1
|
Tasker F, Smith SP, Mohd Mustapa MF, de Berker DAR. British Association of Dermatologists national clinical audit on the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults. Clin Exp Dermatol 2024; 49:810-816. [PMID: 38245826 DOI: 10.1093/ced/llae010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/28/2023] [Accepted: 12/28/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND UK guidelines for managing adults with Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), published by the British Association of Dermatologists (BAD) in 2016, outline a set of audit standards. OBJECTIVES To audit current management of SJS/TEN in adults against standards in the BAD guidelines. METHODS BAD members were invited to submit data on five consecutive adults with SJS/TEN per department over an 8-week period in 2022. RESULTS Thirty-nine dermatology centres in the UK (29%) participated, and data for 147 adults with SJS/TEN were collected. Within 24 h of the diagnosis being made or suspected, the following were documented, per 147 submitted cases: Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN) for 76 (52%), list of medications for 113 (77%) and timelines for commencement/alterations of medications for 104 (71%). The initial assessment was documented of the eyes by an ophthalmologist in 71 (48%), of the mouth in 130 (88%), of the genital skin in 103 (70%) and of the urinary tract in 93 (63%). During the first 10 days after a suspected or confirmed diagnosis of SJS/TEN, daily assessments of the mouth were documented in 26 of 147 cases (18%), of the eyes in 12 (8%), and of the urinary tract and genital skin in 14 (10%). At discharge, a drug was declared to be the cause of SJS/TEN for 130 of 147 cases (88%), while 9 (6%) were thought to be secondary to infection. Eleven of 147 (8%) had no response to this question. Documentation regarding advice was present on avoidance of the culprit drug in 76 of 130 declared SJS/TEN cases (58%), and on requesting a MedicAlert® bracelet/amulet in 9 of the 147 cases (6%). CONCLUSIONS This audit suggests that a clinical review checklist might be needed to enable colleagues to maintain standards outlined in the guidelines, including documentation of SCORTEN, daily assessments of mucosal areas, and advice to avoid culprit drug(s) and to request a MedicAlert® bracelet/amulet.
Collapse
Affiliation(s)
- Fiona Tasker
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Stephen P Smith
- Department of Pathology, University of Cambridge, Cambridge, UK
| | | | | |
Collapse
|
2
|
van Nispen C, Long B, Koyfman A. High risk and low prevalence diseases: Stevens Johnson syndrome and toxic epidermal necrolysis. Am J Emerg Med 2024; 81:16-22. [PMID: 38631147 DOI: 10.1016/j.ajem.2024.04.001] [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: 02/09/2024] [Revised: 03/04/2024] [Accepted: 04/04/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are serious conditions that carry a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of SJS/TEN, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION SJS/TEN is a rare, delayed hypersensitivity reaction resulting in de-epithelialization of the skin and mucous membranes. The majority of cases are associated with medication or infection. Clinicians should consider SJS/TEN in any patient presenting with a blistering mucocutaneous eruption. Evaluation of the skin, mucosal, pulmonary, renal, genital, and ocular systems are essential in the diagnosis of SJS/TEN, as well as in the identification of complications (e.g., sepsis). Laboratory and radiological testing cannot confirm the diagnosis in the ED setting, but they may assist in the identification of complications. ED management includes stabilization of airway and breathing, fluid resuscitation, and treatment of any superimposed infections with broad-spectrum antibiotic therapy. All patients with suspected SJS/TEN should be transferred and admitted to a center with burn surgery, critical care, dermatology, and broad specialist availability. CONCLUSIONS An understanding of SJS/TEN can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
Collapse
Affiliation(s)
- Christiaan van Nispen
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America
| | - Alex Koyfman
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| |
Collapse
|
3
|
Erduran F, Adışen E, Emre S, Hayran Y, Başkan EB, Yazıcı S, Bilgiç A, Alpsoy E, Günaydın SD, Elmas L, Akyol M, Güner R, Arıca DA, Aypek Y, Ergun T, Karavelioğlu D, Yazıcı AC, Aydoğan K, Bayramgürler D, Kıran R, Erdoğan HK, Acer E, Aktaş A. Evaluation of the Factors Influencing Mortality in Patients with Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Multicenter Study of 166 Patients. Dermatol Ther (Heidelb) 2024; 14:1547-1560. [PMID: 38758423 PMCID: PMC11169098 DOI: 10.1007/s13555-024-01180-6] [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: 03/04/2024] [Accepted: 05/01/2024] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening acute mucocutaneous disorders usually triggered by drugs. In this study, we aimed to evaluate the factors affecting mortality in patients with SJS-TEN. METHODS Our study is a retrospective cohort study, analyzing data collected from a total of 12 tertiary care centers between April 2012 and April 2022. RESULTS The study included 59 males and 107 females, a total of 166 patients, with an average age of 50.91 ± 21.25 years. Disease classification was TEN in 50% of cases, SJS in 33.1%, and SJS-TEN overlap in 16.9%. The average SCORTEN within the first 24 h was 2.44 ± 1.42. Supportive care was provided to 99.4% of patients. The most commonly used systemic immunomodulatory treatments were systemic steroids (84.3%), IVIG (intravenous immunoglobulin) (49.3%), and cyclosporine (38.6%). Plasmapheresis was administered to five patients. While 66.3% of patients were discharged, 24.1% resulted in exitus. Our comparative analysis of survivors and deceased patients found no effect of systemic steroids, IVIG, and cyclosporine treatments on mortality. Univariate analysis revealed that the SCORTEN scores on days 1 and 3 as well as the rates of detachment at the onset and during follow-up were significantly higher in deceased patients compared to survivors. The rates of fever, positive blood cultures, and systemic antibiotic use were higher in deceased patients compared to survivors. The presence of comorbidities, diabetes, and malignancy were significantly more common in deceased patients. Multivariate regression analysis indicated that over SCORTEN 2, the mortality risk exponentially rose with each SCORTEN increment, culminating in an 84-fold increase in mortality at SCORTEN 5-6 (odds ratio [95% confidence interval]: 13.902-507.537, p < 0.001) compared to SCORTEN 0-1. Additionally, the utilization of plasmapheresis was associated with a 22-fold increase in mortality (odds ratio [95% confidence interval]: 1.96-247.2, p = 0.012). CONCLUSION Our study found that a high SCORTEN score within the first 24 h and the use of plasmapheresis were related to increased mortality, while systemic steroids, IVIG, and cyclosporine treatments had no impact on mortality. We believe that data gathered from one of the most comprehensive studies which we conducted on SJS-TEN will enrich the literature, although additional research is warranted.
Collapse
Affiliation(s)
- Funda Erduran
- Ankara Bilkent City Hospital, Department of Dermatology, Ankara, Turkey.
| | - Esra Adışen
- Department of Dermatology, Gazi University, Ankara, Turkey
| | - Selma Emre
- Department of Dermatology, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Yıldız Hayran
- Ankara Bilkent City Hospital, Department of Dermatology, Ankara, Turkey
| | | | - Serkan Yazıcı
- Department of Dermatology, Bursa Uludağ University, Bursa, Turkey
| | - Aslı Bilgiç
- Department of Dermatology, Akdeniz University, Antalya, Turkey
| | - Erkan Alpsoy
- Department of Dermatology, Akdeniz University, Antalya, Turkey
| | | | - Leyla Elmas
- Department of Dermatology, Hacettepe University, Ankara, Turkey
| | - Melih Akyol
- Department of Dermatology, Sivas Cumhuriyet University, Sivas, Turkey
| | - RukiyeYasak Güner
- Department of Dermatology, Sivas Cumhuriyet University, Sivas, Turkey
| | - Deniz Aksu Arıca
- Department of Dermatology, Karadeniz Technical University, Trabzon, Turkey
| | - Yağmur Aypek
- Department of Dermatology, Gazi University, Ankara, Turkey
| | - Tülin Ergun
- Department of Dermatology, Marmara University, Istanbul, Turkey
| | | | | | - Kübra Aydoğan
- Department of Dermatology, Mersin University, Mersin, Turkey
| | | | - Rebiay Kıran
- Department of Dermatology, Kocaeli University, Kocaeli, Turkey
| | - Hilal Kaya Erdoğan
- Department of Dermatology, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Ersoy Acer
- Department of Dermatology, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Akın Aktaş
- Department of Dermatology, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| |
Collapse
|
4
|
Sutaria A, Rawlani S, Sutaria AH. Causes and Management of Cutaneous Adverse Drug Reactions: A Comprehensive Review. Cureus 2024; 16:e55318. [PMID: 38562325 PMCID: PMC10982164 DOI: 10.7759/cureus.55318] [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: 07/25/2023] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
Cutaneous adverse drug reactions (CADRs) are one of the most broadly studied and rigorously researched conditions in recent dermatological advancements. Also termed as "toxidermia," they are heavily involved and are of utmost importance to be understood and studied in the modern healthcare industry. In simple terms, they are dermatological manifestations which result from systemic drug administration to patients. Since allopathy is influenced by the medicines and drugs provided to the patients, cutaneous skin eruptions are a common occurrence in recent times. It is a need of the hour to understand the causative factors for such skin eruptions and the correct management and handling of such disorders to provide better healthcare to patients. The withdrawal of the causative drug which induces the reaction plays a key role in treatment. The risk factors are to be thoroughly studied, and dosages must be in accordance with the patient's situation. They are some of the common public health problems. The age group which is affected is highly variable as people from all age groups can be affected. Those who are affected comprise approximately 10% of all hospitalized patients, and it is also observed in about 1-4% of people who are on multiple medications.
Collapse
Affiliation(s)
- Arsh Sutaria
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research (Deemed to be University), Wardha, IND
| | - Shobha Rawlani
- Anatomy, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research (Deemed to be University), Wardha, IND
| | - Amita H Sutaria
- Dermatology, Byramjee Jeejeebhoy (BJ) Medical College and Civil Hospital, Ahmedabad, IND
| |
Collapse
|
5
|
Schroeder JW, Caputo V, Guida S, Conte F, Paolino G, Bonoldi E, Baruffaldi Preis FW, Rongioletti F. Stevens-Johnson syndrome and toxic epidermal necrolysis: 11-year retrospective experience in a high-complexity tertiary hospital in Milan, Italy. Clin Dermatol 2023; 41:712-720. [PMID: 37716583 DOI: 10.1016/j.clindermatol.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe drug-induced hypersensitivity reactions characterized by widespread epidermal necrosis, mucous membrane erosions, and systemic findings. We have provided our 11-year experience from a Milan, Italy tertiary hospital managing SJS/TEN, evaluating the clinical and histopathologic features plus the impact on mortality. We retrospectively analyzed 28 patients diagnosed with SJS/TEN based on the clinical and histopathologic findings, according to the classification criteria of multiple studies. We assessed the dermatographics, comorbidities, drug history, lesion characteristics, clinical findings, treatments, blood tests, and outcomes. Severity scores (SCORTEN, Re-SCORTEN, ABCD-10) were used for treatment evaluation and mortality prediction. Data were statistically analyzed, and significant factors associated with mortality were identified. We found that among the 28 patients, 89.2% had comorbidities, mainly cardiovascular diseases, and 21.4% had autoimmune disorders. All patients had received systemic therapy (46.6% monotherapy, 53.6% combination therapy), with systemic steroids (71.4%) and intravenous immunoglobulins (67.8%) being common treatments. There were complications, including systemic infections (67.9%) and septic shock (10.7%). The overall mortality rate was 17.8%. The statistical analysis indicated that malignancy, a high ABCD-10 score, and a high neutrophil-to-lymphocyte ratio were significantly associated with mortality. The extent of affected body surface area did not correlate significantly with mortality. This study provides insights into SJS/TEN management, revealing factors influencing mortality in a high-complexity tertiary hospital setting.
Collapse
Affiliation(s)
- Jan W Schroeder
- Unit of Allergology and Immunology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Valentina Caputo
- Unit of Pathological Anatomy and Cytogenetics, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefania Guida
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Dermatology Clinic, IRCCS San Raffaele Hospital, Milan, Italy
| | - Francesca Conte
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Paolino
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Emanuela Bonoldi
- Unit of Pathological Anatomy and Cytogenetics, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Franco Rongioletti
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Dermatology Clinic, IRCCS San Raffaele Hospital, Milan, Italy.
| |
Collapse
|
6
|
Zhang L, Lan Y, Qi B, Shuai P, Hou Q, Liu W, Wang Q. RDW-SD and PCT Are Potential Prognostic Factors for In-hospital Death in Patients With Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2023; 15:812-824. [PMID: 37957797 PMCID: PMC10643861 DOI: 10.4168/aair.2023.15.6.812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/12/2023] [Accepted: 06/13/2023] [Indexed: 11/15/2023]
Abstract
PURPOSE Our study aimed to explore potential prognostic factors in Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) patients from easily accessible laboratory data and to investigate whether the combination of these indicators with a score for toxic epidermal necrolysis (SCORTEN) can improve the predictive value. METHODS Data from 85 SJS/TEN patients hospitalized from 2010 to 2021 were retrospectively analyzed. The primary outcome was in-hospital mortality. Univariate analysis was used to screen for laboratory indexes associated with death. Logistic regression was used to analyze significant risk factors for death. The differentiation and calibration of SCORTEN and modified score were assessed using receiver operating characteristic (ROC) curves and Hosmer-Lemeshow goodness-of-fit test. Net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were used to evaluate the incremental prognostic value. RESULTS Among the 85 patients (37 males, 48 females) aged 14-88 years, the mortality rate was 11.8% (n = 10). SCORTEN had good discrimination and calibration to predict mortality in this cohort of patients (area under the ROC curve [AUC] of 0.874, 95% confidence interval [CI], 0.758-0.990; Hosmer-Lemeshow goodness-of-fit test P = 0.994). Red cell distribution width-standard deviation index (RDW-SD) > 47.9 fL and procalcitonin (PCT) > 0.67 ng/mL were significant risk factors for death. When adding the 2 factors to SCORTEN, AUC was 0.915 (95% CI, 0.833-0.997), but not statistically different compared to SCORTEN alone (P = 0.091). The NRI was 1.2 (95% CI, 0.672-1.728; P < 0.001) and the IDI was 0.09 (95% CI, 0.011-0.173; P = 0.026), still suggesting that the modified score had better discriminatory and predictive power than SCORTEN alone. The modified score also showed good calibration (Hosmer-Lemeshow goodness-of-fit test, P = 0.915). CONCLUSIONS SCORTEN is a good predictor of mortality in SJS/TEN patients in southwest China. Combining RDW-SD > 47.9 fL and PCT > 0.67 ng/mL with SCORTEN may enhance the ability to predict prognosis.
Collapse
Affiliation(s)
- Lixia Zhang
- The Institute of Dermatology and Venereology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yunping Lan
- Department of Intensive Care Unit, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Bo Qi
- Department of Intensive Care Unit, 903 Hospital, Mianyang, China
| | - Ping Shuai
- Department of Health Management & Institute of Health Management, School of Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Qinchuan Hou
- School of Public Health, Southwest Medical University, Luzhou, China
| | - Wei Liu
- The Institute of Dermatology and Venereology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.
| | - Qian Wang
- The Institute of Dermatology and Venereology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.
| |
Collapse
|
7
|
Hsieh TS, Chan TC, Cho YT, Chu CY. Comparison of performance of SCORTEN, ABCD-10 and Re-SCORTEN in a cohort of patients with Stevens-Johnson syndrome/toxic epidermal necrolysis. J Eur Acad Dermatol Venereol 2023; 37:e514-e516. [PMID: 36377280 DOI: 10.1111/jdv.18734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 11/08/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Tyng-Shiuan Hsieh
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Tom C Chan
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yung-Tsu Cho
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chia-Yu Chu
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| |
Collapse
|
8
|
Zhang Z, Yu K, Jiang Z, Liu O, Wan C, Wu H, Cao X. Clinical value of the prognostic nutritional index and red blood cell distribution width‐to‐albumin ratio for the prediction of severity of and mortality associated with Stevens–Johnson syndrome/toxic epidermal necrolysis. J Dermatol 2022; 50:518-524. [PMID: 36478458 DOI: 10.1111/1346-8138.16661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/09/2022] [Accepted: 11/12/2022] [Indexed: 12/12/2022]
Abstract
The prognostic nutritional index (PNI) and red blood cell distribution width-to-albumin ratio (RAR) are considered to be related to the prognosis of disease severity. However, the role of these biomarkers in predicting Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) severity and mortality is unclear. The aim of the current study was to investigate the association of PNI and RAR with severity and mortality in individuals with SJS/TEN. Clinical data were retrospectively collected from 74 individuals with SJS/TEN and 74 healthy individuals, who were matched for age and sex during the same period. PNI, RAR, and other indicators were compared between individuals with SJS/TEN and healthy controls. The association of PNI and RAR with SJS/TEN severity was assessed using Spearman or Pearson correlation analyses. Individuals with SJS/TEN were categorized into two groups, either survivors or nonsurvivors. The correlation between PNI, RAR, and SJS/TEN mortality was analyzed using univariate and multivariate logistic regression. The predictive value of the previously mentioned indicators on the mortality of patients with SJS/TEN was assessed using receiver operating characteristic curve analysis. The RAR level of patients with SJS/TEN was greater than that of the control group (p < 0.05), whereas PNI was lower. In compliance with correlation analysis, RAR was positively correlated with SCORTEN (Score of Toxic Epidermal Necrolysis) and ABCD-10 (age, bicarbonate, cancer, dialysis, 10% body surface area) (p < 0.05), and PNI was negatively correlated (p < 0.05). RAR is a risk factor for death in patients with SJS/TEN, but an elevated PNI level is a protective factor for mortality. The best cutoff values of PNI and RAR for predicting death in patients with SJS/TEN were 31.375 (sensitivity, 84.7%; specificity, 80%) and 0.486 (sensitivity, 73.3%; specificity, 84.7%). These results underscore the potential clinical value of PNI and RAR as appropriate and meaningful biomarkers to assess the severity of SJS/TEN and the mortality associated with it.
Collapse
Affiliation(s)
- Zhibin Zhang
- Department of Dermatology The First Affiliated Hospital of Nanchang University Nanchang China
| | - Kaihui Yu
- Health Management Center The First Affiliated Hospital of Nanchang University Nanchang China
| | - Zhenyu Jiang
- Department of Burn The First Affiliated Hospital of Nanchang University Nanchang China
| | - Ougen Liu
- Department of Dermatology The Second Affiliated Hospital of Nanchang University Nanchang China
| | - Chuan Wan
- Department of Dermatology The First Affiliated Hospital of Nanchang University Nanchang China
| | - Hongxuan Wu
- Department of Dermatology The First Affiliated Hospital of Nanchang University Nanchang China
| | - Xianwei Cao
- Department of Dermatology The First Affiliated Hospital of Nanchang University Nanchang China
| |
Collapse
|
9
|
Dobry AS, Himed S, Waters M, Kaffenberger BH. Scoring Assessments in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Front Med (Lausanne) 2022; 9:883121. [PMID: 35783656 PMCID: PMC9245022 DOI: 10.3389/fmed.2022.883121] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/25/2022] [Indexed: 11/29/2022] Open
Abstract
Epidermal necrolysis, the unifying term for Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), is a severe cutaneous drug reaction associated with high morbidity and mortality. Given the rarity of this disease, large-scale prospective research studies are limited. Significant institutional and geographical variations in treatment practices highlight the need for standardization of clinical assessment scores and prioritization of research outcome measures in epidermal necrolysis. At the present, clinical assessment is typically simplified to total body surface area (BSA) involvement, with little focus on morphology. Validated clinical scoring systems are used as mortality prognostication tools, with SCORTEN being the best-validated tool thus far, although the ABCD-10 has also been recently introduced. These tools are imperfect in that they tend to either overestimate or underestimate mortality in certain populations and are not designed to monitor disease progression. Although mortality is often used as a primary endpoint for epidermal necrolysis studies, this outcome fails to capture more nuanced changes in skin disease such as arrest of disease progression while also lacking a validated skin-directed inclusion criterion to stratify patients based on the severity of skin disease at study entry. In addition to mortality, many studies also use BSA stabilization or time to re-epithelialization as endpoints, although these are not clearly defined morphologically, and inter- and intra-rater reliability are unclear. More specific, validated cutaneous assessment scores are necessary in order advance therapeutic options for epidermal necrolysis. In this review, we summarize the strengths and weaknesses of current clinical assessment practices in epidermal necrolysis and highlight the need for standardized research tools to monitor cutaneous involvement throughout the hospitalization.
Collapse
Affiliation(s)
- Allison S. Dobry
- Department of Dermatology, University of California, San Francisco, San Francisco, CA, United States
- *Correspondence: Allison S. Dobry
| | - Sonia Himed
- Division of Dermatology, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Margo Waters
- Ohio State University College of Medicine, Columbus, OH, United States
| | - Benjamin H. Kaffenberger
- Division of Dermatology, Ohio State University Wexner Medical Center, Columbus, OH, United States
- Ohio State University College of Medicine, Columbus, OH, United States
| |
Collapse
|
10
|
Impact of multiple medical interventions on mortality, length of hospital stay and reepithelialization time in Toxic Epidermal Necrolysis, Steven-Johnsons Syndrome, and TEN/SJS Overlap - Metanalysis and metaregression of observational studies. Burns 2022; 48:263-280. [PMID: 34903405 DOI: 10.1016/j.burns.2021.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 09/08/2021] [Accepted: 11/04/2021] [Indexed: 12/14/2022]
Abstract
Stevens-Johnson's Syndrome (SJS) and Toxic Epidermal Necrolysis are rare, life-threatening dermatologic conditions with acute onset and not clearly established treatment protocol. A plethora of observational studies are present with lack of up-to-date consensus based on evaluation of objective endpoints, among others mortality. Thorough analysis of available databases (Pubmed, EMBASE, Cinahl, Web of Science, Clinical Trials) was conducted according to PRISMA guidelines. Authors initially identified 700 papers, with 82 of them potentially eligible according to adopted criteria. A total of 42 studies were included into pooled synthesis. For continuous outcomes we analyzed the pooled means for endpoint scores using observed cases data. Categorical outcomes were analyzed by calculating the pooled event rates. We conducted subgroup and exploratory maximum likelihood random effects meta-regression analyses regarding SCORTEN of all outcomes. Using random-effects model, the overall pooled Mortality Rate was 0.191 (95%CI, 0.132-0.269). The lowest mortality rate was found to be linked with Etanercept and highest in Total Plasma Exchange (TPE) and Intravenous Immunoglobulin (IVIG). Overall reepithelization was 13.278 days (95%CI, 8.773-17.784),The highest was found in cyclosporine treatment; 14.739 whilst the lowest for steroids. Length of hospital stay in overall analysis was 19.99 days (95%CI, 16.53-23.44),the highest was linked with TPE/TPE+IvIg treatment, the lowest with steroids. Risk of bias of assessed studies was estimated to be high (for observational studies mean STROBE score 12.44). High quality TEN and SJS studies are lacking. Almost all papers report observational data without randomization and double-blind control. Therefore, the pooled analysis cannot be presented with initial bias. In our meta-analysis the most successful regimen was Etanercept treatment. It was linked with the lowest mortality. The most negative treatment outcome was observed in studies reporting TPE and IVIG. Randomized trials of high quality are needed in SJS and TEN.
Collapse
|
11
|
Yang L, Shou YH, Li F, Zhu XH, Yang YS, Xu JH. Intravenous Immunoglobulin Combined With Corticosteroids for the Treatment of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: A Propensity-Matched Retrospective Study in China. Front Pharmacol 2022; 12:750173. [PMID: 35115922 PMCID: PMC8804212 DOI: 10.3389/fphar.2021.750173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but life-threatening severe adverse drug reactions. The use of corticosteroids and intravenous immunoglobulin (IVIg) in SJS/TEN remains controversial. Methods: In this single-center, observational, propensity-matched, retrospective study, we collected a total of 224 patients with SJS/TEN who were hospitalized in our department from 2008 to 2019; according to treatment with IVIg combined with corticosteroids or with corticosteroids alone, patients were divided into combination therapeutic group (163 patients) and monotherapeutic group (61 patients). Patients from the two groups were matched by their propensity score in blocks of 2:1. Comparisons of the clinical characteristics and prognoses between propensity-matched SJS/TEN patients treated with IVIg combined with corticosteroids and corticosteroids alone were made. Results: After our propensity matching, a total of 145 patients were yielded, including 93 patients treated with IVIg and 52 patients not treated with IVIg. All of the 23 variables reflected good matching between patients treated with/without IVIg, and no significant difference was observed. Although there was no significant difference between the totally predicted and actual mortality in both of our groups, the actual mortality was lower than it was predicted in patients treated with IVIg [p > 0.250, the standardized mortality ratio (SMR) was 0.38, 95% CI 0.00-0.91] and patients treated without IVIg (p = 1.000, the SMR was 0.75, 95% CI 0.00-1.76). IVIg tended toward reducing the time to arrest of progression by 1.56 days (p = 0.000) and the length of hospital stay by 3.37 days (p = 0.000). The mortality rate was 45% lower for patients treated with IVIg combined with corticosteroids than those only treated with corticosteroid therapy, although it was not statistically significant (p = 0.555). The incidence of skin infections was significantly lower in the combined therapy group (p < 0.025), and the total infection rate of patients treated with combination therapy tended to decrease by 67% compared to patients treated with corticosteroids alone (p = 0.047). Conclusion: The actual mortality rate of patients treated with corticosteroids alone or IVIg combined with corticosteroids tended to be lower than those predicted by TEN-specific severity-of-illness score (SCORTEN), although there was no significance. Compared with those treated by corticosteroids alone, combination therapy was prone to bring a better prognosis for SJS/TEN patients.
Collapse
Affiliation(s)
- Lu Yang
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yan-Hong Shou
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Feng Li
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiao-Hua Zhu
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yong-Sheng Yang
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jin-Hua Xu
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| |
Collapse
|
12
|
Houschyar KS, Tapking C, Borrelli MR, Puladi B, Ooms M, Wallner C, Duscher D, Pförringer D, Rein S, Reumuth G, Schulz T, Nietzschmann I, Maan ZN, Grieb G, Philipp-Dormston WG, Branski LK, Siemers F, Lehnhardt M, Schmitt L, Yazdi AS. Stevens-Johnson syndrome and toxic epidermal necrolysis: a systematic review and meta-analysis. J Wound Care 2021; 30:1012-1019. [PMID: 34881995 DOI: 10.12968/jowc.2021.30.12.1012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare and severe skin and mucosal reactions that are associated with high mortality. Despite the severity, an evidence-based treatment protocol for SJS/TEN is still lacking. METHOD In this systematic review and meta-analysis, the PubMed database was searched using the following terms: [Stevens-Johnson syndrome] OR [toxic epidermal necrolysis] AND [therapy] OR [treatment] over a 20-year period (1999-2019) in the German and English language. All clinical studies reporting on the treatment of SJS/TEN were included, and epidemiological and diagnostic aspects of treatment were analysed. A meta-analysis was conducted on all comparative clinical studies that met the inclusion criteria. RESULTS A total of 88 studies met the inclusion criteria, reporting outcomes in 2647 patients. Treatment was either supportive or used systemic corticosteroid, intravenous immunoglobulin, plasmapheresis, cyclosporine, thalidomide or cyclophosphamide therapy. The meta-analysis included 16 (18%) studies, reporting outcomes in 976 (37%) patients. Systemic glucocorticoids showed a survival benefit for SJS/TEN patients in all analyses compared with other forms of treatment. Cyclosporine treatment also showed promising results, despite being used in a small cohort of patients. No beneficial effects on mortality could be demonstrated for intravenous immunoglobulins. CONCLUSION Glucocorticoids and cyclosporine may be tentatively recommended as the most promising immunomodulatory therapies for SJS/TEN, but these results should be investigated in future prospective controlled trials.
Collapse
Affiliation(s)
- Khosrow S Houschyar
- Department of Dermatology and Allergology, University Hospital Aachen, Germany
| | - Christian Tapking
- Department of Surgery, Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, 815 Market Street, Galveston, TX 77550, US.,Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany
| | - Mimi R Borrelli
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford School of Medicine, Stanford, CA 94305, US
| | - Behrus Puladi
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH, Aachen
| | - Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH, Aachen
| | - Christoph Wallner
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Dominik Duscher
- Department of Plastic Surgery and Hand Surgery, Technical University Munich, Munich, Germany
| | - Dominik Pförringer
- Clinic and Policlinic of Trauma Surgery, Klinikum Rechts der Isar, Technische Universität München, Germany
| | - Susanne Rein
- Department of Plastic and Hand Surgery-Burn Center-Clinic St. Georg, Leipzig, Germany
| | - Georg Reumuth
- Department of Plastic Surgery and Hand Surgery, Evangelische Elisabeth Klinik, Luetzowstraße 26, 10785 Berlin, Germany
| | - Torsten Schulz
- Department of Plastic and Hand Surgery, Burn Unit, Trauma Center Bergmannstrost Halle, Halle, Germany
| | - Ina Nietzschmann
- Department of Plastic and Hand Surgery, Burn Unit, Trauma Center Bergmannstrost Halle, Halle, Germany
| | - Zeshaan N Maan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford School of Medicine, Stanford, CA 94305, US
| | - Gerrit Grieb
- Department of Plastic Surgery and Hand Surgery, Gemeinschaftskrankenhaus Havelhoehe, Teaching Hospital of the Charité Berlin, Kladower Damm 221, 14089 Berlin, Germany
| | | | - Ludwik K Branski
- Department of Surgery, Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, 815 Market Street, Galveston, TX 77550, US
| | - Frank Siemers
- Department of Plastic and Hand Surgery, Burn Unit, Trauma Center Bergmannstrost Halle, Halle, Germany
| | - Marcus Lehnhardt
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Laurenz Schmitt
- Department of Dermatology and Allergology, University Hospital Aachen, Germany
| | - Amir S Yazdi
- Department of Dermatology and Allergology, University Hospital Aachen, Germany
| |
Collapse
|
13
|
Villanueva-Paz M, Niu H, Segovia-Zafra A, Medina-Caliz I, Sanabria-Cabrera J, Lucena MI, Andrade RJ, Alvarez-Alvarez I. Critical Review of Gaps in the Diagnosis and Management of Drug-Induced Liver Injury Associated with Severe Cutaneous Adverse Reactions. J Clin Med 2021; 10:5317. [PMID: 34830594 PMCID: PMC8618381 DOI: 10.3390/jcm10225317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/12/2021] [Accepted: 11/14/2021] [Indexed: 12/12/2022] Open
Abstract
Drug-induced liver injury (DILI) encompasses the unexpected damage that drugs can cause to the liver. DILI may develop in the context of an immunoallergic syndrome with cutaneous manifestations, which are sometimes severe (SCARs). Nevirapine, allopurinol, anti-epileptics, sulfonamides, and antibiotics are the most frequent culprit drugs for DILI associated with SCARs. Interestingly, alleles HLA-B*58:01 and HLA-A*31:01 are associated with both adverse reactions. However, there is no consensus about the criteria used for the characterization of liver injury in this context, and the different thresholds for DILI definition make it difficult to gain insight into this complex disorder. Moreover, current limitations when evaluating causality in patients with DILI associated with SCARs are related to the plethora of causality assessment methods and the lack of consensual complementary tools. Finally, the management of this condition encompasses the treatment of liver and skin injury. Although the use of immunomodulant agents is accepted for SCARs, their role in treating liver injury remains controversial. Further randomized clinical trials are needed to test their efficacy and safety to address this complex entity. Therefore, this review aims to identify the current gaps in the definition, diagnosis, prognosis, and management of DILI associated with SCARs, proposing different strategies to fill in these gaps.
Collapse
Affiliation(s)
- Marina Villanueva-Paz
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
| | - Hao Niu
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Antonio Segovia-Zafra
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Inmaculada Medina-Caliz
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
| | - Judith Sanabria-Cabrera
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Plataforma ISCIII de Ensayos Clinicos, UICEC-IBIMA, 29071 Malaga, Spain
| | - M. Isabel Lucena
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Plataforma ISCIII de Ensayos Clinicos, UICEC-IBIMA, 29071 Malaga, Spain
| | - Raúl J. Andrade
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Ismael Alvarez-Alvarez
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| |
Collapse
|
14
|
Zhu WF, Fang DR, Fang H. Drug-induced erythroderma in patients with acquired immunodeficiency syndrome. World J Emerg Med 2021; 12:299-302. [PMID: 34512827 DOI: 10.5847/wjem.j.1920-8642.2021.04.008] [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: 02/10/2021] [Accepted: 07/08/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND To explore the clinical manifestations, diagnosis, and treatment of patients with acquired immunodeficiency syndrome (AIDS) complicated with drug-induced erythroderma. METHODS The clinical data of 12 AIDS patients with drug-induced erythroderma in our hospital were retrospectively analyzed. The general information, offending medications, complications, modified severity-of-illness score for toxic epidermal necrolysis (SCORTEN) scores, and disease outcome spectrums were analyzed. RESULTS Drug-induced erythroderma was mostly caused by antiviral drugs, antituberculosis drugs, antibiotics, traditional Chinese medicine, and immune checkpoint inhibitors. The spectrum of sensitizing drugs was broad, the clinical situation was complex, and infections were common. The affected areas were greater than 40% body surface area in all patients. The modified SCOTERN score averaged 3.01±0.99. All patients were treated with glucocorticoids, and nine patients were treated with intravenous immunoglobulin (IVIG) pulse therapy at the same time. The average time to effectiveness was 7.08±2.23 days, and the average hospital stay was 17.92±8.46 days. Eleven patients were cured, and one patient died of secondary multiple infections, who had a modified SCORTEN score of 5 points. The mortality rate in this study was 8.3%. CONCLUSIONS The clinical situation of AIDS patients with drug-induced erythroderma in hospitalized patients is complex and the co-infection rate is high. The use of modified SCORTEN score may objectively and accurately assess the conditions, and the use of glucocorticoid combined with IVIG therapy may improve the prognosis.
Collapse
Affiliation(s)
- Wei-Fang Zhu
- Department of Dermatology, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310003, China
| | - De-Ren Fang
- Department of Dermatology, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Hong Fang
- Department of Dermatology, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310003, China
| |
Collapse
|
15
|
Frantz R, Huang S, Are A, Motaparthi K. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Review of Diagnosis and Management. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:895. [PMID: 34577817 PMCID: PMC8472007 DOI: 10.3390/medicina57090895] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 12/15/2022]
Abstract
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are rare diseases that are characterized by widespread epidermal necrosis and sloughing of skin. They are associated with significant morbidity and mortality, and early diagnosis and treatment is critical in achieving favorable outcomes for patients. In this scoping review, Excerpta Medica dataBASE and PubMed were searched for publications that addressed recent advances in the diagnosis and management of the disease. Multiple proteins (galectin 7 and RIP3) were identified that are promising potential biomarkers for SJS/TEN, although both are still in early phases of research. Regarding treatment, cyclosporine is the most effective therapy for the treatment of SJS, and a combination of intravenous immunoglobulin (IVIg) and corticosteroids is most effective for SJS/TEN overlap and TEN. Due to the rare nature of the disease, there is a lack of prospective, randomized controlled trials and conducting these in the future would provide valuable insights into the management of this disease.
Collapse
Affiliation(s)
- Robert Frantz
- College of Medicine, University of Florida, Gainesville, FL 32606, USA; (R.F.); (A.A.)
| | - Simo Huang
- Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA;
| | - Abhirup Are
- College of Medicine, University of Florida, Gainesville, FL 32606, USA; (R.F.); (A.A.)
| | - Kiran Motaparthi
- College of Medicine, University of Florida, Gainesville, FL 32606, USA; (R.F.); (A.A.)
- Department of Dermatology, College of Medicine, University of Florida, Gainesville, FL 32606, USA
| |
Collapse
|
16
|
Cokan A, Lovrec VG, Takač I. A Case of Stevens-Johnson Syndrome in Recurrent Late-Stage Ovarian Cancer Patient after Management of Chronic Pain with Elastomeric Pump. Curr Oncol 2021; 28:2928-2932. [PMID: 34436022 PMCID: PMC8395433 DOI: 10.3390/curroncol28040256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 07/29/2021] [Accepted: 08/01/2021] [Indexed: 01/03/2023] Open
Abstract
(1) Background. Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe mucocutaneous reactions, characterized by extensive necrosis and detachment of the epidermis. (2) Case presentation. We present a case of a 46-year-old patient with late-stage high-grade serous ovarian cancer who was primarily treated with neoadjuvant chemotherapy and interval debulking, which was followed by adjuvant chemotherapy. At first recurrence, she was again treated with chemotherapy, and due to severe abdominal pain, an elastomeric pump containing analgesics, anti-inflammatories, and ondansetron was administered. In the same month, she was admitted to the hospital due to severe dysphagia, and in the following days she developed haemorrhagic vesiculobullous lesions on the facial skin and trunk. Stevens-Johnson syndrome was confirmed and ondansetron as a plausible leading cause was discontinued. Despite multimodal treatment, her condition deteriorated, and she died. (3) Discussion and conclusion. Although gynaecologists rarely encounter Stevens-Johnson syndrome, high mortality of the disease should ensure a low threshold for diagnosing and treating this disease.
Collapse
Affiliation(s)
- Andrej Cokan
- Department for Gynaecological and Breast Oncology, University Medical Centre Maribor, Ljubljanska ulica 5, 2000 Maribor, Slovenia
- Medical Faculty, University of Maribor, Taborska ulica 8, 2000 Maribor, Slovenia; (V.G.L.); (I.T.)
- Correspondence: or
| | - Vida Gavrić Lovrec
- Medical Faculty, University of Maribor, Taborska ulica 8, 2000 Maribor, Slovenia; (V.G.L.); (I.T.)
- Department for Reproductive Medicine and Gynaecological Endocrinology, University Medical Centre Maribor, Ljubljanska ulica 5, 2000 Maribor, Slovenia
| | - Iztok Takač
- Medical Faculty, University of Maribor, Taborska ulica 8, 2000 Maribor, Slovenia; (V.G.L.); (I.T.)
- Clinic for Gynaecology and Perinatology, University Medical Centre Maribor, Ljubljanska ulica 5, 2000 Maribor, Slovenia
| |
Collapse
|
17
|
Houschyar KS, Tapking C, Borrelli MR, Nietzschmann I, Puladi B, Ooms M, Rein S, Houschyar M, Duscher D, Maan ZN, Reumuth G, Branski LK, Modabber A, Kluwig D, Schmitt L, Philipp-Dormston WG, Yazdi AS, Siemers F. Stevens-Johnson syndrome and toxic epidermal necrolysis: a 10-year experience in a burns unit. J Wound Care 2021; 30:492-496. [PMID: 34121430 DOI: 10.12968/jowc.2021.30.6.492] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Stevens-Johnson syndrome (SJS) and its more severe counterpart, toxic epidermal necrolysis (TEN), are skin hypersensitivity reactions defined by epidermal blistering and necrosis. The exact pathophysiology of SJS/TEN is yet to be deciphered, but a number of risk factors have been identified including adverse drug reactions. The diagnosis of SJS/TEN is made on a clinical basis, and treatment consists of supportive care and occasionally immunosuppressants, such as cyclosporin, high-dose intravenous immunoglobulins and/or corticosteroids. Mortality rates can reach 20-25% in adults but are reduced with early intervention. To identify optimal treatment regimens, to better understand the patient cohort affected, and to help identify key risk factors for mortality, we report our experience with the treatment and management of SJS/TEN patients. METHODS A retrospective review of consecutive patients with SJS and/or TEN admitted to a single burns centre in Germany, between 2008 and 2018, was conducted. The primary outcomes of demographics, clinical course, treatment and patient-reported outcomes were recorded and compared with a control group of patients with burns without a diagnosis of SJS/TEN. RESULTS A total of 23 patients with SJS/TEN met the inclusion criteria: 17 (74%) with TEN; four (17%) with SJS/TEN overlap; and two (9%) with SJS. Of the patients, 14 (61%) were female and nine (39%) were male. Patient age ranged from 32-78 years (mean: 52 years). A matched cohort of 23 patients with burns served as the control group. All patients received standard of care with a multidisciplinary team. Compared with the control group, SJS/TEN patients had higher mortality rates (n=6, 26% versus n=8, 35%, respectively). The average age of death was 69 years in SJS/TEN patients versus 63 years in control group patients. Age and SCORTEN scores were significant predictors of mortality. CONCLUSIONS SJS and TEN are rare but extreme reactions of the skin and mucosa, associated with high disease mortality rates. This 10-year single-centre retrospective review contributes to the bank of information for reviews evaluating the management of SJS/TEN patients.
Collapse
Affiliation(s)
- Khosrow S Houschyar
- Department of Dermatology and Allergology, University Hospital RWTH Aachen, Germany.,Department of Plastic and Hand Surgery, Burn Unit, Trauma Center Bergmannstrost Halle, Halle, Germany
| | - Christian Tapking
- Department of Surgery, Shriners Hospital for Children-Galveston, University of Texas Medical Branch, Galveston, US.,Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany
| | - Mimi R Borrelli
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford School of Medicine, Stanford, US
| | - Ina Nietzschmann
- Department of Plastic and Hand Surgery, Burn Unit, Trauma Center Bergmannstrost Halle, Halle, Germany
| | - Behrus Puladi
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH, Aachen, Germany
| | - Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH, Aachen, Germany
| | - Susanne Rein
- Department of Plastic and Hand Surgery-Burn Center-Clinic St. Georg, Leipzig, Germany
| | - Madeline Houschyar
- Department of Dermatology and Allergology, University Hospital RWTH Aachen, Germany
| | - Dominik Duscher
- Department of Plastic Surgery and Hand Surgery, Technical University Munich, Munich, Germany
| | - Zeshaan N Maan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford School of Medicine, Stanford, US
| | - Georg Reumuth
- Department of Plastic Surgery and Hand Surgery, Evangelische Elisabeth Klinik, Berlin, Germany
| | - Ludwik K Branski
- Department of Surgery, Shriners Hospital for Children-Galveston, University of Texas Medical Branch, Galveston, US
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH, Aachen, Germany
| | - David Kluwig
- Department of Dermatology and Allergology, University Hospital RWTH Aachen, Germany
| | - Laurenz Schmitt
- Department of Dermatology and Allergology, University Hospital RWTH Aachen, Germany
| | | | - Amir S Yazdi
- Department of Dermatology and Allergology, University Hospital RWTH Aachen, Germany
| | - Frank Siemers
- Department of Plastic and Hand Surgery, Burn Unit, Trauma Center Bergmannstrost Halle, Halle, Germany
| |
Collapse
|
18
|
Owen CE, Jones JM. Recognition and Management of Severe Cutaneous Adverse Drug Reactions (Including Drug Reaction with Eosinophilia and Systemic Symptoms, Stevens-Johnson Syndrome, and Toxic Epidermal Necrolysis). Med Clin North Am 2021; 105:577-597. [PMID: 34059239 DOI: 10.1016/j.mcna.2021.04.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Severe cutaneous adverse reactions to medications (SCARs) include drug reaction with eosinophilia and systemic symptoms, Stevens-Johnson syndrome, toxic epidermal necrolysis, and acute generalized exanthematous pustulosis. They are all non-immunoglobulin E mediated hypersensitivity reaction patterns, distinguished from simple cutaneous drug eruptions by immunologic pathogenesis and internal organ involvement. Herein the clinical features, diagnostic workup, and management considerations are presented for each of these major SCARs.
Collapse
Affiliation(s)
- Cindy England Owen
- Division of Dermatology, Department of Medicine, 3810 Springhurst Boulevard, Suite 200, Louisville, KY 40241, USA.
| | - Jordan M Jones
- Division of Dermatology, Department of Medicine, 3810 Springhurst Boulevard, Suite 200, Louisville, KY 40241, USA
| |
Collapse
|
19
|
Duplisea MJ, Roberson ML, Chrisco L, Strassle PD, Williams FN, Ziemer CM. Performance of ABCD-10 and SCORTEN mortality prediction models in a cohort of patients with Stevens-Johnson syndrome/toxic epidermal necrolysis. J Am Acad Dermatol 2021; 85:873-877. [PMID: 33940101 DOI: 10.1016/j.jaad.2021.04.082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 04/06/2021] [Accepted: 04/27/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Age, bicarbonate, cancer, dialysis, 10% body surface area risk model (ABCD-10) has recently been proposed as an alternative to the SCORe of toxic epidermal necrolysis (SCORTEN) model for predicting in-hospital mortality in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN). In contrast to SCORTEN, ABCD-10 incorporates prior dialysis and upweights the impact of cancer. OBJECTIVE To determine the performance of ABCD-10 compared with that of SCORTEN in mortality prediction at a large, tertiary burn center. METHODS A retrospective analysis of 192 patients with SJS/TEN admitted to the North Carolina Jaycee Burn Center from January 1, 2009, to December 31, 2019, was conducted. Data on these patients were collected using the burn registry and a manual chart review. The performance of both the mortality prediction models was assessed using univariate logistic regression and the Hosmer-Lemeshow test. RESULTS The overall mortality was 22% (n = 43). Nine (5%) patients had cancer, and 7 (4%) had undergone prior dialysis; neither factor was associated with mortality (P = .11 and P = .62, respectively). SCORTEN was well calibrated to predict inpatient mortality (P = .82), whereas ABCD-10 appeared to have a poorer fit (P < .001) in these patients. Both the models showed good discrimination. LIMITATIONS Small sample size. CONCLUSION SCORTEN was a better predictor of inpatient mortality than ABCD-10 in a North American cohort of patients treated at the tertiary burn center.
Collapse
Affiliation(s)
- Michael J Duplisea
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Mya L Roberson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lori Chrisco
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; North Carolina Jaycee Burn Center, Chapel Hill, North Carolina
| | - Paula D Strassle
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Felicia N Williams
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; North Carolina Jaycee Burn Center, Chapel Hill, North Carolina
| | - Carolyn M Ziemer
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| |
Collapse
|
20
|
Koh HK, Fook-Chong S, Lee HY. Assessment and Comparison of Performance of ABCD-10 and SCORTEN in Prognostication of Epidermal Necrolysis. JAMA Dermatol 2021; 156:1294-1299. [PMID: 33084873 DOI: 10.1001/jamadermatol.2020.3654] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Epidermal necrolysis is a rare severe cutaneous drug reaction associated with high mortality. The ABCD-10 score (age, bicarbonate, cancer, dialysis, 10% body surface area), a new prognostic score for mortality in epidermal necrolysis, was recently developed and validated in the US. However, to our knowledge, it remains to be externally validated in other cohorts. Objective To assess ABCD-10 among patients in a contemporary Asian cohort and compare its performance with the Score of Toxic Epidermal Necrosis (SCORTEN) and study the associations of time and immunomodulatory therapy with the performance of ABCD-10 and SCORTEN. Design, Setting, and Participants This retrospective cohort study was conducted over a 17-year period from January 2003 to March 2019 and included 196 patients with epidermal necrolysis who were recruited from Singapore General Hospital, the national referral center for epidermal necrolysis. Main Outcomes and Measures In-hospital mortality. Discrimination and calibration of each risk score were assessed and compared using the area under the receiver operating characteristic curve and calibration plot, respectively. Results Among 196 patients (median [interquartile range] age, 56 [42-70] years; 116 women [59.2%]), 45 (23.0%) did not survive to discharge. All risk factors in ABCD-10 were significantly associated with in-hospital mortality. However, dialysis before admission, the most heavily weighted factor in ABCD-10, performed weaker in this cohort (odds ratio, 3.7; 95% CI, 1.0-13.2, P = .04). Although the discrimination of ABCD-10 and SCORTEN did not differ (area under the curve: ABCD-10, 0.78; 95% CI, 0.72-0.85; vs SCORTEN, 0.77; 95% CI, 0.69-0.84; P = .53), the calibration of ABCD-10 was poorer compared with SCORTEN. From graphical analysis of the calibration plots, ABCD-10 showed mortality underestimation at lower score ranges and overestimation at higher score ranges. By contrast, SCORTEN was generally well calibrated, although at higher score ranges mortality may be overestimated. Assessment of calibration plots showed that there was increasing overestimation of mortality by SCORTEN during the later period or when immunomodulatory therapy was used compared with patients treated with supportive care alone. Calibration of ABCD-10 remained poor even during the later period or among patients treated with immunomodulatory therapy. Conclusions and Relevance In this cohort of patients, the performance of SCORTEN was superior to ABCD-10 in mortality prognostication in epidermal necrolysis. However, it did display time-associated deterioration in calibration leading to overestimation of mortality risk. Future studies may consider revising the existing SCORTEN given its current good discrimination.
Collapse
Affiliation(s)
- Hui Kai Koh
- Department of Internal Medicine, Singapore General Hospital, Singapore
| | - Stephanie Fook-Chong
- Health Services Research Unit, Division of Medicine, Singapore General Hospital, Singapore
| | - Haur Yueh Lee
- Department of Dermatology, Singapore General Hospital, Singapore
| |
Collapse
|
21
|
Bunker CB, Chapman AB. SCORTEN in SJS/TEN: hypoalbuminaemia and oedema. J Eur Acad Dermatol Venereol 2021; 35:e369. [PMID: 33497483 DOI: 10.1111/jdv.17136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/12/2020] [Accepted: 01/14/2021] [Indexed: 11/29/2022]
Affiliation(s)
- C B Bunker
- Dermatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - A B Chapman
- Dermatology, Homerton University Hospital, London, UK
| |
Collapse
|
22
|
Impact of Antibiotics Associated with the Development of Toxic Epidermal Necrolysis on Early and Late-Onset Infectious Complications. Microorganisms 2021; 9:microorganisms9010202. [PMID: 33477980 PMCID: PMC7835845 DOI: 10.3390/microorganisms9010202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 01/01/2023] Open
Abstract
Toxic epidermal necrolysis (TEN) is a rare disease, which predominantly manifests as damage to the skin and mucosa. Antibiotics count among the most common triggers of this hypersensitive reaction. Patients with TEN are highly susceptible to infectious complications due to the loss of protective barriers and immunosuppressant therapy. The aim of this study was to investigate the potential relationship between antibiotics used before the development of TEN and early and late-onset infectious complications in TEN patients. In this European multicentric retrospective study (Central European Lyell syndrome: therapeutic evaluation (CELESTE)), records showed that 18 patients with TEN used antibiotics (mostly aminopenicillins) before the disease development (group 1), while in 21 patients, TEN was triggered by another factor (group 2). The incidence of late-onset infectious complications (5 or more days after the transfer to the hospital) caused by Gram-positive bacteria (especially by Enterococcus faecalis/faecium) was significantly higher in group 1 than in group 2 (82.4% vs. 35.0%, p = 0.007/pcorr = 0.014) while no statistically significant difference was observed between groups of patients with infection caused by Gram-negative bacteria, yeasts, and filamentous fungi (p > 0.05). Patients with post-antibiotic development of TEN are critically predisposed to late-onset infectious complications caused by Gram-positive bacteria, which may result from the dissemination of these bacteria from the primary focus.
Collapse
|
23
|
Kuijper E, French L, Tensen C, Vermeer M, Bouwes Bavinck J. Clinical and pathogenic aspects of the severe cutaneous adverse reaction epidermal necrolysis (EN). J Eur Acad Dermatol Venereol 2020; 34:1957-1971. [PMID: 32415695 PMCID: PMC7496676 DOI: 10.1111/jdv.16339] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 02/25/2020] [Indexed: 12/12/2022]
Abstract
The severe cutaneous adverse reaction epidermal necrolysis (EN) which includes toxic epidermal necrolysis and the milder Stevens-Johnson syndrome is characterized by epidermal loss due to massive keratinocyte apoptosis and/or necroptosis. EN is often caused by a drug mediating a specific TCR-HLA interaction via the (pro)hapten, pharmacological interaction or altered peptide loading mechanism involving a self-peptide presented by keratinocytes. (Memory) CD8 + T cells are activated and exhibit cytotoxicity against keratinocytes via the perforin/granzyme B and granulysin pathway and Fas/FasL interaction. Alternatively drug-induced annexin release by CD14 + monocytes can induce formyl peptide receptor 1 death of keratinocytes by necroptosis. Subsequent keratinocyte death stimulates local inflammation, activating other immune cells producing pro-inflammatory molecules and downregulating regulatory T cells. Widespread epidermal necrolysis and inflammation can induce life-threatening systemic effects, leading to high mortality rates. Research into genetic susceptibility aims to identify risk factors for eventual prevention of EN. Specific HLA class I alleles show the strongest association with EN, but risk variants have also been identified in genes involved in drug metabolism, cellular drug uptake, peptide presentation and function of CD8 + T cells and other immune cells involved in cytotoxic responses. After the acute phase of EN, long-term symptoms can remain or arise mainly affecting the skin and eyes. Mucosal sequelae are characterized by occlusions and strictures due to adherence of denuded surfaces and fibrosis following mucosal inflammation. In addition, systemic pathology can cause acute and chronic hepatic and renal symptoms. EN has a large psychological impact and strongly affects health-related quality of life among EN survivors.
Collapse
Affiliation(s)
- E.C. Kuijper
- Department of DermatologyLeiden University Medical CentreLeidenThe Netherlands
| | - L.E. French
- Department of Dermatology and AllergyUniversity HospitalLMU MunichMunichGermany
| | - C.P. Tensen
- Department of DermatologyLeiden University Medical CentreLeidenThe Netherlands
| | - M.H. Vermeer
- Department of DermatologyLeiden University Medical CentreLeidenThe Netherlands
| | - J.N. Bouwes Bavinck
- Department of DermatologyLeiden University Medical CentreLeidenThe Netherlands
| |
Collapse
|
24
|
Torres‐Navarro I, Briz‐Redón Á, Botella‐Estrada R. Systemic therapies for Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis: a SCORTEN‐based systematic review and meta‐analysis. J Eur Acad Dermatol Venereol 2020; 35:159-171. [DOI: 10.1111/jdv.16685] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/11/2020] [Indexed: 12/20/2022]
Affiliation(s)
- I. Torres‐Navarro
- Dermatology Department Hospital Universitario y Politécnico la Fe València Spain
| | - Á. Briz‐Redón
- Department of Statistics and Operations Research Universitat de València València Spain
| | - R. Botella‐Estrada
- Dermatology Department Hospital Universitario y Politécnico la Fe València Spain
- Department of Medicine Universitat de València València Spain
| |
Collapse
|