This patient has toxic epidermal necrolysis (TEN), and he should be admitted to the hospital and any medications that are possible triggers (minocycline) should be stopped immediately. The most commonly implicated medications are antiepileptic agents, especially carbamazepine, lamotrigine, and phenytoin. Sulfonamides, fluoroquinolones, β-lactam antibiotics, minocycline, pantoprazole, sertraline, NSAIDs (oxicam and acetic acid type), tramadol, and allopurinol are also frequent causes. The treatment of TEN begins with drug cessation and aggressive ICU or burn center care.

Stevens-Johnson syndrome (SJS) and TEN are related clinical syndromes that are characterized by acute epidermal necrosis. The classification of SJS and TEN is determined by the percentage of body surface area with epidermal detachment: SJS involves less than 10%, SJS-TEN overlap involves 10% to 30%, and TEN involves greater than 30%. TEN is a rare disease, with a prevalence of 1:1,000,000. TEN is almost exclusively caused by medications, whereas erythema multiforme and SJS can also be triggered by vaccines or infection. SJS and TEN occur within 8 weeks of drug initiation, often between 4 and 28 days. Patients may have flu-like symptoms for 1 to 3 days prior to the skin eruption. Initially, red-purple macules or patches develop on the trunk and extremities, which enlarge and coalesce. Skin pain is prominent, in contrast to the pruritus associated with a common drug exanthema. Vesicles, bullae, and erosions reflect the epidermal necrosis seen on biopsy. Nikolsky sign (the shearing off of the epidermis with lateral pressure on the skin) is present. Two or more mucosal surfaces, such as the eyes, nasopharynx, mouth, and genitals, are involved in more than 80% of patients. Systemic inflammation can result in pneumonia, hepatitis, nephritis, arthralgia, and myocarditis.

Infliximab is a monoclonal antibody that is used for several conditions including psoriasis; however, it has no role in the management of TEN. There is evidence to show that treatment with systemic glucocorticoids, such as intravenous methylprednisolone, can increase mortality rates in patients with TEN. Infection is a risk for patients with SJS or TEN because of the extensive damage to the skin barrier; however, antibiotics, such as vancomycin and ceftriaxone, are not started without signs or symptoms of infection.