Stevens-Johnson syndrome and toxic epidermal necrolysis

Relationship between Atopic Disease and Acute Ocular and Systemic Outcomes in Patients with Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

OBJECTIVE

To describe the relationship between history of atopic disease on systemic and ocular manifestations of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN).

METHODS

Retrospective chart review of patients with SJS/TEN patients. Those with and without prior atopic diagnosis were compared.

RESULTS

In total, 200 patients with SJS/TEN were identified. A total of 23 patients also had an atopic diagnosis. Four, 10, and 18 had atopic dermatitis, allergic rhinitis, and asthma respectively. Acute ocular severity was significantly worse in the atopic cohort. No significant differences in overall systemic severity of SJS or mortality were found between the atopic and non-atopic cohorts. Compared to our hospital system's general population, prevalence of an atopic diagnosis was significantly higher in those with SJS/TEN.

CONCLUSION

Patients with a history of an atopic diagnosis appear to have more significant acute ocular involvement during their SJS/TEN hospitalization. Atopic conditions appear to occur more frequently in the SJS/TEN population compared to the general population.

Stevens Johnson Syndrome – “Steven Who? And Why I Should Care About His Johnson?”

Diagnosing rashes in the emergency department can be challenging. If the rash is extensive and targetoid, include Stevens-Johnson Syndrome (SJS) on your differential and be sure to obtain a thorough history to identify possible offending agents. Additionally, prioritize supportive care and obtaining a dermatology/burn consult to coordinate appropriate care.

Phenytoin-induced toxic epidermal necrolysis: Review and recommendations

Toxic epidermal necrolysis (TEN) is a serious, life-threatening skin reaction characterized by severe exfoliation and destruction of the epidermis of the skin. In most TEN cases, drugs are believed to be the causative agent; antipsychotics, antiepileptics, and other medications such as sulfonamides are among the most common causes of drug-induced TEN. Phenytoin, a commonly prescribed medication for seizure, was found to cause TEN. Evidence-based treatment guidelines are lacking, so the best strategy is to identify and avoid potential risk factors and to provide intensive supportive care. The aim of this literature review is to focus on phenytoin-induced TEN, to explore the risk factors, and to highlight the possible treatment options once phenytoin-induced TEN is confirmed.

Corticosteroids in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

Objective: To review the evidence for the use of steroids in adults presenting with Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), or overlap. Data Sources: EMBASE (1974 to April 2014), MEDLINE (1946 to April 2014), Cochrane Database of Systematic Reviews, and International Pharmaceutical Abstracts (1970 to January 2014) were searched using the terms: prednisone, methylprednisolone, dexamethasone, prednisolone, steroids, glucocorticoids, corticosteroids, Stevens-Johnson Syndrome, toxic epidermal necrolysis, and SJS/TEN overlap. Study Selection and Data Extraction: English-language, full reports of experimental and observational studies were included. Bibliographies from pertinent publications were reviewed for additional references. Prespecified outcomes included survival, survival to discharge, hospitalization without intensive care, length of intensive care stay, duration of hospitalization, ophthalmological complications, infection rates, and adverse events. Data Synthesis: Six studies that used steroids for SJS, TEN, and/or overlap were included. All studies were retrospective cohort studies with no case-control or cross-sectional studies; 5 studies reported on steroid doses, and 2 studies reported time from disease onset to steroid use (2-4 days). Only 1 of 6 studies reported a statistically significant impact on mortality with steroids use (odds ratio = 0.4; 95% CI = 0.2-0.9). Adverse event rates were not reported in any of the studies. Conclusions: A review of the current evidence reveals a need for prospective, randomized controlled studies to provide more definitive conclusions on steroid use in patients with SJS, TEN, and/or overlap.

Fatal case of cephalexin-induced toxic epidermal necrolysis

Purpose:

To describe a case of toxic epidermal necrolysis likely caused by cephalexin with a review of the literature.

Case:

An 80-year-old male with a known allergy to cephalosporins, residing at a long-term acute care hospital, received cephalexin for a urinary tract infection. And 1 day after starting therapy, the patient developed an extensive erythematous rash accompanied by skin sloughing; 4 days after receiving cephalexin, the patient was directly admitted to the burn intensive care unit and was diagnosed with toxic epidermal necrolysis involving 56% of the total body surface area. Progressive deterioration to multisystem organ failure ensued, and the patient died 5 days following his admission to the burn intensive care unit. At the time of death, ulcerations were noted over approximately 80% of his body.

Summary:

The temporal association of the patient’s ingestion of cephalexin for a urinary tract infection to his onset of toxic epidermal necrolysis suggests that this 80-year-old man developed toxic epidermal necrolysis following the administration of cephalexin for a urinary tract infection.

Pompholyx: a review of clinical features, differential diagnosis, and management

Pompholyx is a vesicobullous disorder of the palms and soles. The condition is hard to treat because of the peculiarities of the affected skin, namely the thick horny layer and richness of the sweat glands. In this article, we review the available therapies, and score the treatments according to the level of evidence. The cornerstones of topical therapy are corticosteroids, although calcineurin inhibitors also seem to be effective. Topical photochemotherapy with methoxsalen (8-methoxypsoralen) is as effective as systemic photochemotherapy or high-dose UVA-1 irradiation. Systemic therapy is often necessary in bullous pompholyx. Corticosteroids are commonly used although no controlled study has been published to date. For recalcitrant cases, corticosteroids are combined with immunosuppressants. Alitretinoin has efficacy in chronic hand dermatitis including pompholyx. Another evolving treatment seems to be the intradermal injection of botulinum toxin. Radiotherapy might be an option for selected patients not responding to conventional treatment. In practice, patients benefit most from a combination of treatments.