8 The most important signs of an impending severe cutaneous reaction are skin pain, epidermolysis, and a positive Nikolsky’s sign (slight rubbing of the skin causes separation of the epidermis and dermis).14 and 15 A retrospective study by Watanabe et al. suggested distinct differences between SJS and TEN and erythema multiforme major that can be helpful in making a definitive diagnosis. SJS and TEN patients were more

likely to have mucous membrane involvement, higher C-reactive protein levels, and hepatic dysfunction. Erythema multiforme major patients had stronger mononuclear cell infiltration and required lower doses of systemic corticosteroids.16 The Score of Toxic Epidermal Necrosis (SCORTEN) scale is a severity-of-illness scale that can be used to determine the mortality rate of an individual patient.17 Although it was initially developed for patients with SJS and TEN, it has been validated and used for patients

with burns Selleckchem Target Selective Inhibitor Library and other exfoliative disorders. Calculations are advised within the first 24 hours after cAMP inhibitor admission and on day 3.17Tables 3 and 4 list the risk factors and mortality scores, showing that more risk factors result in a higher SCORTEN scale score, thereby indicating a higher mortality rate. Diagnostic laboratory values can play a role in prognosis of the disease, especially TEN and SJS. Neutropenia and lymphopenia can occur and may be a negative prognostic factor.18 The use of granulocyte colony-stimulating factor in the treatment of TEN has been shown to reverse the neutropenia with a corresponding increase in reepithelialization.15 Hyperferritinemia as a result of acute liver failure Immune system can be a useful marker for the severity of DIHS.19 Fujita and colleagues developed a rapid immunochromatographic test for detection of granulysin, a cytotoxic lipid-binding protein that causes apoptosis and is present in the blister fluid of patients with SJS and TEN. The granulysin was found to be elevated before skin and mucosal detachment occurred, suggesting that

it may be a useful marker for detection of SJS and TEN in the early stages.20 Patch tests may be useful in most forms of DIHS, but not for SJS, TEN and vasculitis. The lymphocyte transformation test tends to test positive in maculopapular exanthemas, bullous exanthema, acute generalized exanthematous pustulosis, and DRESS, but rarely in TEN, cytopenias, and vasculitis.21 Drug provocation tests may also be useful in diagnosing the drug allergy.19 The first and foremost medical strategy is identification and cessation of the causative agent, usually the last one the patient initiated 1 to 3 weeks prior to onset of symptoms. Thereafter, treatment is predicated on the severity of the symptoms, both cutaneous and systemic. Corticosteroids are used for both treatment of symptoms and prevention of progression. For milder cases, systemic corticosteroids dosed at 0.