A 38-year-old male presented with a rash all over his body and skin peeling for 2 weeks after taking penicillin. Examination found purpuric macules on palms and soles, and erythema of the lips and conjunctiva. Lab results showed abnormalities. He was diagnosed with Stevens-Johnson syndrome/toxic epidermal necrolysis and secondary impetigo. Treatment included IV methylprednisolone, IV vancomycin, topical paraffin, and monitoring for complications. Goals were to relieve symptoms, prevent further skin detachment and improve mucosal healing.

1. Pharm.D

2. Toxic epidermal necrolysis(TEN)/Lyell
disease is a potentially life threatening
dermatologic disorder characterisied by
widespread of erythema, necrosis, bullous
,apoptotic keratinocyte cell death in epidermis
with detachment of epidermis and mucous
membranes resulting in exfoliation. Mucous
membrane involvement can result in GI,
respiratory failure, ocular abnormalities &
genitourinary complications.
Overlap of SJS& TEN is characterized by
irregularly shaped purpuric maculae's result in
detachment of epidermis and erosion on 10-30%
of body surface area.

3. A 38yrs old male patient came to dermatology
department complaining of rash all over the body with
scaling since 2 weeks. He is on Inj.penicillin rash
occurred on the next 15 days with peeling of skin on
back, axillas, upper & lower limbs, face. Presence of
edema, purpuric macules seen on both palms & soles,
conjunctival mucosal and both lips show erythema. Also
mild psoriasis and honey colored crustings seen on face.
He is k/c/o HTN since 3yrs & also a smoker and
alcoholic. He is not able to close eyelids due to
surrounding fissures.

4. On lab investigations:
Se.sodium:124mmol/L(135-145mmol/l),
Se.potassium:2.9mmol/L(3.5-5mmol/L,
Se.calcium:0.16mmol/L(1.05-1.3mmol/l),
Alkaline phosphate:164IU/L(35-
100IU/L),Se.Urea:48md/dl(7-
22mg/dl),Se.TG’s:228mg/dl(<150mg/dl)
On these basis he was hospitalized.
PROBLEM LIST:
 Stevens-Johnsons Syndrome Toxic epidermal necrolysis.
 Secondary impetiginization.

5. CURRENT MEDICATION
DRUG DOSE FREQUENC
Y
ROUTE Start date End Date
Inj.IMIPENEM 500mg TID IV D1 D4
Inj.Methyl
prednisolone
100mg BD IV in NS D1 D5
Liq.Parrafin Every hrly Topical D1 D8
Inj.Pantop 40mg OD PO D1 D6
Inj.KCL 1amp in
500ml NS
OD IV D1 D3
Inj.Optineur
on
1amp OD 1V D1 D5
T.Resodium 30mg OD PO D1 D3

6. DRUG DOSE
FREQUENC
Y
ROUTE Start Date End Date
Inj.Vancomyc
in
1gm BD IV D1 D4
Cap.Fesovit OD PO D4 D8
SYP.Grilinctu
s
2tbsp OD PO D4 D7
E.drops.Lacri
mos
BD Ocular D3 D7
Inj.Meromac 1gm TID IV D3 D5
T.ZOLFRESH 5mg OD PO D5 D8
T.ATIVAN 1mg SOS PO D5 D8
T.Sandocal 500mg BD PO D4 D6

7. TEN,SJS:
 Rash all over the body, Peeling of skin on back, axillas, scrotum
 Scaling &edema, palpable purpuric lesions seen on medial aspect of
both feet.
 Well defined plaques with scaling seen over dorsa of both hands, legs,
Mouth sores ,blisters on eyes & genitals.
 Honey colored crusting seen on face, both lips with erythema.
CURRENT MEDICATIONS:
Inj.MEROMAC 1gm TID IV
Inj.Methyl prednisolone 125 mg IV
Emoderm cream Topical TID
E/D Lacrimos BD
E/Oint Senszvise 5 hrly
Inj. Vancomycin 1gm BD

8. ASSESSMENT:
Etiology:
 Allergic drug-Penicillin
Risk factors:
No risk factors were found in this case.

9. EVALUATE NEED FOR THERAPY ( EVALUATE
CURRENT OR NEW THERAPY):-
Yes patient needs therapy to
1. Alleviate symptoms and prevent further complications
like renal insufficiency, acute tubular necrosis.
2.Prevent the spread of disease.
PLANNING
RECOMMEND DRUG TREATMENT( DRUGS TO BE
AVOIDED; FURTHER TESTS) :
Anti-histamines like Hydroxyzine 50mg PO should be
given.
As the patient is non-ambulatory addition of anti-
coagulants(heparin) added to regimen.
Anti-tumor necrosing alfa like INFIXIMAB(5mg/kg)

10. Goals :
 Symptomatic relief of patient.
 To alleviate the skin detachment from the surface of skin.
 Mucosal recovery.
Monitoring parameters:
 Monitor the detachment extent of body surface area.
 During the usage of these drug monitoring of RFT is
essential.

11. Criteria present score 2 .So, the mortality rate is 12%.If the mortality
rate is 90% should be admitted in ICU.

12. Side effects of vancomycin:
 Dizziness
 low blood pressure
 muscle pain/spasms of the
chest pain.
Side effects of Meromac:
 Diarrhoea
 nausea, vomiting
 abdominal pain
 Headache
 Constipation
 rash, pruritus,
Side effects of Methyl
prednisolone:
 Nausea, vomiting,
 heartburn, headache,
 dizziness,
 appetite changes
 increased sweating.

13. Drug Interactions
No drug interactions were found

14. Secondary Impetigo, Insomnia
 Moist, golden crusts on skin
 Rash, with blisters, inflammation, redness
 Scaling seen at dorsa of legs.
CURRENT MEDICATIONS:
Liq. Paraffin TID
T-Bact cream BD
Inj. Pantop 40mg OD
Inj. Optineuron 1 amp IV OD
Cap. Fesovit PO OD
T. Resodium 30mg
T.ZOLFRESH 5mg OD
T.ATIVAN 1mg SOS

15. ASSESSMENT
Etiology:
 As the skin is already broken by another skin condition a
Secondary impetigo is caused.
 Staphylococcus aureus.
Risk Factors
 Having a compromised immune system
 Mild psoriasis

16.  Yes patient needs therapy to
1. Eliminate the cause.
2. To prevent the further severity of impetigo.
3. To avoid hyperpigmentation condition at regions if crusts.

17.  Antibiotic cream(Clarithromycin)
 Crusts should be cleaned with soapy water before application
of ointment.
 Fusidic acid cream is prescribed for skin infections caused by
staphylococcal bacteria. It works by stopping the growth of
the bacteria causing the infection.
Drugs to be avoided:
 Sulfa containing drugs
 Beta lactam class of antibiotics

18. GOALS & MONITORING PARAMETERS:
Eradicate the cause
Normalize biochemical markers
Relive symptoms
DRUG INTERACTIONS
No major drug inter actions were found

19.  Try to avoid picking at or touching the areas affected
by impetigo. A non-stick dressing can be applied to
reduce the spread of impetigo.
 Do not take any OTC products without physicians
advice.
 Quit smoking
 Stop alcohol consumption

20.  Always wash your hands thoroughly after touching
areas of your skin affected by impetigo.
 Wash your hands properly to avoid spreading of
disease.
 Supportive care is necessary vitals should be
checked.
 Take fresh fruits and vegetables to improve the
immune system, quality of life.

21. Type of problem Possible Cause Comment
Needs different drug
product
More effective drug
available
Infiximab 5mg/kg to
improve the
re-epithethialisation,
Hydroxyzine 500mg
Heparin 5000U IV
No efficient therapy Additional therapy Antibiotic
cream(clarithromycin),
FUSIDIN(fusidic acid)

22. PHARMACOTHERAPY
CARE PLAN
1. Current drug regimen:- -----
Drug therapy problem: Untreated condition
Therapy goals/ Therapy end points: To normalise TG’S level
Therapy recommendations: Gemfibrozil 600mg BD
2. Current drug regimen: ------
Drug therapy problem: More effective drug available (Needs
different drug product)
Therapy goals/ Therapy end points: For faster better result
Therapy recommendations: Infiximab 200mg

23. 3.Current drug regimen: No drug
Drug therapy problem: Additional drug
Therapy goals/ Therapy end points: To avoid
thrombus formation
Therapy recommendations: Heparin 5000U
4.Current drug regimen: -----
Drug therapy problem: Supportive drug to regimen
Therapy goals/ Therapy end points: Efficient
therapeutic outcome
Therapy recommendations: Hydroxyzine 500mg PO,
Antibiotic cream of clarithromycin.

24.  http://www.healthline.com/search?q1=Toxic
+Epidermal+Necrolysis
 http://www.ncbi.nlm.nih.gov/pubmed/
 http://www.patient.co.uk/doctor/toxic-
epidermal-necrolysis
 http://www.drugs.com/ativan.html
 http://www.nlm.nih.gov/medlineplus/drugin
fo/meds/a682815.html
 Lyell A: Toxic epidermal necrolysis: an
eruption resembling scalding of the skin. Br J
Dermatol 1956