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Diagnose on Sight: Diffuse Desquamating Dermatitis


stevens-johnson syndromeCase: An 84 year old female presents with five days of a diffuse rash. She had a seizure and was started on phenytoin 2 weeks ago. Her mouth, labia, and medial canthi are involved. There are scattered areas of desquamation comprising less than a tenth of her total body surface area. She is tachycardic and febrile. Her complete blood count differential is normal. What is the diagnosis?

Poll Results

Harr T, French L. Toxic epidermal necrolysis and Stevens-Johnson syndrome. Orphanet J Rare Dis. 2010;5:39. [PubMed]
Nozaki Y, Fujita H, Okada R, Kou K, Aihara M. Non-drug-induced Stevens-Johnson syndrome successfully treated with high-dose i.v. immunoglobulin. J Dermatol. 2015;42(4):439-440. [PubMed]
Roujeau J, Stern R. Severe adverse cutaneous reactions to drugs. N Engl J Med. 1994;331(19):1272-1285. [PubMed]
Lee H, Lim Y, Thirumoorthy T, Pang S. The role of intravenous immunoglobulin in toxic epidermal necrolysis: a retrospective analysis of 64 patients managed in a specialized centre. Br J Dermatol. 2013;169(6):1304-1309. [PubMed]
The Annals of Emergency Medicine – Decoding the Drug Eruption – It is Hard to Breathe When Your Vocal Cords Don’t Work! EM:RAP. Published February 2015.
Jeff Riddell, MD

Jeff Riddell, MD

ALiEM Assistant Editor
Diagnose on Sight series;
Medical Education Research Fellow
University of Washington / Harborview Medical Center
Jeff Riddell, MD

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  • Gregory Meola, Pharm.D

    A great review of SJS, particularly interesting to me due to the drug-induced nature of the condition.
    I notice that lamotrigine was not on your list of drug-induced causes. Although fairly rare (as with all SJS cases), lamotrigine has been associated with cases of SJS. This is particularly true in pediatric patients, when combined with valproate, as well as when doses are escalated too rapidly.
    Although not all lamotrigine-induced rashes have been diagnosed as SJS, it is another important cause of serious (and sometimes life-threatening) drug-induced skin reactions.

    • jeff riddell

      Excellent point Gregory. Thanks for bringing it to our attention.