The Consideration of Cyclosporine in the Treatment of Stevens-Johnson Syndrome—Reply

Abstract

To the Editor We recently read the work of Miyamoto and colleagues 1 regarding the use of plasmapheresis vs intravenous immunoglobulin (IVIG) therapy as the initial treatment for Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). The authors 1 conducted a trial to assess the benefits of these therapies, acknowledging the lack of guidelines for treating these rare disorders. The study noted that systemic steroids, plasmapheresis, and immunoglobulins were among the most used treatment options. The efficacy of treatment was assessed through analyzing length of hospital stay, cost of treatment, and mortality rate in patients undergoing either IVIG therapy or plasmapheresis first. Although the study was significant in shedding light on the efficacy and mortality benefits of these therapies, we wanted to remind the readership that cyclosporine has gained significant attention as a treatment option for SJS and TEN. 2 In a meta-analysis by Singh et al, 2 patients treated with cyclosporine demonstrated significantly reduced mortality rates; 1 study showed a 51% decrease in true mortality with 3 reported deaths compared with the SCORTEN-predicted mortality rate of 5.9. 2 Another study in the meta-analysis reported a decrease in mortality from a 2.75 SCORTEN-predicted mortality rate to no reported mortality. 2 The study by Miyamoto and colleagues 1 also mentioned the benefits of IVIG in terms of decreased length of stay and hospitalization costs. It is important to mention a meta-analysis by Chen et al 3 that showed a significantly reduced mean hospital stay from 23.9 days to 17.3 days when using a 3-to 10-day course of cyclosporine compared with 3 to 7 days of high-dose IVIG therapy. 3 Miyamoto and colleagues 1 finally mention costs as a possible benefit of treatment with IVIG; however, the administration of cyclosporine has been shown to greatly reduce costs, length of stay, and the risk of infections compared with IVIG, systemic steroids only, or plasmapheresis treatment. 1,3 The purpose of this comment is to bring awareness of cyclosporine as a treatment option and to consider it as a primary treatment for SJS and/or TEN. Additional head-to-head clinical trials would be helpful in supporting the efficacy, decreased length of hospitalization, and cost of cyclosporine treatment compared with IVIG, plasmapheresis, and systemic steroids.