PMC9433559_01
Skin manifestations. (A) Diffuse erythematous-violaceous maculopapular exanthems on the face. (B) Stevens-Johnson syndrome-like atypical flat targets on the neck. (C) Erythematous folliculocentric papules on the back.
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Physical examination showed generalized erythematous-to-violaceous maculopapular eruptions on the face, ears, and upper trunk ( Figure 1A ), sparing upper extremities along with palms and soles. Moreover, atypical flat target lesions that were characteristic for SJS/TEN were noted on the neck and trunk ( Figure 1B ); erythematous folliculocentric papules developed on the back ( Figure 1C ).
Histological features. Skin biopsy demonstrated mild exocytosis, basal layer vacuolization, lymphocyte infiltrate at the interface, and mild melanin incontinence (hematoxylin and eosin stain, A: 200x, B: 400x).
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SJS/TEN could not be ruled out, an effective targeting therapy with anti-tumor necrosis factor alpha (TNF-alpha) blockade with etanercept (Enbrel ), which was effective for both SJS/TEN and aGVHD, was initiated at two doses of 50 mg twice a week. Skin biopsy was performed on the neck, and the histopathology showed exocytosis, dyskeratotic cells, basal layer vacuolization, interface lymphocytic infiltrates, mild melanin incontinence, and papillary dermal edema ( Figure 2 ).
Clinical course after liver transplantation. FK506: tacrolimus, E. coli: Escherichia coli, G-CSF: granulocyte colony-stimulating factor Mini-P*: Methylprednisolone mini-pulse therapy with dose tapering-methylprednisolone 200 mg divided in four doses per day, then 160 mg, 120 mg, and 80 mg, followed by 40 mg divided by two doses per day.
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The clinical course is summarized in  Figure 3 .