Toxic epidermal necrolysis

Toxic epidermal necrolysis and Stevens-Johnson syndrome: a review

OBJECTIVES

The aims of this review are to summarize the definitions, causes, and clinical course as well as the current understanding of the genetic background, mechanism of disease, and therapy of toxic epidermal necrolysis and Stevens-Johnson syndrome.

DATA SOURCES

PubMed was searched using the terms toxic epidermal necrolysis, Stevens-Johnson syndrome, drug toxicity, drug interaction, and skin diseases.

DATA SYNTHESIS

Toxic epidermal necrolysis and Stevens-Johnson syndrome are acute inflammatory skin reactions. The onset is usually triggered by infections of the upper respiratory tract or by preceding medication, among which nonsteroidal anti-inflammatory agents, antibiotics, and anticonvulsants are the most common triggers. Initially the diseases present with unspecific symptoms, followed by more or less extensive blistering and shedding of the skin. Complete death of the epidermis leads to sloughing similar to that seen in large burns. Toxic epidermal necrolysis is the most severe form of drug-induced skin reaction and includes denudation of >30% of total body surface area. Stevens-Johnson syndrome affects <10%, whereas involvement of 10%-30% of body surface area is called Stevens-Johnson syndrome/toxic epidermal necrolysis overlap. Besides the skin, mucous membranes such as oral, genital, anal, nasal, and conjunctival mucosa are frequently involved in toxic epidermal necrolysis and Stevens-Johnson syndrome. Toxic epidermal necrolysis is associated with a significant mortality of 30%-50% and long-term sequelae. Treatment includes early admission to a burn unit, where treatment with precise fluid, electrolyte, protein, and energy supplementation, moderate mechanical ventilation, and expert wound care can be provided. Specific treatment with immunosuppressive drugs or immunoglobulins did not show an improved outcome in most studies and remains controversial. The mechanism of disease is not completely understood, but immunologic mechanisms, cytotoxic reactions, and delayed hypersensitivity seem to be involved.

CONCLUSION

Profound knowledge of exfoliative skin diseases is needed to improve therapy and outcome of these life-threatening illnesses.

Life-threatening acute adverse cutaneous drug reactions

Adverse cutaneous reactions to drugs are frequent, affecting 2% to 3% of all hospitalized patients. Fortunately, only about 2% of adverse cutaneous reactions are severe and very few are fatal. Stevens-Johnson syndrome and toxic epidermal necrolysis are severe life-threatening diseases with a mortality rate reaching 30%, and only prompt recognition and diagnosis, withdrawal of the offensive drug, and referral to an intensive care unit or burn care unit might improve the prognosis and save the patient's life. Drug eruption with eosinophilia and systemic symptoms syndrome, formerly termed drug hypersensitivity syndrome, is a rather distinct severe adverse drug reaction (ADR) characterized by eruption, fever, lymph node enlargement, and single or multiple organ involvement, with a high morbidity and a mortality rate of 10%. These severe ADRs, together with serum sickness-like syndrome, are discussed in this review. Other severe reactions, such as anaphylaxis and vasculitis, are discussed elsewhere in this issue. Although most of the readers, particularly those in the outpatient arena, will not be treating these patients, they are the ones who will see them first, diagnose them, realize the potential danger in their condition, and refer them to the appropriate treatment venue. Therefore, dermatologists should be familiar with these conditions and be prepared to handle them adequately.

Stevens-Johnson syndrome and toxic epidermal necrolysis: a review of the literature

OBJECTIVE

To perform a comprehensive review of Stevens-Johnson syndrome and toxic epidermal necrolysis.

DATA SOURCES

A MEDLINE search was performed for the years 1975 to 2003 using the keywords Stevens-Johnson syndrome and toxic epidermal necrolysis to identify relevant articles published in English in peer-reviewed journals.

STUDY SELECTION

All clinical studies that reported on 4 or more patients, review articles, and experimental studies that concerned disease mechanisms were selected and further analyzed. Clinical reports that included fewer than 4 patients were selected only if they were believed to carry a significant message about disease mechanism or therapy.

RESULTS

Stevens-Johnson syndrome and toxic epidermal necrolysis seem to be variants of the same disease with differing severities. A widely accepted consensus regarding diagnostic criteria and therapy does not exist at present. Despite the recent experimental studies, the pathogenic mechanisms of these diseases remain unknown. Although progress in survival through early hospitalization in specialized burn units has been made, the prevalence of life-long disability from the ocular morbidity of Stevens-Johnson syndrome and toxic epidermal necrolysis has remained unchanged for the past 35 years. Further progress depends on modification of the acute phase of the disease rather than continuation of supportive care. The available published evidence indicates that a principal problem in the pathogenesis is immunologic and that immunomodulatory intervention with short-term, high-dose intravenous steroids or intravenous immunoglobulin holds the most promise for effective change in survival and long-term morbidity.

CONCLUSIONS

The results of this review call for a widely accepted consensus on diagnostic criteria for Stevens-Johnson and toxic epidermal necrolysis and multicenter collaboration in experimental studies and clinical trials that investigate disease mechanisms and novel therapeutic interventions, respectively.

Erythema multiforme, Stevens-Johnson syndrome and toxic epidermal necrolysis in northeastern Malaysia

BACKGROUND

Previous studies have reported that drugs and infections are common causes of erythema multiforme (EM) and Stevens-Johnson syndrome (SJS). Toxic epidermal necrolysis (TEN) is mainly related to drugs. No study has been conducted in Kelantan, the northeastern state of Malaysia, to assess these cutaneous reactions.

METHODS

A retrospective study of all hospitalized cases of EM, SJS, and TEN was conducted covering an 8-year period from 1987 to 1994.

RESULTS

There were four cases (13.8%) of EM, 22 cases (75.9%) of SJS, and three cases (10.3%) of TEN. Drugs as a definitive cause was observed in one case (25%) of EM, 12 cases (54.5%) of SJS, and two cases (66.7%) of TEN. Drugs as a probable cause was observed in seven cases (31.8%) of SJS and one case (33.3%) of TEN. The male to female ratio was equal in EM and SJS. Antiepileptics were the commonest culprits, followed by antibiotics. One patient died of SJS and one patient died of TEN, giving mortality rates of 4.5% and 33.5% respectively. Fever was noted in 18 patients (62.1%). Leukocytosis was noted in 10 patients (34.5%), and nine patients (31.0%) had elevated liver transaminase enzymes. No significant correlation was noted between these biochemical changes and cutaneous eruption. Secondary infections were observed in 11 patients (37.9%): Staphylococcus aureus was the commonest isolated organism.

CONCLUSIONS

This study shows that drugs remain the commonest culprit in SJS and TEN. Despite adequate treatment, the mortality rate remains high, especially in TEN. These findings are similar to those of other reported studies.

Oral manifestations of toxic epidermal necrolysis (TEN) in patients with AIDS: report of five cases

OBJECTIVE

To describe oral findings in HIV-infected individuals with toxic epidermal necrolysis (TEN).

PATIENTS

In a retrospective study over a 10 year period the medical histories of 931 hospitalised HIV-infected patients were reviewed for the occurrence of TEN.

RESULTS

Five cases of TEN were diagnosed (three men, two women; median age: 41 years; median CD4+ T lymphocyte count: 20/microliter). Four patients had been treated with biweekly pyrimethamine/sulfadoxine for prophylaxis against Pneumocystis carinii pneumonia and toxoplasmosis. In one patient flucloxacillin was administered. Signs of TEN with cutaneous epidermolysis occurred and patients showed oral lesions characterized as oropharyngeal blisters and bullae on the palate, buccal mucosa, tongue and floor of the mouth initially. Antibiotics and corticosteroids were administered; none of the patients died.

CONCLUSION

Longacting sulfonamides and antibiotics have been implicated as the cause of severe mucocutaneous reactions. Since rash and oral blisters may be the first signs of TEN in patients receiving these it is mandatory to follow up these patients closely to detect oral or cutaneous changes indicating the development of TEN.

Stevens-Johnson syndrome and abnormal root development: a case report

A boy developed Stevens-Johnson syndrome (erythema multiforme) 2 weeks after taking a course of slow-release theophylline at the age of 9 years. He had suffered from bronchial asthma since early infancy. He did not attend for dental treatment until the age of 14 years, when panoramic radiography demonstrated varying degrees of arrested root development in the permanent dentition.

Stevens-Johnson syndrome and toxic epidermal necrolysis in Thailand

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are potentially life-threatening illnesses that have often been linked to drug exposure.

METHODS

We looked retrospectively for all cases of SJS and TEN that were admitted to Siriraj Hospital between 1981 and 1990 to determine the drug etiology.

RESULTS

Fifty-eight cases of SJS and 20 cases of TEN were identified. Eight patients initially had an SJS-like aspect, which subsequently evolved into TEN. A culpable drug was determined in 60 patients (77%). The mean time from first drug administration to onset of SJS or TEN was 6.8 +/- 6.5 days (range, 1 to 28 days). A longer incubation period was observed with thiacetazone (10.5 +/- 5.6 days), phenytoin (12 +/- 8.5 days), and carbamazepine (11.3 +/- 3.4 days).

CONCLUSIONS

The culprit drugs included the following: antibiotics, 32 cases (penicillin, sulfonamides, tetracycline, erythromycin); anticonvulsants, nine (phenytoin, carbamazepine, barbiturates); antitubercular drugs, eight (thiacetazone); analgesics, four (acetylsalicylic acid, fenbufen); sulfonylurea, two; allopurinol, one; and others, four. The most frequent underlying diseases justifying the ingestion of one or more drugs in our patients were infections (52.7%), followed by pulmonary tuberculosis (10.8%), and by seizures (8.1%). The total mortality rate was 14%; 5% for SJS, and 40% for TEN. Mortality was not affected by the type of drug responsible.

Cephalexin-induced Stevens-Johnson syndrome

OBJECTIVE

To report a case of cephalexin-induced Stevens-Johnson syndrome (SJS), a devastating adverse drug reaction that involves the entire skin surface and mucosal areas of the body.

DATA SOURCES

MEDLINE search (key terms cephalosporins, Stevens-Johnson syndrome, erythema multiforme, and systemic lupus erythematosus) and references identified from bibliographies of pertinent articles.

DATA SYNTHESIS

Clinical presentation and manifestations of SJS include the skin, eyes, gastrointestinal tract, and pulmonary system. Infectious complications are the leading cause of mortality. Early intervention is important to prevent progression of SJS. The case described is consistent with the features of this syndrome. The patient presented with fever, arthralgias, and malaise. Skin lesions included a diffuse violet macular rash with erythema and multiple bullous lesions on her neck and abdomen. The skin biopsy was consistent with SJS. Multiple mucocutaneous ulcers were found in her mouth, but no evidence of lower gastrointestinal tract involvement was documented. She remained relatively free of pulmonary complaints except for the presenting bronchitis.

CONCLUSIONS

Cephalexin should be added to the list of agents to consider as iatrogenic causes of SJS.

Toxic epidermal necrolysis in early infancy

Toxic epidermal necrolysis (TEN) is a life-threatening bullous dermatosis characterized by the sudden onset of full-thickness epidermal necrosis. TEN is a disease of both children and adults, but TEN in early infancy is a rare event; only two well-documented cases in infants less than 6 months of age have been reported. We report a third case of a 6-week-old infant with Escherichia coli sepsis who received ampicillin and other antibiotics and subsequently developed TEN. Despite the withdrawal of ampicillin and aggressive systemic and wound care, the infant died. The infants in the other two reported cases also died, which suggests that TEN in early infancy has an extremely poor prognosis.

Efficacy of cyclophosphamide in toxic epidermal necrolysis. Clinical and pathophysiologic aspects

In this article we describe the immunocytochemical and electron microscopic findings in five patients with toxic epidermal necrolysis. They indicate the occurrence of necrotic keratinocytes with nuclear disintegration associated with apposed dendritic cells with the nuclear chromatin configuration of T lymphocytes. These findings, including the presence of blebbing of the keratinocytes and membrane defects associated with cytoplasmic processes from these apposed lymphoid cells, fit known electron microscopic criteria that suggest the involvement of T lymphocyte-mediated cytolysis of drug-altered target keratinocytes in toxic epidermal necrolysis. The effector cell appears to be a dendritic subset, with the phenotypic characteristics (CD3+, CD4-, CD8+, CD2+, DR+) of a T cell subset. There is some evidence that tumor necrosis factor alpha, secreted by activated macrophages, may play a role in necrolysis of the epidermis. The dramatic response of our patients to cyclophosphamide, which is known to inhibit cell-mediated cytotoxicity by inhibiting both the recognition and lethal hit stages, together with the rapid regrowth of the epidermis within 4 days to a week in patients who received adequate dosage of the drug, supports the preceding concepts.

Mycoplasma pneumoniae infections and Stevens-Johnson syndrome. Report of eight cases and review of the literature

On the basis of a literature review and eight cases of our own, we analyzed 37 cases of Mycoplasma pneumoniae (MP) infection and Stevens-Johnson syndrome (SJS). Our clinical and laboratory findings do not differ from those reported in the literature for MP infection with no exanthem or for SJS of various etiologies. Eighty percent of the children presented with symptoms of upper respiratory tract infection (URTI) (cough, fever, sore throat, malaise, headache), with a mean of 10 days (range 1 to 30) before skin rash broke out. Skin manifestations occurred in 94.2% of the patients after 3 to 21 days (mean 10.3 days) of fever. The exanthem, composed predominantly of maculopapular and vesicular, was distributed chiefly on the trunk and extremities and lasted less than 14 days in 87.8% of the patients. Stomatitis was observed in 91.6% of the patients and conjunctivitis in 50%. No consistent pattern seems to emerge by which one could predict the existence of MP infection causing SJS. The complications of SJS associated with MP seem less frequent (2.7%) and much less severe than in cases where SJS arises from other reported causes. Because coincidence cannot be excluded from the assessments of the degree and rate of improvement for the few patients treated with corticosteroid, from the low frequency of complications, and from the mortality rate of zero in this series of patients, the use of corticosteroids for SJS associated with MP infection is questionable.

Toxic epidermal necrolysis (Lyell syndrome)

Toxic epidermal necrolysis is perhaps the most formidable disease encountered by dermatologists. Uncommon but not rare, toxic epidermal necrolysis occurs in 60 to 70 persons per year in France. It remains as puzzling a disorder as it was 34 years ago, when described by Lyell. Whether or not toxic epidermal necrolysis is the most severe form of erythema multiforme is still the subject of discussion. The physiopathologic events that lead to this rapidly extensive necrosis of the epidermis are not understood. Indirect evidence suggests a hypersensitivity reaction, but the search for potential immunologic mechanisms has resulted in little data to support this hypothesis. Accumulated clinical evidence points to drugs as the most important, if not the only, cause of toxic epidermal necrolysis. Sulfonamides, especially long-acting forms, anticonvulsants, nonsteroidal anti-inflammatory agents, and certain antibiotics are associated with most cases of toxic epidermal necrolysis. Many other drugs have been implicated in isolated case reports. All organs may be involved either by the same process of destruction of the epithelium as observed in the epidermis or by the same systemic consequences of "acute skin failure" as seen in patients with widespread burns. Sepsis is the most important complication and cause of death. Approximately 20% to 30% of all patients with toxic epidermal necrolysis die. Elderly patients and patients with extensive lesions have a higher mortality rate. Surviving patients completely heal in 3 to 4 weeks, but up to 50% will have residual, potentially disabling ocular lesions. The prognosis is improved by adequate therapy, as provided in burn units, that is, aggressive fluid replacement, nutritional support, and a coherent antibacterial policy. Corticosteroids, advocated by some in high doses to halt the "hypersensitivity" process, have been shown in several studies to be detrimental and should be avoided.

Treatment of toxic epidermal necrolysis and a review of six cases

Six cases of drug-induced toxic epidermal necrolysis treated in a burns unit are presented. The mean skin loss was 67.3 per cent of the total body surface area. Two patients developed renal failure and two had ocular symptoms. The mortality rate was 50 per cent, with two patients dying from septicaemia and one from respiratory and renal failure. The diagnosis of toxic epidermal necrolysis can be confirmed by skin biopsy. We recommend that this disease is treated in a burns unit so that both adequate wound care and essential intensive supportive treatment can be given. Antibiotics are indicated only for specific infections such as septicaemia or pneumonia. Steroids have been shown to increase greatly the mortality from septic complications and are not recommended. The mortality ranges from 10 per cent to 70 per cent and bad prognostic factors include increasing age, greater than 50 per cent of body surface skin loss and neutropenia.

Management of Stevens-Johnson syndrome and toxic epidermal necrolysis in children

A retrospective analysis of 21 consecutive patients hospitalized with either Stevens-Johnson syndrome or toxic epidermal necrolysis was carried out to assess morbidity and mortality rates and to establish the value of a specific management practice. Fourteen children with Stevens-Johnson syndrome and seven with toxic epidermal necrolysis were cared for at the Children's Memorial Hospital, Chicago, between 1978 and 1988. All were managed in a well-staffed medical ward or, when necessary, in the pediatric intensive care unit. Supportive measures included reverse barrier isolation, intravenous fluids and nutritional support, meticulous skin care, early detection and treatment of infection, and daily ophthalmologic examination. No patient was treated with systemic steroids. The mortality rate was zero. Eye complications, consisting of dry eyes or mild chronic symblepharon, were the most significant long-term sequelae.

Development of severe Stevens-Johnson syndrome after administration of slow-release theophylline

A 9-year-old boy developed Stevens-Johnson syndrome after taking slow-release theophylline for bronchial asthma. Multisystem symptoms were severe, especially in the skin and eyes. This is the first reported case of Stevens-Johnson syndrome after administration of theophylline (Theodur).

Drug-induced toxic epidermal necrolysis in children

Nine pediatric patients with drug-induced toxic epidermal necrolysis were treated with a regimen of basic burn care and without the use of steroids or topical or systemic antimicrobial agents. Although septic complications continue to occur frequently, infections are better tolerated when potential iatrogenic sources of decreased host resistance, such as steroids, are eliminated. Neutropenia, gram-negative sepsis, and mortality were all greatly reduced with this regimen, while healing was neither impaired nor prolonged. Thus, steroids and sulfa-containing topical agents should be avoided in the treatment of this disorder.

Increasing doses of naloxone hydrochloride by infusion to treat pain due to the thalamic syndrome

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Toxic epidermal necrolysis: an approach to management using cryopreserved allograft skin

Toxic epidermal necrolysis is an acute exfoliation of skin simulating a scald injury. Drug-induced toxic epidermal necrolysis has a mortality of greater than 50%. We report an 8-year-old girl with drug-induced toxic epidermal necrolysis who was treated with cryopreserved cadaver skin, with good outcome. The allograft was clinically and histologically viable. Graft keratinocytes demonstrated epiboly as reepithelialization by the host occurred along the host/graft interface. Host epidermis regenerated rapidly, presumably from adnexae, and displaced the viable allograft along the plane of the host/graft interface. The new epidermis appeared normal in all respects.

Improved burn center survival of patients with toxic epidermal necrolysis managed without corticosteroids

Fifteen consecutive patients with toxic epidermal necrolysis or the Stevens-Johnson syndrome managed without corticosteroids after transfer to the burn center (group 2) are compared to a previous consecutive group of 15 who received high doses of these drugs (group 1). Group 2 had a 66% survival, which was a significant improvement compared to the 33% survival in group 1 (p = 0.057). In group 1, mortality was associated with loss of more than 50% of the body surface area skin. In group 2, mortality was related to advanced age and associated diseases. Age, extent of skin loss, progression of skin loss after burn center admission, incidence of abnormal liver function tests, and the incidence of septic complications were not significantly different in the two groups (p greater than 0.10). The incidence of detected esophageal slough was similar in both groups. Nonsteroid (group 2) management was associated with a decreased incidence of ulceration of gastrointestinal columnar epithelium, Candida sepsis, and an increased survival after septic complications. The combined experience of these 30 patients suggests that corticosteroids are contraindicated in the burn center management of toxic epidermal necrolysis and the Stevens-Johnson syndrome.

Analgesics, allergy and asthma

Intolerance to analgesics is common in patients with bronchial asthma, nasal polyps and urticaria. Symptoms of intolerance resemble those of allergy, but the events precipitating them can rarely be traced to reactions between the drug and a specific antibody or sensitised T-lymphocytes. In 8 to 20% of adult asthmatics, aspirin and several other analgesics provoke asthmatic attacks, probably through inhibition of cyclo-oxygenase. This is a distinct and important clinical syndrome with a specific history, course and clinical presentation and a number of unique peculiarities which still require elucidation at the biochemical level. Up to 40% of patients with chronic urticaria develop an obvious increase in weals and swelling after taking aspirin. These reactions occur only when urticaria is active, and though the reason for them is not known, it appears that different mechanisms may be responsible in different patients. Skin reactions other than exacerbation of chronic urticaria are less common, but may create serious clinical problems. The clinical background of a patient often determines the type of adverse response to an analgesic. Thus, in certain individuals, analgesics can produce anaphylactic reactions and/or urticaria, probably through an immunological mechanism, while in some asthmatics they precipitate bronchoconstriction, probably through inhibition of bronchial cyclooxygenase. Study of untoward reactions to analgesics not only leads to safer pharmacotherapy, but it also offers a fascinating model for better understanding of some diseases.

Dermatologic Problems in the Intensive Care Unit: Part I

Skin disorders are present in many patients hospitalized in the intensive care unit. They range in severity from being the reason for admission to being a nuisance acquired during care These cutaneous problems have been categorized into four groups: (1) serious skin diseases that may incur life-threatening complications; (2) subtle skin findings associated with systemic disorders that may be characterized by critical events; (3) prominent cutaneous manifestations that accompany life-threatening systemic diseases: and (4) skin disorders that develop as complications during intensive care. Diseases in the first category are discussed in this article. Diseases in the second category will be discussed in Part II. The remaining disorders will be covered in Parts III and IV.

Allopurinol-induced toxic epidermal necrolysis

An erythematous eruption with itching developed in an 84-year-old man 4 days after therapy with allopurinol was initiated. The diagnosis of toxic epidermal necrolysis, suspected when separation of the epidermis was noted, was confirmed by skin biopsy. This is the third reported case that can be attributed exclusively to allopurinol and the first patient who did not die.

Systemic glucocorticosteroid therapy of skin disease in children

The role of systemic glucocorticosteroid therapy in the management of dermatologic disorders in children is limited. Most skin diseases requiring the antiinflammatory or antiproliferative effects of steroids are best managed with topical preparations, because they exert local effects almost exclusively and cause few if any systemic side effects when used properly. There are, however, certain skin diseases, which because of their severity or their intrinsic nature, do not respond adequately to these agents. We propose the indications for pharmacologic doses of systemic glucocorticosteroids in dermatologic disease, the preferred route of administration, the most common as well as the more rare side effects of this therapy. Withdrawal of patients from chronic use of these drugs is also discussed.