Plantar (heel and sole) foot skin literally peeled off!!
This is a 32-year-old with Stevens Johnson syndrome (SJS) from piroxicam. On day 4, she shed a good bit of the epidermis of her plantar foot in one piece! Up close, you could even see the dermatoglyphics. The brownish orange color in the last post is henna, which was unrelated to the disease process. After a rough week, this patient did well, and ultimately made a full recovery. SJS and toxic epidermal necrolysis (TEN) are rare severe drug reactions with high fevers, skin tenderness, mucosal erosions, and skin detachment about 1-3 weeks after the inciting medication is started (can be longer with anticonvulsants). SJS/TEN are considered the same disease on opposite ends of the spectrum, the level of skin detachment differentiating them: SJS<10% of body surface area (BSA), TEN>30% BSA. SJS-TEN overlap with 10-30% BSA. But the relationship between TEN and SJS is a great controversy in dermatology, some research suggests that they are actually different diseases based on pathogenic mechanisms. The 3 main medication classes most frequently implicated are NSAIDS, antibiotics, and anticonvulsants. Additional causes besides meds are rare and include immunizations and infections. The primary skin lesions include dusky red macules of irregular size and shape that start on the trunk and spread to the proximal extremities, neck, and face. Within hours to days, the epidermis can detach from the dermis with blister formation. Ocular, oral, and genital mucosa will be affected in more than 90% of cases. SJS has a 1-5% mortality risk, TEN has a 25-35% mortality risk. Anyone who says there are no dermatologic emergencies has not managed SJS/TEN. Rapid identification and withdrawal of the offending drug and aggressive supportive care are the most critical steps in management. Photo by @globaldermie
Hemodynamic stimuli&nonhemodynamic stimuli
