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Lee JS, Mallitt K, Fischer G, Saunderson RB. An individual patient data meta-analysis of wound care in patients with toxic epidermal necrolysis. Australas J Dermatol 2024; 65:128-142. [PMID: 38063272 DOI: 10.1111/ajd.14193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/20/2023] [Accepted: 11/19/2023] [Indexed: 03/10/2024]
Abstract
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.
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Affiliation(s)
- J S Lee
- The University of Notre Dame, Darlinghurst, New South Wales, Australia
| | - K Mallitt
- Sydney School of Public Health, Faculty of Medicine, University of Sydney, Camperdown, New South Wales, Australia
- School of Psychiatry, Faculty of Medicine, UNSW Sydney, Kensington, New South Wales, Australia
| | - G Fischer
- Northern Clinical School, University of Sydney, St Leonards, New South Wales, Australia
- Department of Dermatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - R B Saunderson
- Northern Clinical School, University of Sydney, St Leonards, New South Wales, Australia
- Department of Dermatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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2
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Wasuwanich P, Kumari J, So JM, Egerman RS, Wen TS, Motaparthi K. Pregnancies complicated by Stevens-Johnson syndrome and toxic epidermal necrolysis: a nationwide study. Arch Dermatol Res 2023; 316:34. [PMID: 38079002 DOI: 10.1007/s00403-023-02784-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/28/2023] [Accepted: 11/20/2023] [Indexed: 12/18/2023]
Affiliation(s)
- Paul Wasuwanich
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Jaya Kumari
- Jinnah Sindh Medical University, Karachi, Pakistan
| | - Joshua M So
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Robert S Egerman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Tony S Wen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, 4037 NW 86 Terrace, 4Th Floor, Room 4123 Springhill, Gainesville, FL, 32606, USA.
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3
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Liu WY, Zhang JR, Xu XM, Ye TY. Toxic epidermal necrolysis induced by ritodrine in pregnancy: A case report. World J Clin Cases 2022; 10:1381-1387. [PMID: 35211573 PMCID: PMC8855204 DOI: 10.12998/wjcc.v10.i4.1381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/21/2021] [Accepted: 12/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Preterm birth accounts for about 12% of all pregnancies worldwide and is the leading cause of neonatal morbidity and mortality. In order to avoid premature birth and prolong gestational age, tocolytics are the first and the best choice. Ritodrine is the most commonly used tocolytic medication. However, side effects such as pulmonary edema, hypokalemia, and hyperglycemia are known. Here we report a rare but serious side effect–toxic epidermal necrolysis (TEN)–caused by ritodrine.
CASE SUMMARY A woman (31 years, gravida 4, para 2) was hospitalized because of premature contractions at 27 + 6 wk of gestation. A skin rash with pruritus appeared at 32 + 3 wk of gestation after administration of ritodrine, indomethacin, and dexamethasone, and it spread throughout the whole body in 3 d, particularly the four limbs. After 11 d’ treatment, she was diagnosed with TEN. An emergency cesarean section was performed immediately to deliver the baby and intensive symptomatic treatment was promptly commenced after delivery. She recovered from the severe condition without any sequelae except for slight pigmentation after symptomatic treatment.
CONCLUSION When a skin rash appears during the administration of ritodrine, we are supposed to consider the risk of TEN.
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Affiliation(s)
- Wen-Yu Liu
- Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201600, China
| | - Jia-Rong Zhang
- Department of Obstetrics and Gynecology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Xian-Ming Xu
- Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201600, China
| | - Tian-Yi Ye
- Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201600, China
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4
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McCarthy CM, Hayes Ryan D, O'Shaughnessy F, Hayes N, Donnelly JC, O'Dwyer V. The challenges of termination of pregnancy in the context of previous of Toxic Epidermal Necrolysis. Eur J Obstet Gynecol Reprod Biol 2021; 260:238. [PMID: 33745728 DOI: 10.1016/j.ejogrb.2021.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/04/2021] [Indexed: 11/18/2022]
Affiliation(s)
- C M McCarthy
- Rotunda Hospital, Parnell Square, Dublin 1, Ireland.
| | - D Hayes Ryan
- Rotunda Hospital, Parnell Square, Dublin 1, Ireland
| | | | - N Hayes
- Rotunda Hospital, Parnell Square, Dublin 1, Ireland
| | - J C Donnelly
- Rotunda Hospital, Parnell Square, Dublin 1, Ireland
| | - V O'Dwyer
- Rotunda Hospital, Parnell Square, Dublin 1, Ireland
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5
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Stevens-Johnson syndrome and toxic epidermal necrolysis in pregnant patients: A systematic review. Int J Womens Dermatol 2020; 6:239-247. [PMID: 33015279 PMCID: PMC7522894 DOI: 10.1016/j.ijwd.2020.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 03/12/2020] [Accepted: 04/01/2020] [Indexed: 02/03/2023] Open
Abstract
Background Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are two of the most severe dermatologic emergencies. Although pregnant women comprise a subset of individuals at risk for SJS and TEN development, little is known with regard to outcomes and treatment. Objective This study aimed to conduct a systematic review to characterize the risk factors, outcomes, and treatment of SJS and TEN in pregnant patients and newborns. Methods A primary literature search was conducted using PubMed in September 2019, using the following search terms entered in separate pairs: pregnant or pregnancy and stevens-johnson or SJS or toxic epidermal necrolysis. Reviews, studies in a language other than English, and articles not including pregnant patients were excluded. Results Twenty-six articles were included for review, including a total of 177 patients. The average maternal age for a reaction was 29.9 years, gestational age was 24.9 weeks, and time to reaction after drug initiation was 27.5 days. Approximately 85% of pregnant women in this review were infected with HIV. The most common causative medications were antiretroviral therapy (90% of all cases), antibiotics (3%), and gestational drugs (2%). Of the 94 cases in which outcome data were available, the survival rates of pregnant women and newborns after delivery were 98% and 96%, respectively. Withdrawal of the offending agent and supportive care was often sufficient for treatment, but antibiotics, steroids, and intravenous immunoglobulin were implemented in some cases. Complications included preterm labor, vaginal stenosis, and vaginal adhesions. Conclusion Given the predominance of studies focusing on the subset of pregnant patients who are infected with HIV, SJS and TEN is most commonly reported in young patients after antiretroviral therapy, primarily nevirapine. Overall mortality is lower than that of the general population, but similar to the expected mortality rates of younger adults. Early recognition and withdrawal of the offending agent is essential to mitigate the distinct consequences of these conditions in the pregnant population.
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6
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Seminario-Vidal L, Kroshinsky D, Malachowski SJ, Sun J, Markova A, Beachkofsky TM, Kaffenberger BH, Ergen EN, Mauskar M, Bridges A, Calhoun C, Cardones AR, Chen ST, Chodosh J, Cotliar J, Davis MDP, DeNiro KL, Dominguez AR, Eljure-Téllez J, Femia A, Fox LP, Guda A, Mitchell C, Mostaghimi A, Ortega-Loayza AG, Owen C, Pasieka H, Rahnama-Moghadam S, Saeed HN, Saunderson RB, Shanbhag S, Sharon VR, Strowd L, Venkatesh S, Wanat KA, Wetter DA, Worswick S, Micheletti RG. Society of Dermatology Hospitalists supportive care guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults. J Am Acad Dermatol 2020; 82:1553-1567. [PMID: 32151629 DOI: 10.1016/j.jaad.2020.02.066] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/04/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening conditions with high morbidity and mortality. Supportive care management of SJS/TEN is highly variable. A systematic review of the literature was performed by dermatologists, ophthalmologists, intensivists, and gynecologists with expertise in SJS/TEN to generate statements for supportive care guideline development. Members of the Society of Dermatology Hospitalists with expertise in SJS/TEN were invited to participate in a modified, online Delphi-consensus. Participants were administered 9-point Likert scale questionnaires regarding 135 statements. The RAND/UCLA Appropriateness Method was used to evaluate and select proposed statements for guideline inclusion; statements with median ratings of 6.5 to 9 and a disagreement index of ≤1 were included in the guideline. For the final round, the guidelines were appraised by all of the participants. Included are an evidence-based discussion and recommendations for hospital setting and care team, wound care, ocular care, oral care, urogenital care, pain management, infection surveillance, fluid and electrolyte management, nutrition and stress ulcer prophylaxis, airway management, and anticoagulation in adult patients with SJS/TEN.
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Affiliation(s)
- Lucia Seminario-Vidal
- Department of Dermatology, University of South Florida, Morsani College of Medicine, Tampa, Florida; Cutaneous Oncology Program, H. Lee Moffitt Cancer Center, Tampa, Florida.
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephen J Malachowski
- Department of Internal Medicine, Medical College of Wisconsin Affiliated Hospitals, St. Joseph's Hospital, Milwaukee, Wisconsin
| | - James Sun
- Cutaneous Oncology Program, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Alina Markova
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Elizabeth N Ergen
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Melissa Mauskar
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alina Bridges
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Cody Calhoun
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Adela R Cardones
- Department of Dermatology, Duke University, Durham, North Carolina
| | - Steven T Chen
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - James Chodosh
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Cotliar
- Division of Dermatology, Harbor-University of California, Los Angeles Medical Center, Los Angeles, California
| | - Mark D P Davis
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | | | - Arturo R Dominguez
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Juliana Eljure-Téllez
- Department of Dermatology, "Dr. Manuel Gea González" General Hospital, Mexico City, Mexico
| | - Alisa Femia
- Ronald O. Perelman Department of Dermatology, New York University Langone Health, New York, New York
| | - Lindy P Fox
- Department of Dermatology, University of California, San Francisco, California
| | - Anisha Guda
- University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas
| | - Caroline Mitchell
- Vincent Center for Reproductive Biology, Department of Obstetrics, Gynecology & Reproductive Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Arash Mostaghimi
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | - Cindy Owen
- Division of Dermatology, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Helena Pasieka
- Department of Dermatology, MedStar Washington Hospital Center, Washington, DC
| | | | - Hajirah N Saeed
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Rebecca B Saunderson
- Royal North Shore Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Swapna Shanbhag
- Tej Kohli Cornea Institute, L.V. Prasad Eye Institute, Hyderabad, India
| | - Victoria R Sharon
- Department of Dermatology, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Lindsay Strowd
- Department of Dermatology, Wake Forest University School of Medicine, Wake Forest, North Carolina
| | - Samantha Venkatesh
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Karolyn A Wanat
- Department of Dermatology, University of Southern California, Los Angeles, California
| | - David A Wetter
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Scott Worswick
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert G Micheletti
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
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7
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McPherson T, Exton LS, Biswas S, Creamer D, Dziewulski P, Newell L, Tabor KL, Wali GN, Walker G, Walker R, Walker S, Young AE, Mohd Mustapa MF, Murphy R. British Association of Dermatologists' guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in children and young people, 2018. Br J Dermatol 2019; 181:37-54. [PMID: 30829411 DOI: 10.1111/bjd.17841] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2019] [Indexed: 12/12/2022]
Affiliation(s)
- T McPherson
- Oxford University Hospitals NHS Foundation Trust, Old Road, Headington, Oxford, OX3 7LE, U.K
| | - L S Exton
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - S Biswas
- Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, U.K
| | - D Creamer
- Department of Dermatology, King's Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - P Dziewulski
- St Andrews Centre for Plastic Surgery and Burns, Mid Essex Hospital Services NHS Trust, Chelmsford, CM1 7ET, U.K
| | - L Newell
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, BS2 8BJ, U.K
| | - K L Tabor
- Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, U.K
| | - G N Wali
- Oxford University Hospitals NHS Foundation Trust, Old Road, Headington, Oxford, OX3 7LE, U.K
| | | | | | | | - A E Young
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, BS2 8BJ, U.K
| | - M F Mohd Mustapa
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - R Murphy
- Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Road, Sheffield, S10 2JF, U.K.,Department of Dermatology, Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, S10 2TH, U.K.,University of Nottingham, University Park, Nottingham, NG7 2RD, U.K
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8
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Bohl TG. Fissures, Herpes Simplex Virus, and Drug Reactions: Important Erosive Vulvar Disorders. Obstet Gynecol Clin North Am 2018; 44:421-443. [PMID: 28778641 DOI: 10.1016/j.ogc.2017.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Vulvar fissures, excoriations, and erosions are common problems resulting from a variety of etiologies, many involving other mucosal and cutaneous sites. We present historical and examination features and useful investigations that can help establish a diagnosis so that definitive therapy can be instituted. Vulvar involvement also can be part of life-threatening conditions that require hospital admission and a multidisciplinary approach for optimal patient care. The clinical morphology of these examination findings and response to therapy can be modified by various host factors, particularly immune status, and atypical presentations and responses to therapy should always prompt patient reevaluation.
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Affiliation(s)
- Tanja G Bohl
- Vulva Clinic, Jean Hailes Medical Centre, 173 Carinish Road, Clayton, Victoria 3168, Australia.
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9
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White KD, Abe R, Ardern-Jones M, Beachkofsky T, Bouchard C, Carleton B, Chodosh J, Cibotti R, Davis R, Denny JC, Dodiuk-Gad RP, Ergen EN, Goldman JL, Holmes JH, Hung SI, Lacouture ME, Lehloenya RJ, Mallal S, Manolio TA, Micheletti RG, Mitchell CM, Mockenhaupt M, Ostrov DA, Pavlos R, Pirmohamed M, Pope E, Redwood A, Rosenbach M, Rosenblum MD, Roujeau JC, Saavedra AP, Saeed HN, Struewing JP, Sueki H, Sukasem C, Sung C, Trubiano JA, Weintraub J, Wheatley LM, Williams KB, Worley B, Chung WH, Shear NH, Phillips EJ. SJS/TEN 2017: Building Multidisciplinary Networks to Drive Science and Translation. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2018; 6:38-69. [PMID: 29310768 PMCID: PMC5857362 DOI: 10.1016/j.jaip.2017.11.023] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 11/20/2017] [Accepted: 11/21/2017] [Indexed: 12/17/2022]
Abstract
Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a life-threatening, immunologically mediated, and usually drug-induced disease with a high burden to individuals, their families, and society with an annual incidence of 1 to 5 per 1,000,000. To effect significant reduction in short- and long-term morbidity and mortality, and advance clinical care and research, coordination of multiple medical, surgical, behavioral, and basic scientific disciplines is required. On March 2, 2017, an investigator-driven meeting was held immediately before the American Academy of Dermatology Annual meeting for the central purpose of assembling, for the first time in the United States, clinicians and scientists from multiple disciplines involved in SJS/TEN clinical care and basic science research. As a product of this meeting, this article summarizes the current state of knowledge and expert opinion related to SJS/TEN covering a broad spectrum of topics including epidemiology and pharmacogenomic networks; clinical management and complications; special populations such as pediatrics, the elderly, and pregnant women; regulatory issues and the electronic health record; new agents that cause SJS/TEN; pharmacogenomics and immunopathogenesis; and the patient perspective. Goals include the maintenance of a durable and productive multidisciplinary network that will significantly further scientific progress and translation into prevention, early diagnosis, and management of SJS/TEN.
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Affiliation(s)
- Katie D White
- Vanderbilt University Medical Center, Nashville, Tenn
| | - Riichiro Abe
- Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | | | - Thomas Beachkofsky
- Wilford Hall Ambulatory Surgical Center, Lackland Air Force Base, San Antonio, Texas
| | | | - Bruce Carleton
- University of British Columbia, Vancouver, British Columbia, Canada; B.C. Children's Hospital, British Columbia, Vancouver, British Columbia, Canada
| | - James Chodosh
- Massachusetts Eye and Ear, Harvard Medical School, Boston, Mass
| | - Ricardo Cibotti
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Md
| | - Robert Davis
- University of Tennessee Health Sciences, Memphis, Tenn
| | | | - Roni P Dodiuk-Gad
- Emek Medical Center, Technion-Institute of Technology, Afula, Israel; Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | - James H Holmes
- Wake Forest Baptist Medical Center, Winston-Salem, NC; Wake Forest University School of Medicine, Winston-Salem, NC
| | | | | | | | - Simon Mallal
- Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | - Teri A Manolio
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Md; F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md
| | | | | | - Maja Mockenhaupt
- Medical Center and Medical Faculty-University of Freiburg, Freiburg, Germany
| | | | - Rebecca Pavlos
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | | | - Elena Pope
- University of Toronto, Toronto, Ontario, Canada; Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alec Redwood
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | | | | | | | | | - Hajirah N Saeed
- Massachusetts Eye and Ear, Harvard Medical School, Boston, Mass
| | - Jeffery P Struewing
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Md
| | | | | | - Cynthia Sung
- Duke-NUS Medical School, Singapore, Singapore; Health Sciences Authority, Singapore, Singapore
| | - Jason A Trubiano
- Austin Health, Heidelberg, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | | | - Lisa M Wheatley
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | | | | | | | - Neil H Shear
- Vanderbilt University Medical Center, Nashville, Tenn
| | - Elizabeth J Phillips
- Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia.
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10
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Abstract
During the past decade, major advances have been made in the accurate diagnosis of severe cutaneous adverse reactions (SCARs) to drugs, management of their manifestations, and identification of their pathogenetic mechanisms and at-risk populations. Early recognition and diagnosis of SCARs are key in the identification of culprit drugs. SCARS are potentially life threatening, and associated with various clinical patterns and morbidity during the acute stage of Stevens-Johnson syndrome and toxic epidermal necrolysis, drug reactions with eosinophilia and systemic symptoms, and acute generalised exanthematous pustulosis. Early drug withdrawal is mandatory in all SCARs. Physicians' knowledge is essential to the improvement of diagnosis and management, and in the limitation and prevention of long-term sequelae. This Seminar provides the tools to help physicians in their clinical approach and investigations of SCARs.
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Affiliation(s)
- Tu Anh Duong
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France.
| | - Laurence Valeyrie-Allanore
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France
| | - Pierre Wolkenstein
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France; EA 7379 EpiDermE (Epidémiologie en Dermatologie et Evaluation des Thérapeutiques), Université Paris-Est Créteil Val-de-Marne, Créteil, France
| | - Olivier Chosidow
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France; EA 7379 EpiDermE (Epidémiologie en Dermatologie et Evaluation des Thérapeutiques), Université Paris-Est Créteil Val-de-Marne, Créteil, France; French Satellite of the Cochrane Skin Group, Créteil, France; INSERM, Centre d'Investigation Clinique 1430, Créteil, France
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11
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Lee H, Walsh S, Creamer D. Long-term complications of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN): the spectrum of chronic problems in patients who survive an episode of SJS/TEN necessitates multidisciplinary follow-up. Br J Dermatol 2017; 177:924-935. [DOI: 10.1111/bjd.15360] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2017] [Indexed: 12/14/2022]
Affiliation(s)
- H.Y. Lee
- Department of Dermatology; Singapore General Hospital; Singapore
| | - S.A. Walsh
- Department of Dermatology; King's College Hospital; London U.K
| | - D. Creamer
- Department of Dermatology; King's College Hospital; London U.K
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12
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Peter JG, Lehloenya R, Dlamini S, Risma K, White KD, Konvinse KC, Phillips EJ. Severe Delayed Cutaneous and Systemic Reactions to Drugs: A Global Perspective on the Science and Art of Current Practice. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2017; 5:547-563. [PMID: 28483310 PMCID: PMC5424615 DOI: 10.1016/j.jaip.2017.01.025] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 01/11/2017] [Accepted: 01/18/2017] [Indexed: 12/17/2022]
Abstract
Most immune-mediated adverse drug reactions (IM-ADRs) involve the skin, and many have additional systemic features. Severe cutaneous adverse drug reactions (SCARs) are an uncommon, potentially life-threatening, and challenging subgroup of IM-ADRs with diverse clinical phenotypes, mechanisms, and offending drugs. T-cell-mediated immunopathology is central to these severe delayed reactions, but effector cells and cytokines differ by clinical phenotype. Strong HLA-gene associations have been elucidated for specific drug-SCAR IM-ADRs such as Stevens-Johnson syndrome/toxic epidermal necrolysis, although the mechanisms by which carriage of a specific HLA allele is necessary but not sufficient for the development of many IM-ADRs is still being defined. SCAR management is complicated by substantial short- and long-term morbidity/mortality and the potential need to treat ongoing comorbid disease with related medications. Multidisciplinary specialist teams at experienced units should care for patients. In the setting of SCAR, patient outcomes as well as preventive, diagnostic, treatment, and management approaches are often not generalizable, but rather context specific, driven by population HLA-genetics, the pharmacology and genetic risk factors of the implicated drug, severity of underlying comorbid disease necessitating ongoing treatments, and cost considerations. In this review, we update the basic and clinical science of SCAR diagnosis and management.
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Affiliation(s)
- Jonathan Grant Peter
- Division of Allergology and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rannakoe Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sipho Dlamini
- Division of Infectious Diseases, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kimberly Risma
- Division of Allergy, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Katie D White
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Katherine C Konvinse
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tenn; Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia.
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Combined spinal-epidural anaesthesia for urgent caesarean section in a parturient with Stevens-Johnson syndrome. Int J Obstet Anesth 2017; 30:78-79. [PMID: 28202310 DOI: 10.1016/j.ijoa.2016.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 12/07/2016] [Indexed: 11/24/2022]
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Petukhova TA, Maverakis E, Ho B, Sharon VR. Urogynecologic complications in Stevens-Johnson syndrome and toxic epidermal necrolysis: Presentation of a case and recommendations for management. JAAD Case Rep 2016; 2:202-5. [PMID: 27274537 PMCID: PMC4885137 DOI: 10.1016/j.jdcr.2016.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Tatyana A Petukhova
- Department of Dermatology, University of California, Davis, Sacramento, California
| | - Emanual Maverakis
- Department of Dermatology, University of California, Davis, Sacramento, California
| | - Baran Ho
- Department of Dermatology, University of California, Davis, Sacramento, California
| | - Victoria R Sharon
- Department of Dermatology, University of California, Davis, Sacramento, California
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Belver M, Michavila A, Bobolea I, Feito M, Bellón T, Quirce S. Severe delayed skin reactions related to drugs in the paediatric age group: A review of the subject by way of three cases (Stevens-Johnson syndrome, toxic epidermal necrolysis and DRESS). Allergol Immunopathol (Madr) 2016; 44:83-95. [PMID: 26089185 DOI: 10.1016/j.aller.2015.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 01/31/2015] [Accepted: 02/13/2015] [Indexed: 12/17/2022]
Abstract
Severe delayed drug-induced skin reactions in children are not common but potentially serious. This article describes aspects concerning the etiology, pathogenesis and clinical manifestations of these processes; it presents three paediatric cases, namely STS (Steven Johnson Syndrome), TEN (toxic epidermal necrolysis), probably related to amoxicillin/clavulanate and ibuprofen and DRESS (a drug reaction with eosinophilia and systemic symptoms) secondary to phenytoin; and in relation to them, the diagnosis and the treatment of these processes are discussed and reviewed. The AGEP (acute generalised exanthematous pustulosis) is also reviewed. The aetiological diagnosis of severe non-immediate reactions is difficult, and the value of current allergological testing is not well defined in these cases. Diagnosis is based on clinical history, the empirical risk of drugs to trigger SJS/TEN or DRESS, and the in vivo and in vitro testing of the suspect drug. Skin biopsy confirms that the clinical diagnosis and delayed hypersensitivity tests, especially the patch test and the lymphoblastic transformation test (LTT), may be important to confirm the aetiological diagnosis, in our cases emphasising the latter. These diseases can be life threatening (especially DRESS and TEN) and/or have a high rate of major complications or sequelae (SJS/TEN). The three cases described progressed well without sequelae. All were treated with corticosteroids, which is the most currently accepted treatment although the effect has not been clearly demonstrated.
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Dodiuk-Gad RP, Chung WH, Valeyrie-Allanore L, Shear NH. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: An Update. Am J Clin Dermatol 2015; 16:475-93. [PMID: 26481651 DOI: 10.1007/s40257-015-0158-0] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening mucocutaneous reactions, predominantly drug induced. The mortality rates for SJS and TEN are as high as 30 %, and short- and long-term morbidities are very common. SJS/TEN is one of the few dermatological diseases that constitute a true medical emergency. Early recognition and prompt and appropriate management can be lifesaving. In recent years, our understanding of the pathogenesis, clinical presentation, and management of SJS/TEN has improved. Nevertheless, in 2015, there are still no internationally accepted management guidelines. This review summarizes up-to-date insights on SJS/TEN and describes a protocol for assessment and treatment. We hope these suggested guidelines serve as a practical clinical tool in the management of SJS/TEN. The classic manifestation of SJS/TEN consists of initial "flu-like" symptoms (malaise, fever, anorexia) in the prodromal phase, followed by cutaneous and mucous membrane (ocular, oral, and genital) inflammation and pain, and other systemic involvement. Symptoms usually begin 4-28 days after the onset of drug intake. Treatment is multidisciplinary and includes identification and withdrawal of the culprit drug, transfer to a specialist unit, supportive care, medical treatment, communication, and provision of appropriate information and emotional support.
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Knight L, Todd G, Muloiwa R, Matjila M, Lehloenya RJ. Stevens Johnson Syndrome and Toxic Epidermal Necrolysis: Maternal and Foetal Outcomes in Twenty-Two Consecutive Pregnant HIV Infected Women. PLoS One 2015; 10:e0135501. [PMID: 26267659 PMCID: PMC4534424 DOI: 10.1371/journal.pone.0135501] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 07/22/2015] [Indexed: 11/18/2022] Open
Abstract
Introduction Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) form a spectrum of a rare and life-threatening cutaneous drug reaction. SJS/TEN in pregnancy poses largely unknown risk factors and outcomes for both the mother and foetus compared to the general population. Methods We conducted a study of consecutive pregnant women admitted to single tertiary referral centre in South Africa with SJS/TEN over a 3 year period. They were all managed by the same medical team using the same protocols. We evaluated their underlying illnesses, offending drugs and the course of pregnancy and outcomes to determine factors influencing maternal and foetal outcomes. Results We identified twenty-two women who developed SJS/TEN while pregnant, all of them HIV-infected. Their median age was 29 years. The majority 16/22 (73%) had SJS, the milder variant of the disease affecting < 10% body surface area. Nevirapine was the offending drug in 21/22 (95%) cases. All 22 of the mothers survived with 3/22 (14%) developing postpartum sepsis. Pregnancy outcomes were known in 18/22 women and 9/18 (50%) babies were delivered by caesarean section. There were 2 foetal deaths at 21 and 31 weeks respectively and both were associated with post-partum sepsis. Postnatal complications occurred in 5 cases, 3 involving the respiratory system and the other two being low birth weight deliveries. Eight placentae and one foetus were sent for histology and none showed macroscopic or microscopic features of SJS/TEN. On follow-up, only 12/20 children were tested for HIV at 6 weeks post-delivery and none of them were HIV-infected. All had received prophylactic ARVs including nevirapine. Conclusions TEN, the severe form of the disease, was associated with poorer foetal outcomes. SJS/TEN-associated mortality is not increased in HIV-infected pregnant women. Maternal SJS/TEN does not seem to commonly manifest in the foetus.
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Affiliation(s)
- Lauren Knight
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gail Todd
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rudzani Muloiwa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Mushi Matjila
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa
| | - Rannakoe J. Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
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