Since the genes for these receptors are highly edited, i.e. Only use other eye preparations that have been prescribed by an ophthalmologist (including prior prescriptions). [1] Typical onset is under the age of 30. Texas 75069, 3131 McKinney Avenue [15] No reliable test exists to establish a link between a particular drug and SJS for an individual case. Carefully immerse the patient in the bathwater. Ophthalmology consultation and specialized eye care are mandatory for patients with ocular involvement. Disclaimer. Due to the low clinical incidence rate of SJS, it is not easy to diagnose SJS in the early stage. WebThe SJSAwarenessUK website is dedicated to raising awareness of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in the UK. Bethesda, MD 20894, Web Policies The acute phase of StevensJohnson syndrome / toxic epidermal necrolysis lasts 812 days. If it was caused by a medication, youll need to permanently avoid that drug and others closely related to it. At Another Johns Hopkins Member Hospital: Managing Eczema in Winter and Year Round: A Parents Guide, Got Adult Acne? Symptoms are symmetrical, red, raised skin areas that can appear all over the body. What drug causes Steven-johnson syndrome? SJSAwarenessUK Copyright Perforin and granzyme B can be detected in early blister fluid and it has been suggested that levels may be associated with disease severity. [5] Early symptoms of SJS include fever and flu-like symptoms. It is suitable for patients with bilateral corneal blindness who are difficult to succeed in corneal transplantation, including corneal transplantation failure, severe keratoconjunctival scar vascularization, eyelid atresia, and serious autoimmune diseases (such as Stevens Johnson syndrome and cicatricial pemphigoid) caused by chemical injury, thermal burn, explosion injury, etc, Corneal blindness caused by end-stage dry eye. Face ball adhesion, eyelid position change, limited eye movement, B. However, the current ocular surface inflammation cannot be ignored. The drugs that most commonly cause Stevens-Johnson syndrome/toxic epidermal necrolysis are: StevensJohnson syndrome / toxic epidermal necrolysis usually develops within the first week of antibiotic therapy but up to 2 months after starting an anticonvulsant. This includes upper respiratory infections, otitis media, pharyngitis, and EpsteinBarr virus, Mycoplasma pneumoniae and cytomegalovirus infections. Find more COVID-19 testing locations on Maryland.gov. WebBackground: Stevens-Johnson syndrome and toxic epidermal necrolysis are severe, life-threatening mucocutaneous adverse drug reactions with a high morbidity and mortality that require immediate medical care. We have every resource available to help you through this challenge and seek justice. Severe damage to the skin and mucous membranes makes Stevens-Johnson syndrome/toxic epidermal necrolysis a life-threatening disease. Put the mouthwash solution in glass or syringe. [8], Based on the Asian findings, similar studies in Europe showed 61% of allopurinol-induced SJS/TEN patients carried the HLA-B58 (phenotype frequency of the B*5801 allele in Europeans is typically 3%). levi's black leather jacket men's steven johnson syndrome pictures early stages. that all individuals found to express this HLA serotype avoid treatment with abacovir. The cornea is transparent without epithelial punctate opacity, C. The corneal fluorescence staining showed punctate staining, D. Palpebral conjunctiva is congested and edematous, and pseudomembrane can be seen. The syndrome often begins with flu-like symptoms, followed by a red or purple rash that spreads and forms blisters. [29], Viral diseases reported to cause SJS include: herpes simplex virus (possibly; is debated), AIDS, coxsackievirus, influenza, hepatitis, and mumps. The category cannot always be defined with certainty on initial presentation. The rash caused by Stevens-Johnson syndrome can lead to inflammation in your eyes. In many cases preceded with flu like symptoms and high fever. [8] Other outcomes include organ damage/failure, ocular morbidity, and blindness. It had been thought by many experts to increase mortality because of increased rates of infection and the risk of masking sepsis. [12] SJS, SJS/TEN, and TEN are considered a single disease with common causes and mechanisms.[8]. [3] SJS/TEN reactions are believed to follow a type IV hypersensitivity mechanism. Due to the low clinical incidence rate of SJS, it is not easy to diagnose SJS in the early stage. Genetic changes have been found to increase the risk of Stevens-Johnson syndrome in response to triggering factors such as medications. StevensJohnson syndrome Bullous erythema multiforme, Figure 5. SJS, like TEN and erythema multiforme, is characterized by confluent epidermal necrosis with minimal associated inflammation. Other long-term problems can include impaired taste, difficulty urinating, and genital abnormalities. Although Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis were once thought to be separate conditions, they are now considered part of a continuum. Tap gently with soft wash cloth to dry; do not rub. Dallas, Texas 75204, 500 Marquette Avenue NWSuite 1200 Consider heparin to prevent thromboembolism (blood clots). [13][16], SJS may be caused by the medications rivaroxaban,[17] vancomycin, allopurinol, valproate, levofloxacin, diclofenac, etravirine, isotretinoin, fluconazole,[18] valdecoxib, sitagliptin, oseltamivir, penicillins, barbiturates, sulfonamides, phenytoin, azithromycin, oxcarbazepine, zonisamide, modafinil,[19] lamotrigine, nevirapine,[8] pyrimethamine, ibuprofen,[20] ethosuximide, carbamazepine, bupropion, telaprevir,[21][22] and nystatin. Cross-reactions can occur between: If youve had this condition, avoid the medication that triggered it. Ciclosporin 35 mg/kg/day is reported to reduce mortality by 60% compared to patients with similar SCORTEN score on admission that were not treated with ciclosporin. [2] Overall, the risk of death with SJS is 5 to 10%. blisters; dental emergency; oral mucosal lesions; oral ulcers; skin rash; stevens-johnson syndrome (sjs). Stevens-Johnson syndrome/toxic epidermal necrolysis is a very rare complication of medication use (estimated at 12/million each year for SJS, and 0.41.2/million each year for toxic epidermal necrolysis). Put some petroleum jelly on the eyelids if there is crust or erosions. Early high-dose IVIG 2.7 g/kg over 3 days blocks antibodies and Fas ligand. Then the top layer of affected skin dies, sheds and begins to heal after several days. The cutaneous lesions are characterized as follows: The rash can begin as macules that develop into papules, vesicles, bullae, urticarial plaques, or confluent erythema, The typical lesion has the appearance of a target; this is considered pathognomonic, In contrast to the typical lesions of erythema multiforme, these lesions have only 2 zones of color, The lesions core may be vesicular, purpuric, or necrotic; that zone is surrounded by macular erythema, Lesions may become bullous and later rupture, leaving denuded skin; the skin becomes susceptible to secondary infection, Urticarial lesions typically are not pruritic, Infection may be responsible for the scarring associated with morbidity, Although lesions may occur anywhere, the palms, soles, dorsum of the hands, and extensor surfaces are most commonly affected, The rash may be confined to any one area of the body, most often the trunk. [2][1] Risk factors include HIV/AIDS and systemic lupus erythematosus. When the ocular surface damage of SJS patients is mild, there are few signs and mild symptoms. 10 Berberine Side Effects You Should Know. Unauthorized use of these marks is strictly prohibited. Eye care is undertaken 36 times each day depending on severity of eye involvement. Lasting skin problems may cause your hair to fall out, and your fingernails and toenails may not grow normally. Patients may complain of a burning rash that begins symmetrically on the face and the upper part of the torso. See this image and copyright information in PMC. FDA Safety Alert: Infants at Risk for Aluminum Toxicity with This Unapproved Drug Product, U.S. Supreme Court Overturns Doctors Opioid Prescription Conviction. How can StevensJohnson syndrome / toxic epidermal necrolysis be prevented? HLA) serotypes, prosthetic replacement of the ocular surface ecosystem treatment, "Stevens-Johnson syndrome/toxic epidermal necrolysis", "Recent advances in the understanding of severe cutaneous adverse reactions", "Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Standard Reporting and Evaluation Guidelines", "StevensJohnson Syndrome: An intriguing diagnosis", "Profile and pattern of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in a general hospital in Singapore: Treatment outcomes", "The current understanding of StevensJohnson syndrome and toxic epidermal necrolysis", "ALDEN, an algorithm for assessment of drug causality in Stevens-Johnson Syndrome and toxic epidermal necrolysis: Comparison with case-control analysis", "Scientific conclusions and grounds for the variation to the terms of the marketing authorisation(s)", "Clinical study of cutaneous drug eruptions in 200 patients", Indian Journal of Dermatology, Venereology and Leprology, "A case of bupropion-induced Stevens-Johnson syndrome with acute psoriatic exacerbation", "Carbamazepine The commonest cause of toxic epidermal necrolysis and StevensJohnson syndrome: A study of 7 years", "Acetaminophen induced Steven Johnson syndrome-Toxic Epidermal Necrolysis overlap", "Stevens-Johnson syndrome and toxic epidermal necrolysis", "Acute Generalized Exanthematous Pustulosis: Pathogenesis, Genetic Background, Clinical Variants and Therapy", "Classification of Drug Hypersensitivity into Allergic, p-i, and Pseudo-Allergic Forms", "HLA Association with Drug-Induced Adverse Reactions", "Medical genetics: A marker for StevensJohnson syndrome", "Association between HLA-B*1502 allele and antiepileptic drug-induced cutaneous reactions in Han Chinese", "A marker for StevensJohnson syndrome : Ethnicity matters", "A European study of HLA-B in StevensJohnson syndrome and toxic epidermal necrolysis related to five high-risk drugs", "Pharmacogenomics of off-target adverse drug reactions", "Reference SNP (refSNP) Cluster Report: rs1057910 ** With drug-response allele **", "Genetic variants associated with phenytoin-related severe cutaneous adverse reactions", "StevensJohnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)", "Correlations between clinical patterns and causes of Erythema Multiforme Majus, Stevens-Johnson Syndrome, and Toxic Epidermal Necrolysis results of an international prospective study", "Is universal HLA-B*15:02 screening a cost-effective option in an ethnically diverse population? [13] The skin pattern most commonly associated with SJS is widespread, often joined or touching (confluent), papuric spots (macules) or flat small blisters or large blisters which may also join. 2016 Sep-Oct;62(5):468-73. doi: 10.1590/1806-9282.62.05.468. altered to encode proteins with different amino acid sequences, and since the human population may express more than 100 trillion different (i.e. [10] The immune reaction can be triggered by drugs or infections. Stevens Johnson syndrome on feet. Studies indicate that the mechanism by which a drug or its metabolites accomplishes this involves subverting the antigen presentation pathways of the innate immune system. WebStevens-Johnson syndrome (SJS) is a rare, but very serious skin peeling condition that is caused by an allergic reaction to medications or an illness. Typical prodromal symptoms of Stevens-Johnson syndrome are as follows: Cough productive of a thick, purulent sputum. Careers. One study concluded: "Even when HLA-B alleles behave as strong risk factors, as for allopurinol, they are neither sufficient nor necessary to explain the disease."[43]. Permanent skin damage. It is usually caused by a medicine reaction rather than an infection. Before making any decisions regarding your health, please review your ideas and confirm all data with a licensed medical professional. However, some reports show improved outcomes with early corticosteroid therapy. Before treatment with allopurinol, the American College of Rheumatology guidelines for managing gout recommend HLA-B*58:01 screening. Suite 600 Did you know that erythema multiforme can crawl all over the skin and mucous membrane? Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, life-threatening mucocutaneous reactions most commonly triggered by medications, Blisters on your skin and the mucous membranes of your mouth, nose, eyes and genitals, Shedding of your skin within days after blisters form, Skin detachment < 10% of body surface area (BSA), Widespread erythematous or purpuric macules or at atypical targets, Widespread purpuric macules or at atypical targets, Large epidermal sheets and no purpuric macules. One point is scored for each of seven criteria present at the time of admission. [7][48], The diagnosis is based on involvement of less than 10% of the skin. [8] SJS and TEN most often begin between 4 and 28 days after culprit drug administration. The diagnosis may therefore change during the first few days in hospital. different amino acid sequences) T-cell receptors while an individual express only a fraction of these, a drug's or its metabolite's ability to induce the DRESS syndrome by interacting with a T cell receptor is limited to those individuals whose T cells express a T cell receptor(s) that can interact with the drug or its metabolite. [41][42] This has clinical relevance as it is agreed upon that prior to starting a medication such as allopurinol in a patient of Chinese descent, HLA-B*58:01 testing should be considered. In most affected individuals, the condition also damages the mucous membranes, including the lining of the mouth and the airways, which can cause trouble with swallowing and breathing. Those with chronic ocular surface disease caused by SJS may find some improvement with PROSE treatment (prosthetic replacement of the ocular surface ecosystem treatment). Stevens Johnson syndrome affecting the eye, Figure 3. Figure 1. The first and most important step in treating Stevens-Johnson syndrome is to discontinue any medications that may be causing it. At this point, you may be confused. Stevens-Johnson syndrome/toxic epidermal necrolysis has rarely been associated with vaccination and infections such as mycoplasma and cytomegalovirus. Most of these changes occur in genes that are involved in the normal function of the immune system. Consider genetic testing before taking certain drugs. [50] Erythema multiforme, which is also within the SCAR spectrum, differs in clinical pattern and etiology. No products in the cart. Erythema multiforme minor is not very serious and usually clears up with medicine to control infection or inflammation. They do seem to be more noticeable on the fingers and toes. If you have had Stevens-Johnson syndrome, be sure to: In the future, doctors may be able to predict who is at risk of StevensJohnson syndrome / toxic epidermal necrolysis using genetic screening. Have information about your condition and what caused it inscribed on a medical information bracelet or necklace. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Variation of a specific gene called human leukocyte antigen-B. [23][24], Medications that have traditionally been known to lead to SJS, erythema multiforme, and toxic epidermal necrolysis include sulfonamide antibiotics,[8] penicillin antibiotics, cefixime (antibiotic), barbiturates (sedatives), lamotrigine, phenytoin (e.g., Dilantin) (anticonvulsants) and trimethoprim. The condition is more common in adults than in children. The area beneath is pink and moist, and usually very tender. Various drugs such as antibiotics, anticonvulsants and non-steroidal anti-inflammatory drugs can trigger the disease as an adverse effect. [38][39][40] A study in Europe suggested the gene marker is only relevant for East Asians. We present a case of a 37-year-old male with no past medical history who presented to the dental emergency clinic complaining of dysphagia and burning sensation in the mouth. Did you know that this disease will be more obvious in the eyes? A small percentage of affected individuals develop chronic dryness or inflammation of the eyes, which can lead to increased sensitivity to light (photophobia) and vision impairment. Oakley AM, Krishnamurthy K. In StatPearls [Internet] Treasure Island, FL: StatPearls Publishing; 2020. genetic alleles), genetical-based T cell receptors, or variations in their efficiency to absorb, distribute to tissues, metabolize, or excrete (this combination is termed ADME) a drug are predisposed to develop SJS. Harr T. Current perspectives on stevens-johnson syndrome and toxic epidermal necrolysis. Introduction. SJS is a rare condition, with a reported incidence of around 2.6[10] to 6.1[26] cases per million people per year. About 10 percent of people with Stevens-Johnson syndrome die from the disease, while the condition is fatal in up to 50 percent of those with toxic epidermal necrolysis. They are not effective later in the course of the illness. In severe cases, it can lead to extensive tissue damage and scarring that results in visual impairment and, rarely, blindness. [12], Recent upper respiratory tract infections have been reported by more than half of patients with SJS. However, if a person develops a more severe form of erythema multiforme (erythema multiforme major), the condition can become fatal. CYP2c9*1) cytochrome, have increased blood levels of phenytoin and a high incidence of SJS (as well as SJS/TEN and TEN) when taking the drug. An ophthalmologist should be consulted immediately, as SJS frequently causes the formation of scar tissue inside the eyelids, leading to corneal vascularization, impaired vision, and a host of other ocular problems. In either case, this binding appears to develop only on certain T cell receptors. In particular, it is a type IV, subtype IVc, delayed hypersensitivity reaction dependent in part on the tissue-injuring actions of natural killer cells. [13] These occur primarily on the torso. Does Kisspeptin Shot Help With Low Libido? Doctors are advised to carefully consider using these medications as first-line treatments, particularly if there are safer alternatives. No randomized trials of corticosteroids have been conducted for SJS, and it can be managed successfully without them.[10]. [54] It is helpful to calculate a SCORTEN within the first 3 days of hospitalization. In the case of TEN, some people even lose hair and nails. This finding is compatible with the notion that specific types of T cell receptors are involved in the development of specific drug-induced SCARs. [2] Efforts may include stopping the cause, pain medication, antihistamines, antibiotics, intravenous immunoglobulins or corticosteroids. Your family members also might want to avoid this drug because some forms of this condition have a genetic risk factor. Apply petroleum jelly to the outside of the glove. The routine use of medicines such as antibiotics, antipyretics and analgesics to manage infections can make it difficult to identify if cases were caused by the infection or medicines taken. Patients with documented Mycoplasma infections can be treated with oral macrolide or oral doxycycline. The painful blistering can also affect the urinary tract and genitals. Dutt J, Sapra A, Sheth-Dutt P, Bhandari P, Gupta S. Cureus. Clean the genitals delicately with a compress to remove exudate and necrotic mucosa. Mildly raised liver enzymes are common (30%) and approximately 10% develop overt hepatitis. Intravenous immunoglobulin treatment has shown some promise in reducing the length of the reaction and improving symptoms. The patient or the health provider must put the petroleum-jelly-wrapped compress/glove into the vagina and gently remove it so that the jelly lubricates the lining of the vagina. Ask the patient to gargle with the mouthwash. An antigen presenting cell (APC) takes up these alter proteins; digests them into small peptides; places the peptides in a groove on the human leukocyte antigen (i.e. Treatment with corticosteroids is controversial. If the test result is positive, a blister will form in the area, usually within minutes. There are probably two major pathways involved: In children, Stevens-Johnson syndrome is usually triggered by a viral infection, such as: Less commonly, bacterial infections can also trigger the syndrome. Keywords: The SCORTEN criteria are: The risk of dying from StevensJohnson syndrome / toxic epidermal necrolysis depends on the score. WebStevens-Johnson syndrome/toxic epidermal necrolysis often begins with a fever and flu-like symptoms. In addition to acting through HLA proteins to bind with a T-cell receptor, a drug or its metabolite may bypass HLA proteins to bind directly to a T-cell receptor and thereby stimulate CD8+ T or CD4+ T cells to initiate autoimmune responses. Before WebSJS and TEN are rare conditions; combined, they affect fewer than 8 cases per million persons per year. [53], SJS (with less than 10% of body surface area involved) has a mortality rate of around 5%. Erythema multiforme major is also known as Stevens-Johnson syndrome. To get started with moderating, editi Copyright 2023, Meds Safety. [7][4] These ADME abnormalities, it is also suggested, may interact with particular HLA proteins and T cell receptors to promote a SCARs disorder. [33][34] Accordingly, only rare individuals are predisposed to develop a SCARs in response to a particular drug on the bases of their expression of HLA serotypes:[35] Studies have identified several HLA serotypes associated with development of SJS, SJS/TEN, or TEN in response to certain drugs. Would you like email updates of new search results? No drug is implicated in about 20% of cases. SJS can begin with symptoms similar to the flu, but later progresses to include painful red/purple rashes, It doesn't matter. [36], Variations in ADME, i.e. [10], Mucosal desquamation in a person with StevensJohnson syndrome, Inflammation and peeling of the lipswith sores presenting on the tongue and the mucous membranes in SJS, SJS is thought to arise from a disorder of the immune system. Use the stick to delicately clean the mucosa of cheek, gum, tongue; change sticks frequently and avoid injury to mucosal lesions. Law Office of Gretchen J. Kenney. The mortality for toxic epidermal necrolysis (TEN) is 3040%. Click here to enter the photo gallery. Stevens-Johnson syndrome can have a life-changing impact. People with systemic lupus erythematosus or HIV infections are more susceptible to drug-induced SJS. Clipboard, Search History, and several other advanced features are temporarily unavailable. Accessibility WebSudden, red patches and blisters, usually on the palms of hands, soles of feet, and face Flat, round red "targets" (dark circles with purple-grey centers) Itching Cold sores Fatigue Joint pains Fever The symptoms of erythema multiforme may resemble other skin conditions. Plasmapheresis can remove reactive drug metabolites or antibodies and can be considered. Before treatment with abacavir, the USA Food and Drug Administration recommends screening for HLA-B*57:01 in Caucasian populations. sharing sensitive information, make sure youre on a federal HHS Vulnerability Disclosure, Help J Korean Assoc Oral Maxillofac Surg. In addition, a bilateral forearm erythematous, non-blanching painful rash with some blisters was found after antibiotic administration three days earlier. Presoak the stick with the mouthwash solution. Investigations in StevensJohnson syndrome / toxic epidermal necrolysis, Care of a patient with StevensJohnson syndrome / toxic epidermal necrolysis. Know what caused your reaction. Sulfonamides: sulfamethoxazole, sulfadiazine, sulfapyridine. [33][44] Thus, only rare individuals are predisposed to develop SJS in response to a particular drug on the bases of their expression of specific T-cell receptor types. SCORTEN is an illness severity score that has been developed to predict mortality in SJS and toxic epidermal necrolysis cases. Once the ocular surface is damaged to this extent, surgery is needed to restore the anatomical structure and physiological characteristics of the ocular surface, so as to rebuild the cornea and conjunctival epithelium. [2] It is known as TEN when more than 30% of the skin is involved and considered an intermediate form when 1030% is involved. Other agents have been used, including cyclophosphamide and ciclosporin, but none have exhibited much therapeutic success. [7] For example, CYP2C9 is an important drug-metabolizing cytochrome P450; it metabolizes and thereby inactivates phenytoin. [57][58], In 2015, the NIH and the Food and Drug Administration (FDA) organized a workshop entitled "Research Directions in Genetically-Mediated StevensJohnson Syndrome/Toxic Epidermal Necrolysis".[8]. Lerch M, Mainetti C, Terziroli Beretta-Piccoli B, Harr T. Clin Rev Allergy Immunol. [30][32], Like other SCARs-inducing drugs, SJS-inducing drugs or their metabolites stimulate CD8+ T cells or CD4+ T cells to initiate autoimmune responses. 2020;12:0. Toxic epidermal necrolysis lips and mouth. This means that blisters and erosions appear when the skin is rubbed gently. The drug or metabolite covalently binds with a host protein to form a non-self, drug-related epitope. Estimate total body surface with epidermal detachment. Early retrospective studies suggested corticosteroids increased hospital stays and complication rates. Because the skin normally acts as a protective barrier, extensive skin damage can lead to a dangerous loss of fluids and allow infections to develop. SJS complicated with severe ocular surface damage, A. If you are of Chinese, Southeast Asian or Indian descent, talk with your doctor before taking carbamazepine (Carbatrol, Tegretol). Unable to load your collection due to an error, Unable to load your delegates due to an error. [3] A positive Nikolsky's sign is helpful in the diagnosis of SJS and TEN. 2010 Apr;2(2):123-6. doi: 10.4168/aair.2010.2.2.123. The SCORTEN criteria are: The risk of dying from StevensJohnson syndrome / toxic epidermal necrolysis depends on the score. If ulcerated, prevent vaginal adhesions using intravaginal steroid ointment, soft vaginal dilators. Gently remove dressings, crust, and exudate; avoid scrubbing. The https:// ensures that you are connecting to the Stevens Johnson syndrome. Current trials are underway in Taiwan to define the cost-effectiveness of avoiding phenytoin in SJS, SJS/TEN, and TEN for individuals expressing the CYP2C9*3 allele of CYP2C9. Because its difficult to determine exactly which drug may be causing the problem, your doctor may recommend that you stop taking all nonessential medications. To heal after several days infections are more susceptible to drug-induced SJS SJS in the UK with Mycoplasma... In genes that are involved in the course of the torso differs in clinical pattern and etiology Prescription.. Drug Product, U.S. Supreme Court Overturns Doctors Opioid Prescription Conviction Did you know that erythema multiforme crawl! Multiforme can crawl all over the body the torso Round: a Parents Guide, Got Adult?. If youve had this condition have steven johnson syndrome pictures early stages genetic risk factor than half of patients with ocular involvement hypersensitivity... In Europe suggested the gene marker is only relevant for East Asians cytochrome P450 it. Appears to develop only on certain T cell receptors are involved in the early stage to delicately clean the delicately... Decisions regarding your health, please review your ideas and confirm all data with a medical... Few signs and mild symptoms [ 50 ] erythema multiforme can crawl all over the body condition become... Then the top layer of affected skin dies, sheds and begins to heal after days. Dying from StevensJohnson syndrome / toxic epidermal necrolysis often begins with flu-like symptoms adhesion! Syndrome ( SJS ) with allopurinol, the risk of Stevens-Johnson syndrome in to! 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