Development of a Skin-Directed Scoring System for Stevens-Johnson Syndrome and Epidermal Necrolysis: A Delphi Consensus Exercise

Importance

Scoring systems for Stevens-Johnson syndrome and epidermal necrolysis (EN) only estimate patient prognosis and are weighted toward comorbidities and systemic features; morphologic terminology for EN lesions is inconsistent.

Objectives

To establish consensus among expert dermatologists on EN terminology, morphologic progression, and most-affected sites, and to build a framework for developing a skin-directed scoring system for EN.

Evidence Review

A Delphi consensus using the RAND/UCLA appropriateness criteria was initiated with a core group from the Society of Dermatology Hospitalists to establish agreement on the optimal design for an EN cutaneous scoring instrument, terminology, morphologic traits, and sites of involvement.

Findings

In round 1, the 54 participating dermatology hospitalists reached consensus on all 49 statements (30 appropriate, 3 inappropriate, 16 uncertain). In round 2, they agreed on another 15 statements (8 appropriate, 7 uncertain). There was consistent agreement on the need for a skin-specific instrument; on the most-often affected skin sites (head and neck, chest, upper back, ocular mucosa, oral mucosa); and that blanching erythema, dusky erythema, targetoid erythema, vesicles/bullae, desquamation, and erosions comprise the morphologic traits of EN and can be consistently differentiated.

Conclusions and Relevance

This consensus exercise confirmed the need for an EN skin-directed scoring system, nomenclature, and differentiation of specific morphologic traits, and identified the sites most affected. It also established a baseline consensus for a standardized EN instrument with consistent terminology.

Novel Therapies for Pemphigus Vulgaris

Pemphigus vulgaris (PV) is a severe chronic autoimmune blistering disease that affects the skin and mucous membranes. It is characterized by suprabasal acantholysis due to disruption of desmosomal connections between keratinocytes. Autoantibodies against desmosomal cadherins, desmoglein 3 and 1, have been shown to induce disease. Certain human leukocyte antigen (HLA) types and non-HLA foci confer genetic susceptibility. Until the discovery of corticosteroids in the 1950s, PV was 75% fatal. Since then, multiple PV treatments, such as systemic corticosteroids and adjunctive therapy with immunosuppressive medications (mycophenolate mofetil, azathioprine, cyclophosphamide, cyclosporine, methotrexate, gold, and others) have been introduced; however, none have led to long-term remissions and many have undesired adverse effects. Our growing understanding of the pathophysiologic mechanisms in PV is leading to development of new targeted therapies, such as intravenous immunoglobulin, anti-CD20 monoclonal antibodies, inhibitors of Bruton tyrosine kinase and neonatal Fc receptors, and adoptive cellular transfer, that may result in lasting control of this life-threatening disease.

Diagnosis: psoriasis or not? What are the clues?

Psoriasis is a common inflammatory, hyperproliferative skin disorder that affects 1% to 2% of the population of Western Europe and the United States. Because the clinical presentation of psoriasis is varied, many times the definitive diagnosis depends on the histological examination. However, the histological changes of psoriasis are as varied as the clinical presentations. Therefore, a combination of histopathologic features must be present for the diagnosis of psoriasis to be made. In this article, we review the clues for the histopathologic diagnosis of each type and stage of psoriasis, such as psoriasis vulgaris, pustular psoriasis, and erythrodermic psoriasis, as well as the histopathologic differential diagnosis of these entities.

AIDS-associated Reiter's syndrome

Classically, Reiter's syndrome was defined as a triad of arthritis, urethritis, and conjunctivitis. In 1981, the American Rheumatism Association revised its defining criteria for Reiter's syndrome as an episode of peripheral arthritis of more than 1 month's duration occurring in association with urethritis and/or cervicitis. Reiter's syndrome is also associated with mucocutaneous lesions. Reiter's syndrome was first described in association with the human immuno-deficiency virus (HIV) in 1987. The course of Reiter's syndrome in HIV is more severe, progressive, and refractory to treatment than in non-HIV-positive patients. The immunopathogenesis of Reiter's syndrome is linked to HLA-B27, which has been described as the disease susceptibility factor. The association of Reiter's syndrome and HLA-B27 positivity is 80%. Infectious agents may play a critical role in the initiation or perpetuation of Reiter's syndrome. It has been suggested that an amino acid sequence within the HLA-B27 molecule allows microbial peptides to bind and be presented to T cytotoxic cells (CD8), which results in a primary T cytotoxic cell response against various tissues. The role of the HIV in the pathogenesis of Reiter's syndrome is still being investigated. Human immunodeficiency virus may directly cause arthritis; it may increase the host's susceptibility to infection with arthritogenic organisms. Additionally, HIV infection increases the relative number of CD8 cells, which may play a key role in the pathogenesis of Reiter's syndrome. In this article, we present a case of Reiter's syndrome in an HLA-B27 and HIV-positive patient, and a review of the literature on the infectious, immunologic, and dermatologic aspects of Reiter's syndrome in HIV disease.

Controlling malignant melanoma. A focus on pediatricians

There is evidence that the mortality rate associated with malignant melanoma can be decreased by early identification of the risk factors for melanoma and precursor lesions and by reducing sun exposure in young patients at higher risk. Many of the risk factors for malignant melanoma are seen in the pediatric age group. To determine pediatricians' awareness of risk factors for melanoma and their ability to recognize the precursors of melanoma, we studied three departments of pediatrics--at an urban and a suburban medical center and a medical college. Ninety-six members of the audience, which included full-time faculty, practicing pediatricians, and pediatrics residents, responded to questionnaires before and after a presentation on the risk factors for melanoma. Based on the results of the questionnaires, this group of pediatricians believed that they were not sufficiently knowledgeable about the risk factors for melanoma and did not routinely examine their patients for these risk factors or counsel them on proper sunlight protection. These findings indicate a need for making pediatricians aware of the risk factors for melanoma and of the critical role they play in decreasing the incidence and mortality rate associated with this disease.