Viral Triggers Exposed: A Systematic Review of Virus-Induced Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

Abstract

Aim: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe skin conditions characterized by widespread epidermal necrolysis and mucous membrane involvement. SJS affects less than 10% of the body surface area, while TEN involves over 30%, with cases between 10% and 30% classified as SJS/TEN overlap. Drug hypersensitivity reactions, especially to antibiotics, anticonvulsants, and non-steroidal anti-inflammatory medications, are the most common and well-established causes of SJS/TEN. In addition, infections, including viral ones like herpes simplex virus (HSV), influenza virus, varicella-zoster virus, and human immunodeficiency virus (HIV), have also been implicated as potential inducers, complicating management and requiring careful clinical vigilance. Purpose: This review aims to investigate and compile information on reported cases of SJS/TEN potentially linked to virus infections. Methods: Literature from PubMed, NCBI, ScienceDirect, and Cochrane Library databases was searched. The inclusion criteria were studies reporting details of patients diagnosed with SJS, TEN, or SJS/TEN overlap, potentially induced by viral infections. Cases were included if the viral infection occurred within one week before the rash onset, emphasizing the association between these infections and severe skin reactions. Results: Ten studies were included in this systematic review, most of which demonstrated fair to good methodological quality. The review encompassed cases of virus-induced SJS/TEN, including herpes virus infection, influenza virus infection, varicella-zoster virus, HIV infection, COVID-19, and coxsackie infection, each with distinct manifestations. Conclusion: The evidence strongly suggests that viral infections contribute to the development of SJS/TEN, yet the precise mechanisms remain unclear and warrant further research. Awareness of this risk is crucial, particularly in regions experiencing outbreaks of these viruses.