1
|
Ozhathil DK, Powell CM, Corley CV, Golovko G, Song J, El Ayadi A, Wolf SE, Kahn SA. A retrospective analysis of mortality risk and immunosuppressive therapy for Stevens-Johnson Syndrome and toxic epidermal necrolysis syndrome using the TriNetX research network. Burns 2024; 50:75-86. [PMID: 37734977 DOI: 10.1016/j.burns.2023.08.009] [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: 03/30/2023] [Revised: 07/17/2023] [Accepted: 08/16/2023] [Indexed: 09/23/2023]
Abstract
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) exist on a spectrum of autoimmune conditions which cause epidermal detachment and keratinocyte necrosis. Due to the rare incidence of these conditions, a dramatic heterogeneity in treatment algorithms exists. To better appreciate pharmacologic immunosuppressive therapies' impact on survival, the authors queried a multi-institutional data network. Data for this study was extracted from TriNetX Research Network, a platform that contains ICD-9/ICD-10 coding data from a consortium of international healthcare organizations. Seventy-one institutions were queried to identify adult patients diagnosed with SJS, TEN or SJS-TEN Overlap. Cohorts were created based on the therapy received: systemic steroids (SS), diphenhydramine (DH), cyclosporine (CS), intravenous immunoglobulin (IVIG), tumor necrosis factor alpha inhibitors (TNFαi), or a combination of treatments. Cohorts were then propensity matched with patients who received supportive care. Patients who only received one of the above treatments showed no significant reduction in 90-day mortality. Patients who received CS or IVIG as part of their multitherapy showed a significantly increased risk of death when compared to supportive care (CS: RR = 1.583, 95% CI [1.119, 2.240]; IVIG: RR = 2.132, 95% CI [1.485, 3.059]). Despite their frequent utilization, this study's analysis suggests that none of these therapies confer significant 90-day mortality survival over supportive care alone. These results highlight the heterogeneity of therapies and emphasize the need for critical prospective appraisal of their outcomes in SJS and TEN.
Collapse
Affiliation(s)
- Deepak K Ozhathil
- Department of Surgery, Medical University of South Carolina, 96 Jonathen Lucas Street CSB 420 MSC 613, Charleston, SC 29425, USA.
| | - Carter M Powell
- Department of Surgery, Medical University of South Carolina, 96 Jonathen Lucas Street CSB 420 MSC 613, Charleston, SC 29425, USA
| | - Caroline V Corley
- Department of Surgery, Medical University of South Carolina, 96 Jonathen Lucas Street CSB 420 MSC 613, Charleston, SC 29425, USA
| | - George Golovko
- 301 University Boulevard, Department of Pharmacology, University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
| | - Juquan Song
- 301 University Boulevard, Department of Surgery, University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
| | - Amina El Ayadi
- 301 University Boulevard, Department of Surgery, University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
| | - Steven E Wolf
- 301 University Boulevard, Department of Surgery, University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
| | - Steven A Kahn
- Department of Surgery, Medical University of South Carolina, 96 Jonathen Lucas Street CSB 420 MSC 613, Charleston, SC 29425, USA
| |
Collapse
|
2
|
Nikitina EA, Fomina DS, Markina UA, Andreev SS, Streltsov YV, Kruglova TS, Lebedkina MS, Karaulov AV, Lysenko MA. Positive experience with TNF-α inhibitor in toxic epidermal necrolysis resistant to high-dose systemic corticosteroids. Front Med (Lausanne) 2023; 10:1210026. [PMID: 37554504 PMCID: PMC10404849 DOI: 10.3389/fmed.2023.1210026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/03/2023] [Indexed: 08/10/2023] Open
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, potentially life-threatening syndromes characterized by the development of necrotic epidermal and mucosal lesions. The most common etiologic cause of SJS/TEN is drug-induced mechanisms. The group of drugs with high potential risk includes sulfonamides, anticonvulsants, non-steroidal anti-inflammatory drugs (NSAIDs), allopurinol, phenobarbital, etc. There is no gold standard treatment algorithm for SJS/TEN. In medical practice, systemic glucocorticosteroids (sGCS), intravenous immunoglobulin (IVIG), plasmapheresis, and cyclosporine are used empirically and in various combinations. Recently published studies have demonstrated the efficacy of TNF-α inhibitors as a promising approach in SJS/TEN, including cases resistant to high-dose sGCS, with etanercept and infliximab being the most commonly used drugs. In a large multicenter study by Zhang J et al. (XXXX), 242 patients treated with etanercept, sGCS, or a combination of both had lower mortality compared to the control group. A shorter skin healing time was documented compared to sGCS monotherapy, thus reducing the risk of secondary infections. The published data show a high efficacy with THF-α inhibitor blockade, but the safety of TNF-α inhibitors in patients with SJS/TEN is still questionable due to the paucity of available information. As all clinical research data should be accumulated to provide reliable evidence that the use of TNF-α inhibitors may be beneficial in SJS/TEN, we report a case of etoricoxib-associated SJS with progression to TEN in a 50-year-old woman who was refractory to high-dose sGCS therapy.
Collapse
Affiliation(s)
- Ekaterina A. Nikitina
- City Clinical Hospital No. 52, Moscow, Russia
- The First Sechenov Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Daria S. Fomina
- City Clinical Hospital No. 52, Moscow, Russia
- The First Sechenov Moscow State Medical University (Sechenov University), Moscow, Russia
| | | | | | | | | | | | - Alexander V. Karaulov
- The First Sechenov Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Maryana A. Lysenko
- City Clinical Hospital No. 52, Moscow, Russia
- Department of General Therapy, Pirogov Russian National Research Medical University, Moscow, Russia
| |
Collapse
|
3
|
Cao J, Zhang X, Xing X, Fan J. Biologic TNF-α Inhibitors for Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis, and TEN-SJS Overlap: A Study-Level and Patient-Level Meta-Analysis. Dermatol Ther (Heidelb) 2023:10.1007/s13555-023-00928-w. [PMID: 37178320 DOI: 10.1007/s13555-023-00928-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 04/13/2023] [Indexed: 05/15/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Jiali Cao
- Department of Dermatology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District, Beijing, 100020, China.
| | - Xuan Zhang
- Department of Dermatology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District, Beijing, 100020, China
| | - Xinzhu Xing
- Department of Dermatology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District, Beijing, 100020, China
| | - Jie Fan
- Medical Department, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, Beijing, 101300, China
| |
Collapse
|
4
|
A Review of the Systemic Treatment of Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis. Biomedicines 2022; 10:biomedicines10092105. [PMID: 36140207 PMCID: PMC9495335 DOI: 10.3390/biomedicines10092105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 08/10/2022] [Accepted: 08/24/2022] [Indexed: 11/28/2022] Open
Abstract
Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are uncommon but life-threatening diseases mostly caused by drugs. Although various systemic immunomodulating agents have been used, their therapeutic efficacy has been inconsistent. This study aimed to provide an evidence-based review of systemic immunomodulating treatments for SJS/TEN. We reviewed 13 systematic review and meta-analysis articles published in the last 10 years. The use of systemic corticosteroids and IVIg is still controversial. An increasing number of studies have suggested the effectiveness of cyclosporine and biologic anti-TNF-α in recent years. There were also some promising results of combination treatments. Further large-scale randomized controlled trials are required to provide more definitive evidence of the effectiveness of these treatments. The pathogenesis of SJS/TEN has been elucidated in recent years and advances in the understanding of SJS/TEN may inspire the discovery of potential therapeutic targets.
Collapse
|
5
|
Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in the Era of Systems Medicine. METHODS IN MOLECULAR BIOLOGY (CLIFTON, N.J.) 2022; 2486:37-54. [PMID: 35437717 DOI: 10.1007/978-1-0716-2265-0_3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are severe mucocutaneous bullous disorders characterized by widespread skin and mucosal necrosis and detachment, which are most commonly triggered by medications. Despite their rarity, these severe cutaneous adverse drug reactions will result in high mortality and morbidity as well as long-term sequela. The immunopathologic mechanisms is mainly cell-mediated cytotoxic reaction against keratinocytes leading to massive skin necrolysis. Subsequent studies have demonstrated that immune synapse composed of cytotoxic T cells with drug-specific human leukocyte antigen (HLA) class I restriction and T cell receptors (TCR) repertoire is the key pathogenic for SJS/TEN. Various cytotoxic proteins and cytokines such as soluble granulysin, perforin, granzyme B, interleukin-15, Fas ligand, interferon-γ, tumor necrosis factor-α have been as mediators involved in the pathogenesis of SJS/TEN. Early recognition and immediate withdrawal of causative agents, and critical multidisciplinary supportive care are key management of SJS/TEN. To date, there is yet to be a sufficient consensus or recommendation for the immunomodulants of the treatment in SJS/TEN. Systemic corticosteroids remain one of the most common treatment options for SJS/TEN, though the efficacy remain uncertain. Currently, there is increasing evidence showing that cyclosporine and TNF-α inhibitors decrease the mortality of SJS/TEN. Further multicenter double-blinded, randomized, placebo-controlled trials are required to confirm the efficacy and safety.
Collapse
|
6
|
Jacobsen A, Olabi B, Langley A, Beecker J, Mutter E, Shelley A, Worley B, Ramsay T, Saavedra A, Parker R, Stewart F, Pardo Pardo J. Systemic interventions for treatment of Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS/TEN overlap syndrome. Cochrane Database Syst Rev 2022; 3:CD013130. [PMID: 35274741 PMCID: PMC8915395 DOI: 10.1002/14651858.cd013130.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS/TEN overlap syndrome are rare, severe cutaneous adverse reactions usually triggered by medications. In addition to tertiary-level supportive care, various systemic therapies have been used including glucocorticoids, intravenous immunoglobulins (IVIGs), cyclosporin, N-acetylcysteine, thalidomide, infliximab, etanercept, and plasmapheresis. There is an unmet need to understand the efficacy of these interventions. OBJECTIVES To assess the effects of systemic therapies (medicines delivered orally, intramuscularly, or intravenously) for the treatment of SJS, TEN, and SJS/TEN overlap syndrome. SEARCH METHODS We searched the following databases up to March 2021: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase. We also searched five clinical trial registers, the reference lists of all included studies and of key review articles, and a number of drug manufacturer websites. We searched for errata or retractions of included studies. SELECTION CRITERIA We included only randomised controlled trials (RCTs) and prospective observational comparative studies of participants of any age with a clinical diagnosis of SJS, TEN, or SJS/TEN overlap syndrome. We included all systemic therapies studied to date and permitted comparisons between each therapy, as well as between therapy and placebo. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as specified by Cochrane. Our primary outcomes were SJS/TEN-specific mortality and adverse effects leading to discontinuation of SJS/TEN therapy. Secondary outcomes included time to complete re-epithelialisation, intensive care unit length of stay, total hospital length of stay, illness sequelae, and other adverse effects attributed to systemic therapy. We rated the certainty of the evidence for each outcome using GRADE. MAIN RESULTS We included nine studies with a total of 308 participants (131 males and 155 females) from seven countries. We included two studies in the quantitative meta-analysis. We included three RCTs and six prospective, controlled observational studies. Sample sizes ranged from 10 to 91. Most studies did not report study duration or time to follow-up. Two studies reported a mean SCORe of Toxic Epidermal Necrosis (SCORTEN) of 3 and 1.9. Seven studies did not report SCORTEN, although four of these studies reported average or ranges of body surface area (BSA) (means ranging from 44% to 51%). Two studies were set in burns units, two in dermatology wards, one in an intensive care unit, one in a paediatric ward, and three in unspecified inpatient units. Seven studies reported a mean age, which ranged from 29 to 56 years. Two studies included paediatric participants (23 children). We assessed the results from one of three RCTs as low risk of bias in all domains, one as high, and one as some concerns. We judged the results from all six prospective observational comparative studies to be at a high risk of bias. We downgraded the certainty of the evidence because of serious risk of bias concerns and for imprecision due to small numbers of participants. The interventions assessed included systemic corticosteroids, tumour necrosis factor-alpha (TNF-alpha) inhibitors, cyclosporin, thalidomide, N-acetylcysteine, IVIG, and supportive care. No data were available for the main comparisons of interest as specified in the review protocol: etanercept versus cyclosporin, etanercept versus IVIG, IVIG versus supportive care, IVIG versus cyclosporin, and cyclosporin versus corticosteroids. Corticosteroids versus no corticosteroids It is uncertain if there is any difference between corticosteroids (methylprednisolone 4 mg/kg/day for two more days after fever had subsided and no new lesions had developed) and no corticosteroids on disease-specific mortality (risk ratio (RR) 2.55, 95% confidence interval (CI) 0.72 to 9.03; 2 studies; 56 participants; very low-certainty evidence). Time to complete re-epithelialisation, length of hospital stay, and adverse effects leading to discontinuation of therapy were not reported. IVIG versus no IVIG It is uncertain if there is any difference between IVIG (0.2 to 0.5 g/kg cumulative dose over three days) and no IVIG in risk of disease-specific mortality (RR 0.33, 95% CI 0.04 to 2.91); time to complete re-epithelialisation (mean difference (MD) -2.93 days, 95% CI -4.4 to -1.46); or length of hospital stay (MD -2.00 days, 95% CI -5.81 to 1.81). All results in this comparison were based on one study with 36 participants, and very low-certainty evidence. Adverse effects leading to discontinuation of therapy were not reported. Etanercept (TNF-alpha inhibitor) versus corticosteroids Etanercept (25 mg (50 mg if weight > 65 kg) twice weekly "until skin lesions healed") may reduce disease-specific mortality compared to corticosteroids (intravenous prednisolone 1 to 1.5 mg/kg/day "until skin lesions healed") (RR 0.51, 95% CI 0.16 to 1.63; 1 study; 91 participants; low-certainty evidence); however, the CIs were consistent with possible benefit and possible harm. Serious adverse events, such as sepsis and respiratory failure, were reported in 5 of 48 participants with etanercept and 9 of 43 participants with corticosteroids, but it was not clear if they led to discontinuation of therapy. Time to complete re-epithelialisation and length of hospital stay were not reported. Cyclosporin versus IVIG It is uncertain if there is any difference between cyclosporin (3 mg/kg/day or intravenous 1 mg/kg/day until complete re-epithelialisation, then tapered off (10 mg/day reduction every 48 hours)) and IVIG (continuous infusion 0.75 g/kg/day for 4 days (total dose 3 g/kg) in participants with normal renal function) in risk of disease-specific mortality (RR 0.13, 95% CI 0.02 to 0.98, 1 study; 22 participants; very low-certainty evidence). Time to complete re-epithelialisation, length of hospital stay, and adverse effects leading to discontinuation of therapy were not reported. No studies measured intensive care unit length of stay. AUTHORS' CONCLUSIONS When compared to corticosteroids, etanercept may result in mortality reduction. For the following comparisons, the certainty of the evidence for disease-specific mortality is very low: corticosteroids versus no corticosteroids, IVIG versus no IVIG and cyclosporin versus IVIG. There is a need for more multicentric studies, focused on the most important clinical comparisons, to provide reliable answers about the best treatments for SJS/TEN.
Collapse
Affiliation(s)
- Audrey Jacobsen
- Department of Dermatology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Bayanne Olabi
- Department of Dermatology, Lothian University Hospitals NHS Trust, Lauriston Building, Edinburgh, UK
| | - Annie Langley
- Division of Dermatology, Department of Medicine, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | - Jennifer Beecker
- Division of Dermatology, Department of Medicine, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | - Eric Mutter
- Department of Emergency Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Amanda Shelley
- Division of Dermatology, University of Toronto, Toronto , Canada
| | - Brandon Worley
- Florida Dermatology and Skin Cancer Centers, Lake Wales, Florida, USA
| | - Timothy Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Arturo Saavedra
- Department of Dermatology, University of Virginia Health System, Charlottesville, USA
| | - Roses Parker
- Musculoskeletal, Oral, Skin and Sensory Network, Oxford University Hospitals NHS Foundation Trust Second Floor, OUH Cowley Unipart House Business Centre, Oxford, UK
| | - Fiona Stewart
- Cochrane Children and Families Network, c/o Cochrane Pregnancy and Childbirth, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - Jordi Pardo Pardo
- Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, Ottawa, Canada
| |
Collapse
|
7
|
Zander E, Hintze TD, Sallee B, Allen P, Miller JL, Sagdeo M. Treatment of Toxic Epidermal Necrolysis with Etanercept in a Pediatric Patient. J Pediatr Pharmacol Ther 2021; 26:758-761. [PMID: 34588942 DOI: 10.5863/1551-6776-26.7.758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/08/2021] [Indexed: 12/18/2022]
Abstract
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.
Collapse
|
8
|
Ayele BA, Ali K, Mulatu E. Toxic epidermal necrosis associated with phenobarbitone: a case report and brief review of the literatures. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2021; 17:88. [PMID: 34496964 PMCID: PMC8425050 DOI: 10.1186/s13223-021-00589-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 08/23/2021] [Indexed: 12/04/2022]
Abstract
BACKGROUND Toxic epidermal necrolysis (TEN)/Stevens-Johnson syndrome (SJS) is the spectrum of severe, acute, mucocutaneous, T-cell mediated delayed type IV hypersensitivity reaction and universally related to different drugs. Phenobarbitone is known to cause hypersensitivity reactions with benign pattern; ranging from a mild to moderate rashes but not life-threatening reactions such as TEN/SJS. CASE REPORT We report a 14-year-old asthmatic male patient admitted to a local hospital for an acute exacerbation of asthma, after he presented with shortness of breath, cough, and fever. He was treated with bronchodilator and antibiotics. On subsequent days, the patient developed new onset generalized tonic clonic seizure in the hospital for which he was started on phenobarbitone of 100 mg twice daily. Two weeks after initiation of phenobarbitone, the patient developed extensive blistering skin eruptions; which subsequently exfoliated unevenly. Associated with the hypersensitivity skin reaction, the patient reported low grade fever, sore throat, and dysphagia. The exfoliation also involved oral and conjunctival mucosa; with estimated 65% body surface area involvement. The laboratory investigations were relevant for mild leucocytosis, prolonged prothrombin time, and reduced albumin. Phenobarbitone was discontinued and replaced with clonazepam; and the patient was managed with fluids replacement, IV antibiotics, twice daily wound care, analgesics, and naso gastric tube feeding. On subsequent days the patients' clinical condition started improving; the skin lesion also started to heal and exfoliate in most of the affected skin surface areas, and the patient was discharged improved after ten days of intensive care unit. CONCLUSION In summary, the present case describes, a 14-years-old young child with history of asthma and seizure disorder; and developed toxic epidermal necrosis following exposure to Phenobarbitone. This case also highlighted the better prognosis observed in pediatric population with TEN.
Collapse
Affiliation(s)
- Biniyam A. Ayele
- Department of Neurology, School of Medicine, College of Health Sciences Addis Ababa University, Liberia Street, PO Box 6396, Addis Ababa, Ethiopia
| | - Kemal Ali
- Department of Neurology, School of Medicine, College of Health Sciences Addis Ababa University, Liberia Street, PO Box 6396, Addis Ababa, Ethiopia
| | - Eliyas Mulatu
- Department of Dermatovenereology, Addis Ababa University, Addis Ababa, Ethiopia
| |
Collapse
|
9
|
Faris J, Wilson J, Dolman HS, Isaacson A, Baylor AE, Tyburski JG, White MT. A Cautionary Tale of Etanercept Use in Patients With Toxic Epidermal Necrolysis. J Burn Care Res 2021; 42:586-589. [PMID: 33128367 DOI: 10.1093/jbcr/iraa194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Toxic epidermal necrolysis (TEN) is a severe cutaneous reaction that can be life-threatening. In the United States, there are no established guidelines for the treatment of TEN. Supportive care including fluids and supportive therapies are the current recommendations. Research surrounding TEN involves mostly case studies or small, uncontrolled studies. Recent literature describes the use of tumor necrosis factor blockers in the treatment of TEN with positive results. These case reports describe decreased time to reepithelization, hospital length of stay, and minimal side effects. Conversely, we present three fatalities after the administration of etanercept.
Collapse
Affiliation(s)
| | | | - Heather S Dolman
- Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - Andrew Isaacson
- Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - Alfred E Baylor
- Wayne State University School of Medicine/Detroit Medical Center Affiliated Hospitals, Michigan
| | - James G Tyburski
- Detroit Receiving Hospital, Michigan.,Wayne State University School of Medicine, Detroit, Michigan
| | - Michael T White
- Detroit Receiving Hospital, Michigan.,Wayne State University School of Medicine, Detroit, Michigan
| |
Collapse
|
10
|
Sachdeva M, Maliyar K, Ponzo MG. A Systematic Review of Efficacy and Safety of Monotherapy and Combination Therapy With Biologic for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. J Cutan Med Surg 2021; 25:598-615. [PMID: 33631950 DOI: 10.1177/1203475421993779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Biologic drugs have the potential to halt the progression of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) by decreasing concentrations of tumor necrosis factor-α, a cytokine implicated in epithelial cell death. The objective of this systematic review is to investigate the efficacy and safety of biologic monotherapy and combination therapy for SJS/TEN. METHODS MEDLINE and EMBASE in OVID were searched on October 28, 2020. Inclusion criteria were original studies containing human participants diagnosed with SJS/TEN and treated with biologics. Studies were excluded if they were literature reviews, systematic reviews, letters to the editor, or conference abstracts. RESULTS The 38 articles reviewed included 27 (71.1%) case reports, 6 (15.8%) case series, 3 (7.9%) retrospective reviews, and 2 (5.3%) RCTs. The age range of the included studies was 2 to 85 years, the mean age was 46.4 years. The mean body surface (BSA) across the 38 included articles was 31.0%. The average actual mortality reported within the 38 included articles was 9.2%. Both biologic monotherapy and combination therapy were associated with improved outcomes in SJS/TEN. Furthermore, anti TNF-alpha therapy, specifically etanercept, showed improved outcomes as monotherapy. CONCLUSIONS Overall, reviewed studies presented a strong case for biologic treatment, both monotherapy and combination use, in SJS/TEN treatment. Based on the number of fatal adverse events observed, biologic monotherapy may be safer compared to combination therapy. Further research with a larger sample size and a randomized control trial design is required.
Collapse
Affiliation(s)
- Muskaan Sachdeva
- 7938 University of Toronto, Faculty of Medicine, Toronto, Ontario
| | - Khalad Maliyar
- 7938 University of Toronto, Faculty of Medicine, Toronto, Ontario
| | - Marisa G Ponzo
- 8166 Department of Dermatology and Skin Science, University of British Columbia; Division of Dermatology, St. Paul's Hospital, Vancouver, British Columbia
| |
Collapse
|
11
|
Noe MH, Micheletti RG. Diagnosis and management of Stevens-Johnson syndrome/toxic epidermal necrolysis. Clin Dermatol 2020; 38:607-612. [DOI: 10.1016/j.clindermatol.2020.06.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
12
|
Hasegawa A, Abe R. Recent advances in managing and understanding Stevens-Johnson syndrome and toxic epidermal necrolysis. F1000Res 2020; 9. [PMID: 32595945 PMCID: PMC7308994 DOI: 10.12688/f1000research.24748.1] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2020] [Indexed: 12/15/2022] Open
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening diseases characterized by detachment of the epidermis and mucous membrane. SJS/TEN are considered to be on the same spectrum of diseases with different severities. They are classified by the percentage of skin detachment area. SJS/TEN can also cause several complications in the liver, kidneys, and respiratory tract. The pathogenesis of SJS/TEN is still unclear. Although it is difficult to diagnose early stage SJS/TEN, biomarkers for diagnosis or severity prediction have not been well established. Furthermore, optimal therapeutic options for SJS/TEN are still controversial. Several drugs, such as carbamazepine and allopurinol, are reported to have a strong relationship with a specific human leukocyte antigen (HLA) type. This relationship differs between different ethnicities. Recently, the usefulness of HLA screening before administering specific drugs to decrease the incidence of SJS/TEN has been investigated. Skin detachment in SJS/TEN skin lesions is caused by extensive epidermal cell death, which has been considered to be apoptosis via the Fas-FasL pathway or perforin/granzyme pathway. We reported that necroptosis, i.e. programmed necrosis, also contributes to epidermal cell death. Annexin A1, released from monocytes, and its interaction with the formyl peptide receptor 1 induce necroptosis. Several diagnostic or prognostic biomarkers for SJS/TEN have been reported, such as CCL-27, IL-15, galectin-7, and RIP3. Supportive care is recommended for the treatment of SJS/TEN. However, optimal therapeutic options such as systemic corticosteroids, intravenous immunoglobulin, cyclosporine, and TNF-α antagonists are still controversial. Recently, the beneficial effects of cyclosporine and TNF-α antagonists have been explored. In this review, we discuss recent advances in the pathophysiology and management of SJS/TEN.
Collapse
Affiliation(s)
- Akito Hasegawa
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Riichiro Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| |
Collapse
|
13
|
Lin CC, Chen CB, Wang CW, Hung SI, Chung WH. Stevens-Johnson syndrome and toxic epidermal necrolysis: risk factors, causality assessment and potential prevention strategies. Expert Rev Clin Immunol 2020; 16:373-387. [DOI: 10.1080/1744666x.2020.1740591] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Chu-Chi Lin
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taipei, Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chun-Bing Chen
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taipei, Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chuang-Wei Wang
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taipei, Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shuen-Iu Hung
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taipei, Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China
| |
Collapse
|
14
|
Pham CH, Gillenwater TJ, Nagengast E, McCullough MC, Peng DH, Garner WL. Combination therapy: Etanercept and intravenous immunoglobulin for the acute treatment of Stevens-Johnson syndrome/toxic epidermal necrolysis. Burns 2019; 45:1634-1638. [PMID: 31466921 DOI: 10.1016/j.burns.2018.12.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/12/2018] [Accepted: 12/22/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is an autoimmune condition with significant morbidity and mortality. METHODS A retrospective review was performed at a single institution. All patients admitted to the LAC+USC burn unit from May 1st 2015-January 1st 2018 with a histologic diagnosis of SJS/TEN were reviewed. Patient characteristics and outcomes were recorded. These outcomes were compared to our previously published cohort. RESULTS Thirteen total consecutive SJS/TEN patients were treated with etanercept. Compared to non-etanercept treated patients, etanercept-treated patients did not experience a significant difference in mortality (15.4% vs. 10%, P=0.58), ICU days (6.9 vs. 15.1, P=0.08), length-of-stay (9.8 vs 16.4, P=0.11), or infections (38.5% vs. 57.5%, P=0.58). The standardized mortality ratio in etanercept-treated patients was 0.44 (95% CI, 0.21, 0.65). In general, etanercept-treated patients had higher SCORTENs (3 vs. 2, P=0.03) and longer delays to presentation (5.2 vs. 2.7 days, P<0.01). CONCLUSIONS Etanercept can be considered in the treatment of SJS/TEN patients in addition to IVIg, and supportive care in a burn unit.
Collapse
Affiliation(s)
- Christopher H Pham
- Keck School of Medicine, University of Southern California, 1975 Zonal Avenue, Los Angeles, CA 90033, United States; Division of Plastic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Suite 415, Los Angeles, CA 90033, United States
| | - T Justin Gillenwater
- Keck School of Medicine, University of Southern California, 1975 Zonal Avenue, Los Angeles, CA 90033, United States; Division of Plastic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Suite 415, Los Angeles, CA 90033, United States
| | - Eric Nagengast
- Division of Plastic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Suite 415, Los Angeles, CA 90033, United States
| | - Meghan C McCullough
- Division of Plastic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Suite 415, Los Angeles, CA 90033, United States
| | - David H Peng
- Keck School of Medicine, University of Southern California, 1975 Zonal Avenue, Los Angeles, CA 90033, United States; Department of Dermatology, Keck School of Medicine, University of Southern California, 1441 Eastlake Avenue, Ezralow Tower, Suite 5301, Los Angeles, CA 90033, United States
| | - Warren L Garner
- Keck School of Medicine, University of Southern California, 1975 Zonal Avenue, Los Angeles, CA 90033, United States; Division of Plastic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Suite 415, Los Angeles, CA 90033, United States.
| |
Collapse
|
15
|
Wang R, Zhong S, Tu P, Li R, Wang M. Rapid remission of Stevens-Johnson syndrome by combination therapy using etanercept and intravenous immunoglobulin and a review of the literature. Dermatol Ther 2019; 32:e12832. [PMID: 30659711 DOI: 10.1111/dth.12832] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/25/2018] [Accepted: 12/29/2018] [Indexed: 01/23/2023]
Affiliation(s)
- Ruojun Wang
- Department of Dermatology; Peking University First Hospital; Beijing China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses; Beijing China
- Research Center for Medical Mycology; Peking University; Beijing China
| | - Shaomin Zhong
- Department of Dermatology; Peking University First Hospital; Beijing China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses; Beijing China
| | - Ping Tu
- Department of Dermatology; Peking University First Hospital; Beijing China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses; Beijing China
| | - Ruoyu Li
- Department of Dermatology; Peking University First Hospital; Beijing China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses; Beijing China
- Research Center for Medical Mycology; Peking University; Beijing China
| | - Mingyue Wang
- Department of Dermatology; Peking University First Hospital; Beijing China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses; Beijing China
| |
Collapse
|
16
|
Zhang S, Tang S, Li S, Pan Y, Ding Y. Biologic TNF-alpha inhibitors in the treatment of Stevens-Johnson syndrome and toxic epidermal necrolysis: a systemic review. J DERMATOL TREAT 2019; 31:66-73. [PMID: 30702955 DOI: 10.1080/09546634.2019.1577548] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background: Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS-TEN) is one of severe cutaneous adverse reactions with low morbidity but high mortality. Different systemic immunomodulating treatments are proposed but still remain controversial. Tumor necrosis factor (TNF)-alpha is long thought to be a vital mediator of epithelial cell death in SJS-TEN, indicating a potential target for therapy.Objective: The aim of this systemic review is to evaluate the efficacy and safety of biologic TNF-alpha inhibitors in the treatment of SJS-TEN.Methods: We reviewed the published literature by searching from PubMed, EMBASE, Web of Science and ClinicalTrial.gov. A total of 27 articles fulfilling our inclusion criteria were found and analyzed.Results: There were 21 case reports, four case series and two randomized controlled trials (RCTs) on the biologic TNF-alpha inhibitors for SJS-TEN therapy, comprising 91 patients. TNF-alpha inhibitors were used as monotherapy, second-line therapy or combination therapy. Among them, 79 patients (86.8%) responded well and discharged with few side effects and complications.Conclusions: Biologic TNF-alpha inhibitors are a safe and effective treatment for SJS-TEN. But further, larger RCTs need to be conducted to provide more evidence for clinical application.
Collapse
Affiliation(s)
- Shan Zhang
- Department of Dermatology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Shunli Tang
- Department of Dermatology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Sheng Li
- Department of Dermatology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yunlei Pan
- Department of Dermatology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yingguo Ding
- Department of Dermatology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| |
Collapse
|
17
|
Langley A, Worley B, Pardo Pardo J, Beecker J, Ramsay T, Saavedra A, Farrell-McCawley J, Tugwell P. Systemic interventions for treatment of Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS/TEN overlap syndrome. Hippokratia 2018. [DOI: 10.1002/14651858.cd013130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Annie Langley
- The Ottawa Hospital and the University of Ottawa; Division of Dermatology, Department of Medicine; Ottawa Ontario Canada
| | - Brandon Worley
- The Ottawa Hospital; Division of Dermatology, Department of Medicine; Ottawa Ontario Canada
| | - Jordi Pardo Pardo
- Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus; Centre for Practice-Changing Research; 501 Smyth Road, Box 711 Room L1258 Ottawa ON Canada K1H 8L6
| | - Jennifer Beecker
- The Ottawa Hospital and the University of Ottawa; Division of Dermatology, Department of Medicine; Ottawa Ontario Canada
| | - Timothy Ramsay
- Ottawa Hospital Research Institute; Clinical Epidemiology Program; 501 Smyth Road Ottawa Canada K1H 8L6
| | - Arturo Saavedra
- University of Virginia Health System; Department of Dermatology; Charlottesville USA VA 22908-0718
| | | | - Peter Tugwell
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa ON Canada K1Y 4E9
- Faculty of Medicine, University of Ottawa; Department of Medicine; Ottawa ON Canada K1H 8M5
- Faculty of Medicine, University of Ottawa; Department of Epidemiology and Community Medicine; Ottawa ON Canada K1H 8M5
| |
Collapse
|
18
|
Estrella-Alonso A, Aramburu JA, González-Ruiz MY, Cachafeiro L, Sánchez MS, Lorente JA. Toxic epidermal necrolysis: a paradigm of critical illness. Rev Bras Ter Intensiva 2018; 29:499-508. [PMID: 29340540 PMCID: PMC5764563 DOI: 10.5935/0103-507x.20170075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 04/05/2017] [Indexed: 01/08/2023] Open
Abstract
Toxic epidermal necrolysis is an adverse immunological skin reaction secondary in
most cases to the administration of a drug. Toxic epidermal necrolysis,
Stevens-Johnson syndrome, and multiform exudative erythema are part of the same
disease spectrum. The mortality rate from toxic epidermal necrolysis is
approximately 30%. The pathophysiology of toxic epidermal necrolysis is similar
in many respects to that of superficial skin burns. Mucosal involvement of the
ocular and genital epithelium is associated with serious sequelae if the
condition is not treated early. It is generally accepted that patients with
toxic epidermal necrolysis are better treated in burn units, which are
experienced in the management of patients with extensive skin loss. Treatment
includes support, elimination, and coverage with biosynthetic derivatives of the
skin in affected areas, treatment of mucosal involvement, and specific
immunosuppressive treatment. Of the treatments tested, only immunoglobulin G and
cyclosporin A are currently used in most centers, even though there is no solid
evidence to recommend any specific treatment. The particular aspects of the
treatment of this disease include the prevention of sequelae related to the
formation of synechiae, eye care to prevent serious sequelae that can lead to
blindness, and specific immunosuppressive treatment. Better knowledge of the
management principles of toxic epidermal necrolysis will lead to better disease
management, higher survival rates, and lower prevalence of sequelae.
Collapse
Affiliation(s)
| | - José Antonio Aramburu
- Instituto de Investigación Sanitaria del Hospital Universitario de Getafe - Madrid, Spain.,Universidad Europea - Madrid, Spain
| | - Mercedes Yolanda González-Ruiz
- Instituto de Investigación Sanitaria del Hospital Universitario de Getafe - Madrid, Spain.,Universidad Europea - Madrid, Spain
| | - Lucía Cachafeiro
- Hospital Universitario La Paz-Cantoblanco-Carlos III, Instituto de investigación IdiPaz - Madrid, Spain
| | - Manuel Sánchez Sánchez
- Hospital Universitario La Paz-Cantoblanco-Carlos III, Instituto de investigación IdiPaz - Madrid, Spain
| | - José A Lorente
- Instituto de Investigación Sanitaria del Hospital Universitario de Getafe - Madrid, Spain.,Universidad Europea - Madrid, Spain.,CIBER de Enfermedades Respiratorias - Madrid, Spain
| |
Collapse
|
19
|
Wang F, Ye Y, Luo ZY, Gao Q, Luo DQ, Zhang X. Diverse expression of TNF-α and CCL27 in serum and blister of Stevens-Johnson syndrome/toxic epidermal necrolysis. Clin Transl Allergy 2018; 8:12. [PMID: 29713456 PMCID: PMC5909236 DOI: 10.1186/s13601-018-0199-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 03/14/2018] [Indexed: 01/13/2023] Open
Abstract
Background The pathogenesis of Stevens–Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) is not fully understood. Our previous study reported that chemokine CCL27 was overexpressed in serum of SJS/TEN patients. The objective of this study was to investigate the levels of CCL27 and TNF-α in serum and blister fluid from patients with SJS/TEN during the acute stage or resolution phase. Methods A total of 27 patients with SJS/TEN and 39 healthy donors were recruited to the study. Serum and vesicular levels of CCL27 and TNF-α were determined by enzyme-linked immunosorbent assays. Results Serum levels of CCL27 and TNF-α were significantly elevated in patients with SJS/TEN during the acute stage as compared to the resolution phase and also compared with levels observed in normal controls (P = 0.001/< 0.001; P = 0.012/< 0.001). Serum TNF-α levels were significantly higher in patients with SJS/TEN during the resolution phase compared with normal controls (P < 0.001). Serum CCL27 levels were positively correlated with TNF-α levels during the acute stage (rs = 0.660; P < 0.001). Blister fluid exhibited much lower CCL27 levels than serum did during the acute stage (P = 0.008). TNF-α levels were much higher in vesicles in contrast to serum from acute stage (P = 0.040) as well as serum from resolution phase (P = 0.029). Conclusions Our study demonstrated roles of CCL27 and TNF-α in promoting the course of SJS/TEN. CCL27 may act early in the course of disease, via the circulation, whereas TNF-α acts throughout the course of disease, in skin lesions.
Collapse
Affiliation(s)
- Fang Wang
- 1Department of Dermatology, First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080 China
| | - Yanting Ye
- 1Department of Dermatology, First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080 China
| | - Ze-Yu Luo
- 1Department of Dermatology, First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080 China
| | - Qian Gao
- 1Department of Dermatology, First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080 China
| | - Di-Qing Luo
- 2Department of Dermatology, Eastern Hospital of First Affiliated Hospital, Sun Yat-sen University, 183 Huangpu Rd. E, Guangzhou, 510700 China
| | - Xingqi Zhang
- 1Department of Dermatology, First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080 China
| |
Collapse
|
20
|
Chong I, Chao A. Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis and Treatment With a Biologic: A Case Report. Perm J 2018; 21:16-060. [PMID: 28488978 DOI: 10.7812/tpp/16-060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION One of the most dangerous dermatologic emergencies is Stevens-Johnson Syndrome (SJS)/toxic epidermal necrolysis (TEN). Although a rare disease, it can often lead to significant mortality. CASE PRESENTATION In this case report, we present a 77-year-old man who developed a sloughing rash that was secondary to a nonsteroidal anti-inflammatory drug. In addition to the recommended supportive care, the patient was treated with etanercept, a new, less commonly used intervention. DISCUSSION We provide a brief review of SJS/TEN. Nonsteroidal anti-inflammatory drugs are a rare cause of SJS/TEN, and additionally, the use of biologics is a novel treatment modality for SJS/TEN.
Collapse
Affiliation(s)
- Ian Chong
- Attending Physician in Emergency Medicine at the Zion Medical Center in San Diego, CA.
| | - Alice Chao
- Attending Physician in Emergency Medicine at the Santa Clara Medical Center in CA.
| |
Collapse
|
21
|
Abstract
Cutaneous adverse drug reactions comprise a significant proportion of all adverse drug reactions. They may mimic other dermatologic or systemic illnesses and may cause significant morbidity or mortality. Seven morphologic groups encompass the most commonly encountered cutaneous drug reaction syndromes: exanthematous (maculopapular), dermatitic/eczematous, urticarial, pustular, blistering, purpuric, and erythrodermic. Drug reactions may have significant downstream consequences for the older individual.
Collapse
|
22
|
Wang CW, Yang LY, Chen CB, Ho HC, Hung SI, Yang CH, Chang CJ, Su SC, Hui RCY, Chin SW, Huang LF, Lin YYW, Chang WY, Fan WL, Yang CY, Ho JC, Chang YC, Lu CW, Chung WH. Randomized, controlled trial of TNF-α antagonist in CTL-mediated severe cutaneous adverse reactions. J Clin Invest 2018; 128:985-996. [PMID: 29400697 PMCID: PMC5824923 DOI: 10.1172/jci93349] [Citation(s) in RCA: 159] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 12/19/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Cytotoxic T lymphocyte-mediated (CTL-mediated) severe cutaneous adverse reactions (SCARs), including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), are rare but life-threatening adverse reactions commonly induced by drugs. Although high levels of CTL-associated cytokines, chemokines, or cytotoxic proteins, including TNF-α and granulysin, were observed in SJS-TEN patients in recent studies, the optimal treatment for these diseases remains controversial. We aimed to evaluate the efficacy, safety, and therapeutic mechanism of a TNF-α antagonist in CTL-mediated SCARs. METHODS We enrolled 96 patients with SJS-TEN in a randomized trial to compare the effects of the TNF-α antagonist etanercept versus traditional corticosteroids. RESULTS Etanercept improved clinical outcomes in patients with SJS-TEN. Etanercept decreased the SCORTEN-based predicted mortality rate (predicted and observed rates, 17.7% and 8.3%, respectively). Compared with corticosteroids, etanercept further reduced the skin-healing time in moderate-to-severe SJS-TEN patients (median time for skin healing was 14 and 19 days for etanercept and corticosteroids, respectively; P = 0.010), with a lower incidence of gastrointestinal hemorrhage in all SJS-TEN patients (2.6% for etanercept and 18.2% for corticosteroids; P = 0.03). In the therapeutic mechanism study, etanercept decreased the TNF-α and granulysin secretions in blister fluids and plasma (45.7%-62.5% decrease after treatment; all P < 0.05) and increased the Treg population (2-fold percentage increase after treatment; P = 0.002), which was related to mortality in severe SJS-TEN. CONCLUSIONS The anti-TNF-α biologic agent etanercept serves as an effective alternative for the treatment of CTL-mediated SCARs. TRIAL REGISTRATION ClinicalTrials.gov NCT01276314. FUNDING Ministry of Science and Technology of Taiwan.
Collapse
Affiliation(s)
- Chuang-Wei Wang
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital (CGMH), Linkou, Taipei and Keelung, Taiwan
- Chang Gung Immunology Consortium, CGMH and Chang Gung University, Taiwan
| | | | - Chun-Bing Chen
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital (CGMH), Linkou, Taipei and Keelung, Taiwan
| | - Hsin-Chun Ho
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital (CGMH), Linkou, Taipei and Keelung, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shuen-Iu Hung
- Department and Institute of Pharmacology, School of Medicine, Infection and Immunity Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Chih-Hsun Yang
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital (CGMH), Linkou, Taipei and Keelung, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chee-Jen Chang
- Graduate Institute of Clinical Medical Science, Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan
- Biostatistical Center for Clinical Research, CGMH, Linkou, Taiwan
| | - Shih-Chi Su
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital (CGMH), Linkou, Taipei and Keelung, Taiwan
- Whole-Genome Research Core Laboratory of Human Diseases, CGMH, Keelung, Taiwan
| | - Rosaline Chung-Yee Hui
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital (CGMH), Linkou, Taipei and Keelung, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - See-Wen Chin
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital (CGMH), Linkou, Taipei and Keelung, Taiwan
| | | | - Yang Yu-Wei Lin
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital (CGMH), Linkou, Taipei and Keelung, Taiwan
| | | | - Wen-Lang Fan
- Whole-Genome Research Core Laboratory of Human Diseases, CGMH, Keelung, Taiwan
| | - Chin-Yi Yang
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital (CGMH), Linkou, Taipei and Keelung, Taiwan
| | - Ji-Chen Ho
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, CGMH, Chiayi, Taiwan
| | - Ya-Ching Chang
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital (CGMH), Linkou, Taipei and Keelung, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Wei Lu
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital (CGMH), Linkou, Taipei and Keelung, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital (CGMH), Linkou, Taipei and Keelung, Taiwan
- Chang Gung Immunology Consortium, CGMH and Chang Gung University, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Whole-Genome Research Core Laboratory of Human Diseases, CGMH, Keelung, Taiwan
| | | |
Collapse
|
23
|
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: 120] [Impact Index Per Article: 20.0] [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.
Collapse
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.
| |
Collapse
|
24
|
Treatments for Severe Cutaneous Adverse Reactions. J Immunol Res 2017; 2017:1503709. [PMID: 29445753 PMCID: PMC5763067 DOI: 10.1155/2017/1503709] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 11/16/2017] [Indexed: 12/17/2022] Open
Abstract
Severe cutaneous adverse reaction (SCAR) is life-threatening. It consists of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), acute generalized exanthematous pustulosis (AGEP), and generalized bullous fixed drug eruptions (GBFDE). In the past years, emerging studies have provided better understandings regarding the pathogenesis of these diseases. These diseases have unique presentations and distinct pathomechanisms. Therefore, theoretically, the options of treatments might be different among various SCARs. However, due to the rarity of these diseases, sufficient evidence is still lacking to support the best choice of treatment for patients with SCAR. Herein, we will provide a concise review with an emphasis on the characteristics and treatments of each SCAR. It may serve as a guidance based on the current best of knowledge and may shed light on the directions for further investigations.
Collapse
|
25
|
Mereniuk A, Jaque A, Jeschke MG, Shear NH. Toxic Epidermal Necrolysis Spectrum Management at Sunnybrook Health Sciences Centre: Our Multidisciplinary Approach After Review of the Current Evidence. J Cutan Med Surg 2017; 22:213-219. [PMID: 29202605 DOI: 10.1177/1203475417746148] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Toxic epidermal necrolysis spectrum (TENS) is a rare yet severe adverse drug reaction associated with a high mortality rate. Beyond supportive care, there is still no established therapy for TENS, although recent meta-analyses and UK guideline recommendations have attempted to offer a review of relevant literature on this difficult topic. As most directed treatments lack clear consensual evidence, care centres often resort to establishing their own strategies. As Canada's largest adult burn centre and the provincial reference centre for most burn patients in Ontario, our team at the Ross Tilley Burn Centre, in collaboration with the Department of Dermatology at Sunnybrook Health Sciences Centre, Toronto, Canada, has managed over 60 confirmed cases of TENS over the past 2 decades. We would like to share our management, experience, and present our treatment protocol that we recently established by a collaborative multidisciplinary team approach to help guide treatment of these complex patients not only in Canada but worldwide.
Collapse
Affiliation(s)
- Alexandra Mereniuk
- 1 Division of Dermatology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Alejandra Jaque
- 1 Division of Dermatology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Marc G Jeschke
- 2 Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Department of Immunology, Division of Plastic and Reconstructive Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Neil H Shear
- 1 Division of Dermatology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
26
|
Prieto-Barrios M, Velasco-Tamariz V, Tous-Romero F, Burillo-Martinez S, Zarco-Olivo C, Rodriguez-Peralto JL, Ortiz-Romero PL. Linear immunoglobulin A dermatosis mimicking toxic epidermal necrolysis: a case report of etanercept treatment. Br J Dermatol 2017; 178:786-789. [PMID: 28222222 DOI: 10.1111/bjd.15400] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2017] [Indexed: 11/29/2022]
Abstract
A 65-year-old pluripathological woman attended our hospital with a cutaneous eruption of sudden appearance after vancomycin treatment. She presented targetoid lesions affecting approximately 25-30% of her body surface, large erosions with mucosal lesions and positive Nikolsky sign. Under the initial clinical suspicion of toxic epidermal necrolysis (TEN), and considering the recent literature of successful use of etanercept in these cases, she was treated with a single dose of this antitumour necrosis factor (anti-TNF) agent. Subsequently, the exanthema progression stopped and resolution of the lesions happened in a few days. Later on, histopathology revealed a subepidermal blister with dense neutrophilic infiltrate and linear deposits of immunoglobulin A (IgA) on the dermoepidermal junction, allowing us to establish the diagnosis of drug-induced linear IgA dermatosis mimicking TEN. Linear IgA dermatosis can have severe clinical manifestations, even mimicking TEN, and can have high mortality, especially in drug-induced cases. We have not found any other report of linear IgA dermatosis treated with etanercept in the English literature. Anti-TNF medications could represent useful therapeutic alternatives in this dermatosis.
Collapse
Affiliation(s)
- M Prieto-Barrios
- Departments of Dermatology, Hospital Universitario 12 de Octubre, I + 12 Research Institute, Universidad Complutense, Madrid, Spain
| | - V Velasco-Tamariz
- Departments of Dermatology, Hospital Universitario 12 de Octubre, I + 12 Research Institute, Universidad Complutense, Madrid, Spain
| | - F Tous-Romero
- Departments of Dermatology, Hospital Universitario 12 de Octubre, I + 12 Research Institute, Universidad Complutense, Madrid, Spain
| | - S Burillo-Martinez
- Departments of Dermatology, Hospital Universitario 12 de Octubre, I + 12 Research Institute, Universidad Complutense, Madrid, Spain
| | - C Zarco-Olivo
- Departments of Dermatology, Hospital Universitario 12 de Octubre, I + 12 Research Institute, Universidad Complutense, Madrid, Spain
| | - J L Rodriguez-Peralto
- Departments of Pathology, Hospital Universitario 12 de Octubre, I + 12 Research Institute, Universidad Complutense, Madrid, Spain
| | - P L Ortiz-Romero
- Departments of Dermatology, Hospital Universitario 12 de Octubre, I + 12 Research Institute, Universidad Complutense, Madrid, Spain
| |
Collapse
|
27
|
Leman RE, Chen L, Shi X, Rolimpandoei SP, Ling X, Su Y. Drug reaction with eosinophilia and systemic symptoms (DRESS) successfully treated with tumor necrosis factor-α inhibitor. JAAD Case Rep 2017; 3:332-335. [PMID: 28752124 PMCID: PMC5518151 DOI: 10.1016/j.jdcr.2017.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Ryan Edrick Leman
- Department of Dermatology, Second Affiliated Hospital of Suzhou University, Suzhou, China
| | - Lingling Chen
- Department of Dermatology, Second Affiliated Hospital of Suzhou University, Suzhou, China
| | - Xin Shi
- Department of Dermatology, Second Affiliated Hospital of Suzhou University, Suzhou, China
| | | | - Xin Ling
- Department of Dermatology, Second Affiliated Hospital of Suzhou University, Suzhou, China
| | - Yuhua Su
- Department of Dermatology, Second Affiliated Hospital of Suzhou University, Suzhou, China
| |
Collapse
|
28
|
Zimmermann S, Sekula P, Venhoff M, Motschall E, Knaus J, Schumacher M, Mockenhaupt M. Systemic Immunomodulating Therapies for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Systematic Review and Meta-analysis. JAMA Dermatol 2017; 153:514-522. [PMID: 28329382 PMCID: PMC5817620 DOI: 10.1001/jamadermatol.2016.5668] [Citation(s) in RCA: 184] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/27/2016] [Indexed: 12/13/2022]
Abstract
Importance Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are rare but severe adverse reactions with high mortality. There is no evidence-based treatment, but various systemic immunomodulating therapies are used. Objectives To provide an overview on possible immunomodulating treatments for SJS/TEN and estimate their effects on mortality compared with supportive care. Data Sources A literature search was performed in December 2012 for articles published in MEDLINE, MEDLINE Daily, MEDLINE Inprocess, Web of Science, EMBASE, Scopus, and the Cochrane Library (Central) from January 1990 through December 2012, and updated in December 2015, in the English, French, Spanish, and German languages looking for treatment proposals for SJS/TEN. Other sources were screened manually. Study Selection Initially, 157 randomized and nonrandomized studies on therapies (systemic immunomodulating therapies or supportive care) for SJS/TEN were selected. Data Extraction and Synthesis Relevant data were extracted from articles. Authors were contacted for further information. Finally, 96 studies with sufficient information regarding eligibility and adequate quality scores were considered in the data synthesis. All steps were performed independently by 2 investigators. Meta-analyses on aggregated study data (random-effects model) and individual patient data (IPD) (logistic regression adjusted for confounders) were performed to assess therapeutic efficacy. In the analysis of IPD, 2 regression models, stratified and unstratified by study, were fitted. Main Outcomes and Measures Therapy effects on mortality were expressed in terms of odds ratios (ORs) with 95% CIs. Results Overall, 96 studies (3248 patients) were included. Applied therapies were supportive care or systemic immunomodulating therapies, including glucocorticosteroids, intravenous immunoglobulins, cyclosporine, plasmapheresis, thalidomide, cyclophosphamide, hemoperfusion, tumor necrosis factor inhibitors, and granulocyte colony-stimulating factors. Glucocorticosteroids were associated with a survival benefit for patients in all 3 analyses but were statistically significant in only one (aggregated data: OR, 0.5; 95%% CI, 0.3-1.01; IPD, unstratified: OR, 0.7; 95% CI, 0.5-0.97; IPD, stratified: OR, 0.8; 95% CI, 0.4-1.3). Despite the low patient size, cyclosporine was associated with a promising significant result in the only feasible analysis of IPD (unstratified model) (OR, 0.1; 95% CI, 0.0-0.4). No beneficial findings were observed for other therapies, including intravenous immunoglobulins. Conclusions and Relevance Although all analyses, including the unstratified model, had limitations, glucocorticosteroids and cyclosporine were the most promising systemic immunomodulating therapies for SJS/TEN. Further evaluation in prospective studies is required. However, this work provides a comprehensive overview on proposed systemic immunomodulating treatments for SJS/TEN, which is of great relevance for treating physicians.
Collapse
Affiliation(s)
- Stefanie Zimmermann
- Dokumentationszentrum schwerer Hautreaktionen, Department of Dermatology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Pierre Fabre Pharma GmbH, Freiburg, Germany
| | - Peggy Sekula
- Institute for Medical Biometry and Statistics, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Moritz Venhoff
- Dokumentationszentrum schwerer Hautreaktionen, Department of Dermatology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Sander & Kollegen Dental Practice, Haslach im Kinzigtal, Germany
| | - Edith Motschall
- Institute for Medical Biometry and Statistics, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jochen Knaus
- Institute for Medical Biometry and Statistics, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Schumacher
- Institute for Medical Biometry and Statistics, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Maja Mockenhaupt
- Dokumentationszentrum schwerer Hautreaktionen, Department of Dermatology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
29
|
Toxic Epidermal Necrolysis-like Reaction After Hematopoietic Stem Cell Transplantation in Children. J Pediatr Hematol Oncol 2017; 39:254-258. [PMID: 28267083 DOI: 10.1097/mph.0000000000000820] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This study report clinical course, etiology, management, and long-term outcome of children who developed toxic epidermal necrolysis-like reaction (TEN-LR) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). We retrospectively collected children with TEN-LR occurring after allo-HSCT performed in 2 pediatric bone marrow units between 2005 and 2014. We identified 6 cases of TEN-LR of 322 patients (1.8%). Possible triggers of TEN included antibiotics, antiepileptics, antimycotics, and Mycoplasma infection. In 3 patients TEN-LR occurred concurrently with severe multiorgan acute graft versus host disease. The management of TEN included administration of high doses of intravenous immunoglobulins and steroids (n=6), anti-tumor necrosis factor (n=3), and plasmapheresis (n=3) and whenever possible, discontinuation of the potentially causative drugs. Four patients (66%) reached a complete clinical response of TEN-LR after a median of 11.2 days. Two children (34%) are presently alive, 1 with long-term ocular sequelae. TEN-LR is a potentially lethal complication that may occur after HSCT also in pediatric patients. In our experience, TEN-LR and acute graft versus host disease probably coexisted and an overlap between the 2 forms is suggested. The multidisciplinary approaches involving specialized nurses, hematologists, dermatologists, burn surgeons, and infectious disease specialists is crucial to treat these patients.
Collapse
|
30
|
Affiliation(s)
- Bryan Baillis
- Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | | |
Collapse
|
31
|
Dodiuk-Gad RP, Chung WH, Shear NH. Adverse Medication Reactions. CLINICAL AND BASIC IMMUNODERMATOLOGY 2017. [PMCID: PMC7123512 DOI: 10.1007/978-3-319-29785-9_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cutaneous adverse drug reactions (ADRs) are among the most frequent adverse reactions in patients receiving drug therapy. They have a broad spectrum of clinical manifestations, are caused by various drugs, and result from different pathophysiological mechanisms. Hence, their diagnosis and management is challenging. Severe cutaneous ADRs comprise a group of diseases with major morbidity and mortality, reaching 30 % mortality rate in cases of Toxic Epidermal Necrolysis. This chapter covers the terminology, epidemiology, pathogenesis and classification of cutaneous ADR, describes the severe cutaneous ADRs and the clinical and laboratory approach to the patient with cutaneous ADR and presents the translation of laboratory-based discoveries on the genetic predisposition and pathogenesis of cutaneous ADRs to clinical management guidelines.
Collapse
|
32
|
Abstract
Toxic epidermal necrolysis (TEN) is a serious, life-threatening skin reaction characterized by severe exfoliation and destruction of the epidermis of the skin. In most TEN cases, drugs are believed to be the causative agent; antipsychotics, antiepileptics, and other medications such as sulfonamides are among the most common causes of drug-induced TEN. Phenytoin, a commonly prescribed medication for seizure, was found to cause TEN. Evidence-based treatment guidelines are lacking, so the best strategy is to identify and avoid potential risk factors and to provide intensive supportive care. The aim of this literature review is to focus on phenytoin-induced TEN, to explore the risk factors, and to highlight the possible treatment options once phenytoin-induced TEN is confirmed.
Collapse
Affiliation(s)
- Osama M Al-Quteimat
- Department of Pharmacy Services, Clevevland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| |
Collapse
|
33
|
Owczarczyk-Saczonek A, Zdanowska N, Znajewska-Pander A, Placek W. Stevens-Johnson syndrome in a patient with rheumatoid arthritis during long-term etanercept therapy. J Dermatol Case Rep 2016; 10:14-6. [PMID: 27119002 DOI: 10.3315/jdcr.2016.1224] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 03/20/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Etanercept and other anti-TNF-alpha agents have been indicated as a therapeutic option in severe drug reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis. Etanercept has been shown to quickly reduce the detachment of the epidermis and shorten healing time. Cases of etanercept-induced severe adverse drug reactions were also described. MAIN OBSERVATIONS A 27-year-old woman with a 4-year history of etanercept and sulfasalazine treatment for rheumatoid arthritis was admitted with Stevens-Johnson syndrome. The patient received one dose of an OTC drug containing acetaminophen, phenylephrine and pheniramine two days prior to developing fist mucocutaneous symptoms. The most probable causative agent was paracetamol. Throughout the successful routine therapy of Stevens-Johnson syndrome etanercept therapy was continued. Sulfosalazin administration was stopped and administered again after recovery with no recurrence of the skin and mucosal symptoms. CONCLUSIONS This case indicates that there is no justification for discontinuation of long-term anti-TNF-alpha treatment in patients who develop Stevens- Johnson syndrome / toxic epidermal necrolysis.
Collapse
Affiliation(s)
- Agnieszka Owczarczyk-Saczonek
- Department of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, Faculty of Medical Sciences, University of Warmia and Mazury in Olsztyn, Poland
| | - Natalia Zdanowska
- Department of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, Faculty of Medical Sciences, University of Warmia and Mazury in Olsztyn, Poland
| | - Aleksandra Znajewska-Pander
- Department of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, Faculty of Medical Sciences, University of Warmia and Mazury in Olsztyn, Poland
| | - Waldemar Placek
- Department of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, Faculty of Medical Sciences, University of Warmia and Mazury in Olsztyn, Poland
| |
Collapse
|
34
|
Jain R, Sharma N, Basu S, Iyer G, Ueta M, Sotozono C, Kannabiran C, Rathi VM, Gupta N, Kinoshita S, Gomes JAP, Chodosh J, Sangwan VS. Stevens-Johnson syndrome: The role of an ophthalmologist. Surv Ophthalmol 2016; 61:369-99. [PMID: 26829569 DOI: 10.1016/j.survophthal.2016.01.004] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 01/22/2016] [Accepted: 01/25/2016] [Indexed: 01/03/2023]
Abstract
Stevens-Johnson syndrome (SJS) is an acute blistering disease of the skin and mucous membranes. Acute SJS leads to the acute inflammation of the ocular surface and chronic conjunctivitis. If not properly treated, it causes chronic cicatricial conjunctivitis and cicatricial lid margin abnormalities. Persistent inflammation and ulceration of the ocular surface with cicatricial complications of the lids leads to chronic ocular sequelae, ocular surface damage, and corneal scarring. The destruction of the glands that secrete the tear film leads to a severe form of dry eye that makes the management of chronic SJS difficult. The option that is routinely used for corneal visual rehabilitation, keratoplasty, is best avoided in such cases. We describe the management strategies that are most effective during the acute and chronic stages of SJS. Although treatments for acute SJS involve immunosuppressive and immunomodulatory therapies, amniotic membrane transplantation is also useful. The options for visual rehabilitation in patients with chronic SJS are undergoing radical change. We describe the existing literature regarding the management of SJS and highlight recent advances in the management of this disorder.
Collapse
Affiliation(s)
- Rajat Jain
- Cornea, Ocular Surface and Anterior Segment Services, Department of Ophthalmology, drishtiCONE Eye Care, New Delhi, India
| | - Namrata Sharma
- Cornea and Refractive Surgery Services, Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Sayan Basu
- Cornea and Anterior Segment Services, Department of Ophthalmology, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Geetha Iyer
- C J Shah Cornea Services, Department of Ophthalmology, Dr. G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Sankara Nethralaya, Chennai, India
| | - Mayumi Ueta
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Ophthalmology, Doshisha University, Kyotanabe, Japan
| | - Chie Sotozono
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Chitra Kannabiran
- Department of Ophthalmology, Kallam Anji Reddy Molecular Genetics Laboratory, L V Prasad Eye Institute (LVPEI), Hyderabad, Telangana, India
| | - Varsha M Rathi
- Cornea Services, Department of Ophthalmology, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Nidhi Gupta
- Department of Ophthalmology, Dr. Shroff Charity Eye Hospital, Delhi, India
| | - Shigeru Kinoshita
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - José A P Gomes
- Cornea and External Disease Service, Department of Ophthalmology, Federal University of Sao Paulo/Escola Paulista de Medicina (UNIFESP/EPM), São Paulo, Brazil; Advanced Ocular Surface Center (CASO), Department of Ophthalmology, Federal University of Sao Paulo/Escola Paulista de Medicina (UNIFESP/EPM), São Paulo, Brazil
| | - James Chodosh
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Virender S Sangwan
- Department of Ophthalmology, Srujana Center for Innovation, L V Prasad Eye Institute, Hyderabad, Telangana, India.
| |
Collapse
|
35
|
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.
Collapse
|
36
|
Boroda K, Li L, Riina L, Ahmed S. Cephalosporin-Induced Toxic Epidermal Necrolysis Treated with Intravenous Immunoglobulin. Cureus 2015; 7:e359. [PMID: 26623214 PMCID: PMC4659687 DOI: 10.7759/cureus.359] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Toxic epidermal necrolysis (TEN) is a life-threatening cutaneous reaction to various medications, including antipsychotics and antibiotics. While cephalosporin-induced TEN is very rare, we present a case of cefepime-induced TEN. There are several commonly used therapies for TEN, including immunosuppressive agents and intravenous immunoglobulin (IVIG), but their true efficacy has not been proven. In this case, the patient was treated with IVIG. The role of IVIG as therapy for TEN is currently being investigated. Prior observational studies suggest IVIG infers clinic benefit; however, recent meta-analyses have not shown any benefit. Our patient initially showed clinical improvement with IVIG therapy but, unfortunately, later succumbed to sepsis. We will provide a brief review of the current research of the pathological mechanism of Stevens-Johnson syndrome (SJS)/TEN and the mechanism of action of IVIG specifically in TEN/SJS.
Collapse
Affiliation(s)
- Konstantin Boroda
- Radiology, Stony Brook University ; Internal Medicine, Albert Einstein College of Medicine
| | - Li Li
- Internal Medicine, Nassau University Medical Center
| | - Louis Riina
- Plastic Surgery, Nassau University Medical Center
| | - Shadab Ahmed
- Infectious Disease, Nassau University Medical Center
| |
Collapse
|
37
|
Watanabe H, Kamiyama T, Sasaki S, Kobayashi K, Fukuda K, Miyake Y, Aruga T, Sueki H. Toxic epidermal necrolysis caused by acetaminophen featuring almost 100% skin detachment: Acetaminophen is associated with a risk of severe cutaneous adverse reactions. J Dermatol 2015; 43:321-4. [DOI: 10.1111/1346-8138.13073] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 07/10/2015] [Indexed: 12/29/2022]
Affiliation(s)
- Hideaki Watanabe
- Department of Dermatology; Showa University School of Medicine; Tokyo Japan
| | - Taisuke Kamiyama
- Department of Dermatology; Showa University School of Medicine; Tokyo Japan
| | - Shun Sasaki
- Department of Dermatology; Showa University School of Medicine; Tokyo Japan
| | - Kae Kobayashi
- Department of Dermatology; Showa University School of Medicine; Tokyo Japan
| | - Kenichiro Fukuda
- Department of Emergency and Critical Care Medicine; Showa University; Tokyo Japan
| | - Yasufumi Miyake
- Department of Emergency and Critical Care Medicine; Showa University; Tokyo Japan
| | - Tohru Aruga
- Department of Emergency and Critical Care Medicine; Showa University; Tokyo Japan
| | - Hirohiko Sueki
- Department of Dermatology; Showa University School of Medicine; Tokyo Japan
| |
Collapse
|
38
|
Wilken R, Li CS, Sharon VR, Kim K, Patel FB, Patel F, Maverakis E. Topical clobetasol for the treatment of toxic epidermal necrolysis: study protocol for a randomized controlled trial. Trials 2015; 16:374. [PMID: 26297574 PMCID: PMC4546316 DOI: 10.1186/s13063-015-0879-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 07/20/2015] [Indexed: 12/02/2022] Open
Abstract
Background Toxic epidermal necrolysis (TEN) is a rare systemic allergic drug eruption with high patient mortality. Currently, no established treatments have been shown to be effective for TEN beyond supportive care. Prior studies of systemic corticosteroids have yielded conflicting data, with some showing a possible benefit and others reporting in increased mortality. However, topical steroids have shown promise for treatment of ocular sequelae of TEN, such as scarring and vision loss. We have designed a randomized controlled trial to evaluate topical clobetasol for treatment of the epidermal manifestations of TEN. In addition, we propose genetic studies to characterize the TEN transcriptome and alterations in cutaneous gene expression that might occur following topical steroid treatment. Methods/Design This split-body randomized, double-blind, placebo-controlled Phase IIa proof-of-concept trial will evaluate the safety and efficacy of once-daily topical clobetasol applied to the skin of patients with TEN. This multicenter trial will recruit a total of 15 patients between the ages of 12 and 85 from the University of California Davis Medical Center and Shriners Hospital for Children inpatient burn units. Designated treatment areas on opposite sides of the body will be treated with blinded clobetasol 0.05 % ointment or control petrolatum ointment daily for 14 days. On day 3 of therapy, a biopsy will be taken from the treated area for genetic studies. The primary study aims will be to establish the safety of topical clobetasol treatment and determine the time to cessation of skin detachment for the control and clobetasol-treated areas. Secondary endpoints will evaluate efficacy using parameters such as time to 90 % re-epithelialization and percentage of affected skin at 0, 3, 6, 9, 12 and 15 days. Genomic DNA and RNA will be obtained from biopsy samples, to characterize the TEN transcriptome and identify changes in gene expression after topical steroid treatment. Discussion Topical steroids have shown promise for treating ocular complications of TEN, but to date have not been evaluated for cutaneous manifestations of the disease. This trial will investigate clinical and molecular outcomes of topical clobetasol application and hopefully provide insight into the disease pathophysiology. Trial registration ClinicalTrials.gov NCT02319616. https://clinicaltrials.gov/ct2/show/NCT02351037
Collapse
Affiliation(s)
- Reason Wilken
- Department of Dermatology, University of California, Davis School of Medicine, 3301 C Street, Suite 1400, Sacramento, CA, 95816, USA.
| | - Chin Shang Li
- Department of Dermatology, University of California, Davis School of Medicine, 3301 C Street, Suite 1400, Sacramento, CA, 95816, USA.
| | - Victoria R Sharon
- Department of Dermatology, University of California, Davis School of Medicine, 3301 C Street, Suite 1400, Sacramento, CA, 95816, USA.
| | - Kyoungmi Kim
- Department of Dermatology, University of California, Davis School of Medicine, 3301 C Street, Suite 1400, Sacramento, CA, 95816, USA.
| | - Falin B Patel
- Department of Dermatology, University of California, Davis School of Medicine, 3301 C Street, Suite 1400, Sacramento, CA, 95816, USA.
| | - Forum Patel
- Department of Dermatology, University of California, Davis School of Medicine, 3301 C Street, Suite 1400, Sacramento, CA, 95816, USA.
| | - Emanual Maverakis
- Department of Dermatology, University of California, Davis School of Medicine, 3301 C Street, Suite 1400, Sacramento, CA, 95816, USA.
| |
Collapse
|
39
|
Abstract
The advent of biologics in dermatologic treatment armentarium has added refreshing dimensions, for it is a major breakthrough. Several agents are now available for use. It is therefore imperative to succinctly comprehend their pharmacokinetics for their apt use. A concerted endeavor has been made to delve on this subject. The major groups of biologics have been covered and include: Drugs acting against TNF-α, Alefacept, Ustekinumab, Rituximab, IVIG and Omalizumab. The relevant pharmacokinetic characteristics have been detailed. Their respective label (approved) and off-label (unapproved) indications have been defined, highlighting their dosage protocol, availability and mode of administration. The evidence level of each indication has also been discussed to apprise the clinician of their current and prospective uses. Individual anti-TNF drugs are not identical in their actions and often one is superior to the other in a particular disease. Hence, the section on anti-TNF agents mentions the literature on each drug separately, and not as a group. The limitations for their use have also been clearly brought out.
Collapse
Affiliation(s)
- Virendra N Sehgal
- Dermato-Venereology (Skin/VD) Center, Sehgal Nursing Home, Delhi, India
| | - Deepika Pandhi
- Department of Dermatology and STD, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Delhi, India
| | - Ananta Khurana
- Department of Dermatology and STD, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Delhi, India
| |
Collapse
|
40
|
Scott-Lang V, Tidman M, McKay D. Toxic epidermal necrolysis in a child successfully treated with infliximab. Pediatr Dermatol 2014; 31:532-4. [PMID: 23072342 DOI: 10.1111/pde.12029] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A 7-year-old boy developed severe toxic epidermal necrolysis (TEN) secondary to carbamazepine and was transferred to our center after further deterioration despite receiving one dose of intravenous immunoglobulin. After administration of one dose of infliximab, there was a clear halting of progression of blistering and an apparent dramatic improvement. We consider it likely that the administration of infliximab led to the improvement in this child and that anti-tumor necrosis factor-alpha therapy may be a logical treatment for TEN, given the possible underlying pathologic process. Well-conducted studies on the safety and efficacy of any such treatment are urgently required.
Collapse
Affiliation(s)
- Victoria Scott-Lang
- Department of Dermatology, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
| | | | | |
Collapse
|
41
|
Paradisi A, Abeni D, Bergamo F, Ricci F, Didona D, Didona B. Etanercept therapy for toxic epidermal necrolysis. J Am Acad Dermatol 2014; 71:278-83. [PMID: 24928706 DOI: 10.1016/j.jaad.2014.04.044] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 04/13/2014] [Accepted: 04/15/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Toxic epidermal necrolysis (TEN) is a severe and potentially lethal drug reaction for which no standard treatment is available. OBJECTIVE To describe a case series of patients with TEN treated with a single dose of etanercept. METHODS We observed 10 consecutive patients with TEN. For each patient, we recorded the presence of comorbidities and all the drugs recently started (ie, in the last month). In all cases, 50 mg of etanercept was administered in a single subcutaneous injection. The clinical severity of disease was computed using the SCORe of Toxic Epidermal Necrosis (SCORTEN) scale. Using the probabilities of death linked to each level of SCORTEN score, we calculated the expected probability of death in our patients. Healing was defined as complete reepithelialization, and a time to healing curve was then obtained using the Kaplan-Meier method. RESULTS All patients promptly responded to treatment, reaching complete reepithelialization without complications or side effects. The median time to healing was 8.5 days. LIMITATIONS This is a small, uncontrolled case series. CONCLUSION These preliminary results suggest the possibility that tumor necrosis factor-alfa may be an effective target for control of TEN, a dangerous skin condition for which no effective cure has yet been found.
Collapse
Affiliation(s)
| | - Damiano Abeni
- Health Services Research Unit, IDI-IRCCS, Rome, Italy
| | | | - Francesco Ricci
- Department of Dermatology, Catholic University of the Sacred Heart, Rome, Italy
| | - Dario Didona
- Department of Dermatology, "La Sapienza" University, Rome, Italy
| | | |
Collapse
|
42
|
Paquet P, Jennes S, Rousseau AF, Libon F, Delvenne P, Piérard GE. Effect of N-acetylcysteine combined with infliximab on toxic epidermal necrolysis. A proof-of-concept study. Burns 2014; 40:1707-12. [PMID: 24726294 DOI: 10.1016/j.burns.2014.01.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 01/02/2014] [Accepted: 01/26/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION The pathophysiology of toxic epidermal necrolysis (TEN) is thought to be related to a drug-induced oxidative stress combined with TNFα overexpression by keratinocytes. None of the current treatments for TEN including systemic corticosteroids, cyclosporine and intravenous administration of immunoglobulins has proven superior over supportive care only. METHODS A total of 10 TEN patients were enrolled to be treated at admission in burn units with the antioxidant N-acetylcysteine [NAC, 150mg/kg in a 20-h intravenous (IV) administration], or the combination of the same IV NAC perfusion with the anti-TNFα antibody infliximab (Remicade(®)), administered at a 5mg/kg dosage as a single 2-h IV administration. TEN was confirmed by a skin biopsy taken from a bullous lesion. At entry in the trial and 48h later, the illness auxiliary score (IAS) of clinical severity was determined and the extent in altered skin area (erythema and blisters) was assessed as a relative body area. Skin biopsies of both clinically uninvolved and erythematous areas were collected and immunohistochemistry was performed for assessing the density of inflammatory cells (CD8+ T cells, CD68+ macrophages) and keratinocytes enriched in intracellular calcium (Ca(++)) identified by the Mac387 anti-calprotectin antibody. RESULTS No unexpected drug-induced adverse event was noticed. After 48h of both treatment modalities, improvements were not observed in the extent of skin involvement and in IAS. Immunohistopathology showed the absence of reduction in the amount of intraepidermal inflammatory cells. An increased intracellular Ca(++) load in clinically uninvolved keratinocytes and in erythematous epidermis was noticed. This latter finding suggested the progression in the way of the apoptotic process. On burn unit discharge, the survival in each modality of treatment was not improved compared to the expected outcomes determined from the IAS at admission. CONCLUSIONS In this proof-to-concept attempt, NAC treatment or its combination with infliximab did not appear to reverse the evolving TEN process.
Collapse
Affiliation(s)
- Philippe Paquet
- Department of Dermatopathology, Unilab Lg, University Hospital of Liège, 4000 Liège, Belgium
| | - Serge Jennes
- Burn Center, Military Hospital of Brussels, Neder-Over-Heembeek, Belgium
| | | | - Florence Libon
- Department of Dermatology, University Hospital of Liège, Liège, Belgium
| | - Philippe Delvenne
- Department of Dermatopathology, Unilab Lg, University Hospital of Liège, 4000 Liège, Belgium
| | - Gérald E Piérard
- Laboratory of Skin Bioengineering and Imaging (LABIC), Department of Clinical Sciences, Liège University, Liège, Belgium.
| |
Collapse
|
43
|
Napolitano M, Giampetruzzi AR, Didona D, Papi M, Didona B. Toxic epidermal necrolysis-like acute cutaneous lupus erythematosus successfully treated with a single dose of etanercept: report of three cases. J Am Acad Dermatol 2014; 69:e303-5. [PMID: 24238188 DOI: 10.1016/j.jaad.2013.07.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 07/22/2013] [Accepted: 07/23/2013] [Indexed: 01/28/2023]
|
44
|
Thong BYH. Stevens-Johnson syndrome / toxic epidermal necrolysis: an Asia-Pacific perspective. Asia Pac Allergy 2013; 3:215-23. [PMID: 24260726 PMCID: PMC3826606 DOI: 10.5415/apallergy.2013.3.4.215] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 09/22/2013] [Indexed: 01/11/2023] Open
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe cutaneous adverse reactions (SCAR) to drugs which are associated with significant morbidity and mortality. High risk drugs in Asia are similar to those reported worldwide. Human leukocyte antigen (HLA)-related risk alleles for carbamazepine and allopurinol SCAR are unique to Asians. Although prognostic scoring systems like the SCORTEN have been used for more than a decade, pitfalls and caveats need to be recognized, in particular in patients with multiple medical co-morbidities and systemic features in SJS/TEN. In centres without a tertiary Burns Centre, SJS/TEN patients can still be managed successfully in general and dermatology wards with well-executed supportive/nursing care. Controversy remains regarding the effectiveness of immunomodulation in reducing SJS/TEN morbidity, mortality and hastening re-epithelialization. Despite paucity of robust evidence, intravenous immunoglobulins and ciclosporin remain the most commonly used modalities worldwide. Acute and long-term ocular effects are an important source of morbidity for which emerging ophthalmic therapies appear promising. Quality of life issues have now become an important outcome in patients with SJS/TEN as they often impact survivors' future attitudes towards pharmacotherapy. Even though pharmacogenetic testing for high-risk drugs appears to be the panacea for preventing carbamazepine- and allopurinol-induced SJS/TEN in ethnic Asians, many issues remain before health regulators in our region can conclusively determine whether testing should be made mandatory or highly recommended as standard of care.
Collapse
Affiliation(s)
- Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore 308433, Singapore
| |
Collapse
|
45
|
Schwartz RA, McDonough PH, Lee BW. Toxic epidermal necrolysis: Part II. Prognosis, sequelae, diagnosis, differential diagnosis, prevention, and treatment. J Am Acad Dermatol 2013; 69:187.e1-16; quiz 203-4. [PMID: 23866879 DOI: 10.1016/j.jaad.2013.05.002] [Citation(s) in RCA: 179] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 05/06/2013] [Accepted: 05/10/2013] [Indexed: 02/01/2023]
Abstract
Toxic epidermal necrolysis (TEN) is a life-threatening, typically drug-induced, mucocutaneous disease. TEN has a high mortality rate, making early diagnosis and treatment of paramount importance. New but experimental diagnostic tools that measure serum granulysin and high-mobility group protein B1 (HMGB1) offer the potential to differentiate early TEN from other, less serious drug reactions, but these tests have not been validated and are not readily available. The mainstay of treatment for TEN involves discontinuation of the offending drug, specialized care in an intensive care unit or burn center, and supportive therapy. Pharmacogenetic studies have clearly established a link between human leukocyte antigen allotype and TEN. Human leukocyte antigen testing should be performed on patients of East Asian descent before the initiation of carbamezapine and on all patients before the initiation of abacavir. The effectiveness of systemic steroids, intravenous immunoglobulins, plasmapheresis, cyclosporine, biologics, and other agents is uncertain.
Collapse
Affiliation(s)
- Robert A Schwartz
- Dermatology, Preventive Medicine, and Pathology, Rutgers University New Jersey Medical School, Newark, New Jersey 07103-2714, USA.
| | | | | |
Collapse
|
46
|
Use of etanercept to treat toxic epidermal necrolysis in a human immunodeficiency virus-positive patient. DERMATOL SIN 2013. [DOI: 10.1016/j.dsi.2012.06.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
47
|
Immunological mechanisms of epidermal damage in toxic epidermal necrolysis. Curr Opin Allergy Clin Immunol 2012; 12:376-82. [PMID: 22688730 DOI: 10.1097/aci.0b013e328355b865] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW The purpose of the present review is to introduce recent findings on the pathomechanisms of toxic epidermal necrolysis (TEN), which is characterized by widespread epidermal detachment due to keratinocyte apoptosis. RECENT FINDINGS In the mechanism of epidermal damage, the roles of drug metabolites, cytotoxic lymphocytes, and apoptosis-inducing factors have been noted. In addition, recent studies have focused on monocytes/macrophages, which may participate in epidermal damage through the production of apoptosis-inducing factors and the expression of costimulatory factors with the ability to activate CD8 T cells. SUMMARY Epidermal keratinocyte death is a hallmark of TEN. In a very high proportion of cases, drugs are responsible for TEN. It has been suggested that toxic drug metabolites produced by keratinocytes act like electrophilic agents to induce apoptosis and inflammation. Next, cytotoxic lymphocytes and monocytes function in the development of widespread epidermal damage through direct or indirect cytotoxic pathways. In addition, T-cell activation may be strengthened by the impairment of regulatory T-cell function and activated monocytes. The development of epidermal damage in TEN may require the coordinated action of these factors.
Collapse
|
48
|
Viard-Leveugle I, Gaide O, Jankovic D, Feldmeyer L, Kerl K, Pickard C, Roques S, Friedmann PS, Contassot E, French LE. TNF-α and IFN-γ are potential inducers of Fas-mediated keratinocyte apoptosis through activation of inducible nitric oxide synthase in toxic epidermal necrolysis. J Invest Dermatol 2012; 133:489-98. [PMID: 22992806 DOI: 10.1038/jid.2012.330] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Toxic epidermal necrolysis (TEN) is a severe immune-mediated adverse cutaneous drug eruption characterized by rapid and extensive epithelial cell death in the epidermis and mucosae. The molecular events leading to this often fatal condition are only partially understood, but evidence suggests a dual mechanism implicating a "drug"-specific immune response on one side and the onset of target cell death by proapoptotic molecules including FasL on the other side. Herein, we describe a potential molecular bridge between these two events that involves inducible nitric oxide synthase (iNOS), which is highly upregulated in the skin of TEN patients. We show that activated T cells secrete high amounts of tumor necrosis factor-α (TNF-α) and IFN-γ, and that both cytokines lead to increased expression and activity of keratinocyte iNOS. A similar observation has been made with drug-specific T lymphocytes from a TEN patient exposed to the culprit drug. The resulting increase in nitric oxide significantly upregulates keratinocyte FasL expression, resulting in Fas- and caspase-8-mediated keratinocyte cell death. Taken together, our data suggest that T-lymphocyte activation by drugs in TEN patients may indirectly lead to FasL-mediated keratinocyte apoptosis, via a molecular bridge involving TNF-α, IFN-γ, and iNOS.
Collapse
|
49
|
Noordally SO, Sohawon S, Vanderhulst J, Duttmann R, Corazza F, Devriendt J. A fatal case of cutaneous adverse drug-induced toxic epidermal necrolysis associated with severe rhabdomyolysis. Ann Saudi Med 2012; 32:309-11. [PMID: 22588445 PMCID: PMC6081042 DOI: 10.5144/0256-4947.2012.309] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Toxic epidermal necrolysis represents an immunologic reaction to a foreign antigen and is most often caused by drugs. Atorvastatin, a blood cholesterol-lowering agent, is a recognized cause of rhabdomyolysis; while naproxen, a widely used nonsteroidal anti-inflammatory drug, is a known cause of photo-induced skin lesions. We report the first fatal case of drug-induced toxic epidermal necrolysis associated with severe muscle necrosis due to the use of a nonsteroidal anti-inflammatory drug and a statin with very high levels of creatine phosphokinase leading to acute kidney injury, disseminated intravascular coagulation, and complete skin necrosis leading to death.
Collapse
Affiliation(s)
- Sheik Oaleed Noordally
- Department of Critical Care Medicine, Centre Hospitalier Universitaire de Tubize-Nivelles, 1400 Nivelles, Belgium.
| | | | | | | | | | | |
Collapse
|
50
|
|