Corticosteroids for erythema multiforme?

Reactivated herpetic gingivostomatitis with secondary herpes‐associated erythema multiforme and oral candidiasis post‐COVID infection: A case report

The presence and reactivation of oral lesions such as herpetic gingivostomatitis, erythema multiforme, and candidiasis in a COVID‐19 recovered patient could be related to COVID‐19s profound role in immune dysregulation or related therapies.

[Use of intravenous immunoglobulin in toxic epidermal necrolysis and Stevens-Johnson syndrome]

Toxic epidermal necrolysis and Stevens-Johnson syndrome are described as variants of the same disease with distinct severity and constitute the most frequent cutaneous reactions in children, causing considerable morbidity. Several reports support the use of intravenous immunoglobulin therapy in these entities. We report the cases of two patients, one with toxic epidermal necrolysis and the other with Stevens-Johnson syndrome, in whom immunoglobulin treatment was successfully used. We also reviewed the outcomes of 13 patients with toxic epidermal necrolysis and Stevens-Johnson syndrome in the previous 10 years in the Hospital Infantil de Mexico, in whom conventional treatment was used.

Intravenous immunoglobulins for the management of Stevens-Johnson syndrome with minimal skin manifestations

Here we describe the successful use of intravenous immunoglobulin (IVIG) in the management of mycoplasma-induced, atypical Stevens-Johnson syndrome (SJS) with minimal skin manifestations. The patient was successfully managed with high-dose IVIG 0.5 g/kg for 4 consecutive days. No complications were noted. IVIG may be useful in the management of mycoplasma-induced SJS.

Use of intravenous immunoglobulin in children with stevens-johnson syndrome and toxic epidermal necrolysis: seven cases and review of the literature

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis are the most severe cutaneous reactions that occur in children. Off-label use of human intravenous immunoglobulin (IVIG) has been reported in a number of autoimmune and cell-mediated blistering disorders of the skin, including severe cutaneous drug reactions. We review 28 previous reports in which IVIG was used in pediatric patients with SJS and toxic epidermal necrolysis and discuss our experience in 7 children with SJS, in whom no new blisters developed within 24 to 48 hours after IVIG administration and rapid recovery ensued. IVIG seems to be a useful and safe therapy for children with severe cutaneous drug reactions. Well-controlled, prospective, multicenter clinical trials are needed to determine optimal dosing guidelines and to compare the efficacy and safety of IVIG with other potentially effective modalities.

Progress in the understanding of the pathology and pathogenesis of cutaneous drug eruptions : implications for management

Cutaneous drug eruptions are among the most common adverse reactions to drug therapy. The etiology may reflect immunologic or nonimmunologic mechanisms, the former encompassing all of the classic Gell and Combs immune mechanisms. Cumulative and synergistic effects of drugs include those interactions of pharmacokinetic and pharmacodynamic factors reflecting the alteration by one drug of the effective serum concentration of another and the functions of drugs and their metabolites that interact to evoke cutaneous and systemic adverse reactions. Recent observations include the role of concurrent infection with lymphotropic viruses and drug effects that, through the enhancement of lymphoid blast transformation and/or lymphocyte survival and the contribution of intercurrent systemic connective tissue disease syndromes, promote enhanced lymphocyte longevity and the acquisition of progressively broadening autoantibody specificities. The latter are particularly opposite to drug-induced lupus erythematosus and to drug reactions in the setting of HIV infection. Specific common types of cutaneous drug eruptions will be discussed in this review. Successful management of cutaneous drug eruptions relies upon the prompt discontinuation of the causative medication; most drug eruptions have a good prognosis after this is accomplished. Oral or topical corticosteroids can be administered to aid in the resolution of some types of eruptions. Antihistamines or anti-inflammatory agents may also be administered for some eruptions.

Stevens-Johnson syndrome developing in a girl with systemic lupus erythematosus on high-dose corticosteroid therapy

Stevens-Johnson syndrome (SJS) is a vesiculobullous disease of the skin and mucosa. This generalized hypersensitivity reaction is well known to occur in association with certain drugs, particularly sulfonamides, nonsteroidal anti-inflammatory agents (NSAIDs), and anticonvulsants. The disease is usually seen in children and young adults and is often treated with corticosteroids. We present a 9-year-old girl with lupus nephritis who developed cutaneous bullae and mucositis while being treated with intravenous methylprednisolone. The initial differential diagnosis included bullous lupus, but skin biopsy specimen findings supported a diagnosis of SJS. She was treated with intravenous immunoglobulin (IVIg).

Scrotal temperature is increased in disposable plastic lined nappies

OBJECTIVES

Male reproductive health has deteriorated in recent decades. It is proposed that increased testicular temperature in early childhood, due to the use of modern disposable plastic lined nappies (diapers), could be an important factor contributing to this decline.

STUDY DESIGN

Scrotal skin temperature was measured non-invasively in 48 healthy children aged 0-55 months (three age groups) for two 24 hour periods in randomised order (either cotton or disposable plastic lined nappies) using a portable, miniature recorder.

RESULTS

Mean 24 hour scrotal temperature (2880 measurements) was significantly higher in all age groups during the periods of plastic nappy use than with cotton nappies (p < 0.001). The rectoscrotal temperature difference was significantly higher with cotton than with plastic nappy use (p < 0.01).

CONCLUSIONS

Scrotal hypothermia is an important factor for normal spermatogenesis. This study shows that scrotal temperature, which closely reflects testicular temperature, is increased in boys wearing disposable plastic lined nappies. The physiological testicular cooling mechanism is blunted and often completely abolished during plastic nappy use. The present results establish the basis for further research on the impact of increased testicular temperature in infancy on later spermatogenesis.

Diagnosis, classification, and management of erythema multiforme and Stevens-Johnson syndrome

BACKGROUND

In adults, erythema multiforme (EM) is thought to be mainly related to herpes infection and Stevens-Johnson syndrome (SJS) to drug reactions.

AIMS

To investigate this hypothesis in children, and to review our experience in the management of these patients.

METHODS

A retrospective analysis of 77 paediatric cases of EM or SJS admitted to the Children's Hospital in Bordeaux between 1974 and 1998.

RESULTS

Thirty five cases, inadequately documented or misdiagnosed mostly as urticarias or non-EM drug reactions were excluded. Among the remaining 42 patients (14 girls and 28 boys), 22 had EM (11 EM minor and 11 EM major), 17 had SJS, and three had isolated mucous membrane involvement and were classified separately. Childhood EM was mostly related to herpes infection and SJS to infectious agents, especially Mycoplasma pneumoniae. Only two cases were firmly attributed to drugs (antibiotics). No patient died. EM and SJS sequelae were minor and steroids were of no overall benefit.

CONCLUSION

In paediatric practice EM is frequently misdiagnosed. The proposal that SJS is drug related in adults does not apply to children, and in our recruitment EM and SJS are mostly triggered by infectious agents. The course of both diseases, even though dramatic at onset, leads to low morbidity and mortality when appropriate symptomatic treatment is given.

Toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) is a rare but life-threatening adverse drug reaction. Implicated drugs are sulfonamides, anticonvulsants, allopurinol, and pyrazolone derivatives. Recently, advances in pathogenesis have been made in two directions. It is now known that (1) most patients with TEN have an abnormal metabolism to the culprit drug; and (2) the mechanism leading to epidermal necrolysis seems to be a cell-mediated cytotoxic reaction. The treatment remains symptomatic.

High-dose systemic corticosteroids can arrest recurrences of severe mucocutaneous erythema multiforme

We treated two children with a total of five recurrences of erythema multiforme major with pulsed dose, systemic corticosteroid therapy on an open basis, and report herein the beneficial effects of this regime. We mean to further reevaluate this therapy on a controlled study basis.

Advances in toxic epidermal necrolysis

On the basis of the clinicopathologic and causative characteristics, one can separate an erythema multiformis spectrum from a toxic epidermal necrolysis (TEN)-Stevens Johnson syndrome which is a drug induced disease. Despite a well-known clinical aspect, several cutaneous diseases may be mistaken for TEN. Responsible drugs are sulfonamides anticonvulsants, and nonsteroidal antiinflammatory drugs--patients infected with HIV are at a higher risk of developing TEN. Pathogenesis includes abnormal drug metabolism and cell mediated immune keratinocyte apoptosis. Treatment relies on symptomatic management and so-called specific treatments including steroids are probably harmful.

A case report of Stevens-Johnson syndrome with Mycoplasma pneumoniae infection

We encountered an 8 year old boy who suffered from Stevens-Johnson syndrome with Mycoplasma pneumoniae infection. He had multiple erythema with vesicles in oral mucosa, and on his palms and feet, trunk and genital regions. We treated him with prednisolone (1 mg/kg per day) and antibiotics. His skin lesions improved dramatically, and a persistent fever and toxic general condition also showed dramatic improvement. Although the use of corticosteroids for Stevens-Johnson syndrome has recently been controversial, we thought that administration of corticosteroids was an effective treatment for some selective cases of Stevens-Johnson syndrome. The patient reported in this study had many beneficial effects in response to corticosteroid treatment.

A case of herpes-associated erythema multiforme in a Japanese child

A case of a five-year-old Japanese boy with herpes-associated erythema multiforme (HAEM) was reported. The patient had eleven recurrences of herpes labiaris within one year; four of these recurrences were accompanied by erythema multiforme. A study of the human leukocyte antigens revealed the presence of HLA-DQW3, which has been reported to be significantly frequent in Caucasian patients with HAEM. Oral administration of acyclovir at the onset of herpes labialis was effective in preventing HAEM. Early administration of oral steroids at the onset of HAEM also prevented its exacerbation.

Blistering disorders in childhood

Many conditions present in childhood with vesicles and bullae, ranging from benign conditions to life-threatening diseases. This article reviews selected blistering disorders, with emphasis on new information that is helpful to the practicing physician. Entities that are discussed in this article include childhood zoster and fetal varicella syndrome, urticaria pigmentosa, scabies, bullous bug bites, lichen sclerosus et atrophicus, epidermolysis bullosa, and erythema multiforme.

Toxic epidermal necrolysis: a review

This article reviews the many facets of toxic epidermal necrolysis. Emphasis is placed on the importance of early diagnosis, burn unit placement, supportive care, and avoidance of systemic steroids. Discussion also includes other therapeutic options and the pathophysiology of the disease.

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

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

Toxic epidermal necrolysis (Lyell syndrome)

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

Toxic epidermal necrolysis after bone marrow transplantation: study of nine cases

Acute graft-versus-host reaction after allogeneic bone marrow transplantation has been reported to induce toxic epidermal necrolysis. To assess the respective role of acute graft-versus-host disease and of drug reaction in this setting, we retrospectively reviewed nine cases of toxic epidermal necrolysis that occurred in a series of 152 allogenic bone marrow recipients. In five cases visceral involvement was suggestive of acute graft-versus-host disease without any drug more than "doubtfully" suspected. In four cases extracutaneous symptoms were absent or mild and suspect drugs (mainly sulfonamides) had been administered with a timing suggestive of "possible" causality. All nine patients died, mainly from infection possibly aggravated by high doses of corticosteroids. We conclude that toxic epidermal necrolysis may be more frequent than generally thought after bone marrow transplantation and has a poor prognosis. It seems to be related to a drug reaction to sulfonamides as often as to acute graft-versus-host disease.