Stevens-Johnson syndrome and toxic epidermolysis bullosa are two skin diseases that produce rashes, epidermal peeling, mucosal breakdown and life-threatening conditions. #◆ Stevens-Johnson syndrome and toxic epidermolysis bullosa are usually caused by drugs or bacterial infections. ◆Typical symptoms of both diseases include fever, generalized pain, erythema, blistering of mucosal areas, and small epidermal peeling (Stevens-Johnson syndrome) or large epidermal peeling (toxic epidermolysis bullosa). ◆Patients should be hospitalized in a burn unit, given fluids, sometimes corticosteroids and antibiotics, and discontinued from all suspected medications. Patients with Stevens-Johnson syndrome may have blisters on the mucous membranes, preferably in the mouth, eyes, and vagina, and may have a flaky rash. In patients with toxic epidermolysis bullosa, similar blistering of the mucous membranes may occur, but there may also be a generalized loss of the epidermal layer of skin. Both diseases can be life-threatening. Almost all cases are caused by a reaction to a drug, most commonly sulfonamide antibiotics; barbiturates; antiepileptic drugs such as phenytoin and carbamazepine; certain nonsteroidal anti-inflammatory drugs (NSAIDs); or allopurinol. There are also some cases caused by bacterial infections. There are also occasional cases of unknown pathogenesis. The disease can occur in all age groups, but is commonly seen in the elderly, probably due to the higher use of medications in the elderly. The disease is also more common in patients with AIDS. Stevens-Johnson syndrome and toxic epidermolysis bullosa often have fever, headache, cough, and generalized pain as the first symptoms. This is followed by a red macular rash on the face or trunk that spreads immediately to other areas in an irregular pattern. The rash expands and spreads, often forming blisters in the center of the rash. The blisters have a loose epidermis that is easy to peel. In patients with Stevens-Johnson syndrome, typically less than 10% of the body epidermis is involved. In patients with toxic epidermolysis bullosa, only light touching or tugging can cause extensive skin peeling, with many patients peeling even more than 30% of the body surface area. The affected skin feels painful and uncomfortable with chills and fever. Some patients may exhibit hair and nail loss. The acute phase of the rash and skin loss usually lasts from 1 to 14 days. In both diseases, blisters occur in the mucous membranes of the mouth, throat, anus, vulva, and eyes. Damage to the mucous membranes in the mouth causes difficulty in eating and pain when the mouth is closed, so the patient often salivates a lot. The damage that occurs in the eye is also very painful, swollen and filled with pus, and the cornea can be damaged and scarred. The urethra may also be affected, causing difficulty and pain in urination. Sometimes the mucous membranes of the digestive and respiratory tracts are also involved, causing diarrhea and respiratory distress. In toxic epidermolysis bullosa, the loss of skin is as life-threatening as a severe burn. Large amounts of body fluids and electrolytes leak from large areas of broken skin. Such patients are highly susceptible to organ failure and infection of the exposed areas of damage. Infection is the most common cause of death in patients. Patients with Stevens-Johnson syndrome or toxic epidermolysis bullosa require hospitalization. Any medication suspected of causing the disease should be stopped immediately. If available, patients should be treated in a burn unit and require careful care to avoid infection. If the patient is out of danger, the skin can be restored to its original state, unlike a burn, so no skin implants are necessary. Loss of fluids and electrolytes from the damaged skin requires intravenous replacement. The use of corticosteroids to treat this disease is controversial. Some physicians believe that high doses of corticosteroids given a few days before the onset of the disease can help, while others believe that corticosteroids should not be used. These drugs suppress the immune system and can increase the likelihood of serious infection. If an infection develops, antibiotics should be given immediately. In many cases, physicians treat toxic epidermolysis bullosa with IV human immunoglobulin to help prevent further immune damage to the skin and to stop the further development of blisters.