A 16-year experience with toxic epidermal necrolysis

Abstract

Toxic epidermal necrolysis (TEN) is a devastating medication-induced extensive epidermal detachment with a reported mortality rate of 30–60% in adults. As in severe burns, fluid losses are massive, and superinfection, impairment of thermoregulation, excessive energy expenditure and alteration of immunologic functions are usual complications. Moreover, mucous membrane involvement increases morbidity. Previously reported data suggest that age, total body surface area (TBSA) involvement, late recognition and treatment of TEN are poor prognostic indicators. The purpose of the clinical study was to evaluate the effects of special intensive and nutritional management on the outcome of patients with TEN. Between 1988 and 2004 13 patients (five men, eight women, mean age 51 years) were admitted to our department. Two patients were in very poor condition at admission and died within 24 hours. They were excluded from the clinical study. Patients had a TBSA skin slough of 25–85% and a mean APACHE II score of 11.75. Eleven patients were placed in a bacteria-controlled nursing unit, wounds were treated with topical debridement and antimicrobial medications. Nutritional therapy (enteral and/or parenteral) was instituted after fluid and electrolyte replacement. The daily caloric intake reached 146 kJ/kg body weight with a nitrogen–caloric ratio of 1:150. Enteral feeding (sip feeds, nasogastric tube, PEG) was forced as early as possible. One patient had diabetes mellitus (NIDDM). With the complex treatment of 13–26 days in the ICU, nine patients recovered. Two patients died due to septic complications (infected central venous catheter, extended gastrointestinal mucousa involvement – mortality rate: 18%). In the last 8-year period all the patients with TEN healed, only one patient (86-year-old woman) died later due to acute myocardial infarction. Our clinical experiences show that early recognition of TEN may decrease the morbidity and mortality. The local and general management of TEN should be carried out at an isolated, aseptic unit of an intensive care department. The conventional therapy combined with vigorous nutritional management may improve the patients survival. Our results for a group of older patients with TEN, with extensive skin and/or mucosal involvement suggest that age, a delay in proper hospitalisation, steroids and early empiric antibiotic treatment are associated with a poor prognosis.