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”

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.