Erythema exsudativum multiforme, Stevens‐Johnson‐Syndrom/toxische epidermale Nekrolyse – Diagnostik und Therapie

Etanercept leads to a rapid recovery of a Dabrafenib-/Trametinib-associated toxic epidermal necrolysis-like severe skin reaction

Targeted therapy with BRAF- and MEK-Inhibitors (BRAFi, MEKi) provides an excellent therapeutic option for patients with malignant melanomas with a BRAF-Mutation. Mild cutaneous adverse events have been common under the BRAF- and MEK-Inhibitor therapy, on the contrary, severe cutaneous adverse reactions to drugs (SCARs) are rarely reported. We present the case of a 59- year-old female patient who after the resection of cutaneous in-transit metastases of a malignant melanoma received one adjuvant cycle of Nivolumab followed by a switch of the therapy to an oral BRAFi/MEKi therapy. 3-4 Weeks after the therapy switch she developed high fever, chills, progredient general weakness, headaches, abdominal complaints, generalised rash as well as thrombocytopaenia, eosinophilia, elevated liver enzymes, declining kidney, and pulmonary function as well as a maculopapular exanthema. She was diagnosed with drug reaction with eosinophilia and systemic symptoms (DRESS) and quickly started recovery after initiation of a high steroid substitution. Under steroid dose reduction, the exanthema worsened and toxic epidermal necrolysis (TEN) was histologically diagnosed. After a series of unsuccessful therapeutic approaches (high dose steroid, human immunoglobulins and ciclosporin) the patient received a single dose of the TNF-alpha inhibitor etanercept, which led to a quick recovery. This case demonstrates that DRESS and TEN can present a spectrum of possibly transitioning SCARs providing a diagnostic and therapeutic challenge. Nevertheless, in a such complicated therapeutic setting, etanercept may be lifesaving even after multiple previous unsuccessful therapies. This effective approach provides evidence SCARs due to BRAF/MEK targeted therapy may be driven by TNF-alpha.

[Ocular involvement in Stevens-Johnson syndrome and toxic epidermal necrolysis]

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare severe and often life-threatening reactions of the skin and mucous membranes. They are considered as a single disease entity with different expressions of severity and are summarized under the term epidermal necrolysis (EN). There is a high risk of ocular involvement, which can lead to long-lasting eye problems and even blindness without immediate ophthalmological treatment. The acute occurrence, the unpredictable course and extreme variation in the manifestation of complications require an interdisciplinary approach. A rapid diagnosis of eye involvement and initiation of an intensive lubricating and anti-inflammatory surface treatment is of utmost importance for the long-term outcome. This article should help ophthalmologists to have a better understanding of this condition and therefore lead to substantial improvement in visual outcome and the quality of life of patients.