Thread by @DrStevenTChen

In preparation of my upcoming talk on #dermatology emergencies for the @SHMlive conference, I thought I'd put together my first #tweetorial on Stevens Johnson Syndrome (SJS). Having never done this, apologies in advance for subpar tweeting! Here we go!
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#medtwitter #dermtwitter

SJS and its more severe cousin, Toxic Epidermal Necrolysis (TEN), are life-threatening dermatologic toxicities, usually caused by a drug trigger. In rare cases, they can be triggered by infection (more commonly seen in the #pediatric population).

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#SJS usually presents with an atypical targetoid macular (flat) eruption with +nikolsky. This is in contrast to another entity on the ddx, erythema multiforme, which has classic target papular (raised) lesions. See the difference? (hands are EM, back is SJS). CC @dermnetnz!

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A brief interlude - how do you tell the difference between classic "targets" and "targetoid" lesions? Target lesions have three zones - Red outside, then white, then red center (think of the logo for Target stores). Targetoid usually are more "blobby," and 2 zones of color.

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SJS/TEN classically presents with mucocutaneous involvement. The hemorrhagic lips here are classic for SJS/TEN. The eyes are often injected and patients complain of a foreign body sensation. Sequelae from mucous membrane involvement can be severe, so beware! cc @dermnetnz

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So what's the difference between SJS and TEN? SJS is defined by <10% BSA skin detachment or impending detachment. TEN is >30%, and in between 10 and 30 is SJS/TEN overlap syndrome. Importantly, the BSA is of detached skin, NOT of total BSA of rash! CC:@dermnetnz

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A recent collaborative study by #dermatologists from the @dermhospitalist group looked at a cohort of patients hospitalized with SJS/TEN in the US. What do you think was the most common culprit drug to be implicated?

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This paper found Trimethoprim/Sulfamethoxasole to be the most common culprit. Another interesting point: patients seemed to do better than what would have been predicted based on old prediction models (SCORTEN)!

jidonline.org/article/S0022-…

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Treatment? First, stop the drug trigger, and consider the burn unit, especially if severe! If you've got an SJS/TEN patient, please consider consulting your friendly dermatologist! We can help direct possible drug therapy and guide supportive wound care.

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Ultimately, a #multidisciplinary approach is critical, often involving ophtho and GYN/urology. Avoid unnecessary medications, and beware of infection. The broken skin barrier makes sepsis both highly possible, and potentially deadly.

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Was this helpful? Would more #skin #tweetorials be good? Let me know, and if you'll be at the SHM 2019 annual meeting, I'll be discussing more details and more diseases there. Thanks all, and thanks to @tony_breu for the initial inspiration!

@Massgeneralnews #MedEd @harvardmed