Correspondence Lower than expected mortality with dexamethasone in toxic epidermal necrolysis: 30-year experience of a Northern Mexico reference hospital Dear Editor, Patients with Stevens-Johnson Syndrome (SJS)/Toxic Epider- mal Necrolysis (TEN) are well-known to have high mortality. Since 2000, a severity-of-illness score for toxic epidermal necrolysis (SCORTEN) has been employed to assess severity and predict mortality. 1 Current therapeutic approaches are based on strategies aimed at controlling the various possible etiopathogenic mechanisms involved to avoid complications and sequelae as well as to improve survival. 2 The objective of this report was to describe our experience in the management of TEN with dexamethasone in the past 30 years in a tertiary care setting at University Hospital in Northeast Mexico. A retrospective study of patients with clinical and histopathological diagnosis of TEN was performed. All patients were treated under the dexamethasone protocol carried out by a multidisciplinary team within the first 3–5 days of evolution since symptoms started (Table 1) with intravenous dexametha- sone (16 mg/day in adults, and 0.15 mg/kg/day in children) divided into four doses for 7 days until epidermal necrosis stopped with posterior progressive reduction. When 50% of the initial dose was reached, it was replaced with an equivalent oral dose of prednisone in adults and methylprednisolone in chil- dren, completing the regimen over the following 15 days. A total of 32 patients were included and classified into SCORTEN 2 and 3; 19 patients had a SCORTEN of 2, and 13 had a SCORTEN of 3 (Table 2). Twenty-eight survived (87.5%) and four (12.5%) died, with a mortality of 10.5% for patients with a SCORTEN of 2 and 15.4% for those with SCORTEN of 3. A mean of 2.8 days elapsed prior to treatment initiation, with a therapeutic response evident 7.0 days after hospitalization. Twenty-six patients reported the use of a single drug, metami- zole being the most prevalent. Controversy regarding the use of systemic steroids for the spectrum SJS-TEN has existed. The routine use of systemic steroids for SJS-TEN has been proposed, suggesting that their administration should be instituted early in the course of the dis- ease, prior to significant skin involvement, followed by rapid withdrawal. 3 In our experience, IV dexamethasone at a dose of 0.15 mg/kg/day over 7–14 days, given early in the course of the disease, can abruptly halt the rapid course of epidermal necro- sis, resulting in an overall survival of more than 87.5% in our center over the last three decades. Advantages and disadvan- tages of using this scheme must be stated. One of the advan- tages of dexamethasone in patients with TEN is the lower cost of using steroids in comparison with other drugs, making this a feasible option in hospitals with limited resources. Moreover, mortality rate between 20 and 25% has been reported in TEN patients during acute phase, and the mortality rate of our thera- peutic approach can be compared with other published schemes; 4 also, mortality rate of SCORTEN 2 (10.5%) and SCORTEN 3 (15.4%) is lower in patients using our scheme in comparison with the expected mortality rate. Overall mortality in our series was 12.5%. Disadvantage of the use of dexametha- sone in the late phase is that extensive skin detachment strongly predisposes to infection and sepsis; however, none of our patients presented sepsis or complicated infections due to the use of corticosteroids. Therefore, at this stage, the use of systemic steroids is of little benefit and may even be detrimen- tal. Overall, we showed that early dexamethasone Table 1 Detailed protocol for TEN at the University Hospital UANL Procedure Hospitalization under strict isolation SCORTEN measurement Suspension of suspected drug Close monitoring of vital signs, electrolyte balance, and glycemia Complete medical history Detailed physical examination including skin and mucous membranes Laboratory tests: complete blood count with differential, erythrocyte sedimentation rate, biochemical profile, electrolytes, blood pH, carbon dioxide, prothrombin time, partial thromboplastin time, and fibrinogen Skin biopsy Chest x-ray Nasal, skin, and blood bacterial cultures Maintenance of a permeable peripheral venous route, in some patients, subclavian central venous catheter for administration of fluids and drugs Hypercaloric, hyperproteic, and low carbohydrate nutritional support to avoid complications of hyperglycemia. Preferred enteral route with nasogastric tube in case of oral intolerance Antacids (omeprazole) Administration of antibiotics according to culture and sensibilities Denudated areas were healed using compresses with potassium permanganate solution. Stanford mouthwash was used for cleansing of the oral mucosa, while ocular mucosa was lubricated and cleaned with saline solution.Hypercaloric and hyperproteic nutritional support with low carbohydrates to prevent hyperglycemia. Enteral nutrition always preferred; if impossible, nasogastric tube feeding was used. Nutrition support carried out by the nutrition department. TEN, toxic epidermal necrolysis; UANL, Universidad Aut onoma de Nuevo Le on. ª 2019 The International Society of Dermatology International Journal of Dermatology 2019 1