Profile of patients with epidermal necrolysis at Dr. Soetomo General Hospital, Surabaya Period 2021-2023

 Corresponding author: Sylvia Anggraeni Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution License 4.0. Profile of patients with epidermal necrolysis at Dr. Soetomo General Hospital, Surabaya Period 2021-2023 An Nisa Nur Izzah Fitria Efendi 1, Sylvia Anggraeni 2, *, Lita Diah Rahmawati 3 and Damayanti 2 1 Medical Programme, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia. 2 Department of Dermatology and Venereology, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia. 3 Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia. World Journal of Advanced Research and Reviews, 2025, 28(03), 424-433 Publication history: Received on 28 October 2025; revised on 03 December 2025; accepted on 06 December 2025 Article DOI: https://doi.org/10.30574/wjarr.2025.28.3.4076 Abstract Epidermal necrolysis, encompassing Stevens-Johnson Syndrome (SJS), SJS-TEN overlap, and Toxic Epidermal Necrolysis (TEN), is a life-threatening hypersensitivity reaction characterized by extensive epidermal and mucosal damage, often induced by specific medications. This study aimed to describe the prevalence, demographic distribution, causative factors, clinical manifestations, SCORTEN scores, comorbidities, management approaches, consultations, and outcomes of epidermal necrolysis patients treated at Dr. Soetomo General Hospital, Surabaya, during 2021–2023. A descriptive retrospective method was employed using medical record data. A total of 28 cases were identified, with SJS as the most common type (57%). The majority of patients were aged 36–45 years (21%), female (53.5%), residents of Surabaya (68%), and employed in the private sector (32%). Paracetamol was the most frequent trigger (16%). Skin lesions, particularly macules, were the predominant clinical manifestation (48%), with SCORTEN scores mainly ranging between 0–1 (43%). Sepsis was the most common comorbidity (8.5%), and the primary treatment involved discontinuation of the offending drug (24%). The Department of Internal Medicine was the most frequently consulted (51%), and 57% of patients recovered. In conclusion, most epidermal necrolysis cases were classified as SJS, predominantly affecting middle-aged females, with paracetamol as the leading causative drug. Early identification and prompt withdrawal of the causative medication remain crucial for favorable outcomes. Keywords: Epidermal necrolysis; SSJ; TEN; SCORTEN; Drug reaction; Epidermolysis 1. Introduction Epidermal necrolysis is an acute mucocutaneous hypersensitivity reaction characterized by extensive epidermal necrosis and detachment, leading to severe complications and potentially fatal outcomes [1]. The condition encompasses a clinical spectrum ranging from Stevens-Johnson Syndrome (SJS) to Toxic Epidermal Necrolysis (TEN), which differ mainly by the percentage of body surface area involved [2]. Although rare, SJS/TEN carries significant clinical importance due to its high morbidity and mortality rates. Globally, the incidence varies from 1 to 2 cases per million annually, with a higher prevalence among females aged 40–60 years [3, 4]. Drug exposure is the most common trigger, accounting for approximately 77–95% of all SJS/TEN cases, particularly involving medications such as allopurinol, carbamazepine, phenytoin, lamotrigine, and certain antibiotics and NSAIDs [5–7]. In Indonesia, epidemiological data on epidermal necrolysis remain limited. Previous studies from Dr. Soetomo General Hospital, Surabaya, revealed that most patients were female, aged 25–44 years, with drug-induced reactions—mainly analgesics—being the leading cause [8]. Given its rarity yet severe clinical impact, a comprehensive understanding of local case profiles is crucial to guide early diagnosis, management, and prevention strategies. Therefore, this study aims World Journal of Advanced Research and Reviews, 2025, 28(03), 424-433 425 to describe the demographic, clinical, and therapeutic characteristics of epidermal necrolysis cases at Dr. Soetomo General Hospital, Surabaya, during the 2021–2023 period, thereby contributing to national data on this life-threatening dermatological emergency and supporting better pharmacovigilance efforts in Indonesia. 2. Material and methods The research method applied was a descriptive retrospective study using electronic medical record data of epidermal necrolysis patients at Dr. Soetomo General Hospital, Surabaya in 2021-2023. Data were collected using a total sampling technique from the entire population of epidermal necrolysis patients. Furthermore, each data was evaluated one by one to assess the completeness of information according to the variables defined in the study. The information collected included patient identity, which consisted of age, gender, domicile, and occupation. In addition, data on epidermal necrolysis disease history was also extracted, including causative factors, clinical manifestations, SCORTEN scores, comorbidities, management, consultations needed, and cure and mortality rates. 3. Results and discussion 3.1. Prevalence Table 1 Distribution of new cases of epidermal necrolysis Year Number of new case Percentage (%) 2021 6 21.43% 2022 8 28.57% 2023 14 50.00% Total 28 100.00% Source: Research data, processed During 2021–2023, a total of 28 eligible epidermal necrolysis cases were identified at Dr. Soetomo General Hospital. The number of cases increased each year, from 6 (21.43%) in 2021 to 14 (50.00%) in 2023. This upward trend might be linked to indirect impacts of the COVID-19 pandemic, such as reduced healthcare access, self-medication, and immune activation post-infection or vaccination [9–11]. Table 2 Distribution of epidermal necrolysis patient classifications Classification Number of new case Percentage ( %) Stevens-Johnson Syndrome (SJS) 16 57.14% SJS/TEN overlap 3 10.71% Toxic Epidermal Necrolysis (TEN) 9 32.14% Total 28 100.00% Source: Research data, processed Clinically, 57.14% were Stevens–Johnson Syndrome (SJS), 32.14% Toxic Epidermal Necrolysis (TEN), and 10.71% SJS– TEN overlap. The dominance of SJS aligns with global data showing that SJS is more frequent due to its milder presentation, whereas TEN predominates in tertiary centers receiving severe cases [1,7]. World Journal of Advanced Research and Reviews, 2025, 28(03), 424-433 426 3.2. Demographic Characteristics Table 3 Age distribution of patients with epidermal necrolysis Age Classification Frequency (n) Percentage (%) SJS SJS/TEN overlap TEN 0-5 years old 0 0 0 0 0.00% 5-11 years old 1 0 1 2 7.14% 12-16 years old 1 1 0 2 7.14% 17-25 years old 1 0 0 1 3.57% 26-35 years old 5 0 0 5 17.86% 36-45 years old 3 1 2 6 21.43% 46-55 years old 3 0 2 5 17.86% 56-65 years old 1 0 1 2 7.14% >65 years old 1 1 3 5 17.86% Total 16 3 9 28 100.00% Source: Research data, processed Most patients were aged 36–45 years (21.43%), followed by 26–35 years, 46–55 years, and >65 years (each 17.86%). This finding supports reports that epidermal necrolysis is more common among adults aged 20–59 years [3–5], likely due to higher drug exposure and comorbidities. No cases were recorded in children under five, consistent with the lower medication exposure in that group [12]. Table 4 Gender distribution of patients with epidermal necrolysis Classification Gender Frequency (n) Male Female Stevens-Johnson Syndrome (SJS) 6 10 16 SJS/TEN overlap 2 1 3 Toxic Epidermal Necrolysis (TEN) 5 4 9 Total 13 15 28 Percentage (%) 46.43% 53.57% 100.00% Source: Research data, processed Females accounted for 53.57% of cases, consistent with prior studies showing slightly higher risk among women due to hormonal and immunologic factors [2,7]. Table 5 Residence distribution of patients with epidermal necrolysis Classification Residence Surabaya Outside Surabaya Stevens-Johnson Syndrome (SJS) 12 4 SJS/TEN overlap 2 1 Toxic Epidermal Necrolysis (TEN) 5 4 Total 19 9 Percentage (%) 67.86% 32.14% Source: Research data, processed World Journal of Advanced Research and Reviews, 2025, 28(03), 424-433 427 Table 6 Occupational distribution of patients with epidermal necrolysis Occupation SJS SJS/TEN overlap TEN Frequency (n) Percentage (%) Private employee 7 0 2 9 32.14% Housewife 4 1 2 7 25.00% Student 2 0 1 3 10.71% Entrepreneur 1 0 2 3 10.71% Farmer 1 0 1 2 7.14% Day laborer 0 1 0 1 3.57% Unidentified 1 1 1 3 10.71% Source: Research data, processed Most patients lived in Surabaya (67.86%), while 32.14% were referrals from outside regions, reflecting the hospital’s role as a tertiary referral center [8]. Regarding occupation, private employees (32.14%) and housewives (25.00%) dominated, consistent with other reports associating epidermal necrolysis with the productive age group [13]. 3.3. Etiology Table 7 Drug consumption history distribution of patients with epidermal necrolysis Drug consumption history SJS SJS/TEN overlap TEN Frequency (n) Percentage (%) Paracetamol 4 2 3 9 32.14% Ciprofloxacin 1 0 3 4 14.29% Amoxicillin 2 0 1 3 10.71% Ceftriaxone 2 0 1 3 10.71% Metamizole 1 0 2 3 10.71% Herbal medicine 1 1 0 2 7.14% Valproic acid 2 0 0 2 7.14% Mefenamic acid 1 1 0 2 7.14% Carbamazepine 1 0 1 2 7.14% Dexamethasone 1 0 1 2 7.14% Allopurinol 2 0 0 2 7.14% Erythromycin 1 0 0 1 3.57% Dapsone 1 0 0 1 3.57% Phenytoin 1 0 0 1 3.57% Metoclopramide 1 0 0 1 3.57% Cefadroxil 1 0 0 1 3.57% Halmezin Syrup 1 0 0 1 3.57% Farmalat 1 0 0 1 3.57% Paratusin 1 0 0 1 3.57% Fenofibrate 1 0 0 1 3.57% Cefixime 0 1 0 1 3.57% World Journal of Advanced Research and Reviews, 2025, 28(03), 424-433 428 Sinovac Vaccine 0 0 1 1 3.57% Ketoconazole 0 0 1 1 3.57% Moxifloxacin 0 0 1 1 3.57% Sulfamethoxazole 0 0 1 1 3.57% Sodium Diclofenac 0 0 1 1 3.57% Unidentified 2 1 2 5 17.86% Total 29 6 19 54 100.00% Note: One patient may take more than one type of medication. Source: Research data, processed Drugs were the leading cause of epidermal necrolysis, with paracetamol (32.14%) as the most frequent suspected agent, followed by ciprofloxacin (14.29%), amoxicillin, ceftriaxone, and metamizole (each 10.71%). These findings are consistent with local studies at Dr. Soetomo General Hospital reporting paracetamol as the leading trigger [8,14], although globally, allopurinol and antiepileptics such as carbamazepine remain the predominant agents [1,4,6,15]. Five cases (17.86%) had unidentified causes, and a few were linked to herbal remedies (7.14%) and post–COVID-19 vaccination (3.57%), though vaccine-related SJS/TEN is extremely rare (<1 per million doses) [11,16]. Table 8 Infection history distribution of patients with epidermal necrolysis Infection history SJS SJS/TEN overlap TEN Frequency (n) Percentage (%) HIV 2 0 0 2 7,14% Total 2 0 0 2 7,14% Source: Research data, processed Two patients (7.14%) were HIV-positive, supporting literature showing a markedly increased epidermal necrolysis risk in HIV infection due to immune dysregulation and polypharmacy [17,18]. 3.4. Clinical Manifestations Table 9 Clinical manifestations distribution of patients with epidermal necrolysis Classification Clinical manifestations Frequency (n) Skin Mucosa Extracutaneous Stevens-Johnson Syndrome (SJS) 15 13 3 31 SJS/TEN overlap 3 3 1 7 Toxic Epidermal Necrolysis (TEN) 9 6 3 18 Total 27 22 7 56 Percentage (%) 96.43% 78.57% 25.00% 100.00% Note: one patient may have more than one clinical manifestation. Source: Research data, processed Table 10 Skin manifestations distribution of patients with epidermal necrolysis Skin manifestations SJS SJS/TEN overlap TEN Frequency (n) Percentage (%) Macule 13 2 8 23 82.14% Erosion 6 2 5 13 46.43% Bulla 5 2 3 10 35.71% Squama 5 0 3 8 28.57% Crust 3 1 3 7 25.00% World Journal of Advanced Research and Reviews, 2025, 28(03), 424-433 429 Plaque 2 1 0 3 10.71% Papule 0 0 2 2 7.14% Pustule 0 1 1 2 7.14% Vesicle 0 0 1 1 3.57% Nodule 0 0 0 0 0.00% Ulcer 0 0 0 0 0.00% Itching 1 1 1 3 10.71% Total 35 10 27 72 100.00% Note: one patient may have more than one skin manifestation. Source: Research data, processed Cutaneous involvement was observed in 96.43% of cases—mainly macules (82.14%), erosions (46.43%), and bullae (35.71%)—consistent with the classical clinical course of epidermal necrolysis progressing from erythematous macules to flaccid bullae and epidermal detachment [1,2,19]. Table 11 Mucosal manifestations distribution of patients with epidermal necrolysis Mucosal manifestations SJS SJS/TEN overlap TEN Frequency (n) Percentage (%) Erosion 6 1 4 11 39.29% Crust 7 2 2 11 39.29% Macule 5 1 1 7 25.00% Plaque 2 0 1 3 10.71% Pustule 1 0 1 2 7.14% Ulcer 0 1 1 2 7.14% Painful swallowing 3 1 2 6 21.43% Red eyes 2 1 2 5 17.86% Edema 1 0 1 2 7.14% Ear pain 1 0 0 1 3.57% Total 28 7 15 50 100.00% Note: one patient may have more than one mucosal manifestation. Source: Research data, processed Table 12 Extracutaneous manifestations distribution of patients with epidermal necrolysis Extracutaneous manifestations SJS SJS/TEN overlap TEN Frequency (n) Percentage (%) Fever 3 1 1 5 17.86% Pain 0 0 1 1 3.57% Edema in the extremities 0 0 1 1 3.57% Total 3 1 3 7 100.00% Note: one patient may have more than one extracutaneous manifestation. Source: Research data, processed Mucosal involvement occurred in 78.57% of patients, especially erosions and crusting (each 39.29%), while extracutaneous features such as fever and limb edema were noted in 25%. This reflects extensive epithelial apoptosis and systemic inflammation typical of EN [3,20]. World Journal of Advanced Research and Reviews, 2025, 28(03), 424-433 430 3.5. SCORTEN Table 13 SCORTEN distribution of patients with epidermal necrolysis SCORTEN SJS SJS/TEN overlap TEN Frequency (n) Percentage (%) SCORTEN 0-1 11 0 1 12 42.86% SCORTEN 2 3 1 3 7 25.00% SCORTEN 3 2 1 1 4 14.29% SCORTEN 4 0 1 4 5 17.86% ≥ SCORTEN 5 0 0 0 0 0.00% Total 16 3 9 28 100.00% Source: Research data, processed Most patients had SCORTEN 0–1 (42.86%), suggesting mild disease, while 17.86% scored 4, predicting >50% mortality. Common factors included age >40 years (57.14%), BSA >10% (53.57%), and tachycardia >120 bpm (35.71%). 3.6. Comorbidities Table 14 Comorbidities distribution of patients with epidermal necrolysis Comorbidities SJS SJS/TEN overlap TEN Frequency (n) Percentage (%) Sepsis 3 1 5 9 32.14% Anemia 5 0 2 7 25.00% Hypoosmolar hyponatremia 2 0 3 5 17,86% Hypoalbuminemia 3 0 2 5 17,86% Hypertension 3 0 2 5 17,86% Pneumonia 3 2 0 5 17,86% Bilirubin metabolism disorder 3 0 2 5 17,86% Blepharoconjunctivitis 2 1 1 4 14.29% Hyponatremia 2 0 1 3 10.71% Type 2 diabetes mellitus 1 0 2 3 10.71% Acute renal failure 2 0 1 3 10.71% Malnutrition 0 2 1 3 10.71% Epilepsy 2 0 1 3 10.71% Renal failure 2 0 1 3 10.71% HIV 2 0 0 2 7.14% Hyperkalemia 2 0 0 2 7.14% Candidiasis 2 0 0 2 7.14% Candidal stomatitis 1 1 0 2 7.14% Type 1 respiratory failure 1 0 1 2 7.14% Hypernatremia 1 0 1 2 7.14% SLE 2 0 0 2 7.14% Note: One patient may have more than one comorbidity. Source: Research data, processed World Journal of Advanced Research and Reviews, 2025, 28(03), 424-433 431 Sepsis (32.14%), anemia (25%), and electrolyte disorders (17.86%) were leading comorbidities. Sepsis correlated with higher SCORTEN and mortality, confirming its role as a major prognostic determinant [5,21]. 3.7. Treatments Table 15 Treatments distribution of patients with epidermal necrolysis Treatments SJS SJS/TEN overlap TEN Frequency (n) Percentage (%) Discontinuation of medication 16 3 9 28 100.00% Injections 13 3 7 23 82.14% Wound care 11 3 7 21 75.00% Infusions 8 1 6 15 53.57% Oral medication 5 1 2 8 28.57% Fluid balance 6 0 0 6 21.43% Monitoring vital signs 3 1 1 5 17.86% Maintaining hygiene 2 1 0 3 10.71% Oxygenation 1 0 2 3 10.71% NGT 1 0 2 3 10.71% Occupational therapy 1 0 0 1 3.57% Change position every 2 hours 1 0 0 1 3.57% Total 68 13 36 117 100.00% Note: one patient may receive more than one treatment. Source: Research data, processed All patients underwent discontinuation of the suspected drug (100%), along with systemic corticosteroids or antibiotics (82.14%), wound care (75%), IV fluids (53.57%), and oral antihistamines (28.57%). These interventions follow standard epidermal necrolysis management emphasizing causative drug withdrawal and supportive therapy [6,19]. 3.8. Consultations Table 16 Consultations distribution of patients with epidermal necrolysis Consultations SJS SJS/TEN overlap TEN Frequency (n) Percentage (%) Internal Medicine 13 3 7 23 82.14% Ophthalmology 4 0 4 8 28.57% ENT 3 0 2 5 17.86% Dermatology and Venereology 2 0 2 4 14.29% Cardiology 0 0 2 2 7.14% Pediatrics 1 0 0 1 3.57% Neurology 1 0 0 1 3.57% Psychiatry 0 0 1 1 3.57% Total 24 3 18 45 100.00% Note: One patient may consult with more than one department. Source: Research data, processed Consultations were mainly with internal medicine (82.14%), ophthalmology (28.57%), and ENT (17.86%). World Journal of Advanced Research and Reviews, 2025, 28(03), 424-433 432 3.9. Outcomes Table 17 Outcomes distribution of patients with epidermal necrolysis Classification Outcomes Frequency (n) Improved Deceased Forcibly discharged Referred SJS 10 4 1 1 16 SJS/TEN overlap 1 1 1 0 3 TEN 5 4 0 0 9 Total 16 9 2 1 28 Percentage (%) 57.14% 32.14% 7.14% 3.57% 100.00% Source: Research data, processed Recovery was achieved in 57.14% of cases, while mortality reached 32.14%, mostly among TEN patients with high SCORTEN scores. 4. Conclusion This study identified 28 cases of epidermal necrolysis at Dr. Soetomo General Hospital, Surabaya, between 2021 and 2023, with Stevens-Johnson Syndrome (SJS) being the most common subtype. The condition predominantly affected individuals aged 36–45 years, with a higher incidence in females, residents of Surabaya, and private-sector workers. Paracetamol was the most frequently associated causative drug, and the primary clinical manifestation was macular skin lesions. Most patients presented with low SCORTEN scores (0–1) and sepsis as the leading comorbidity. Drug withdrawal was the most frequently applied management approach, and the Department of Internal Medicine was the most consulted specialty. The overall recovery rate reached 57%, while mortality was recorded at 32%. These findings emphasize the importance of early recognition and prompt cessation of the causative drug to improve survival outcomes. This study contributes to enhancing clinical awareness and supports preventive efforts through better drug monitoring and patient education, ultimately benefiting public health and guiding future research on drug-induced epidermal necrolysis. Compliance with ethical standards Acknowledgments We gratefully acknowledge the institutional support provided by Universitas Airlangga. We also extend our sincere appreciation to all contributing authors for their valuable input, constructive feedback, and approval of the final version of this manuscript. Disclosure of conflict of interest The authors declared there is no conflict of interest. Statement of ethical approval The study was approved by the Ethics Committee of Dr. Soetomo Regional General Hospital. References [1] Roujeau JC. Stevens–Johnson syndrome and toxic epidermal necrolysis: Clinical patterns, pathogenesis, and therapy. New England Journal of Medicine. 1995;333(24):1600–1607. [2] Stocka-Łabno A, Maciejewska M, Jenerowicz D, Danczak-Pazdrowska A, Adamski Z. Stevens–Johnson syndrome and toxic epidermal necrolysis – clinical presentation and pathogenesis. Advances in Dermatology and Allergology. 2016;33(4):247–252.