Sertraline-induced stevens-johnson syndrome managed successfully with cognitive behavioural therapy: a rare case

Objectives

Stevens-Johnson Syndrome (SJS) is a rare, life-threatening condition characterised by severe mucocutaneous epidermal necrolysis. SJS is a rare but severe side effect of many commonly administered drugs. The majority of reports on drug-induced SJS in psychiatry relate to lamotrigine, and only four case reports of sertraline causing this manifestation have been found in the literature [1]. Here, we present a fifth case — notable for its post-disaster trauma context and the successful use of cognitive behavioural therapy (CBT) as an alternative after pharmacotherapy was contraindicated — of a patient with panic disorder who developed SJS with sertraline, a selective serotonin reuptake inhibitor (SSRI).

Case Presentation

Written consent was obtained from the patient. A 55-year-old female presented with anxiety, aggressiveness, and panic attacks that began two months after the 2023 Kahramanmaraş earthquakes and continued for six months. This was her first psychiatric examination. She had no other comorbidities and all laboratory investigations and hormone levels were within normal limits. Panic disorder was diagnosed — post-traumatic stress disorder was excluded based on the absence of re-experiencing and avoidance criteria — and sertraline 50 mg/day was initiated. Ten days later, rashes appeared on her face and arms. When the rash spread rapidly throughout her body, she was admitted to the emergency department and diagnosed with SJS by dermatology, confirmed by biopsy. Given the strong temporal association (Naranjo Adverse Drug Reaction Probability Scale: 6), sertraline was discontinued. SJS treatment was initiated in the dermatology clinic and lesions resolved within two weeks. During this period, the patient had no panic attacks, but her anxiety continued and fears of death emerged. Following discharge, she was re-evaluated in our outpatient clinic and declined further pharmacotherapy. By mutual decision, CBT for panic disorder was initiated. After ten sessions over four months, her anxiety receded and panic attacks resolved completely. She was followed up at three-month intervals for one year with no complaints.

Discussion

This case demonstrates that sertraline — widely considered safe in psychiatric practice — can lead to dangerous, potentially fatal events such as SJS. While lamotrigine-induced SJS is well-documented due to its broad effects on immune pathways, SSRI-induced SJS is far less recognised. The mechanism involves drug-specific CD8+ cytotoxic lymphocytes, the Fas-Fas ligand apoptosis pathway, granule-mediated exocytosis, and tumour necrosis factor-alpha signalling; SSRIs are capable of activating these same pathways and should not be overlooked as potential triggers [1]. Clinicians should remain vigilant for severe cutaneous reactions even when prescribing agents considered low-risk. Equally important, this case illustrates that CBT alone can achieve full remission in panic disorder when pharmacotherapy is contraindicated — reinforcing that CBT should be regarded as a priority treatment given its status as one of the most effective and evidence-based interventions for anxiety disorders [2, 3].

References

1. Halder, A., Ravindran, N.P., Naga, D., Keshri, S., 2023. Sertraline induced Stevens-Johnson syndrome — a case series. Ann. Indian Psychiatry 7(1), 80-82.
2. Ziffra, M., 2021. Panic disorder: a review of treatment options. Ann. Clin. Psychiatry 33(2), 124-133.
3. Hofmann, S.G., Kasch, C., Reis, A., 2025. Effect sizes of randomized-controlled studies of cognitive behavioral therapy for anxiety disorders over the past 30 years. Clin. Psychol. Rev. 117, 102553.