In SJS/TEN, Treatment With Plasmapheresis vs IVIG Has Similar Mortality Rates

Administration of IVIG before plasmapheresis may be the preferred course of treatment when corticosteroids have been ineffective in patients with SJS/TEN.

There is no significant difference in mortality rate in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) who first receive plasmapheresis instead of intravenous immunoglobulin (IVIG) therapy following ineffective systemic corticosteroid therapy, according to study findings published in JAMA Dermatology.

Researchers conducted a retrospective cohort study that compared clinical outcomes of patients with SJS/TEN who were treated with plasmapheresis first with the outcomes of those who were treated with IVIG first. Participants in both groups had been unresponsive to systemic corticosteroid therapy.

Eligible participants were hospitalized patients aged 18 years and older who were diagnosed with SJS or TEN from July 2010 through March 2019. Those who had received at least 1000 mg daily of methylprednisolone-equivalent systemic corticosteroids within 3 days of hospitalization were included. In-hospital mortality rate was the primary outcome.

A total of 213 participants received IVIG first within 5 days of the index date (IVIG-first group), and 53 received plasmapheresis first or on the same day as IVIG administration within 5 days of the index date (plasmapheresis-first group). Participants had a mean (SD) age of 56.7 (20.2) years, and 57.1% were women. In the plasmapheresis-first group, 56.6% of participants received IVIG later, and 6.6% of patients received plasmapheresis later in the IVIG-first group.

[P]lasmapheresis may be associated with higher cost and longer hospital stays.

Among crude outcomes, the in-hospital mortality rates were 14.1% in the IVIG-first group and 18.9% in the plasmapheresis-first group. The mean (SD) length of hospital stay was 34.7 (26.5) days in the IVIG-first group and 44.8 (32.0) days in the plasmapheresis-first group. The total (SD) costs were $23,584 ($19,002) USD and $34,527 ($25,498) USD in the IVIG-first and plasmapheresis-first groups, respectively.

Adjusted outcomes using overlap weighting showed no significant difference in the in-hospital mortality rate between the those in the plasmapheresis-first and IVIG-first groups (18.3% vs 19.5%; odds ratio, 0.93; 95% CI, 0.38-2.23; P =.86). Participants in the plasmapheresis-first group had a longer average hospital stay compared with those in the IVIG-first group (45.3 vs 32.8 days; difference, 12.5 days; 95% CI, 0.4-24.5 days; P =.04) and higher average total costs ($34,262 USD vs $23,054 USD; difference, $11,207 USD; 95% CI, $2789-$19 626; P =.009).

Limitations of the study include unmeasured confounding factors could have biased the findings. The study also focused on which treatment was given first, but combination therapy may have led to residual confounding.

“The findings of this retrospective cohort study suggest that there is no clear benefit to administering plasmapheresis before IVIG therapy to patients with SJS/TEN unresponsive to systemic corticosteroids, and plasmapheresis may be associated with higher cost and longer hospital stays,” the study authors conclude.


Miyamoto Y, Ohbe H, Kumazawa R, et al. Evaluation of plasmapheresis vs immunoglobulin as first treatment after ineffective systemic corticosteroid therapy for patients with Stevens-Johnson syndrome and toxic epidermal necrolysis. JAMA Dermatol. March 8, 2023. doi:10.1001/jamadermatol.2023.0035