UK guidelines for the management of Stevens–Johnson syndrome/toxic epidermal necrolysis in adults 2016

Systematic review, methodological appraisal, and recommendation mapping of clinical practice guidelines for managing patients with Stevens-Johnson syndrome and toxic epidermal necrolysis

PURPOSE

The Appraisal of Guidelines for Research and Evaluation II Instrument (AGREE II) was developed to enhance the methodological rigor of clinical practice guidelines (CPGs), aiming to generate trustworthy recommendations for various clinical scenarios. Despite its importance, there exists a gap in the quality of CPGs pertaining to Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (SJS-TEN). The aim of the study was to evaluate SJS-TEN CPGs to shed light on areas for enhancing SJS-TEN guidelines' quality.

MATERIALS AND METHODS

A systematic review was conducted to identify SJS-TEN CPGs from January 2011 to December 2023 across bibliographic and guideline databases, as well as dermatology association websites. Four reviewers employed the AGREE II instrument to appraise the quality of eligible CPGs. Subsequently, AGREE II domain scores were calculated and their recommendations mapped.

RESULTS AND CONCLUSIONS

Seven eligible SJS-TEN CPGs reviewed, originating from Europe, North America, Asia, and an authorship Group. The highest AGREE II domain scores were observed in scope and purpose (mean: 63%, standard deviation [SD]: 23.195%) and clarity of presentation (mean: 70%, SD: 14.5%). Conversely, the lowest score was noted in the applicability domain (mean: 28%, SD: 17.44%). Only two guidelines by the British Association of Dermatologists (28.6%) met the 'recommend' level. Recommendations from all CPGs were compared in tabular form.

Clinical features of nivolumab-induced Stevens-Johnson syndrome/toxic epidermal necrolysis: retrospective analysis based on case reports

Background

Stevens - Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a life-threatening adverse reaction to nivolumab. This study investigated the clinical features of nivolumab induced SJS/TEN to provide evidence for diagnosis and treatment.

Methods

Relevant articles on nivolumab induced SJS/TEN published before December 31, 2024 were collected by searching the database, and then extracting the data for summary analysis.

Results

Thirty-one patients were enrolled with a median age of 65 years (range 43, 86). SJS/TEN appear at a median of 5.5 weeks (range, 0.9 108). Bullae/blisters (64.5%), erythema (54.8%), skin rash (54.8%), epidermal detachment (29.0%) and pain (29.0%) were the main skin symptoms. Skin biopsy showed epidermal necrosis (41.9%), keratinocytic necrosis (38.7%), interface dermatitis (29.0%) and inflammatory cell infiltration (45.2%). After stopping nivolumab and receiving treatment, 74.2% of the patients had improvement in skin symptoms, and 22.6% of the patients died of TEN.

Conclusion

As a rare immune-related adverse event of nivolumab, SJS/TEN should be closely monitored during the treatment. Nivolumab induced SJS/TEN has a long incubation period, serious clinical symptoms and poor prognosis.

PICC management for bladder tumor patient with toxic epidermal necrolysis: A crisis intervention case report

Crisis intervention is crucial in managing acute medical crises to improve outcomes. Toxic Epidermal Necrolysis (TEN), a severe skin reaction often triggered by drug exposure, poses challenges, especially in chemotherapy patients. Evidence on nursing care for TEN patients with Peripherally Inserted Central Catheter (PICC) retention during chemotherapy is limited. We present a 69-year-old male with recurrent bladder tumor receiving atezolizumab via PICC, developing TEN and catheter-associated skin impairment (CASI). Despite extensive skin breakdown, PICC retention was essential and innovative PICC care was necessary. A crisis management team implemented a six-step crisis intervention model, ensuring safety and treatment adherence. A three-layer dressing protocol was used to optimize wound care, prevent further CASI, and ensure the patient's comfort. This case underscores the efficacy of crisis intervention in managing TEN with PICC during chemotherapy, highlighting interdisciplinary collaboration and innovation in complex medical scenarios.

Toxic epidermal necrolysis: management strategies in burns units

OBJECTIVE

The most common severe exfoliative condition is toxic epidermal necrolysis (TEN), also known as Lyell's syndrome, for which patients may sometimes require admission to hospital burns units. This study analyses the experience of the authors and results in this condition at the Cruces University Hospital in Bilbao, Spain.

METHOD

Over the last 22 years, the authors carried out a retrospective analytical observational study of TEN cases at the hospital and analysed risk factors including age, associated comorbidities, percentage of body surface area affected, positive bacterial culture, and treatment strategies used to assess their potential influence on prognosis.

RESULTS

The results indicated an association between mortality and age (ρ (rho)=0.60, 95% CI [0.29, 0.79], p<0,001), ocular (ρ=0.58, 95% CI [0.28, 0.78], p<0.001), oropharyngeal (ρ=0.64, 95% CI [0.36, 0.81], p<0.001), genitourinary (ρ=0.58 CI [0.28, 0.78], p<0.001) respiratory mucosa involvement (ρ=0.53, 95 % CI [0.28, 0.78], p<0.001) and bacteraemia (ρ=0.44, 95% CI [0.17, 0.64], p=0.020). Bacteraemia also showed a higher incidence in elderly patients (ρ=0.4, 95% CI [0.03, 0.67], p=0.033) and in those with a higher Score for Toxic Epidermal Necrolysis at admission (ρ=0.51, CI [0.17, 0.74], p=0.006). A reduction in mortality was found in patients who received systemic treatment; cyclosporine, etanercept or a combination of both (ρ=-0.44, Cl [-0.70, -0.09], p=0.018).

CONCLUSION

TEN is a rare but serious exfoliative condition. Traditionally, management of denuded skin was seen as the main prognostic factor; yet, systemic damage, especially to the respiratory mucosa, significantly increases mortality risk. While life support is crucial and recovery is possible, preventing long-term sequelae relies on effective care protocols. Current treatments may offer benefits, though their efficacy remains unclear. Clinicians in burns units should develop standardised protocols and collaborate on long-term studies to enhance patient care.

Toxic Epidermal Necrolysis Observed in a Patient With the HLA-B*1502 Treated With Levofloxacin

PURPOSE

To determine the relationship between HLA-B gene mutations and levofloxacin-induced toxic epidermal necrolysis (TEN).

METHODS

A 71-year-old Chinese woman developed TEN after oral administration of solifenacin (5 mg) and levofloxacin (0.5 g) for cystitis. HLA-B*5801 and HLA-B*1502 alleles were detected using real-time PCR.

FINDINGS

After supportive therapy (antiallergic treatments, plasma exchange, etc) and withdrawal of the culprit medication levofloxacin, the patient was discharged with re-epithelialization of the exfoliated skin. The patient was HLA-B*1502 allele positive and HLA-B*5801 allele negative.

IMPLICATIONS

This is the first report of levofloxacin-induced TEN suspected to be caused by mutations in the HLA-B*1502 allele.

Toxic epidermal necrolysis - clinicopathological aspects and therapeutic management

Toxic epidermal necrolysis (TEN) is a serious dermatological condition often triggered by different drugs or medications or, less commonly, by infections, leading to extensive epidermal detachment and multisystemic complications, resembling the severity and systemic impact of burn injuries. This case report portrays a 26-year-old female patient with a history of psychiatric treatment and recreational drug use, presenting with typical prodromal symptoms and characteristic manifestations on the integument and mucosae. Clinical management involved an interdisciplinary team in a burn center, administering immunoglobulins, systemic steroids, and supportive therapies to prevent complications including infection and to support skin re-epithelization. Histopathological findings confirmed the diagnosis. Despite the extensive lesions, prompt treatment facilitated a positive outcome. The report emphasizes the necessity of referral to specialized centers and the complex, multidisciplinary management required for TEN patients to optimize survival and minimize long-term sequelae.

Greater mechanistic understanding of the cutaneous pathogenesis of Stevens-Johnson syndrome/toxic epidermal necrolysis can shed light on novel therapeutic strategies: a comprehensive review

PURPOSE OF REVIEW

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) are severe cutaneous adverse drug reactions (SCARs) characterized by widespread epithelial detachment and blistering, which affects the skin and mucocutaneous membranes. To date, therapeutic interventions for SJS/TEN have focused on systematic suppression of the inflammatory response using high-dose corticosteroids or intravenous immunoglobulin G (IgG), for example. No targeted therapies for SJS/TEN currently exist.

RECENT FINDINGS

Though our understanding of the pathogenesis of SJS/TEN has advanced from both an immunological and dermatological perspective, this knowledge is yet to translate into the development of new targeted therapies.

SUMMARY

Greater mechanistic insight into SJS/TEN would potentially unlock new opportunities for identifying or repurposing targeted therapies to limit or even prevent epidermal injury and blistering.

Causes and Management of Cutaneous Adverse Drug Reactions: A Comprehensive Review

Cutaneous adverse drug reactions (CADRs) are one of the most broadly studied and rigorously researched conditions in recent dermatological advancements. Also termed as "toxidermia," they are heavily involved and are of utmost importance to be understood and studied in the modern healthcare industry. In simple terms, they are dermatological manifestations which result from systemic drug administration to patients. Since allopathy is influenced by the medicines and drugs provided to the patients, cutaneous skin eruptions are a common occurrence in recent times. It is a need of the hour to understand the causative factors for such skin eruptions and the correct management and handling of such disorders to provide better healthcare to patients. The withdrawal of the causative drug which induces the reaction plays a key role in treatment. The risk factors are to be thoroughly studied, and dosages must be in accordance with the patient's situation. They are some of the common public health problems. The age group which is affected is highly variable as people from all age groups can be affected. Those who are affected comprise approximately 10% of all hospitalized patients, and it is also observed in about 1-4% of people who are on multiple medications.

To Debride or Not to Debride: A Review of Wound Management for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are immune-mediated skin reactions with high mortality as a result of severely compromised skin barrier function. Currently, there is no consensus on the topical management of these conditions. Some advocate for surgical debridement of affected skin as a means of preventing infection and facilitating reepithelialization with synthetic and biological wound coverage. Others prefer a conservative approach that relies on leaving the blistered skin in situ. A consensus is lacking, primarily due to the rarity of the disease and the lack of high-quality evidence supporting one particular form of management. The goal of this review is to explore and compare the two treatment approaches for SJS and TEN, namely conservative management and surgical debridement.

An individual patient data meta-analysis of wound care in patients with toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) involves extensive mucocutaneous loss, and care is supportive. The approach to wound care includes surgical debridement or using dressings while leaving the epidermis intact. Robust evidence for either approach is lacking. We compared surgical debridement to the use of dressings while leaving the epidermis in situ (referred to hereon as dressings) in adult patients with TEN. The primary outcome assessed was mortality. The secondary outcome was time to re-epithelialisation. The impact of medications was evaluated. An individual patient data (IPD) systematic review and meta-analysis was undertaken. A random effects meta-analysis and survival analysis for IPD data examined mortality, re-epithelisation time and the effect of systemic medications. The quality of evidence was rated per the Grading of Recommendations Assessment, Development and Evaluation (GRADE). PROSPERO: CRD42021266611 Fifty-four studies involving 227 patients were included in the systematic review and meta-analysis, with a GRADE from very low to moderate. There was no difference in survival in patients who had surgical debridement or dressings (univariate: p = 0.91, multivariate: p = 0.31). Patients who received dressings re-epithelialised faster than patients who underwent debridement (multivariate HR: 1.96 [1.09-3.51], p = 0.023). Intravenous immunoglobulin (univariate HR: 0.21 [0.09-0.45], p < 0.001; multivariate HR: 0.22 [0.09-0.53], p < 0.001) and cyclosporin significantly reduced mortality (univariate HR: 0.09 [0.01-0.96], p = 0.046; multivariate HR: 0.06 [0.01-0.73], p = 0.028) irrespective of the wound care. This study supports the expert consensus of the dermatology hospitalists, that wound care in patients with TEN should be supportive with the epidermis left intact and supported with dressings, which leads to faster re-epithelialisation.

Quantifying the clinical and economic burden of desquamating dermatological conditions: Implications for a supraregional burns centre

INTRODUCTION

This study aimed to identify the spectrum of desquamating skin diseases referred for tertiary burns care and quantify the care requirements and expenses associated with caring for these patients within the burns service.

METHODS

Patient records were identified with nonburn-induced skin loss between 2016 and 2022. Data was extracted from inpatient records, operative notes, and dressing clinic records. A cost analysis was conducted using figures from the National Schedule of National Health Service Costs and our own unit-specific costs.

RESULTS

Twenty patients were identified, with a median age of 46.5 and a median total body surface area of 30%. The mean length of stay was 21.2 days, with 8/20 patients requiring intensive care. Overall mortality was 30%, rising to 50% if patients required intensive treatment unit (ITU) admission. Patients had a mean of 1.5 procedures under general anaesthesia and a mean operative time of 169 min per patient. Postoperatively, a mean of 8.3 dressing changes was required per patient (range 1-21). Of 75% of patients referred as suspected toxic epidermal necrolysis syndrome (TENS), only 32% of patients histologically had TENS (32%), with linear IgA disease, pemphigus vulgaris and bullous lupus comprising the other diagnoses. Cost analysis predicted a total cost to the unit of £1,422,106.

CONCLUSION

Desquamating dermatological diseases are life-threatening conditions with exhaustive care requirements. Our experiences highlight the importance of awareness of the range of desquamating skin conditions beyond TENS to enable optimum management and the need to ensure adequate financial provisions to accommodate the care requirements mandated by these patients.

Steven-Jonhson Syndrome in a Patient With Dengue Infection in Peru: A Case Report

Stevens-Johnson syndrome is an infrequent condition affecting the skin and mucous membranes, it involves cutaneous detachment with high mortality without adequate treatment. We present the case of a 40-year-old male with a history of epilepsy treated with valproic acid and lamotrigine, previously diagnosed with dengue. Evaluation showed erythematous blisters on skin and mucosa with bleeding and desquamation, covering 10% of the body surface. The patient progressed favorably with the medical care received. Stevens-Johnson syndrome should be studied in association with arboviral diseases.

Biologic TNF-α Inhibitors for Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis, and TEN-SJS Overlap: A Study-Level and Patient-Level Meta-Analysis

INTRODUCTION

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe cutaneous adverse reactions with high morbidity and mortality and not clearly established treatment protocol. This meta-analysis aimed to evaluate the efficacy and safety of three biologic TNF-α inhibitors (infliximab, etanercept, adalimumab) in the treatment of SJS, SJS-TEN overlap, and TEN.

METHODS

Electronic databases were searched for original studies containing human participants diagnosed with SJS/TEN and treated with biologic TNF-α inhibitors. Individual patient data were collected and summarized to provide a comprehensive overview on therapeutic efficacy of different biologic TNF-α inhibitors for SJS, SJS-TEN overlap, and TEN, respectively. Meta-analyses on aggregated study data were conducted using random-effects model.

RESULTS

Overall, 55 studies with 125 sets of individual patient data were included. Infliximab was used to treat 3 patients with SJS-TEN overlap and 28 patients with TEN, and the actual mortality rate was 33.3% and 17%, respectively. Etanercept was administered to 17 patients with SJS, 9 patients with SJS-TEN overlap, and 64 patients with TEN, and mortality rate was reported to be 0%, 0%, and 12.5%, respectively. For participants with TEN, no significant difference was found in time of reepithelialization, hospitalization time, and mortality rate comparing etanercept with infliximab. More sequelae were reported in patients receiving infliximab than in patients treated with etanercept (39.3% versus 6.4%). Adalimumab was administered to four patients with TEN, and mortality rate was 25%. Meta-analyses on aggregated study data revealed significantly shortened hospitalization time in etanercept compared with non-etanercept groups [weighted mean differences (WMD) -5.30; 95% confidence interval (CI) -8.65 to -1.96]. Etanercept was associated with a survival benefit for patients when compared with non-etanercept treatment, however, the analysis was not statistically significant (odds ratio 0.55; 95% CI 0.23-1.33).

CONCLUSIONS

On the basis of the current findings, etanercept is currently the most promising biologic therapy for SJS/TEN. Further evaluation in prospective studies is required to confirm its efficacy and safety.

Nutritional and metabolic characteristics of critically ill patients admitted for severe toxidermia

INTRODUCTION

Drug-induced toxidermia is an idiosyncratic adverse skin reaction that may become life-threatening in a small portion of patients, requiring intensive care unit (ICU) admission. The treatment recommendations are extrapolated from those of major burns, while prospective data remain sparse. The objective was to observe the application of these recommendations in patients treated in a burn ICU.

METHOD

Retrospective cohort study including patients requiring ICU between 2006 and 2020 in a tertiary university hospital.

INCLUSION CRITERIA

Age >18 years. Patients were categorized as Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN), or other toxidermia.

VARIABLES

severity scores, body surface area (BSA) involvement, nutritional and metabolic variables, trace element status, outcome variables. Descriptive statistics: median [IQR].

RESULTS

Altogether 35 patients were included (27 SJS/TEN and 8 "other"), aged 58 [48; 69] years. Skin involvement was 45% [30; 60] of body surface, 17 patients required mechanical ventilation, and length of ICU stay was 16 [6.5; 26] days. Hospital mortality was 23%. Fluid resuscitation requirements were moderate, despite intense inflammation (admission CRP (144 [89; 218] mg/L). The first 2 weeks' energy and protein intakes were below recommendations (p < 0.0001), lowest with oral feeding. Indirect calorimetry showed high energy expenditure in 11 patients (30.4 [23.9; 35.5] kcal/kg) resulting in negative energy balances (mean -245 kcal/day). Copper and zinc levels were below reference range during the first week, the low copper values being a novel finding.

CONCLUSION

Trace elements should be monitored. The cohort was underfed with intakes lower than our ICU protocols, partly explained by short intubation times, and mucocutaneous involvement complicating the management and placement of feeding tubes. Oral feeding was least efficient and may become an indication for supplemental parenteral nutrition in the absence of an enteral feeding tube.

CLINICALTRIALS

gov Identifier: NCT05320653.

TEN mimics: Classification and practical approach to toxic epidermal necrolysis-like dermatoses

Toxic epidermal necrolysis (TEN) is an acute life-threatening dermatologic emergency. However, many dermatoses can present with a TEN-like eruption. Those "TEN-mimics" are a true diagnostic challenge and an alarming differential diagnosis to such a serious condition. Herein, we will expose and classify the landscape of TEN-mimics. Also, the key differentiating clinical and/or laboratory points will be highlighted to help an accurate diagnosis of either a TEN or a TEN-like presentation.

High Serum Level of TNF-α in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

BACKGROUND: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis are severe cutaneous adverse drug reactions. Some immunological and genetic factors are believed to be involved in the pathogenesis of SJS/TEN, including tumor necrotic factor-alpha (TNF-α). Activated T-cells secrete high amounts of TNF-α and interferon-gamma that both cytokines lead to increased expression and activity of keratinocyte inducible nitric oxide synthase playing an important role in the apoptosis of keratinocytes. AIM: This study aims to evaluate the serum level of TNF-α in SJS/TEN and the relation between it and the progress of SJS/TEN. METHODS: This was a sectional descriptive study conducted at the National Hospital of Dermatology and Venereology, in Hanoi, Vietnam, from October 2017 to September 2019. Forty-eight SJS/TEN patients, 43 erythema multiforme (EM) patients, and 20 healthy controls (HCs) participated. TNF-α levels were measured using the fluorescence covalent microbead immunosorbent assay (FCMIA) (ProcartaPlex Immunoassay Panels kit, Thermo Fisher Scientific, USA). The Mann–Whitney U-test was used to compare serum TNF-α levels of two groups. The Wilcoxon tests were used to compare quantitative variables before and after the treatment. Differences were considered to be statistically significant at p < 0.05. RESULTS: Nineteen SJS patients (39.5%) and 29 TEN patients (60.5%) participated in our study. The mean age was 49.3, range 19−77 years (47.9% of males and 52.1% of females). The most common causative drugs were traditional medicine (29.1%), carbamazepine (12.5%), and allopurinol (12.5%). On the day of hospitalization, the mean serum level of the SJS/TEN group was 32.6 pg/ml with a range from 1.3 pg/ml to 771.2 pg/ml. This level was significantly higher than that of the HCs group (p < 0.05) but not higher than that of the EM group. The mean serum level of TNF-α in the SJS/TEN patients on the day of hospitalization was 32.6 pg/ml, higher than that on the day of re-epithelialization (2.7 pg/ml) and the difference was statistically significant with p < 0.05. CONCLUSION: Serum TNF-α levels are a good biomarker to evaluate the progress of SJS/TEN but it is not good to differentiate SJS/TEN from EM.

Amoxicillin-associated Stevens-Johnson syndrome or toxic epidermal necrolysis: systematic review

Our aim was to explore and summarize available cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) suspected to be associated with amoxicillin reported in the literature. Electronic searches were conducted in several databases. Fifty-one publications describing a total of 64 patients who satisfied inclusion criteria were included in the review. The age of the patients ranged from 1.5-80 years (median: 24.5 years). TEN, SJS and SJS/TEN overlap were diagnosed in 30 (46.9%), 28 (43.8%) and 1 (1.6%) patients, respectively. SJS/TEN may occur promptly after administration of amoxicillin, but it could also be a delayed adverse effect. The total length of hospital stay ranged from 3-70 days (median: 16 days). Amoxicillin-induced SJS/TEN is accompanied by frequent occurrence of serious complications, long-term ocular and skin sequelae and high mortality rate. Clinicians should be aware that amoxicillin alone or combined with clavulanic acid can cause SJS/TEN in patients of all ages.

Impact of multiple medical interventions on mortality, length of hospital stay and reepithelialization time in Toxic Epidermal Necrolysis, Steven-Johnsons Syndrome, and TEN/SJS Overlap - Metanalysis and metaregression of observational studies

Stevens-Johnson's Syndrome (SJS) and Toxic Epidermal Necrolysis are rare, life-threatening dermatologic conditions with acute onset and not clearly established treatment protocol. A plethora of observational studies are present with lack of up-to-date consensus based on evaluation of objective endpoints, among others mortality. Thorough analysis of available databases (Pubmed, EMBASE, Cinahl, Web of Science, Clinical Trials) was conducted according to PRISMA guidelines. Authors initially identified 700 papers, with 82 of them potentially eligible according to adopted criteria. A total of 42 studies were included into pooled synthesis. For continuous outcomes we analyzed the pooled means for endpoint scores using observed cases data. Categorical outcomes were analyzed by calculating the pooled event rates. We conducted subgroup and exploratory maximum likelihood random effects meta-regression analyses regarding SCORTEN of all outcomes. Using random-effects model, the overall pooled Mortality Rate was 0.191 (95%CI, 0.132-0.269). The lowest mortality rate was found to be linked with Etanercept and highest in Total Plasma Exchange (TPE) and Intravenous Immunoglobulin (IVIG). Overall reepithelization was 13.278 days (95%CI, 8.773-17.784),The highest was found in cyclosporine treatment; 14.739 whilst the lowest for steroids. Length of hospital stay in overall analysis was 19.99 days (95%CI, 16.53-23.44),the highest was linked with TPE/TPE+IvIg treatment, the lowest with steroids. Risk of bias of assessed studies was estimated to be high (for observational studies mean STROBE score 12.44). High quality TEN and SJS studies are lacking. Almost all papers report observational data without randomization and double-blind control. Therefore, the pooled analysis cannot be presented with initial bias. In our meta-analysis the most successful regimen was Etanercept treatment. It was linked with the lowest mortality. The most negative treatment outcome was observed in studies reporting TPE and IVIG. Randomized trials of high quality are needed in SJS and TEN.

Systemic Corticosteroid Therapy for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in Vietnam: Clinical Evaluation and Analysis of Serum Cytokines

Abstract BACKGROUND: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis are severe cutaneous adverse drug reactions. There are some immunological and genetic factors which are believed to be involved in the pathogenesis of SJS/TEN. The treatment of SJS/TEN is still controversial in which several studies showed variable results. AIMS: To evaluate clinically the efficacy of systemic corticosteroid and to analyze some related cytokines in the treatment of SJS/TEN. METHODS: This open, pilot and uncontrolled study was conducted at National Hospital of Dermatology and Venereology, in Hanoi, Vietnam, from October 2017 to September 2019. Methylprednisolone was indicated from the first day of hospitalization with the dose of 0.5-2.5 mg/kg/day (calculated according to prednisolone dose) once daily. It was continued until the patients got re-epithelialization. The efficacy of methylprednisolone was evaluated by observing clinically and analyzing related cytokines before and after the treatment. RESULTS: The mean time of re-epithelialization was 15.9 days, of hospitalization was 15.9 days (range 5-30 days). There was no in-hospital mortality in this study. The most common complication was transient glycaemia (40.6%), there was no patient with sepsis. At the day of hospitalization, serum concentrations of TNF-α, IFN-γ, IL-2, IL-5, IL-13 and IL-10 were significantly higher than those at the day of re-epithelialization (p<0.05). Serum levels of IL-4, did not have significant differences between two time points (p>0.05). CONCLUSION: The systemic corticosteroid is a good choice in the treatment of SJS/TEN. It can reduce serum levels of some cytokines that help SJS/TEN patients with avoiding mortality.

Stevens–Johnson syndrome and toxic epidermal necrolysis: 11-year demographic clinical and prognostic characteristics

Background:

Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are acute, life-threatening, severe drug reactions. Randomized studies on these diseases are difficult to perform.

Aims and Objectives:

The purpose of this study was to summarize the demographic and clinical characteristics of patients with SJS and TEN in a tertiary hospital in Turkey.

Materials and Methods:

We evaluated the records of 33 patients with SJS and TEN who were followed in our clinic or examined between January 2008 and June 2019, retrospectively. Age, sex, time of admission to hospital, causative drug, presence of concomitant disease, skin findings, mucosal involvement, the severity-of-illness score for TEN, the medication used, antibiotic use, transfer to intensive care, development of complications, and death or discharge status were noted.

Results:

Of the 33 patients, 11 (33.3%) had SJS, 3 (9.1%) had SJS/TEN overlap, and 19 (57.6%) had TEN. The majority (60.6%) of the patients were female. Nineteen (57.6%) patients had one, and 13 (39.4%) had more than one suspected drug exposure in their history. The most commonly suspected drugs were antibiotics. Twelve (36.4%) patients had intensive care unit hospitalization. Ten (30.3%) patients died.

Conclusion:

The demographic data of our study were consistent with the literature. Similar to the literature, antibiotics were the most common reaction-causing drugs. However, antiepileptic drugs, which were more frequently reported in other studies, were identified as suspicious in only one patient. We believe that our study will contribute to the determination of characteristics of this rare disease with real-life data.

Critical Review of Gaps in the Diagnosis and Management of Drug-Induced Liver Injury Associated with Severe Cutaneous Adverse Reactions

Drug-induced liver injury (DILI) encompasses the unexpected damage that drugs can cause to the liver. DILI may develop in the context of an immunoallergic syndrome with cutaneous manifestations, which are sometimes severe (SCARs). Nevirapine, allopurinol, anti-epileptics, sulfonamides, and antibiotics are the most frequent culprit drugs for DILI associated with SCARs. Interestingly, alleles HLA-B*58:01 and HLA-A*31:01 are associated with both adverse reactions. However, there is no consensus about the criteria used for the characterization of liver injury in this context, and the different thresholds for DILI definition make it difficult to gain insight into this complex disorder. Moreover, current limitations when evaluating causality in patients with DILI associated with SCARs are related to the plethora of causality assessment methods and the lack of consensual complementary tools. Finally, the management of this condition encompasses the treatment of liver and skin injury. Although the use of immunomodulant agents is accepted for SCARs, their role in treating liver injury remains controversial. Further randomized clinical trials are needed to test their efficacy and safety to address this complex entity. Therefore, this review aims to identify the current gaps in the definition, diagnosis, prognosis, and management of DILI associated with SCARs, proposing different strategies to fill in these gaps.

Stevens-Johnson syndrome/toxic epidermal necrolysis successfully treated with Chinese herbal medicine Pi-Yan-Ning: A case report

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a rare adverse cutaneous reaction with a low incidence and high mortality. Despite posing a serious threat to patients' health and lives, there is no high-quality evidence for a standard treatment regimen. Here we report the case of a 62-year-old man with stage IV pancreatic cancer who experienced immunotherapy-induced SJS/TEN. After consensus-based regular treatments at a local hospital, his symptoms became worse. Thus, he consented to receive Chinese herbal medicine (CHM) therapy. The affected parts of the patient were treated with the CHM Pi-Yan-Ning which was applied externally for 20 min twice a day. After 7 days of treatment, the dead skin began peeling away from the former lesions that had covered his hands, feet, and lips, indicating that skin had regenerated. After 12 days of treatment, the patient's skin was completely recovered. In this case, SJS/TEN was successfully treated with Pi-Yan-Ning, suggesting that there might be tremendous potential for the use of Pi-Yan-Ning in the treatment of severe skin reactions to drug treatments. Further basic investigations and clinical trials to explore the mechanism and efficacy are needed.

Treatment of Toxic Epidermal Necrolysis with Etanercept in a Pediatric Patient

Toxic epidermal necrolysis is a rare, life-threatening skin disease with no consensus on adjunctive treatment, particularly in pediatric patients. We present the case of a 13-year-old previously healthy patient with drug-associated toxic epidermal necrolysis who experienced significantly shortened length of hospital stay and duration of symptoms compared with published literature when treated with 2 doses of etanercept 50 mg during 5 days.

Case Report: A Case Report and Literature Review on Severe Bullous Skin Reaction Induced by anti-PD-1 Immunotherapy in a Cervical Cancer Patient

Background: Anti-programmed cell death protein 1 (PD-1) has been successfully used in carcinomas treatment. However, it causes significant adverse effects (AEs), including cutaneous reactions, particularly the life-threatening severe bullous skin reactions (SBSR) and toxic epidermal necrolysis (TEN).

Case summary: Herein, we described for the first time a case report of SBSR induced by anti-PD-1 therapy in a cervical cancer patient. In addition, we revised existing literature on anti-PD-1 induced cutaneous reactions. We reported a cervical cancer patient who was treated with four successive cycles of Sintilimab and Toripalimab injections and developed systemic rashes, bullae, and epidermal desquamation, which worsened and led to infection, eventually causing death after being unresponsive to aggressive treatments.

Conclusion: Anti-PD-1 antibodies commonly cause skin toxicity effects, some of which may be deadly. Therefore, healthcare providers should observe early symptoms and administer proper treatment to prevent aggravation of symptoms.

Case Report: Positive Outcome of a Suspected Drug-Associated (Immune Mediated) Reaction in a 4-Year-Old Male French Bulldog

Toxic epidermal necrolysis (TEN) is a rare and severe life-threatening syndrome characterized by apoptosis of keratinocytes resulting in devitalization of the epidermis affecting more than 30% of skin surface. In humans and animals, this condition is mostly triggered by drugs. Identification of the putative agent and its withdrawal are crucial to successful management of a patient with TEN. In this case study, we report the clinical features, histopathological findings and management of a dog with TEN. A 4-year-old intact male French bulldog presented with acute onset of severe lethargy and cutaneous ulcerations on the footpads, scrotum, and hind limbs associated with marked pain. A Stevens-Johnson syndrome/TEN was suspected and drugs, especially beta-lactams, were withdrawn. Histopathology confirmed the diagnosis of epidermal necrosis. Advanced supportive therapy, pain management and skin care led to rapid remission. Early identification and removal of the suspected medication was crucial to improving TEN prognosis in this dog. Antibiotics (penicillin, ampicillin, cephalexin, and sulfonamides) are frequently involved in adverse cutaneous reactions in dogs. Ideal treatment remains elusive is humans and dogs and this disease has a poor prognosis. Supportive care combined with pain management and treatment of the cutaneous ulcerations is essential.

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Review of Diagnosis and Management

Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are rare diseases that are characterized by widespread epidermal necrosis and sloughing of skin. They are associated with significant morbidity and mortality, and early diagnosis and treatment is critical in achieving favorable outcomes for patients. In this scoping review, Excerpta Medica dataBASE and PubMed were searched for publications that addressed recent advances in the diagnosis and management of the disease. Multiple proteins (galectin 7 and RIP3) were identified that are promising potential biomarkers for SJS/TEN, although both are still in early phases of research. Regarding treatment, cyclosporine is the most effective therapy for the treatment of SJS, and a combination of intravenous immunoglobulin (IVIg) and corticosteroids is most effective for SJS/TEN overlap and TEN. Due to the rare nature of the disease, there is a lack of prospective, randomized controlled trials and conducting these in the future would provide valuable insights into the management of this disease.

Altered levels of complement components associated with non-immediate drug hypersensitivity reactions

Nonimmediate drug hypersensitivity reactions (niDHRs) range from mild-type maculopapular exanthema (MPE) to severe type Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) with unentirely clarified pathogenesis. This study sought to explore whether complement components participated in niDHRs. The participants comprised of three groups as follows: MPE (n = 65), SJS/TEN (n = 13, contains 7 SJS, 2 SJS-TEN overlap and 4 TEN), and equal healthy controls (n = 78). Skin pathological changes were confirmed by hematoxylin and eosin staining. The mRNA and protein levels of complement components were assessed. In the MPE group, there were no alterations in complement components at the protein and mRNA levels found except for a decrease in factor H mRNA. In the SJS/TEN group, up-regulated levels of C3aR and C5aR mRNA and down-regulated factor H mRNA levels in blood were noted. A lower plasma protein level of C3, Factor H and a higher level of C3a, C5, C5a, C5b-9, Factor B (p < 0.05) were found in the SJS/TEN group compared with in the control (p < 0.05). In SJS/TEN skin lesions, indirect immunofluorescence assays showed positive specific staining for C5b-9, but not C3. Both C3aR and C5aR were positive staining in the SJS/TEN samples, while staining for C1q, mannose-binding lectin (MBL), Factor B, and Factor H were only weak or negative. The findings reported here are the first to define the expression profiles/extent of the presence of various complement components at the mRNA and protein levels in niDHRs, especially in SJS/TEN. These altered complement components might, at least in part, be integral to the mechanisms underlying the pathogeneses of SJS and TEN.

Genetic Determinants in HLA and Cytochrome P450 Genes in the Risk of Aromatic Antiepileptic-Induced Severe Cutaneous Adverse Reactions

Adverse drug reaction (ADR) is a pressing health problem, and one of the main reasons for treatment failure with antiepileptic drugs. This has become apparent in the event of severe cutaneous adverse reactions (SCARs), which can be life-threatening. In this review, four hypotheses were identified to describe how the immune system is triggered in the development of SCARs, which predominantly involve the human leukocyte antigen (HLA) proteins. Several genetic variations in HLA genes have been shown to be strongly associated with the susceptibility to developing SCARs when prescribed carbamazepine or phenytoin. These genetic variations were also shown to be prevalent in certain populations. Apart from the HLA genes, other genes proposed to affect the risk of SCARs are genes encoding for CYP450 drug-metabolising enzymes, which are involved in the pharmacokinetics of offending drugs. Genetic variants in CYP2C9 and CYPC19 enzymes were also suggested to modulate the risk of SCARs in some populations. This review summarizes the literature on the manifestation and aetiology of antiepileptic-induced SCARs, updates on pharmacogenetic markers associated with this reaction and the implementation of pre-emptive testing as a preventive strategy for SCARs.

Toxic epidermal necrolysis in a patient on atorvastatin therapy expressing human leukocyte antigen alleles: A case report

RATIONALE

Toxic epidermal necrolysis (TEN) is a rare, severe mucosal response of the skin associated with a high mortality rate. TEN is most commonly caused by drugs, and is characterized by extensive skin epidermal exfoliation.

PATIENT CONCERNS

A 68-year-old woman presented with a rash that had persisted for four days. The patient who had undergone a mitral valve replacement 1 month prior and was taking atorvastatin at the time of admission.

DIAGNOSES

The patient exhibited more than 30% exfoliation surfaces and the severe drug eruption was considered to be TEN. According to human leukocyte antigen (HLA) allele detection and ALDEN score, HLA alleles which found in this case report may be an cause of TEN induced by atorvastatin.

INTERVENTIONS

All drugs used prior to admission were discontinued and the patient was given antiallergic drugs.

OUTCOMES

After 3 weeks following Antiallergic treatment, the rash on patient's calf had subsided, the edema was relieved, and the patient was no longer experiencing pain. After 60 days following discharge, the patient's skin has regrown.

LESSONS

This is the first report describing the induction of TEN by atorvastatin in a HLA alleles carrier. For HLA alleles carrier, atorvastatin may need to be used with caution to avoid TEN. Future systematic research is also required to confirm this finding and avoid similar serious skin adverse reactions.

Genetic Markers for Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis in the Asian Indian Population: Implications on Prevention

This review attempts to collate all the studies performed in India or comprising a population originating from India and to find out if there is an association between the HLA (human leucocyte antigen) type of individual and development of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) subsequent to medication use. The authors performed a PubMed search of all articles published in English from 2009 to 2019 for articles that studied HLA type in patients who developed SJS/TEN after intake of a specific drug in the Asian Indian population or in individuals of Asian Indian origin. The selection criteria were satisfied by a total of 11 studies that reported HLA associations with specific drugs, which induced SJS/TEN, mainly anti-epileptic drugs, and cold medicine/non-steroidal anti-inflammatory drugs. These studies involved a small number of patients, and hence, there is limited evidence to conclude if these associations can be extrapolated to a larger population of the same ethnicity. Similar multi-center studies need to be conducted with a larger sample size to confirm these associations. This would have implications in policy making and for understanding the potential of using genetic markers as a screening tool before prescribing a drug to a patient, which might make them susceptible to developing a potentially life-threatening disease such as SJS/TEN. This is possibly the only mode of primary prevention for this potentially fatal severe cutaneous adverse drug reaction.

Asymptomatic Hyperamylasemia in Stevens-Johnson Syndrome Is Associated with Intestinal Barrier Dysfunction

Methods

A retrospective study on SJS patients was conducted at a tertiary medical center. All patients diagnosed as SJS, with available serum amylase index, were included. Clinical data of all subjects were retrospectively collected and analyzed. Colonic mucosal biopsies were obtained to measure tight junction protein expression.

Results

A total of nine patients were included in the present study for study analysis. The average serum amylase of the study cohort was 228.78 ± 204.18 U/L. Among which, five patients had a positive fecal occult blood test (FOBT). Colonic mucosal biopsies were obtained and stained with occludin and zonula occludens-1 (ZO-1). The expression of occludin and ZO-1 was significantly downregulated in SJS patients (p < 0.01), which was indicative of intestinal barrier dysfunction.

Conclusion

Hyperamylasemia often extends beyond pancreatic diseases. Clinical awareness of asymptomatic hyperamylasemia secondary to other systemic diseases can help avoid unnecessary overexamination and overtreatment.

Ventilatory support in Stevens-Johnson syndrome and toxic epidermal necrolysis: a systematic review and meta-analysis

Introduction: Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are blistering cutaneous disorders that often manifest with epidermal and mucosal necrosis. In extreme cases, the upper or bronchial airways are threatened, necessitating intubation and mechanical ventilation. This systematic review and meta-analysis examines the prevalence of mechanical ventilation (MV) in patients with SJS or TENS, despite maximal medical therapy, and additionally aims to identify the risk factors associated with this requirement.Materials and methods: A systematic review of the literature was performed using the PRISMA guidelines and meta-analysis of proportions.Results: Six articles were included, with pooled total of 18648 cases. The weighted prevalence of MV was 27.5% (95%CI 17.8-39.9%). The need for MV was more closely associated with TEN, compared to SJS (OR 4.40, 95%CI 2.73-7.10, I²=48%, p<.00001.) Risk factors associated with the need for MV included bacteremia (OR 5.02, 95%CI 2.87-8.79, I²=0%, p<.00001), shock/organ failure on admission (OR 261.99, 95%CI 21.88-3137, I²=71, p<.0001), total body surface area (TBSA) >30% (OR 4.47, 95%CI 1.41-14.20, I²=71, p=.01.)Conclusion: Limited published evidence with significant heterogeneity exists within the literature regarding the need for MV in SJS and TEN. Greater cutaneous involvement, and more critically unwell patients appear more likely to require MV.

Stevens-Johnson syndrome/toxic epidermal necrolysis: treatment with low-dose corticosteroids, vitamin C and thiamine

We present the case of a 33-year-old woman with no significant past medical history who was admitted to an outside hospital for the abrupt onset of fevers, malaise and a diffuse mucocutaneous rash. Her constellation of symptoms and presentation were most consistent with a diagnosis of Stevens-Johnson syndrome/toxic epidermal necrolysis overlap syndrome secondary to ibuprofen exposure. Her rash continued to worsen and she was transferred to our medical intensive care unit (ICU), where broad-spectrum antibiotics were discontinued and she was treated with supportive care as well as 'low-dose' intravenous hydrocortisone, ascorbic acid (vitamin C) and thiamine (HAT therapy). After starting this therapy, the patient demonstrated a dramatic response with rapid improvement of her cutaneous and mucosal lesions. She was tolerating a diet provided by the hospital on day 4 and was discharged from the ICU a few days later.

Toxic Epidermal Necrolysis Therapy with TPE and IVIG-10 Years of Experience of the Burns Treatment Center

Toxic epidermal necrolysis (TEN) is a potentially life-threatening, exfoliative disease. It is described as idiosyncratic, severe, skin reaction to drugs. With Stevens-Johnson's Syndrome, it presents as a continuum of a disease being categorized relating to the percentage of affected skin. Without any multicenter trials comparing TEN treatment modalities, there is dearth of strong evidence-based guidelines of care. Total plasma exchange with intravenous immunoglobulin (IVIG) is one among plethora of possible treatment strategies. In our 10-year experience, we have observed 21 patients admitted to our burns center due to TEN. All of them were placed under intensive care with daily plasmapheresis (TPE) and IVIG. We have observed 52% mortality, with observed severe concomitant diseases in every patient in nonsurvivor group (average Acute Physiology and Chronic Health Evaluation II score at admission: 31.5%). We consider that TPE with IVIG might be of use in selected group of patients with TEN without any severe comorbidities. However, further multicenter trials are needed because in some cases it may raise mortality.

A Review of the Management of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

Stevens-Johnson syndrome and toxic epidermal necrolysis represent a spectrum of severe cutaneous adverse reactions that carry the potential for severe, long-term adverse effects, including death. Although medications are most commonly implicated in the development of these diseases, other factors, including infection and genetics, play a role. Management is generally supportive in nature and includes maintenance of the patient's airway, breathing, and circulation. Special disease considerations include the use of skin barrier management, unique infection prevention measures, and systemic immunomodulatory therapies.