A 28-year-old Indian woman presents with a 5-day history of fever, malaise, and painful skin lesions. She had started carbamazepine 3 weeks ago for newly diagnosed epilepsy. On examination, she has dusky atypical target lesions on the trunk and extremities, and the structure marked **B** in the diagram shows hemorrhagic crusts with severe pain. She also has conjunctivitis and a positive Nikolsky sign. Her HLA-B*1502 status was not checked before initiating carbamazepine. What is the MOST appropriate IMMEDIATE management step?

Explanation

## Why Option 1 is correct The presence of oral mucosal involvement (marked **B** — hemorrhagic crusts) combined with ocular involvement (conjunctivitis) and dusky atypical target lesions establishes the diagnosis of Stevens-Johnson Syndrome (SJS). Per Robbins 10e Ch 25, mucosal involvement (oral + ocular ± genital) is a REQUIRED diagnostic criterion that distinguishes SJS/TEN from erythema multiforme minor. The clinical anchor states that **discontinuation of the offending drug is the MOST IMPORTANT intervention** — every day of delay increases mortality by approximately 30%. Carbamazepine is a high-risk aromatic anticonvulsant, and HLA-B*1502 screening (common in South Asian populations including India) should have been performed before initiation. Immediate drug withdrawal, ICU/burn unit admission, and supportive care (fluid management, sterile environment, wound care, ophthalmology consult, pain control) are the standard of care. The time-critical nature of this condition makes drug discontinuation the first and most critical step. ## Why each distractor is wrong - **Option 2**: Systemic corticosteroids are explicitly contraindicated in SJS/TEN. Per the clinical anchor, steroids have no proven benefit and may worsen outcomes by increasing infection risk in a patient with severe mucosal and epidermal damage. Continuing the offending drug while adding steroids is dangerous and delays the critical intervention of drug withdrawal. - **Option 3**: While IVIG has emerging use in some centers, it is NOT first-line therapy and should never be used as a substitute for drug discontinuation. The clinical anchor clearly states that IVIG evidence is mixed and controversial. Continuing carbamazepine at any dose while the patient is actively developing SJS is contraindicated and will perpetuate the reaction. - **Option 4**: Topical management alone is insufficient for SJS with significant mucosal involvement and systemic signs. Delaying drug withdrawal by 48 hours is dangerous — the clinical anchor emphasizes that every day of delay increases mortality risk. This approach fails to address the life-threatening nature of the condition and the need for ICU-level care. **High-Yield:** In SJS/TEN, **STOP THE DRUG FIRST** — mucosal involvement (oral + ocular) confirms diagnosis; drug withdrawal is time-critical (every day delay ↑ mortality ~30%); avoid steroids; treat like a burn patient in ICU. [cite: Robbins 10e Ch 25; clinical anchor: mucosal involvement required for SJS/TEN diagnosis; drug withdrawal most important management]