Toxic epidermal necrolysis (TEN)

Toxic epidermal necrolysis (TEN) is a rare, unpredictable, life threatening condition where there is widespread skin erythema that rapidly progresses to necrosis of the epidermidis with subsequent sloughing of skin (1,2).

There is full thickness necrosis of the epidermis which is detached from the underlying dermis.

Frequent involvement of the occular mucous membrane and oral mucous membrane can be seen (3).

Most of the cases of TEN are caused by adverse drug reactions.

It is thought to be a cell-mediated immunologic reaction against drug metabolites caused by an abnormal metabolism of the offending drugs (3).

It can be seen in all age groups presenting from infants to elderly people (4).

Stevens-Johnson syndrome and toxic epidermal necrolysis are thought to represent a single mucocutaneous disease with an increasing severity (4).

Stevens-Johnson syndrome (SJS) and TEN are differentiated by the extent of body surface involvement (3)

• in SJS - epidermal detachment is seen in <10% of the body surface area
• n TEN - epidermal detachment is seen in >30% of body surface area
• overlap SJS-TEN - when detachment is between 10-30% of the body surface area (4)

Study evidence showed that antibiotics were associated with more than one-quarter of SJS/TEN cases described worldwide, and sulfonamide antibiotics remained the most important association (5)

With respect to systemic interventions for treatment of Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS/TEN overlap syndrome (6):

• found when compared to corticosteroids, etanercept may result in mortality reduction
• certainty of evidence for disease-specific mortality is very low for corticosteroids versus no corticosteroids, IVIG (intravenous immunoglobulins) versus no IVIG and cyclosporin versus IVIG

Reference:

• 1. Pereira FA, Mudgil AV, Rosmarin DM. Toxic epidermal necrolysis. J Am Acad Dermatol 2007;56(2):181-200
• 2. Hackel J.G, Nicholias V.M, Morgan J.G. Photo quiz - Rash in an Adolescent. AFP 2004;70(3)
• 3. Sheridan R.L, Liu V, Anupindi S. Case 34-2005 - A 10-Year-Old Girl with a Bullous Skin Eruption and Acute Respiratory Failure. NEJM 2005; 353:2057-2066
• 4. Gupta S, Devkaran A. Toxic epidermal necrolysis. Student BMJ 2008;16:168-170
• 5. Lee EY, Knox C, Phillips EJ. Worldwide Prevalence of Antibiotic-Associated Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Systematic Review and Meta-analysis. JAMA Dermatol. Published online February 15, 2023. doi:10.1001/jamadermatol.2022.6378
• 6. Jacobsen A, Olabi B, Langley A, Beecker J, Mutter E, Shelley A, Worley B, Ramsay T, Saavedra A, Parker R, Stewart F, Pardo Pardo J. Systemic interventions for treatment of Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS/TEN overlap syndrome. Cochrane Database of Systematic Reviews 2022, Issue 3. Art. No.: CD013130. DOI: 10.1002/14651858.CD013130.pub2