The psychological impact of Stevens-Johnson syndrome and toxic epidermal necrolysis on patients' lives: a Critically Appraised Topic

Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis: Macules, Papules, and Bullae

OBJECTIVE

The objective of this discussion paper is to illuminate the importance of early identification and treatment of Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN). SJS/TEN may occur as quickly as 4 days, more commonly 4 to 8 weeks after starting a new medication and early identification is essential.

METHODS

A review of literature revealed there is a lack of diagnostic awareness related to the clinical presentation and diverse populations at risk for this devastating syndrome.

RESULTS

A Boolean search was conducted, and six quantitative and qualitative research articles were discovered that indicate a knowledge disparity between "rash" versus SJS/TEN. Research indicates evidence-based best clinical practices for nurses and health care practitioners for assessment of risks, clinical presentation, and treatment.

CONCLUSIONS

Prompt diagnosis and discontinuation of the suspected medication will reduce potential life-threatening sequelae.

A Case of Toxic Epidermal Necrolysis Caused by Lamotrigine Combined With Valproic Acid and Literature Review

After suffering from frequent symptomatic seizures secondary to cerebral hemorrhage, a 58-year-old male patient was prescribed a one-time 50 mg dose of lamotrigine, which he took for a week. However, the patient's seizure symptoms were not controlled until a dosage of 500 mg of sodium valproate tablets was taken twice daily, which ultimately resolved his seizures. Unfortunately, about two weeks after the combination, the patient developed a rash. Nine days later, the patient developed new blisters, necrotizing epidermal desquamation, and lesions over 80% of their body surface area. This was diagnosed as toxic epidermal necrolysis (TEN) resulting from the combination of lamotrigine and sodium valproate. The sodium valproate and lamotrigine were discontinued and treated symptomatically for about one month. The patient's condition improved as the fatal rash gradually subsided. However, after the onset of TEN, unexpected psychiatric symptoms such as poor sleep, less than four hours of sleep, irritability, paranoia, crying, fear of rash recurrence, and suspicious hallucinations and delusions emerged in the patient. Surprisingly, after discontinuation of lamotrigine and sodium valproate due to the rash, the patient did not experience any further seizures.

Hidradenitis suppurativa and suicide risk: a multivariate analysis in a disease with a high psychological burden

BACKGROUND

Hidradenitis suppurativa (HS) is a disorder that can lead to serious sequelae and important comorbidities. It has been associated with different mental health conditions, such as depression, anxiety or completed suicide. The objective is to analyze the suicide risk (SR) among patients in a monographic HS consultation, as well as to establish individual association factors.

METHODS

Patients older than 18 years seen in our specific HS unit were consecutively included and invited to respond to the self-administered Beck hopelessness scale. Those patients with significant intellectual disabilities or severe mental health conditions, including a history of psychosis, were excluded. In addition, data related to the skin process were collected. Subsequently, it was studied whether there were significant differences between patients with absent-mild SR and those with moderate-severe SR and a logistic regression analysis was performed to determine the relationship of these variables with SR.

RESULTS

A total of 136 patients were included in the study, 51.5% men. Of them, 21.3% presented a moderate or severe SR (score ≥ 9 in the Beck test). This risk was significantly related to having a previous or concomitant psychiatric disorder (OR = 2.586, 95% CI 1.044-6.409, p = 0.040) followed by the history of biological treatment (OR = 2.867, 95% CI 1.004-8.182, p = 0.049). The existence of other affected relatives was confirmed as a protective factor (OR = 0.377, 95% CI 0.150-0.951, p = 0.039).

CONCLUSIONS

The prevalence of SR in patients with HS is higher than that of the general Spanish population. The presence of a psychiatric disorder and the need for biological treatment are established as factors that increase SR, both of which can be interpreted as a more advanced disease. As a protective factor, the presence of other cases in the family is established, which suggests a greater normalization of the disease.

Psychotherapeutic interventions for burns patients and the potential use with Stevens-Johnson syndrome and toxic epidermal necrolysis patients: A systematic integrative review

Background

The existing evidence demonstrates that survivors of SJS/TEN have reported long-lasting psychological effects of their condition. Burns patients experience similar psychological effects. It is important to look at ways to help allay the psychological complications of SJS/TEN. As there is an absence of evidence on SJS/TEN psychotherapeutic interventions, it was judged to be beneficial to determine the evidence underpinning psychotherapeutic interventions used with burns patients.

Aims and objectives

The aim of this systematic integrative review was to synthesize the evidence relating to psychotherapeutic interventions used with adult burns patients and patients with SJS/TEN.

Method

The systematic review was guided by Whittemore and Knafl’s integrative review process and the PRISMA guidelines. Nine databases were searched for English and French language papers published January 2008 to January 2021. The protocol for the review was registered with PROSPERO.

Results

Following a screening process, 17 studies were included in the review. Two themes were identified using content analysis, (i) Empirically supported psychotherapeutic treatments, (ii) Alternative psychotherapeutic treatments. This review revealed no evidence on specific psychotherapeutic interventions for patients with SJS/TEN. Some of the interventions used with burns patients, viz. relaxation therapy, hypnosis and cognitive behavioral therapy showed some significant benefits. However, the evidence for burns patients is mainly focused on pain and pain anxiety as outcomes.

Conclusion

Following further research, some of the interventions deployed in burns patients may be applicable to SJS/TEN patients, particularly stress reduction techniques. In addition, the caring behaviours such as compassion, respect, and getting to know the patient as a person are important components to psychological care.

Stevens-Johnson syndrome and toxic epidermal necrolysis associated with increased risk of developing psychiatric disorders: A retrospective population-based cohort study in Taiwan

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening adverse reactions to drugs and psychological sequelae are also observed to follow the trauma of widespread epidermal necrolysis. To delineate the association between SJS and TEN, and psychiatric disorders, we conducted a retrospective population-based cohort study by including 212 patients diagnosed with first-time SJS or TEN in Taiwan between 2000 and 2013 and 669 population controls. Adjusted hazard ratios were calculated after adjusting for sex, age, comorbidity in the form of Charlson comorbidity index, and facility level of care. Overall, SJS or TEN was associated with an increased risk of developing psychiatric disorders including schizophrenia, major depressive disorder, mania, anxiety, and bipolar with an adjusted hazard ratio of 1.392 (95% CI, 1.192-1.625; p < 0.001). Particularly, the adjusted hazard ratios of psychiatric disorders were 1.290 (95% CI, 1.105-1.506; p < 0.001) for SJS and 1.855 (95% CI, 1.587-2.167; p < 0.001) for TEN.

Psychiatric comorbidity and quality of life in patients with drug hypersensitivity

Background: Compared with advances in a drug hypersensitivity diagnosis and management, little is known about the mental health status of patients with drug hypersensitivity and the impact of this psychological distress on their quality of life (QoL). Objective: The objectives were to evaluate anxiety, depression, and QoL levels in patients with drug hypersensitivity, assess how some related factors may affect them, and determine the impact of disease on their QoL. Methods: A total of 203 patients with drug hypersensitivity and 80 healthy controls were evaluated with the Beck Anxiety (BAI) and the Depression Inventory (BDI), and the short version of the World Health Organization Quality of Life (WHOQOL-BREF) scale. Results: The mean ± standard deviation (SD) BAI scores of the patients and the controls were 13.46 ± 11.78 and 1.94 ± 1.93, respectively (p < 0.0001). The mean ± SD BDI scores were higher in the patient group (9.23 ± 6.36) than in the control group (2.18 ± 2.02) (p < 0.0001). The patients had significantly increased risk of anxiety versus the controls (48.8% versus 7.5%) (odds ratio [OR] 11.74 [95% confidence {CI}, 4.88-28.20]; p < 0.0001) and depression versus the controls (31.5% versus 6.2%) (OR 6.90 [95% CI, 2.66-17.90]; p = 0.0001). The comparison of patients' BAI and BDI scores showed that those with more severe reactions had higher scores than those with moderate and mild reactions. A negative correlation was found among all WHOQOL-BREF scale domain scores and the BAI and BDI scores. Conclusion: Anxiety and depressive symptoms have a high prevalence in patients with confirmed drug hypersensitivity, which leads to a notable decrease in QoL. Self-administered psychological questionnaires were shown to be useful in the psychological examination and management of patients with drug hypersensitivity. Therefore, we found that psychological support is critical to reducing the negative outcomes of hypersensitivity reactions in patients.

The Correlation of Neutrophil-Lymphocyte Ratio and Eosinophil Count with SCORTEN in SJS/TEN

Introduction

Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are acute severe cutaneous adverse reactions commonly caused by medication. Precise evaluation of disease severity in initial setting must be obtained to start appropriate treatment. Neutrophil and lymphocyte ratio (NLR) plays a role in displaying inflammatory reaction while eosinophils count (EC) influences immunological dysregulation including the proliferation of cytotoxic cells in early onset of SJS/TEN.

Objective

To evaluate whether NLR and EC serve as prognostic markers of disease severity in patients with SJS/TEN using SCORTEN.

Methods

A single center study with retrospective study included SJS/TEN patients at Dr. Moewardi General Hospital Surakarta in January 1st 2018–December 31st 2020. The required laboratory data was assessed at the beginning of the patient’s admission through medical records. The significance analysis were performed using one-way ANOVA and Spearman while the receiver-operator curve were used to evaluate the prognostic value of variables for severity in SJS/TEN patients.

Results

The total sample in this study was 24 patients with majority female (58%) and range from 25 to >50 years (54%). The results demonstrated of significant difference and positively correlated between NLR and EC with severity of SJS/TEN (p<0.01; r>0.05). The specificity and sensitivity of 51%;61% and 70%;60%, respectively.

Conclusion

NLR and EC can be used as prognosticators of severity in SJS/TEN while further research on other inflammatory markers with increased number of samples and study centers are needed to provide more actual data.

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Guide for Nurses

Nurses are central to the care of patients with Stevens-Johnson syndrome and toxic epidermal necrolysis. Patients with these conditions present with nuanced symptoms and have complex nursing care needs. Although much of the exact pathophysiology of these diseases is not known, all nurses benefit from a fundamental understanding of the genesis of skin manifestations, associated pharmacology, and prognosis. The care of patients hospitalized with Stevens-Johnson syndrome and toxic epidermal necrolysis consists of wound care, infection prevention, comfort management, hydration and nutrition, psychosocial support, and the prevention of long-term complications. This article provides an overview of these diseases, including clinical diagnosis, history and physical assessment, related pharmacology, and nursing care priorities. A description of the current state of the science in clinical management for nurses at all levels is provided, with an emphasis on nursing's contribution to the best possible patient outcomes.

Chronic pain: a long-term sequela of epidermal necrolysis (Stevens-Johnson syndrome/toxic epidermal necrolysis) - prevalence, clinical characteristics and risk factors

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are associated with various sequelae. Chronic pain, one of these sequelae, has never been systematically evaluated.

OBJECTIVES AND METHODS

To assess the persistence of pain in a single-centre cohort of 113 consecutive patients with SJS/TEN. From this cohort, 81 patients were interviewed more than 1 year after the initial episode and included in the study. Data were collected according to standardized questionnaires.

RESULTS

From the 81 interviewed patients, 52 patients (64%) were painless and 29 patients (36%) were painful. Chronic pain syndrome was associated with a more severe initial acute phase of the disease (larger extent of detachment, higher SCORTEN, increased rate of admission in ICU and complications, and longer hospital stay). Pain was mainly located at the level of eyes (55%), mouth and lower limbs (38-41%), with a moderate daily intensity on average (4.7/10). The 'affective' descriptors prevailed over the 'sensory' descriptors, with the exception of burning and itching sensations. Finally, regarding provoked pain, mechanical allodynia (to brushing and pressure) was more marked than thermal allodynia.

DISCUSSION

The persistence of chronic pain after SJS/TEN is a common phenomenon. Sensory descriptors are consistent with sensitization of both small-diameter nerve fibres (burning and itching sensations) and large-diameter nerve fibres (mechanical allodynia), but the affective-emotional components of pain largely predominate.

CONCLUSIONS

Complex mechanisms lead to persistent pain as long-term sequela of SJS/TEN, among which mechanisms, psychological factors related to post-traumatic stress disorder probably play a key role.