Clinicoetiological study of Stevens-Johnson syndrome and toxic epidermal necrolysis spectrum and the correlation of SCORTEN with prognosis

   Abstract 


Background: Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are severe cutaneous adverse reactions of major concern because of its high mortality. The prognosis of SJS and TEN is widely assessed with SCORTEN (SCORe of TEN). Although, it is a largely useful scale, the predictive ability is still variable. Aims and Objectives: This study was conducted to assess the clinicoetiological profile and outcome of SJS and TEN and to evaluate the validity of SCORTEN in assessing the prognosis in South Indian population. Methods: This prospective observational study was conducted in the Department of Dermatology, Venereology and Leprosy in a Tertiary care hospital from January 2016 to June 2017. Detailed history, examination findings, treatment and SCORTEN scores were recorded. SCORTEN's accuracy in predicting the mortality was assessed on day 1, 3 and 5 of admission. Results: The incidence of SJS/TEN among other drug reactions was 29.5%. The most common age group affected was 30-49years (41.1%), with male preponderance (76.5%). The age range of patients was 6 and 67 years. TEN (64.7%) was the predominant spectrum followed by SJS and SJS-TEN overlap in 17.6% each. Anticonvulsants (47%) were the commonest causative drug, followed by analgesics (35%) and antibiotics (11%). The validity of SCORTEN was the same on days 1, 3, and 5. There was good agreement between the actual and predicted mortality on all three days. A mortality of 17.6% (3 cases) was recorded in this study. Three patients (17.6%) died in our study. All survivors had a score of 4 or less. The predicted mortalities were 0.417, 1.836, and 2.574 and the observed mortalities were 0, 2, and 1 in SJS, SJS-TEN overlap, and TEN respectively. Analysis of SCORTEN on a single day, either day 1, 3, or 5 was found to be as useful as the serial analysis. Conclusion: SCORTEN gave a significant estimation of mortality in SJS-TEN overlap patients, whereas it overestimated mortality in TEN patients. An increase in individual scores for the elevation of blood urea nitrogen (BUN) in existing SCORTEN and the inclusion of new parameters like raised liver enzymes, thrombocytopenia, and pulmonary infiltrates aided in proposing a modified SCORTEN for the South Indian population. Further studies on a larger scale, are needed to validate the modified SCORTEN proposed by us.

Keywords: SCORTEN, SJS, TEN, toxic epidermal necrolysis


How to cite this article:
Kanagarajan A, Murthy AB, Moni PK, Palanivel N. Clinicoetiological study of Stevens-Johnson syndrome and toxic epidermal necrolysis spectrum and the correlation of SCORTEN with prognosis. Indian J Dermatol 2023;68:25-33
How to cite this URL:
Kanagarajan A, Murthy AB, Moni PK, Palanivel N. Clinicoetiological study of Stevens-Johnson syndrome and toxic epidermal necrolysis spectrum and the correlation of SCORTEN with prognosis. Indian J Dermatol [serial online] 2023 [cited 2023 Apr 1];68:25-33. Available from: 
https://www.e-ijd.org/text.asp?2023/68/1/25/373058    Introduction Top

Cutaneous adverse drug reactions (CADRs) are the most frequently (10–30%) reported adverse drug reactions (ADRs) constituting 8% of hospitalization among dermatology inpatients.[1],[2] CADRs can be classified into benign and severe CADRs of which Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis syndrome (TEN) carry significant mortality among severe CADRs with a worldwide estimated incidence of 1.2–6 per million and 0.4–1.9 per million, respectively.[3],[4],[5] Indicator or scoring system is necessary to assess prognosis in SJS-TEN patients. One such scoring system is the Severity of Illness Score for Toxic Epidermal Necrolysis (SCORTEN) developed and validated by Bastuji-Garin et al., in the year 2000 for the European population.[5],[6] But to the best of our knowledge, there is no available literature on the validity of SCORTEN in the South Indian population. Hence, this study was conducted to confirm the accuracy of SCORTEN in the South Indian population among SJS/TEN patients.

   Materials and Methods Top

This prospective observational study was conducted in the Department of Dermatology, Venereology and Leprosy in a tertiary care hospital in South India, from January 2016 to June 2017, after obtaining Institutional Ethical Committee (IEC) clearance. The study population consisted of all consecutive clinically diagnosed cases of SJS, TEN and SJS/TEN overlap. Both informed and written consents were obtained from all patients or their guardians. A detailed questionnaire was prepared including the clinical history, history of drug intake within the past 4 weeks, previous episodes, co-morbidities, general and systemic examination. All patients were followed up for the progression of skin lesions and the area of epidermal detachment and classified into one of the three categories, namely SJS (epidermal detachment <10% body surface area), SJS-TEN overlap (epidermal detachment of 10–30% body surface area) and TEN (epidermal detachment >30% body surface area) according to the consensus classification proposed by Bastuji-Garin et al.[6] Naranjo Adverse Drug Reaction Probability Scale and WHO-UMC causality assessment system were used to assess the causal relationship between the drug and the CADR. Complete haemogram, random blood sugar, liver and renal function tests, serum electrolytes, blood urea nitrogen (BUN) and bicarbonate levels were done. Skin swab culture and sensitivity, throat swab, urine, and blood culture and sensitivity, and skin biopsy for histopathological examination were also done. Ultrasound of the abdomen and pelvis, stool for occult blood and peripheral smear for atypical cells were done to rule out malignancy. Patients who presented one week after the onset of symptoms and those who got treated outside were excluded from the study.

SCORTEN comprises seven parameters, namely age above 40 years, presence of malignancy, tachycardia (heart rate above 120 beats per minute), initial percentage of epidermal detachment >10%, BUN >28 mg/dl, serum glucose >252 mg/d and bicarbonate level <20 mmol/L. Each parameter was given a score of one, and the total score was calculated by summing up the number of abnormal parameters. The score was calculated for all patients on day 1, day 3 and day 5 of admission. Appropriate treatment with an interdisciplinary approach was followed. The patients were followed up till complete recovery noting the complications if any.

The continuous variables were described in terms of means and categorical terms of percentages. Their significance of them was interpreted by independent 't' and if more than two groups by analysis of variance (ANOVA) tests in respect of continuous variables. The significance of categorical variables was interpreted by ċ2 (Chi-square test). The difference between SCORTEN values on days 1, 3 and 5 of admission was evaluated by the Kruskal–Wallis test. The accuracy of SCORTEN for predicting mortality was assessed on days 1, 3 and 5 of admission. The difference in SCORTEN between alive and dead patients was analyzed by the Mann–Whitney test. The individual parameters included in SCORTEN were tested by Fisher's exact test. The Standardized Mortality Ratio was used to signify the predicted and observed mortalities of TEN patients. The P value less than or equal to 0.05 (P ≤ 0.05) was treated as statistically significant.

   Results Top

Sixty-nine cases of drug reactions were reported during the study period. Of these, 19 cases were in the SJS-TEN spectrum, including 3 SJS [Figure 1], 3 SJS-TEN overlap [Figure 2] and 13 cases of TEN [Figure 3] and [Figure 4]. Two cases of TEN were excluded from the study, as they were admitted 1 week after the onset of reaction. So, 17 cases including 3 SJS, 3 SJS-TEN overlap and 11 TEN formed the study population. Of this, 14 cases were the first episode and 3 cases were 2nd episode including 2 cases of TEN (one to Ibuprofen and another to Aspirin and Caffeine combination) and 1 case of SJS-TEN overlap (Phenytoin). The mean age of incidence among males was 39.2 ± 18.4 years, and the same for females was 35.5 ± 24.7 years. The difference in age between the gender was not statistically significant (P > 0.05). The mean age of incidence of total subjects was 38.1 ± 19.3 years with a range of 6 years to 67 years [Table 1]. Of the 17 cases, 13 were male and 4 were female including a male child (11 years) and a female child (6 years), respectively. Patients presented within a range of 1–6 days of onset of skin lesions (median – 3 days). Nearly half the patients (n = 8; 47.05%) presented within 3 days of onset, while 2 of the patients presented on the day of onset itself, as it was the second episode for them.

Figure 1: A 16-year-old female with crusted plaques and erosion over both lips and erythematous patches over face (SJS)

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Figure 2: A 36-year-old male with crusted plaques over lips, erythematous macules and patches over face, chest and upper back (SJS/TEN overlap)

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Figure 3: A 42-year-old male with crusted plaques over lips, generalized erythematous macules and patches and multiple bullae over abdomen (TEN)

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Figure 4: A 56-year-old female with multiple erythematous macules, patches surmounting vesicles and bullae over chest and neck with two erosions over supra sternal region (TEN)

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The lesions began in the mucosa in 8 (47%) cases, whereas in 7 (41.7%) cases, the skin lesions were preceded by the mucosal lesions and in 2 cases (11.76%) simultaneous onset in skin and mucosa was observed. On the skin, the trunk was the first site of onset in 12 (70.58%) of the 17 patients, followed by the face and neck in 3 (17.64%) and proximal extremities in 2 (11.76%) patients. In mucous membrane, the oral mucosa was the first to be involved in 16 of 17 (94.11%) patients, including 5 (29.41%) patients with simultaneous onset of lesion in oral and genital and in 1 (5.88%) patient genital was the first involved mucosa. The majority of patients, 12 (70.58%), gave a history of the prodrome before the onset of cutaneous lesions. Fever with malaise (7 patients – 41.2%) and itch (5 patients – 29.41%) were the most common systemic and cutaneous prodromes observed respectively in the study.

The various presenting complaints of patients are explained in [Figure 5] with painful oral erosions being present in all patients (100%). Of the 17 cases, a history of drug intake was present in all (100%), and the causative drug was identified in 16 cases (94.11%) and 1 (5.88%) was unidentified, which was due to an unknown analgesic. Data on individual drugs and drug groups that were responsible for SJS-TEN spectra are depicted in [Table 2].

Figure 5: Presenting complaints of patients. X-axis shows various complaints of patients and Y-axis shows the number of patients having each complaint

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Among the total cases, 11 patients (64.7%) had co-morbidities of which CVA and epilepsy were the most common comorbidity being present in 7 of 17 patients (41.17%) in our study, followed by diabetes and chronic kidney disease (CKD) in two and systemic lupus erythematosus (SLE), lung carcinoma, HIV infection and tuberculosis in one patient each. Necrotic epidermis and erosion were the common findings, being present in 12 of 17 cases (70.58%), while vesicles and bulla occurred in 8 patients (47.05%).

Trunk and abdomen were involved in 15 cases (88.2%) followed by arms and thighs in 11 cases (64.7%) each. Scalp and face were involved in 2 (11.8%) and 10 cases (58.8%), respectively. Palms and soles involvement was seen in nine patients (52.9%). The forearm and leg were involved in two cases (11.8%) each. The scalp was spared in all patients of TEN, except one HIV-positive patient who had 100% body surface area involvement. Distal extremities were the next common spared site in TEN patients, being uninvolved in 8 of 11 patients (72.72%). All three patients (100%) with SJS-TEN overlap had involvement of the trunk and proximal limbs.

The day 1 body surface area of the study subjects is shown in [Figure 6]. Oral mucosal involvement was seen in all cases (100%), while other mucosal sites involved were urogenital (76.5%), conjunctiva (64.7%) followed by the pharynx and nasal mucosa in eight cases each (47.1%).

Figure 6: Body surface area (BSA) involvement among patients. X-axis shows the percentage BSA involved. Y-axis shows the number of patients having the corresponding BSA involvement

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The mean recovery time of skin and mucosa was 11.6 ± 3.2 days. In SJS, the mean recovery time was 15.7 ± 0.6 days, and the mean recovery time in TEN was 10.6 ± 2.5 days. The difference was statistically significant (P < 0.05). The mean recovery time of SJS-TEN overlap was 11.0 ± 4.6 days. The difference in mean recovery time between SJS or TEN and SJS/TEN overlap was not statistically significant (P > 0.05). For the mucosa, the recovery time was prolonged for SJS patients than for TEN patients, and the difference was not statistically significant (P > 0.05).

The laboratory abnormalities observed in patients are depicted in [Table 3]. SCORTEN was calculated for all patients on day 1, day 3 and day 5 of admission which was 2.411 ± 1.460, 2.588 ± 1.372 and 2.470 ± 1.772, respectively. Mortality was observed in 3 (17.64%) cases, which included 2 patients with SJS-TEN overlap and 1 patient with TEN. Kruskal–Wallis test was performed to identify differences in the mean SCORTEN scores on days 1, 3 and 5. No significant difference was observed between the three groups. The causes of three deaths were acute respiratory distress syndrome (ARDS), sepsis, pre-renal azotemia in TEN patients (phenytoin), acute kidney injury in chronic kidney disease for the remaining two SJS/TEN overlap patients (norfloxacin and phenytoin).

The predicted mortalities were 0.417, 1.836 and 2.574, and the observed mortalities were 0, 2 and 1 in SJS, SJS-TEN overlap and TEN, respectively. The overall predicted mortality was 4.827, and observed mortality was 3 [Table 4]. The Standardised Mortality Ratio (SMR) of SJS-TEN overlap was 1.1, and TEN was 0.389. The SMR of SJS-TEN overlap was statistically significant (P < 0.05), and the SMR of TEN was not statistically significant (P > 0.05). From [Table 5], it is clear that SCORTEN correlates significantly with mortality on all the 3 days in our study. [Table 6] associates the SCORTEN factors, and parameter wise with the alive and dead subjects. The factors, namely age above 40 years, cancer, epidermal detachment above 10% and serum HCO3 <20, did not associate significantly with mortality (P > 0.05). The heart rate above 120/min and RBS >252 mg% was associated significantly with the death of the subjects (P < 0.05). The BUN above 28% was highly associated with death (P < 0.01) in our study.

Table 6: Univariate analysis of individual factors of SCORTEN on mortality

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   Discussion Top

CADRs are considered exasperating both for the patients and treating clinicians resulting in significant morbidity and even mortality in some cases. CADRs are classified into benign and severe CADRs based on the severity of clinical manifestations. SJS and TEN are classified under severe CADRs along with acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS), exfoliative dermatitis and generalized bullous FDE.[7] Erythema multiforme (EMF), SJS and TEN were considered a continuum of the spectrum since 1983.[8] Later, it was redesignated by Bastuji-Garin et al. in 1993 and Roujeau et al. in 1994, and EMF was kept separately.[6],[9] Histopathological examination shows widespread keratinocyte apoptosis, with separation of the dermo-epidermal junction and mononuclear infiltrate in the dermis [Figure 7] and [Figure 8].

Figure 7: Section showing spongiosis, intraepidermal vesicles, necrosis of individual keratinocytes, extravasated erythrocytes, basal cell vacuolization, lymphocytic infiltrates in papillary dermis and papillary dermal oedema suggestive of toxic epidermal necrolysis. (H and E stain, 10x)

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Figure 8: Section showing complete detachment of epidermis from dermis with remnant basal cells, extravasated erythrocytes, dense lymphocytic infiltrates and upper dermal oedema suggestive of toxic epidermal necrolysis. (H and E stain, 10x)

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About half of SJS is attributed to drugs and the remaining to infection, while 95% of TEN is attributed to drugs. Several drugs are at increased risk of causing SJS-TEN, including sulphonamide antibiotics, aminopenicillin, cephalosporins, quinolones, aromatic anticonvulsants and NSAIDs of the Oxicam group. However recently, infections with mycoplasma pneumonia, Klebsiella pneumonia, Herpes virus infection, vaccination and graft vs host disease (GVHD) have also been well documented to be causally associated.[10]

The mortality rate ranges from 1–5% in SJS to 10–15% in transitional forms and 25–35% in established TEN.[11],[12],[13] Hence predicting the severity and mortality of such diseases is of paramount importance which also warrants a specific scoring system like SCORTEN.

A total of 69 cases of drug reaction were reported during the study period including 19 cases that fell under SJS and TEN spectrum. This relatively high incidence (29.53%) of SJS-TEN spectrum in our study was similar to a retrospective study by Sushma et al., on 404 hospitalized patients over a 9-year period, who also showed a higher incidence (19.5%) of SJS and TEN spectra in South India when compared to other countries.[14]

The mean age among males and females in this study was 39.2 ± 18.4 and 35.5 ± 24.7, respectively, which followed the study by Roujeau et al., where the majority involved was in the age group of 40–50 years.[9] In 11 patients (64%), the age of onset was after 30 years and in 4 patients (23%) the onset was after 60 years, supporting the view that the incidence increases with age.

Our study showed a male preponderance, with a male: female ratio of 3.25:1. Male preponderance has also been seen in a few of the previous studies by Ting et al. and Shah et al.[15],[16] A higher incidence in females was reported by Roujeau et al. in their retrospective study of 253 patients with a male: female ratio being 0.6:1.[9]

The majority of the patients [8 cases (47.9%)] in this study, presented within the first 3 days of onset which was comparable with the original study by Bastuji-Garin et al., with a mean day of hospitalization being 2 days.[6] The period of delay in hospitalization showed no significant impact in the outcome of patients in terms of mortality in our study (P > 0.05) which was consistent with the finding of Guegan et al.[5]

Cutaneous prodrome occurred in the form of itching, burning sensation and skin pain. Cutaneous prodrome was positive in 9 of 17 cases (53%). All the patients who had skin pain as prodrome ultimately developed toxic epidermal necrolysis. To the best of our knowledge, this inference has not been highlighted in any other studies published so far. The skin pain before the onset of TEN may be due to subclinical keratinocyte necrosis.

A positive history of drug intake was obtained in 100% of our study population in the preceding 3 weeks, and a single culprit drug could be determined in 15 out of 17 cases (88%) of patients in our study. Anticonvulsant was the commonest drug implicated as a cause of SJS/TEN in 47% of cases, followed by analgesic in 35%, antibiotics in 11% and ATT in 5.88% of patients. This was in accordance with other Indian studies by Sharma et al. and Devi et al. who also reported anticonvulsants as the most common causative drug in 35% and 53% of the patients, respectively. The causative anticonvulsants were replaced by levetiracetam which is structurally unrelated to common anticonvulsants without an aromatic ring.[17],[18]

In chest X-ray, infiltrate was seen in three patients (17.64%), and two of these three cases succumbed to death. Hague et al. suggested that respiratory involvement could be a poor prognostic factor in SJS/TEN that is not reflected in SCORTEN. Hence, modification might be needed in SCORTEN requiring involving respiratory component also.[19]

The associated biochemical abnormalities in this study are depicted in [Table 3]. All patients affected with thrombocytopenia and raised creatinine showed mortality. White blood cell (WBC) abnormalities like leucocytosis (35.3%) and leucopenia (11.7%) and raised serum creatinine (17.6%) have also been reported in 24%, 6% and 29% of the patients, respectively, in a study of 34 cases by Ting et al.[15] Association of thrombocytopenia with mortality is not reported in the literature and needs further exploration. Abnormal renal parameters can be explained by pre-renal acute kidney injury. Renal function impairment was shown to be associated with negative survival in the study by Kim et al. and Bansal et al.[20],[21] The main cause of renal failure in SJS/TEN is defective barrier function of the stratum corneum leading to increased fluid loss and pre-renal acute kidney injury. Hence, timely correction of hypovolaemia by appropriate fluid management must be a priority in all cases of SJS and TEN.

Electrolyte derangement was seen in the form of hyponatraemia, and hyperkalaemia in 2 (11.76%) and 1 (5.88%) cases, respectively. Hung et al. reported hyponatraemia and late hypokalaemia in 15.6% and 7.3% of the patients, respectively, who found a positive association of electrolyte derangements with certain drugs like NSAIDs, anticonvulsants, and allopurinol.[22]

Three patients (17.6%) who died had a score of 6, 5 and 4 on day 1. All the patients were above the age of 40 years and had elevated BUN and thrombocytopenia, 2 patients had infiltrates on chest X-ray and elevated liver enzymes along with elevated BUN. An overall mortality rate of 16.7% was observed by Bansal et al. as similar to our study.[20] All of our patients who died had an underlying systemic illness in the form of chronic renal disease, diabetes and lung cancer.

In this study, more than half (64.7%) had co-morbidities. According to a study by Bastuji-Garin et al., AIDS is not usually associated with poorer hospital prognosis among TEN patients, which is proved in our study.[4] Pre-existing circulatory co-morbidity has shown a relatively high risk of TEN in a study by Oen et al.[23] However, in our study, we did not encounter circulatory or cardiovascular co-morbidity in any of our patients. Studies by Devi et al. and Vaishampayan et al. also reported a high incidence of co-existent morbidities in Indian patients.[17],[24]

The mean SCORTEN values on days 1, 3 and 5 were 2.411, 2.588 and 2.470, respectively. Kruskal–Wallis test to identify the difference in the predictive value of SCORTEN on these three days showed no significant difference. This is similar to the study by Bastuji-Garin et al., where SCORTEN was performed within 24 hours of hospitalization, and a Taiwanese study by Ho et al.[6],[25] In a study on 144 patients by Guegan et al., SCORTEN was found to perform best on day 3 rather than on day 1.[5] This is in contrast to our study as others like Bansal et al. and Vaishampayan et al., where the SCORTEN performance was best on day 5.[20],[24] This variation in the performance of SCORTEN may be due to the mean delay in hospitalization which varies in each study.

On comparing actual and predicted mortalities, it was observed that the overall actual mortality was comparable to the predicted mortality by SCORTEN on all 3 days. The discriminative power of SCORTEN was acceptable for all 3 days calculated, similar to Bansal et al.[20]

On calculating the standardized mortality ratio (SMR), SCORTEN scoring was statistically significant for patients with SJS-TEN overlap (SMR >1). In TEN patients, SMR was 0.389, with the observed and predicted mortality being 1 and 2.574, respectively. Thus, SCORTEN gives an overestimation of mortality in patients falling in the severe end of the spectrum. This is similar to an observation by Koh et al., who also found that SCORTEN did not perform well in severely affected patients.[26]

On univariate analysis of individual factors in SCORTEN, BUN >28 mg% was more significantly associated with mortality in our study (P < 0.01) followed by heart rate >120/mt and RBS >252 mg% which were significantly associated with mortality (P < 0.05). This was similar to a study by Kim et al., where on univariate analysis, kidney function abnormality, pneumonia, and anaemia showed a significant negative correlation with survival.[21]

Another factor associated with a significant fatal outcome in our study was pneumonitis like the study by Hague et al. But this is not reflected in SCORTEN.[19]

The percentage of body surface area detachment did not influence the mortality in our study. Four patients had 100% body surface area detachment at some point of hospitalization. Proper supportive care and barrier nursing helped them to recover completely. This is in discordance with the study by Vaishampayan et al., where BSA detachment >30% was associated with a significant increase in mortality compared to BSA >10%.[24]

We also conclude that the performance of SCORTEN in our study showed no difference between days 1, 3 and 5. Hence, doing it in one day will provide valuable information regarding the prognosis. We also suggest certain modifications could be done to the existing SCORTEN, based on the observation made in our study. A modified SCORTEN is proposed by us for South Indian patients as shown in [Table 7].

Table 7: Suggested modified SCORTEN for the South Indian population based on our findings

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Of the three patients who suffered mortality in this study, all the patients had elevated BUN with thrombocytopenia, two had infiltrates on chest X ray and elevated liver enzymes each. Hence we have proposed a modified SCORTEN for the South Indian population. ROC curve analysis was performed for SCORTEN (area under curve: 0.9762) and modified SCORTEN (area under curve: 1). We observed modified SCORTEN to have better sensitivity and specificity. DeLong's test for two correlated ROC curves showed that modified SCORTEN was comparable with SCORTEN with no significant difference (p value: 0.4081). The increased sensitivity, specificity of modified SCORTEN and insignificant difference between the two scoring systems could be justified by our low sample size. Hence further studies in South Indian population using our proposed modified SCORTEN with more sample size is warranted.

The limitation of this study includes the fact that the aetiologic agents were determined by history and not by immunologic analysis. Owing to the small sample size, statistically, significant conclusions could not be derived from our study. Also, our study did not include genetic susceptibility testing to SJS and TEN.

   Conclusion Top

Though SJS and TEN are severe life-threatening drug reactions associated with a poor prognosis, appropriate and timely management of the patients in a tertiary care setup can significantly reduce mortality and shorten the course of illness for which mortality predictors like SCORTEN prove to be highly beneficial. Because of the paucity of prospective/controlled studies on SJS and TEN and the lack of studies confirming the validity of SCORTEN in Indian patients, studies analyzing larger sample sizes are needed to validate our study. Further research is also warranted for validating the modified SCORTEN proposed by us.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

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    25.Ho YL, Chang YT, Chu YT, Wu SC. Performance of the SCORTEN in Taiwanese patients with Stevens-Johnson syndrome and toxic epidermal necrolysis. Dermatol Sin 2010;28:15-20.  Back to cited text no. 25
    26.Koh HK, Fook-Chong S, Lee HY. Assessment and Comparison of Performance of ABCD-10 and SCORTEN in Prognostication of Epidermal Necrolysis. JAMA Dermatol. 2020;156:1294-9.  Back to cited text no. 26
    
  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]

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