Management Of Toxic Epidermal Necrolysis Research Articles

Anesthetic management of toxic epidermal necrolysis: a report of two cases

Toxic epidermal necrolysis (TEN), is an acute, life-threatening emergent disease involving the skin and mucous membranes with serious systemic complications. It is characterized by widespread epidermal sloughing. Drugs are the most common triggers of TEN, but infection, vaccination, radiation therapy and malignant neoplasms can all induce it in susceptible patients. We report two cases in whom a hair dye and a COVID-19 vaccine (BioNTech®, Pfizer) were believed to be the causative agents. These patients have to undergo repeated debridements of the necrotic tissue. In this manuscript the anesthetic management of TEN patients is discussed. Detailed preoperative evaluation, aggressive fluid and electrolyte replacement, avoidance of hypothermia during debridement, minimizing anesthetic agents and limiting traumatic procedures are key points in the management.
 Abbreviations: BUN: blood urea nitrogen; BSA: Body surface area; Cr: Creatinine; OR: Operating room; SJS: Stevens-Johnson Syndrome; TEN: Toxic epidermal necrolysis
 Key words: Anesthesia; COVID-19; Toxic epidermal necrolysis; Vaccine
 Citation: Bilge B, Erkilic E, İlhan G, Akin M, Kanbak O. Anesthetic management of toxic epidermal necrolysis: a report of two cases. Anaesth. pain intensive care 2022;27(1):135−138; DOI: 10.35975/apic.v27i1.2113
 Received: November 22, 2022; Reviewed: November 29, 2022; Accepted: December 02, 2022

Lamotrigine, a Miscreant in Toxic Epidermal Necrolysis: A Rare Case Report

This case report is about a rural 39 years old female of Asian origin and laborer by profession who developed Toxic Epidermal Necrolysis (TEN) with lamotrigine. She was a known case of Bipolar Affective Disorder Type 1 with psychosis on treatment with quetiapine, duloxetine, escitalopram, and etizolam for the last one and a half years and had no history of adverse effects with those drugs. Recently Lamotrigine was added to her regimen at a dose of 50 mg/day. She developed Stevens-Johnson syndrome (SJ syndrome) within two weeks of adding lamotrigine which progressed to Toxic Epidermal Necrolysis (TEN), SCORTEN scores 3, in the next 3-4 days. The sequence of events, reports of laboratory investigations, and management of TEN have been elaborated in this case report. On the Naranjo scale of causality, the suspected adverse drug reaction was established as ‘probable’ because the suspected culprit drug discontinuation led to improvement in the patient’s condition but a rechallenge was not tried.

Management of toxic epidermal necrolysis with oral involvement with candidiasis in stage III cervical carcinoma patients

Toxic epidermal necrolysis (TEN) is the most serious cutaneous adverse drug reaction characterized by extensive detachment of epidermis and erosions of oral mucosal. Early diagnosis and proper therapy are an essential for reduction the morbidity and mortality of this disease. This article is aimed to describe the management of TEN with oral involvement accompanied candi-diasis in patient with carcinoma cervix stage III. A 53-year-old female patient with carcinomacervix stage III and diagnosed of TEN was referred to Oral Medicine Clinic with complaint of painful throughout the oral mucosa, on the lips and during swal-lowing. The patient had a medication history after 25th radiotherapy i.e. cefixime and mefenamic acid. Erythema and erosive le- sion were seen at almost of the bodymainly in back, waist and belly except on palm hand and sole. Erosion also found on the lips with hemorrhagic crusts which bleed easily. Erosive lesion andcandidiasis were seen in the labial mucosa, dorsum and late-ral of tongue, and buccal mucosa. The patient was given NaCl 0.9% for lips compress, chlorhexidinedigluconate 0.12%, hya-ruronic acid mouthwash, vaseline album, whilst therapy for candidiasis was nystatin oral suspension 100,000 IU. The pa-tient was also given education to maintain oral hygiene. It was concluded that oral lesions and candidiasis were healed after 2 weeks of therapy and the patient had significant improvement on the oral mucosal. The appropriate pharmacological and non-pharmacological therapies given were successful on reducing the morbidity and mortality to the patient.

Oral manifestations and management of toxic epidermal necrolysis in an intensive care unit: case report

Toxic epidermal necrolysis (TEN) is a mucocutaneous disorder characterized by the detachment of epidermal and mucous tissues and areas of necrosis, resulting from hypersensitivity reactions to different drugs. We report a clinical case of a 19-year-old male patient diagnosed with TEN, with 90% involvement of the body surface and severe oral involvement. The patient was monitored by dentists from the multidisciplinary team of an intensive care unit, where adjuvant treatment was performed through photobiomodulation to control pain and regenerate the oral mucosa. The case represents the importance of early performance in oral TEN injuries and the role of the multidisciplinary team for comprehensive treatment.

A Case Report on Ibuprofen Induced Toxic Epidermal Necrolysis

Ibuprofen is a non steroidal anti-inflammatory drug that exhibits analgesic and antipyretic activities by inhibiting prostaglandin synthesis. Though available as an OTC drug, ibuprofen is potent enough to cause serious dermatologic adverse reactions like erythema multiforme, erythroderma, SJS (Stevens - Johnson syndrome), TEN (toxic epidermal necrolysis). TENis a potentially life threatening dermatologic disorder and a severe cutaneous ADR that involves skin and mucous membrane, characterized by widespread erythema, necrosis and bullous detachment, resulting in exfoliation & possible sepsis and/or death, which is most commonly drug induced. Toxic epidermal necrolysis is characterized by inappropriate immune activation in response to certain medications or their metabolites. The exact pathogenic mechanism of TEN is still uncertain. The exposure to drugs has increased with demographic shifts associated with a higher morbidity of the population. Along with this phenomenon, a rise in the incidence of adverse drug reactions (ADRs) has been observed. Hypersensitivity- syndrome associated with ibuprofen is a host-dependent idiosyncratic drug-reaction. Though ibuprofen is most widely used over the counter (OTC) medication, which is considered to be relatively safe, it is essential to understand its potential adverse effects. This rare case report addresses the fact that severe hypersensitivity reactions can occur with ibuprofen, which can be potentially dangerous and life threatening. This case report also adds a note on the diagnosis and management of Toxic Epidermal Necrolysis.

A contemporary snippet on clinical presentation and management of toxic epidermal necrolysis.

IntroductionToxic epidermal necrolysis (TEN) is one of the most severe cutaneous adverse reactions with a mortality rate of 30%. Due to a lack of consensus regarding the treatment and management of TEN, therapy is individualized on a case-to-case basis.PurposeThe scientific literature about Stevens-Johnson Syndrome (SJS) and TEN is summarized and assessed to aid and assist in determining the optimal course of treatment.MethodsPubMed and Google Scholar, among others, were searched with the keywords: “Toxic Epidermal Necrolysis”, “corticosteroids”, “cyclosporine”, “etanercept”, “intravenous immunoglobulin”, “Stevens-Johnson syndrome” and filtered by year. The research articles generated by the search, and their references, were reviewed.ResultsTEN is a severe dermatological condition that is mainly caused by medicines. World-wide guidelines differ in care plans. As there is no consensus on the management of TEN, this article aims to summarize the efficacy and feasibility of the management aspect of TEN from previous studies. Supportive care is highly accepted, along with early discontinuation of all medicines (hydration & electrolytes). Corticosteroids and cyclosporine have been used in therapy. Intravenous immunoglobulin (IVIG) is currently being administered; however, their efficacy by themselves and in combination remains uncertain.ConclusionCurrent evidence predominantly from retrospective studies suggests no individual treatment has sufficient efficacy and a multi-faceted regimen stands to be favored. Therapeutic regimens from corticosteroids to IVIG are under constant evaluation. The life-threatening nature of TEN warrants further confirmation with more extensive, robust randomized, controlled trials.Lay SummaryToxic epidermal necrolysis (TEN) is a serious skin reaction with a 30% chance of mortality. Commonly TEN is caused by medicines and results in a burn like appearance and sensation in patients. Usually administered medicine is cleared effectively by the human body but when the clearance of few metabolites from medicine is disrupted due to few genes, it leads to an ominous response by the body. This response involves several intermediate chemicals that primarily attack skin cells. Treatment guidelines differ globally. Supportive care is highly accepted, along with early discontinuation of all medicine. Currently, a multi-faceted treatment regimen is favored. Treatments like corticosteroids to immunoglobulins are under constant evaluation. Identification of the perfect combination of treatment needs confirmation from robust randomized controlled trials.

Management of toxic epidermal necrolysis in an adult patient: Challenges and their management during COVID-19 pandemic

An adult male patient who underwent neurosurgery for extradural hematoma following road traffic accident presented with toxic epidermal necrolysis (TEN) secondary to phenytoin. The patient was semiconscious and not responding to verbal commands. The patient was admitted and managed with oral cyclosporine and supportive measures. TEN is a dermatological emergency presenting as acute skin failure. The management requires multidisciplinary approach in an intensive care setup. The treatment includes the administration of immunosuppressant drugs and maintenance of hemodynamic stability. However, the COVID-19 pandemic has resulted in a lot of limitations regarding the use of immunosuppressant drugs and in-patient care because of the possibility of transmission of COVID-19 infection among patients, their caretakers and health-care professionals. Here, we are presenting a case of TEN managed successfully during the pandemic of COVID-19. Strict adherence to all the guidelines recommended by concerned authorities related to the prevention of transmission of COVID-19 and judicious use of immunosuppressant drugs based on risk and benefit ratio is very crucial.

N-acetyl cysteine in management of toxic epidermal necrolysis: A case series

Steven–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are a severe form of adverse drug reactions with significant morbidity and mortality. No definitive treatment is available for SJS/TEN. Multiple drugs such as corticosteroids and cyclosporine have been used with doubtful efficacy. In recent years, few successful reports of N-acetylcysteine use are reported in this disorder. Multiple modes of action have been postulated for its effectiveness in SJS/TEN. Antioxidant action is one of the proposed mechanisms. We tried n-acetyl cysteine in 5 patients of SJS/TEN as per paracetamol poisoning protocol. All 5 patients showed favorable outcome and discharged in satisfactory condition.

Boosting effect of cyclosporine on corticosteroids in the acute management of toxic epidermal necrolysis

<p class="abstract">Toxic epidermal necrolysis (TEN) is a life-threatening dermatological emergencies. It is a rare, acute mucocutaneous disorder that usually occur secondarily as an idiosyncratic reaction to certain drugs. Prompt identification and discontinuation of the causative drug is mandatory along with adequate supportive care like proper hydration, minimize the number of skin manipulation, prevention of secondary infections. Many immunosuppressive modalities have been tried with variable results. In this manuscript, we reported 12 consecutive cases of TEN presented to our hospital over a period of 2 years from 2017 to 2019. All the cases presented with varying percentage of skin blistering and mucosal involvement secondary to an offending drug. The incriminated drug was discontinued, supportive care was initiated along with combination therapy of cyclosporine and corticosteroids as immunosuppressants. The clinical presentation, etiological drugs and treatment protocol followed and its efficacy will be described in details.</p>

A 10-year retrospective cohort study of the management of toxic epidermal necrolysis and Stevens-Johnson syndrome in a New South Wales state referral hospital from 2006 to 2016.

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are life-threatening severe cutaneous drug reactions. There have been no Australian data published since 2007. To explore whether there is an association between prognosis and the type of systemic immune-modulation treatment administered in a cohort of patients with SJS, SJS-TEN overlap, and TEN at the New South Wales State SJS/TEN referral center - Concord Repatriation General Hospital. This is a retrospective, single center, cohort study of patients admitted with SJS/TEN from January 1, 2006, to December 31, 2016, at Concord Repatriation General Hospital. Data on demographic information, the causative agent, treatment, and final survival outcome were analyzed. Forty-two patients included: 26 (62%) with TEN, six (14%) with SJS/TEN overlap, and 10 (24%) with SJS. Overall mortality was 19% (n=8), and seven suffered TEN. The average age of those who died was 60years. Eighty-one percent of patients were managed within the burn unit. Twenty-nine patients (70%) received IVIG within this group; 13 individuals also received systemic corticosteroids. Seven (17%) were managed with corticosteroid therapy alone. The incidence of death was 0% in the combined IVIG and corticosteroid group. This series of 42 patients contributes valuable information to a serious condition with low global incidence and high mortality. There appears to be an apparent reduced mortality in the group of SJS/TEN patients managed with combined IVIG and corticosteroid. Larger cohorts are required to validate this relationship due to the risk of bias inherent to the retrospective study design and small sample size.

Management of Toxic Epidermal Necrolysis with Plasmapheresis and Cyclosporine A: Our 10 Years' Experience.

Background:The management of toxic epidermal necrolysis (TEN) is controversial and there is no uniform strategy.Objective:To share our 10 years’ experience in treating severe TEN with a novel protocol based on the association of cyclosporine A and plasmapheresis.Methods:In this case series, we retrospectively collected and assessed the 12 cases of severe TEN treated from 2005 to 2015 at the Burn Unit of the University of Bari Policlinico hospital.Results:Average body surface area was 77; average SCORETEN was 4.3. The 12 patients had been treated with culprit drug withdrawal, systemic corticosteroids, and/or cyclosporine A with no response. The protocol was successfully administered in all 12 cases. Average time to response from protocol start was 4.9 days. Average time to remission from protocol start was 22 days; average hospital stay at our unit was 24.8 days. Four patients developed severe complications; 1 patient died. No complications linked to the protocol therapeutic measures were observed. The relatively small number of cases given the rarity of the condition is a limitation of this report.Conclusion:Our protocol based on the association of cyclosporine A and plasmapheresis is safe and efficacious in treating severe TEN.

Advancement in the diagnosis and management of toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) is a potentially life-threatening condition usually attributed to severe adverse drug reactions. The evolvement of TEN, including extensive epidermal sloughing, fluid and electrolyte imbalances, hypermetabolism, immune dysfunction, sepsis and organs failure, are very similar to that of extensive burn. There is no unified therapeutic regimen for TEN due to its unclear pathogenesis.This article reviews the recent progress in regard to TEN in etiology, pathogenesis, diagnosis, differential diagnosis, treatment, new standard diagnostic approach, primary care, and supportive treatment.

Cyclosporine in toxic epidermal necrolysis: a brief review of the emerging therapeutic modality

Toxic epidermal necrolysis (TEN) is a severe life-threatening adverse drug reaction that predominantly involve the skin and mucous membranes, and is associated with high mortality (25-35% or even higher) and with various long term sequelae. There is no universally accepted treatment for TEN, but key elements of management include rapid diagnosis, identification and interruption of the culprit drug, evaluation of the prognosis using SCORTEN, specialized supportive care ideally in an intensive care unit, and consideration of immunomodulating agents. Cyclosporine has recently emerged as a promising immunomodulating agent in the management of TEN and we have performed a brief review of evidence highlighting its role in TEN management.

Nevirapine Induced Toxic Epidermal Necrolysis Managed Successfully with Etanercept (A Case Report)

Toxic epidermal necrolysis (TEN) is a rare, idiosyncratic, unpredictable drug reaction. It is potentially a life threatening dermatological disorder. At present there is no definite consensus regarding the management of TEN. Treatment of TEN with etanercept has shown promising results in the recent literature where conventional systemic therapies are either contraindicated or have failed. We report a case of nevirapine induced TEN treated successfully by administering single dose of 50 mg etanercept given subcutaneously that resulted in complete re-epithelialization and without any complications.

Role of nanocrystalline silver dressings in the management of toxic epidermal necrolysis (TEN) and TEN/Stevens-Johnson syndrome overlap.

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are severe mucocutaneous eruptions. There is currently no defined optimal approach to wound care. The objective of this study was to evaluate silver dressings in the wound-care management of TEN and SJS/TEN syndrome overlap with a retrospective case review of nine patients with TEN and SJS/TEN overlap presenting to our institution. Nanocrystalline silver dressings appear to be useful in the rapid commencement of healing in these patients. TEN and SJS/TEN overlap are rare conditions. This contributed to a relatively small number of cases included in the study. The ease of application, antimicrobial properties and low frequency of change make nanocrystalline silver dressings ideal in TEN/SJS.

Toxic epidermal necrolysis: an update

Toxic epidermal necrolysis (TEN), also known as Lyell's syndrome, is a rare, life-threatening dermatological condition that is usually induced by reaction to medications. It is characterized by the detachment of the top layer of skin (the epidermis) from the lower layers of the skin (the dermis) all over the body. There is broad agreement in medical literature that TEN can be considered a more severe form of Stevens Johnson syndrome, and debate whether it falls on a spectrum of disease that includes erythema multiforme. Some authors consider that there is an overlap between the two syndromes (usually between 10% and 30% of skin detachment). This article deals with history, epidemiology, diagnosis, pathophysiology treatment and management of TEN.

RE: The management of toxic epidermal necrolysis

RE: The management of toxic epidermal necrolysis

IVIg in TEN: time to re-evaluate the efficacy of intravenous immunoglobulin in the management of toxic epidermal necrolysis

IVIg in TEN: time to re-evaluate the efficacy of intravenous immunoglobulin in the management of toxic epidermal necrolysis

The management of toxic epidermal necrolysis

The mortality rate of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) is high; approximately 5% for SJS and 25% for TEN. It is therefore vital for the treating physician to recognise SJS and TEN promptly through the identification of these diseases' characteristic clinical features so that the offending drug is promptly withdrawn, supportive therapy is administered and adjunctive therapies are considered. Supportive therapy addressing the manifestations and complications of acute skin failure include monitoring the fluid - electrolyte balance and providing enteral or parenteral nutrition, wound care and treatment of sepsis. In addition, supportive care of the affected mucosal surfaces is required through the use of aggressive ocular lubrication, topical corticosteroids, hygienic mouthwashes and oral anaesthetics, together with monitoring for urinary retention. There is sufficient evidence for the use of intravenous immune globulin in the acute management of SJS/TEN provided an adequate dose of 2-3 g/kg is administered. Cyclosporine appears to also be an effective agent although randomised control studies are required to demonstrate its benefit and establish the dose, duration of therapy and safety profile. The role of corticosteroids is currently under revision. Some earlier studies have shown a lack of efficacy or increased mortality in their use but the use of high doses early in the course of disease may actually reduce morbidity and mortality. The role of plasmapheresis, anti-tumour necrosis factor (TNF) biologics and N-acetylcysteine is promising but further studies are required to elucidate their benefit. Preventative strategies such as pharmacogenetic screening needs to be strongly considered, with the provision of cost-effective assays with a rapid turn-around time.

A case of steroid-induced psychosis in a child having nephrotic syndrome with toxic epidermal necrolysis

= Abstract = Toxic epidermal necrolysis (TEN) and Stevens Johnson syndrome (SJS) are rare, life-threatening mucocutaneous diseases, - usually attributable to drugs and infections. Corticosteroids have been used in the management of TEN for the last 30 years. This remains controversial and is still much debated. TEN can occur despite administration of high doses of systemic corticosteroids. The psychiatric side effects of corticosteroids can include headache, insomnia, depression, and mood dis- orders with or without psychotic episodes. Steroid-induced psychosis is dealt with by tapering or discontinuing the steroid; antipsychotics are also sometimes used. We report a case of an 11-year-old boy who was admitted with TEN. He had also been diagnosed as having nephrotic syndrome in the past. Remission was achieved through induction therapy and by maintaining the use of steroids. After a full-dose intravenous dexamethasone for TEN, he showed psychotic symptoms. We diagnosed him as having steroid-induced psychosis. We tapered the steroid use and initiated an atypical antipsychotic medication, olazapine and intravenous immunoglobulin (IV-IG). His symptoms dramatically improved and he was dis- charged. (Korean J Pediatr 2010;53:437-441)