Amisulpride-induced toxic epidermal necrolysis: A clinician’s alert

Respected Sir, We wish to draw your attention to a rare yet potentially fatal dermatological reaction associated with psychotropic use—Amisulpride-induced Toxic Epidermal Necrolysis (TEN). The case underscores the critical importance of early identification of cutaneous adverse drug reactions (CADRs) and close collaboration between psychiatry and dermatology to ensure better outcomes. We encountered a 26-year-old female diagnosed with schizophrenia in Emergency room, who had developed extensive epidermal necrosis following the introduction of Amisulpride 8 days back for negative symptoms. Despite the appearance of early rashes, it was not acted upon promptly and the medication was continued for several days, leading to widespread erythematous and mucosal erosions involving >30% of the body surface area Figure 1. There was no history of any other drug intake for example non-steroidal anti-inflammatory drugs (NSAIDs), antibiotic, or anti-epileptic in past month except newly administered psychotropic drug. Differentials of Bullous Erythema Multiforme, Acute Generalized Exanthematous Pustulosis (AGEP) were considered. But Nikolsky’s sign was positive, and skin biopsy confirmed epidermal necrolysis strongly suggesting TEN. Routine investigations were within normal limits, and viral serologies were negative. A Naranjo Adverse Drug Reaction (ADR) probability score of 9 indicated a definite association between Amisulpride and TEN.Figure 1: Image shows widespread erythematous skin lesions and multiple large bullae along with spots and crusting In the abdomenAmisulpride was immediately discontinued, and the patient was managed in a multidisciplinary setup in ICU with systemic corticosteroids, antihistamines, and supportive care. Psychotic symptoms were stabilized with Olanzapine (10 mg/day) as a safer alternative, which was well tolerated. Within 2 weeks, the dermatological lesions subsided, though residual ocular synechiae were observed at follow-up, requiring ophthalmologic intervention. Amisulpride, a selective dopamine D2/D3 receptor antagonist, is generally well tolerated; however, severe cutaneous adverse reactions such as TEN remain exceedingly rare. Previous literature primarily reports pityriasiform eruptions or erythema multiforme rather than full-blown TEN.1,2 The immunopathogenesis involves keratinocyte apoptosis via Fas-FasL and granulysin-mediated pathways, resulting in extensive epidermal necrosis.3 Factors such as toxic metabolite formation, delayed drug cessation, and host genetic predisposition have been implicated.4 Similar drug-induced TEN cases have been reported in the literature, emphasizing the unpredictable and idiosyncratic nature of this reaction.5 This case reinforces that any dermatological manifestation during psychotropic therapy demands prompt evaluation and discontinuation of the suspected agent. Early dermatological referral and timely psychiatric coordination prevented further systemic deterioration and allowed continuity of psychiatric management through drug substitution. In India, pharmacovigilance reporting of psychotropic-induced dermatologic reactions remains underrepresented. We urge clinicians to document and report such cases to improve awareness of rare, life-threatening ADRs, and inform safer prescribing practices so that early dermatological manifestations do not go unnoticed. Also, this case emphasizes the vital role of consultation-liaison psychiatry in recognizing and managing systemic complications arising from psychotropic medications. Effective liaison between psychiatry, dermatology, ophthalmology, and intensive care teams ensures holistic management, minimizes morbidity, and preserves psychiatric stability. Strengthening consultation-liaison psychiatry practices in both inpatient and outpatient settings is essential to improving patient safety and interdisciplinary care outcomes. Author contributions All authors participated in all stages of manuscript preparation and approved the final draft. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.