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The Need to Examine the Risks and Benefits of Intravenous Immunoglobulin Therapy in Severe Cutaneous Adverse Reactions :  Comment on “Poor Benefit/Risk Balance of Intravenous Immunoglobulins in DRESS”

Cindy England Owen, MD
Arch Dermatol. 2012;148(4):545. doi:10.1001/archdermatol.2011.3156.
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Severe cutaneous adverse reactions (SCARs) include drug rash with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN). These reactions are rare but serious, with mortality ranging up to 10% in DRESS and as high as 30% in TEN. Despite the seriousness of SCARs, there is a lack of evidence-based consensus on treatment for these conditions.

Since Viard et al1 showed success with intravenous immunoglobulin therapy (IVIG) in 10 patients with TEN,1 IVIG has become commonly prescribed for this condition. While DRESS is most often treated with systemic steroids, Joly et al describe a reasonable hypothesis for the use of IVIG in this condition. In the trial, however, treatment with IVIG demonstrated a poor benefit/risk ratio, with 5 of 6 patients experiencing an adverse reaction, and only 1 complete and 1 partial response. Based on this small study, IVIG should be avoided in DRESS, pending further research.

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