Treatment

Seek specialist advice.

A patient history should be obtained to identify the offending drug and should be discontinued without delay (1)

Management is mainly supportive. Patients should be managed in a burn unit due to the similarities in management which is required by patients with extensive burns (2).

The main aim is to protect the denuded skin from infection, to monitor fluid and electrolyte balance and to provide nutritional support to the patient (1)

Cutaneous wound management:

• the idea is to prevent dehydration and superinfection and to control pain
• topical antimicrobial if surface infection is present
• membrane dressings for clean wounds
• control of pain (2)

Visceral wound management:

• mainly supportive till the reepithelialization of these surfaces
• treat infections as they arise
• replacement therapy in blood losses
• supporting failing organ systems (2)

Conjunctival sloughing is quite often a serious, painful condition which may lead to desiccation, corneal ulceration, and destructive local infection. There might be adhesion between the palpebral and globular conjunctivae.

Management strategies include:

• pain control
• frequent ocular lubrication
• use of topical corticosteroid
• frequent culturing
• administration of focused topical antibiotics
• regular separation of lids from the globes to prevent adhesions (2)

According to some non-controlled studies, use of intravenous immunoglobin has been shown to improve the outcome in TEN patients (1). Treatment with Corticosteroids and Plasma exchange have been proposed but lack data demonstrating benefit (2)

With respect to systemic interventions for treatment of Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS/TEN overlap syndrome (3):

• 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. Gupta S, Devkaran A. Toxic epidermal necrolysis. Student BMJ 2008;16:168-170
• 2. 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
• 3. 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