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Ivig in sjs or tens

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"Stevens-Johnson Syndrome"[MeSH Terms] AND immunoglobulin

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Stevens-Johnson syndrome toxic epidermal necrolysis IVIG treatment guideline 2025

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"Stevens-Johnson Syndrome"[MeSH Terms] AND "Toxic Epidermal Necrolysis"[MeSH Terms]

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British Association of Dermatologists guideline Stevens Johnson syndrome toxic epidermal necrolysis IVIG recommendation

IVIG can be considered in SJS/TEN, but it is not routine first-line therapy because evidence for mortality benefit is inconsistent.
What matters most:
  1. Immediately stop the suspected causative drug
  2. Urgent admission to a burns unit, ICU, or specialist dermatology center as appropriate
  3. Meticulous supportive care: fluids, temperature control, wound care, nutrition, pain relief, eye and mucosal care, and infection surveillance
  4. Early dermatology, ophthalmology, and critical-care input
IVIG has been used, often as high-dose 2 g/kg total over 3-4 days, usually early in progressive disease. However, treatment decisions are specialist-led. Studies and guidelines do not establish it as a universally effective standalone treatment, and alternatives such as corticosteroids, cyclosporine, or etanercept may be considered depending on the patient, timing, local protocol, and expertise. The UK SJS/TEN guideline emphasizes specialist supportive management; pharmacologic therapy remains an area without clear international consensus.
Do not delay transfer/supportive care while arranging IVIG. IVIG also has important risks, including thrombosis, hemolysis, renal injury, fluid overload, and infusion reactions.
Recent reviews continue to find heterogeneous and limited evidence for systemic therapies, including IVIG. This uncertainty is reflected in a 2025 guideline review (PMID 40010698) and recent SJS/TEN systematic reviews (PMID 34881995).
If this concerns a person with suspected SJS/TEN now, especially blistering or peeling skin, mouth/eye/genital sores, fever, or facial swelling after a medication, seek emergency care immediately.

Doses and administration

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"Stevens-Johnson Syndrome"[MeSH Terms] AND "Immunoglobulins, Intravenous"[MeSH Terms]

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SJS TEN IVIG 2 g kg 3 days administration guideline

For SJS/TEN, IVIG is an adjunctive, specialist-directed treatment. There is no universally accepted regimen because benefit remains uncertain.

Commonly used IVIG regimen

  • Total dose: 2 g/kg IV
  • Schedule: divided over 2-3 days
    • 1 g/kg/day for 2 days, or
    • 0.67 g/kg/day for 3 days
  • Some centers use 2-3 g/kg total over 2-3 days. DermNet’s SJS/TEN guidance lists 2-3 g/kg over 2-3 days.
Give it as early as possible if the specialist team elects to use it, ideally while new blistering/detachment is progressing. It must never delay immediate withdrawal of the culprit drug and burn/ICU-level supportive care.

Administration

  • Use the actual body weight or local institutional IVIG dosing-weight policy. Do not independently cap, adjust, or calculate the dose without pharmacist/specialist review.
  • Give through a dedicated IV line using the specific product’s package insert infusion-rate schedule. IVIG products have different concentrations, stabilizers, and permitted starting/maximal rates.
  • Usual approach:
    1. Ensure adequate hydration and assess renal function.
    2. Start at the manufacturer-recommended low initial rate.
    3. Increase stepwise only if tolerated.
    4. Slow or stop for headache, fever/rigors, dyspnea, chest/back pain, hypotension, rash, or other infusion reaction.

Monitoring and precautions

  • Before and during treatment: BP, pulse, temperature, urine output, fluid balance, CBC, creatinine/eGFR, and signs of thrombosis or hemolysis.
  • Use particular caution with renal impairment, dehydration, hyperviscosity/thrombotic risk, heart failure, prior IVIG reactions, and IgA deficiency with anti-IgA antibodies.
  • Avoid volume overload and nephrotoxic drugs where possible.
  • Premedication such as paracetamol and an antihistamine is not routine for everyone, but may be used under local protocol or in those with prior infusion reactions.
A systematic review found the evidence for systemic therapies, including IVIG, remains low-certainty and heterogeneous (Cochrane review, PMID 35274741). Thus, this regimen should be prescribed by dermatology, burns/ICU, and pharmacy teams rather than used as a standalone protocol.
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