoglobulins and complement was negative | N/A | Lymphocytic infiltrate at the dermal–epidermal junction with some apoptotic keratinocytes consistent with TEN | Intact stratum corneum with interface dermatitis and full thickness epidermal necrosis compatible with SJS | Necrotic epidermis and interface dermatitis with vacuolization Direct immunofluorescence was negative | N/A | Interface dermatitis with scattered dyskeratosis, consistent with SJS/TEN Direct immunofluorescence was negative | Findings consistent with SJS |
Reported flu-like prodrome (Y/N) Reported initial signs/symptoms | N Severe erythema confined to sun-exposed areas. Within the next 3 days fever and malaise accompanied the concomitant development of round, annular, concentric typical iris lesions in sun-protected areas | N Pruriginous and erythematous eruptions | N General malaise, fever, conjunctival injection, erythematous and infiltrated lesions (Quadro de malestar general, fiebre, inyeccion conjunctival, lesiones eritematosas e infiltadas) | N Severe cutaneous eruption that had started 3 days after sun exposure, No abdominal pain, nausea, vomiting, or fever was present | N An erythematous and bullous rash had started on his face and neck, which rapidly spread to his arms and legs | N Facial swelling and a painful erythematous eruption with lethargy and anorexia | N Whole body itched and he developed restlessness, then wheal-like erythematous, itching skin rashes | N Four hours following the tanning bed exposure the patient noted increased itchiness of her tanning bed exposed skin. The next morning the patient experienced severe redness, pain, and the beginning of blister formation on her tanning bed exposed abdomen, back, face, and proximal arms | N A red rash concentrated on her chest developed | N Without any prodromes, developed rash on upper trunk | No initial symptoms reported | N Diffusely pruritic eruption involving her upper back and chest that later extended to the face and extremities, including the palms and soles | N Onset of an erythematous burning rash on her shoulders |
Treatment | Systemic corticosteroids and antibiotics (4 weeks to recovery) | Pentoxifylline and prophylactic systemic antimicrobials, supportive measures | methyl-prednisolone | N/A | Methylprednisolone | Benzyl penicillin, Flucloxacillin, prophylactic low molecular weight heparin, eye steroid and lubricant | Antibiotics (4 weeks to recovery) | IM Corticosteroid and vancomycin, 2 days I.V. cyclosporine, 3 days of intravenous immunoglobulin G | N/A | 3-week course of oral steroids and betamethasone dipropionate ointment | N/A | 5-day regimen of oral cyclosporine 5 mg/kg/d | Prophylactic oral doxycycline and topical oral and ocular medications |
Data synthesis and analysis
Results
Reference to study | [28] | [22] | [29] | [30] | [31] | [32] | [33] | [34] | [35] | [36] | [37] | [38] | [39] |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Delay from initial drug component intake to onset of reaction (index day)a | +3 | +3 | +3 | −1 | +3b | −1 | +3 | +3b | +3 | +1 | N/A | +3 | +3 |
Drug present in the body on index dayc | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | -3 |
Prechallenge/rechallenged | 0 | 0 | 0 | 0 | +4 | 0 | 0 | +1 | 0 | 0 | N/A | 0 | 0 |
Dechallengee | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
Type of drug (notoriety)f | +3 | +3 | +3 | +3 | +3 | +3 | +3 | +3 | +3 | +3 | +3 | +3 | +2 |
Other causeg | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
Final Scoreh | 6 | 6 | 6 | 2 | 10 | 2 | 6 | 7 | 6 | 4 | N/A | 6 | 2 |
Case classifications: SJS 7/13 (53.8%), SJS/TEN overlap 0/13 (0%), and 6/13 (46.2%) |
Patients ranged between 12- and 66-year-old with a female predominance of 9/13 (69.2%) |
All cases described rash presentation as photodistributed |
All cases reported ultraviolet radiation prior to rash onset |
All cases recognized a causal drug |
All patients recovered |
10 cases reported source of the UVR: 8 cases from direct sunlight, 2 cases from tanning bed |
10 cases provided images of rash extension to clothing covered skin (lack of linear demarcation, satellite lesions) |
10 cases described rash progression/worsening > 48 h (up to weeks) |
12 cases report various mucous membrane involvement, all with oral mucositis |
9 cases included biopsy findings, all consistent with SJS/TEN (4 cases reported direct immunofluorescence findings, all negative) |
7 cases reported time from UVR exposure to rash onset, all 1–3 days later |
6 cases reported Nikolsky sign findings, 5 positive |
6 cases reported palmar and plantar findings, 5 positive for rash |
No cases reported an influenza-like prodrome |
Discussion
The role of UVR in photodistributed SJS/TEN
Causal drug
Pathogenesis theories of photodistributed SJS/TEN
Drug name | Photosensitivity (non-specific) | Phototoxicity | Photoallergy |
---|---|---|---|
Chloroquine asulfadoxine –pyrimethamine | [56] [60] | ||
Carbamazepine | |||
Chlorpromazine | [65] | ||
Ciprofloxacin | |||
Clobazam | [70] | ||
Hydroxychloroquine | [65] | [71] | |
Ibuprofen | |||
Itraconazole | [75] | ||
Lamotrigine | [76] | [77] | |
Naproxen sodium | |||
Sulfasalazine | [57] | ||
Tramadol | [80] |
Differential diagnoses
Photosensitive reactions
UVR reaction type | Phototoxic | Photoallergic | Photodistributed SJS/TEN |
---|---|---|---|
Incidence | High | Low | Low |
Pathophysiology | Direct tissue injury | Type IV hypersensitive reaction | Type IV hypersensitive reactiona |
Sensitization Required | No | Yes | Yes |
Required dose of medication | High | Low | Low |
Cross-reactions to related agents | Low | High | Mediumb |
Agent type | Oral > topical | Oral < topical | Oral > topical |
Onset after light exposure | < 24 h (less common > 24 h) | > 24 h | > 24 h |
Progression / worsening of rash | 24–48 h | 48–72 h | > 48 h (up to week(s)) |
Clinical skin appearance | Exaggerated sunburn | Eczematous / Dermatitis | Photodistributed erythematous macules and flat atypical target lesions with vesicles/bullae and confluence of lesions |
Distribution | Only UVR exposed areas | UVR exposed areas; may spread outside UVR areas | UVR exposed areas; may spread outside UVR areas |
Palmar and plantar erythema | Uncommonc | Uncommonc | Common |
Mucous membrane involvement | Uncommonc | Uncommonc | Always |
Nikolsky sign | Negativec | Negativec | Positive |
Histology | Necrotic keratinocytes, predominantly lymphocytic and neutrophilic dermal infiltrate | Epidermal spongiosis, exocytosis of lymphocytes and perivascular inflammatory infiltrate | Subepidermal blisters with widespread necrosis (full thickness) and apoptotic keratinocytes associated with minimal lymphocytic inflammatory infiltrate |
Direct Immunofluorescence | Negative | May be positived | Negative |
Photodistributed erythema multiforme
Autoimmune bullous diseases, porphyria disorders, and SJS/TEN-Like LE
Distinguishing factors for photodistributed SJS/TEN
Must identify = need all 4: |
1. A photodistributed rash as a result of UVR exposure after drug initiation (or other known SJS/TEN cause) |
2. Rash progression/worsening > 48 h to include vesicles/bullae and/or sloughing of the epidermis |
3. Negative direct immunofluorescence |
4. More likely SJS/TEN than erythema multiforme |
Major criteria (should identify) = need 3/4: |
1. A causal drug |
2. Mucous membrane involvement |
3. Positive Nikolsky sign |
4. Histopathology demonstrating full-thickness epidermal necrosis with subepidermal bullae development |
Minor criteria (common findings) = need 2/4: |
1. Palmar and plantar rash |
2. Delayed rash onset that presents no earlier than the day after UVR exposure |
3. Satellite lesions/non-discrete borders on UVR protected (clothing covered) skin |
4. No flu-like prodrome |