The Use of Systemic Immunomodulating Drugs and Management Practices in Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis among Dermatologists in the Philippines: A Cross-sectional Survey Study
DOI:
https://doi.org/10.2340/actadv.v106.adv-2026-0499Keywords:
inpatient dermatology, resource-limited setting, Stevens-Johnson syndrome, immunosuppressive agents, surveys and questionnaires, referral and consultationAbstract
Stevens–Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are rare, life-threatening cutaneous adverse drug reactions with potential morbidity and mortality. Despite increasing use of systemic immunomodulatory therapies, consensus regarding optimal medical management remains lacking, particularly in resource-limited settings. We evaluated management practices and treatment preferences for SJS/TEN among board-certified dermatologists in the Philippines using a clinical vignette-based (CV) survey approach. Methods: A cross-sectional online survey was conducted among Philippine board-certified dermatologists from January to June 2025. The survey assessed res-pondent characteristics, clinical experience with SJS/TEN, management practices, referral patterns, and treatment preferences across six6 standardized CVs. Ordinal data were analysed using weighted scores, Friedman tests, and Kendall’s coefficient of concordance to assess inter-physician agreement.. Results: There were forty-eight48 dermatologists participated. Most respondents reported prior SJS/TEN experience and inpatient clinical exposure. Corticosteroids were the most commonly used systemic therapy (85.4%), while 35.4 % reported managing selected cases with supportive care alone. Significant differences in treatment rankings were observed across all six6 vignettes (all p<0.001). Agreement was large for CV1 (W=0.516), moderate for CV2–5 (W=0.398–0.465), and small for CV6 (W=0.236). Corticosteroids and IVIG consistently ranked highest, while other immunosuppressants showed scenario-dependent variability. Conclusions: The use of systemic immunosuppressants remains to be preferred in SJS/TEN treatment. However, treatment practices among Filipino dermatologists demonstrate substantial heterogeneity especially in complex cases. These findings highlight the need for stratified treatment frameworks and persistent uncertainty in SJS/TEN management.
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Preclaro IAC, Liwag KIL, Tabalon-Morales M, Iniego-Rodas MC. Severe cutaneous adverse reactions: A narrative literature reNarrative Literature Review. J Philipp Dermatol Soc 2024; 33: 67–79. DOI: https://doi.org/10.4103/JPDS.JPDS_38_24
Kang S, Amagai M, Bruckner AL, Enk AH, Margolis DJ, McMichael AJ, et al. Fitzpatrick’s Dermatology, 9e. New York, NY: McGraw-Hill Education; 2019.
Creamer D, Walsh SA, Dziewulski P, Exton LS, Lee HY, Dart JKG, et al. UK guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults 2016. J Plast Reconstr Aesthet Surg 2016; 69: e119–e153. DOI: https://doi.org/10.1016/j.bjps.2016.01.034
Widgerow AD. Toxic epidermal necrolysis - management issues and treatment options. Int J Burns Trauma 2011; 1: 42–50.
Preclaro IAC, Bollenbach-Venturina LAM, Llantos SAA, Reyes-Ramos AR, Templonuevo JR, Tabalon-Morales M. Stevens-Johnson syndrome as the presenting manifestation of human immunodeficiency virus and syphilis coinfection. Dermatol Online J 2025; 31. DOI: https://doi.org/10.25251/h5hgtj57
Han JJ, Creadore A, Seminario-Vidal L, Micheletti R, Noe MH, Mostaghimi A. Medical management of Stevens-Johnson syndrome/toxic epidermal necrolysis among North American dermatologists. J Am Acad Dermatol 2022; 87: 429–431. DOI: https://doi.org/10.1016/j.jaad.2021.08.051
Genuino RF, Jamora MJJ, Espiritu L, Villanueva EQ. The distribution of dermatologists in the Philippines. Cureus 2024; 16: e60402. DOI: https://doi.org/10.7759/cureus.60402
Alharithy R, Alotaibi HM, Shadid A, Alhaddad S, Alotaibi MA, Alsubhi AM, et al. Recent trends in dermatologists’ career choices: a cross-sectional study in Saudi Arabia. J Nat Sci Med 2023; 6: 186–191. DOI: https://doi.org/10.4103/jnsm.jnsm_49_23
Okoth LA, Mirieri HM. Nursing care of stevens johnson syndrome and toxic epidermal necrolysis: case study of dermatology unit of referral hospital, Kenya. OJN 2019; 09: 742–756. DOI: https://doi.org/10.4236/ojn.2019.97056
Justice J, Mukherjee E, Martin-Pozo M, Phillips E. Updates in the pathogenesis of SJS/TEN. Allergol Int 2025; 74: 361–371. DOI: https://doi.org/10.1016/j.alit.2025.05.002
Creamer D, Walsh SA, Dziewulski P, Exton LS, Lee HY, Dart JKG, et al. U.K. guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults 2016. Br J Dermatol 2016; 174: 1194–1227. DOI: https://doi.org/10.1111/bjd.14530
Schneck J, Fagot JP, Sekula P, Sassolas B, Roujeau JC, Mockenhaupt M. Effects of treatments on the mortality of Stevens-Johnson syndrome and toxic epidermal necrolysis: A retrospective study on patients included in the prospective EuroSCAR Study. J Am Acad Dermatol 2008; 58: 33–40. DOI: https://doi.org/10.1016/j.jaad.2007.08.039
Zimmermann S, Sekula P, Venhoff M, Motschall E, Knaus J, Schumacher M, et al. Systemic immunomodulating therapies for stevens-johnson syndrome and toxic epidermal necrolysis: a systematic review and meta-analysis. JAMA Dermatol 2017; 153: 514–522. DOI: https://doi.org/10.1001/jamadermatol.2016.5668
Gupta LK, Martin AM, Agarwal N, D’Souza P, Das S, Kumar R, et al. Guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis: An Indian perspective. Indian J Dermatol Venereol Leprol 2016; 82: 603–625. DOI: https://doi.org/10.4103/0378-6323.191134
Hama N, Aoki S, Chen CB, Hasegawa A, Ogawa Y, Vocanson M, et al. Recent progress in Stevens–Johnson syndrome/toxic epidermal necrolysis: diagnostic criteria, pathogenesis and treatment. Br J Dermatol 2024; 192: 9–18. DOI: https://doi.org/10.1093/bjd/ljae321
Sen S, Rudra O, Gayen T. Extracorporeal therapy in dermatology. Indian J Dermatol 2021; 66: 386–392. DOI: https://doi.org/10.4103/ijd.IJD_897_20
Weiss D, Nordhorn I, Tizek L, Werfel T, Zink A, Biedermann T, et al. Prescription behaviour and barriers to prescription of biologicals for treatment of chronic inflammatory skin diseases in dermatological practice in two Two German Federal States. Acta Derm Venereol 2021; 101: adv00560. DOI: https://doi.org/10.2340/00015555-3901
Ng QX, De Deyn MLZQ, Venkatanarayanan N, Ho CYX, Yeo WS. A meta-analysis of cyclosporine treatment for Stevens-Johnson syndrome/toxic epidermal necrolysis. J Inflamm Res 2018; 11: 135–142. DOI: https://doi.org/10.2147/JIR.S160964
Watanabe Y, Hama N. Recent advances in the diagnosis and treatment of Stevens-Johnson syndrome/toxic epidermal necrolysis. Allergol Int 2025; 74: 345–355. DOI: https://doi.org/10.1016/j.alit.2025.05.008
Seminario-Vidal L, Kroshinsky D, Malachowski SJ, Sun J, Markova A, Beachkofsky TM, et al. Society of dermatology hospitalists supportive care guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults. J Am Acad Dermatol 2020; 82: 1553–1567. DOI: https://doi.org/10.1016/j.jaad.2020.02.066
Lee HY, Walsh SA, Creamer D. Long-term complications of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN): the spectrum of chronic problems in patients who survive an episode of SJS/TEN necessitates multidisciplinary follow-up. Br J Dermatol 2017; 177: 924–935. DOI: https://doi.org/10.1111/bjd.15360
Ozhathil DK, Powell CM, Corley CV, Golovko G, Song J, El Ayadi A, et al. A retrospective analysis of mortality risk and immunosuppressive therapy for Stevens-Johnson Syndrome and toxic epidermal necrolysis syndrome using the TriNetX research network. Burns 2024; 50: 75–86. DOI: https://doi.org/10.1016/j.burns.2023.08.009
Sotozono C, Ueta M. Updates on the ocular manifestations and treatment of SJS/TEN. Allergol Int 2025; 74: 356–360. DOI: https://doi.org/10.1016/j.alit.2025.05.003
White KD, Abe R, Ardern-Jones M, Beachkofsky T, Bouchard C, Carleton B, et al. SJS/TEN 2017: Building multidisciplinary networks to drive science and translation. J Allergy Clin Immunol Pract 2018; 6: 38–69. DOI: https://doi.org/10.1016/j.jaip.2017.11.028
Bouraima MB, Jovčić S, Švadlenka L, Simic V, Badi I, Maraka ND. An integrated multi-criteria approach to formulate and assess healthcare referral system strategies in developing countries. Healthcare Analytics 2024; 5: 100315. DOI: https://doi.org/10.1016/j.health.2024.100315
Wang J, Yamada R. In silico study of medical decision-making for rare diseases: heterogeneity of decision-makers in a population improves overall benefit. PeerJ 2018; 6: e5677. DOI: https://doi.org/10.7717/peerj.5677
Sekula P, Dunant A, Mockenhaupt M, Naldi L, Bouwes Bavinck JN, Halevy S, et al. Comprehensive survival analysis of a cohort of patients with Stevens-Johnson syndrome and toxic epidermal necrolysis. J Invest Dermatol 2013; 133: 1197–1204. DOI: https://doi.org/10.1038/jid.2012.510
Nazerian A, Jafarzadeh A, Salehi S, Ghasemi M, Goodarzi A. Cyclosporin for the treatment of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN): a systematic review of observational studies and clinical trials focusing on single therapy, combination therapy, and comparative assessments. Inflammopharmacology 2025; 33: 485–503. DOI: https://doi.org/10.1007/s10787-024-01590-0
Wolkenstein P, Latarjet J, Roujeau JC, Duguet C, Boudeau S, Vaillant L, et al. Randomised comparison of thalidomide versus placebo in toxic epidermal necrolysis. The Lancet 1998; 352: 1586–1589. DOI: https://doi.org/10.1016/S0140-6736(98)02197-7
Frangogiannis NG, Boridy I, Mazhar M, Mathews R, Gangopadhyay S, Cate T. Cyclophosphamide in the treatment of toxic epidermal necrolysis. South Med J 1996; 89: 1001–1003. DOI: https://doi.org/10.1097/00007611-199610000-00015
Wang L, Varghese S, Bassir F, Lo YC, Ortega CA, Shah S, et al. Stevens-Johnson syndrome and toxic epidermal necrolysis: A systematic review of PubMed/MEDLINE case reports from 1980 to 2020. Front Med 2022; 9. DOI: https://doi.org/10.3389/fmed.2022.949520
Kimura H, Oginezawa M, Hama N, Watanabe Y, Yamaguchi Y, Nakajima S, et al. Efficacy and safety of eta Safety of Etanercept in Japanese patients with stevens-johnson syndrome and toxic epidermal necrolysis unresponsive to systemic steroid therapy: A Multicenter, open-label, single-arm study. J Dermatol 2025; 52: 1536–1544. DOI: https://doi.org/10.1111/1346-8138.17860
Miyamoto Y, Ohbe H, Kumazawa R, Matsui H, Fushimi K, Yasunaga H, et al. Evaluation of plasmapheresis vs immunoglobulin as first treatment after ineffective systemic corticosteroid therapy for patients with stevens-johnson syndrome and toxic epidermal necrolysis. JAMA Dermatol 2023; 159: 481–487. DOI: https://doi.org/10.1001/jamadermatol.2023.0035
Watanabe H, Ogawa Y, Yamaguchi Y, Nakajima S, Mizukawa Y, Mushiroda T, et al. Guidelines for the man Management of Stevens–Johnson syndrome and toxic epidermal necrolysis 2025 supplement. J Dermatol 2026; 53. DOI: https://doi.org/10.1111/1346-8138.70136
Zabala DAR, Guillano VP, Lugasan MBD. The economic burden of psoriasis: a cross-sectional study in a tertiary hospital in the Philippines. J Philipp Dermatol Soc 2022; 31: 01671546–202231010.
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