Edit concept Question Editor Create issue ticket

Toxic Epidermal Necrolysis

TENS

Toxic epidermal necrolysis is a dangerous drug-induced skin lesion characterized by extensive, mucocutaneous blistering.


Presentation

Toxic epidermal necrolysis usually begins with flu-like prodrome, with a high-grade fever, sore-throat, cough, runny nose, redness of eyes, decreased appetite, malaise, arthralgia, myalgia, and generalized body aches. This is usually followed by drug exposure on average 14 days prior to the onset of symptoms. There is then an abrupt onset of red-purple, dusky, flat spots known as macules on the face and trunk, often spreading later to the rest of the body in an irregular fashion [10]. The maximum extent is usually reached after 4 days. These skin lesions then transform into large blisters. Sheets of blisters coalesce and denude with the underlying skin becoming painful and erythematous. Large areas of affected skin become necrotic and peel off with just a gentle touch. In toxic epidermal necrolysis, more than 30% of the skin area is involved. The blisters most often damage the mucous membranes lining the mouth, throat, anus, genitals and eyes. It makes eating difficult. Closing the mouth may be painful. Nikolsky sign is positive in these patients; that is, the epidermis easily separates from its underlying surface when gentle pressure is applied [11] [12] [13]. Hypotension and tachycardia can develop after dehydration and hypovolemia. In addition to skin, other organs including liver, kidney, lungs and those of the urinary system may also be involved. A person who has this disorder is very susceptible to chronic infections, which if not untreated might lead to death.

Fever
  • High fever occurs in these conditions, frequently before the skin and/or mucosa is affected.[ncbi.nlm.nih.gov]
  • Prior to this, she complained of fever and discomfort upon swallowing. Skin biopsy had shown epidermal necrosis compatible with Stevens Johnson Syndrome and Toxic Epidermal Necrolysis.[ncbi.nlm.nih.gov]
  • KEYWORDS: SJS-TEN; chikungunya; fever; necrosis; polyarthralgia; vesicles[ncbi.nlm.nih.gov]
  • The initial manifestations are nonspecific: a seemingly banal rash, fever, and a burning sensation involving the eyes, mouth and genitalia. The rash rapidly progresses to become vesicular and bullous on the face and body.[web.archive.org]
Malaise
  • SJS/TEN manifest with an "influenza-like" prodromal phase (malaise, fever), followed by painful cutaneous and mucous membrane (ocular, oral, and genital) lesions, and other systemic symptoms.[ncbi.nlm.nih.gov]
  • Toxic epidermal necrolysis usually begins with flu-like prodrome, with a high-grade fever, sore-throat, cough, runny nose, redness of eyes, decreased appetite, malaise, arthralgia, myalgia, and generalized body aches.[symptoma.com]
  • Clinical Presentation • Prodromal phase of fever, cough, malaise • Nikolsky-positive macules (epidermal separation induced by gentle lateral pressure on skin surface) • Mucosal surface often involved, systemic involvement is variable (30% of cases have[slideshare.net]
  • Before these severe findings develop, people often have a flu-like prodrome, with a cough, runny nose, fever, decreased appetite and malaise.[en.wikipedia.org]
  • Symptoms and Signs Within 1 to 3 wk after the start of the offending drug, patients develop a prodrome of malaise, fever, headache, cough, and keratoconjunctivitis.[merckmanuals.com]
Malnutrition
  • They include: Sloughing of the mucous membranes in the mouth, throat, and digestive tract: this creates difficulty in eating and drinking and leads to dehydration and malnutrition Bacterial skin infections Conjunctival sloughing and other eye problems[web.archive.org]
  • Intravenous vitamins B and C (Pabrinex ) were added because of concern over malnutrition (BMI 16 kg/m2 at presentation). By the third hospital day approximately half the body surface area was denuded of epithelium.[bmj.com]
  • During the acute phase, potentially fatal complications include: Dehydration and acute malnutrition Infection of skin, mucous membranes, lungs (pneumonia), septicaemia (blood poisoning) Acute respiratory distress syndrome Gastrointestinal ulceration ,[dermnetnz.org]
Weight Loss
  • Center Bascom Palmer Eye Institute Font Size Group 30 Group 30 Contrast logo Menu Search University of Miami Health System Close Search Find a Doctor Treatments Page 1 Featured Treatments For Allergy and Immunology Arthritis (Rheumatology) Bariatrics (Weight[uhealthsystem.com]
  • Signs and Symptoms Approximate number of patients (when available) Abnormal blistering of the skin 90% Abnormality of temperature regulation 90% Acantholysis 90% Hypermelanotic macule 90% Malabsorption 90% Nausea and vomiting 90% Weight loss 90% Abnormality[web.archive.org]
  • Nutrition Poor oral intake in combination with increased calorie requirements can result in weight loss.[bjaed.oxfordjournals.org]
Hypothermia
  • Hypothermia can also develop. TEN usually involves the eyes and the mucous membranes such as the mouth, nose, genitalia and anus. Description of the intervention There is no clear agreement on the treatment for TEN.[doi.org]
  • Re-epithelization begins 1 week after onset, takes up to 3 weeks; faster in children 30 Mucosal and other complications Large wound area leads to severe pain, massive fluid and protein loss, electrolyte imbalances, bleeding, evaporative heat loss with subsequent hypothermia[emdocs.net]
Severe Clinical Course
  • In this manuscript we present a case of a 59-year- old patient with cefaclor-induced severe clinical course of TEN syndrome.[termedia.pl]
Sore Mouth
  • mouth and throat Fatigue Cough Burning eyes When to see a doctor Stevens-Johnson syndrome requires immediate medical attention.[mayoclinic.org]
Decreased Lacrimation
  • A Sjogrenlike syndrome with decreased lacrimal secretion causes dry eye and predisposes to corneal abrasions and corneal scarring with neovascularization.[emedicine.com]
Red Eye
  • A 38-year-old woman presented to casualty with bilateral red eyes associated with a recent upper respiratory tract infection.[ncbi.nlm.nih.gov]
  • Symptoms may include fever – persistent and high, cough, sore throat, difficulty swallowing, runny nose, sore red eyes, conjunctivitis, and general aches and pains.[ozarkderm.com]
  • Symptoms may include: Fever 39 C Sore throat, difficulty swallowing Runny nose and cough Sore red eyes, conjunctivitis General aches and pains.[dermnetnz.org]
  • eyes [2] Complications Dehydration, sepsis, pneumonia, multiple organ failure. [2] Usual onset Age 40 [3] Risk factors HIV/AIDS, systemic lupus erythematosus, genetics [2] Diagnostic method 30% of the skin involved, skin biopsy [3] Differential diagnosis[en.m.wikipedia.org]
Erythema
  • BACKGROUND AND DESIGN: To conduct a prospective case-control study about causative factors of severe bullous erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis, we needed to define criteria for classifying the cases and standardize[ncbi.nlm.nih.gov]
  • Both patients presented erythema after hospital discharge following initial paraquat poisoning and then developed a widespread eruption of diffuse erythema on almost the whole body, with bullae, epidermal necrosis and sloughing.[ncbi.nlm.nih.gov]
  • […] multiforme, EM, bullous erythema multiforme, Stevens-Johnson syndrome, SJS, mucocutaneous reaction, widespread erythema, necrosis, bullous detachment of the epidermis, SJS-TEN, TEN with spots, TEN without spots, drug-induced skin disorder Background[web.archive.org]
  • , unspecified L52 Erythema nodosum L53 Other erythematous conditions L53.1 Erythema annulare centrifugum L53.2 Erythema marginatum L53.3 Other chronic figurate erythema L53.8 Other specified erythematous conditions Reimbursement claims with a date of[icd10data.com]
Eruptions
  • Eruptions are deemed "fixed" because upon repeated exposure they recur at previously affected sites. Generalized bullous fixed drug eruption (GBFDE) is a rare FDE variant occurring in patients with a previous history of FDE.[ncbi.nlm.nih.gov]
  • Abstract Fever is a symptom that often accompanies skin eruptions, especially in children. It can be a sign of an infectious condition presenting with exanthems or it may precede an exanthematous eruption.[ncbi.nlm.nih.gov]
  • Severe bullous eruptions in systemic lupus erythematosus (SLE) patients include bullous SLE, Rowell syndrome, toxic epidermal necrolysis (TEN), and TEN-like eruption of acute cutaneous lupus (TEN-like ACLE).[ncbi.nlm.nih.gov]
  • We review key physical examination findings that will help the clinician diagnose a viral etiology in the setting of an acute blistering eruption with mucosal involvement.[ncbi.nlm.nih.gov]
  • Both patients presented erythema after hospital discharge following initial paraquat poisoning and then developed a widespread eruption of diffuse erythema on almost the whole body, with bullae, epidermal necrosis and sloughing.[ncbi.nlm.nih.gov]
Ulcer
  • We describe a case of oxcarbazepine induced TEN, who presented with erythematous ulcerative maculopapular rash.[ncbi.nlm.nih.gov]
  • Resurgence of thalidomide began as an immunomodulator when it was shown to be effective in the management of multiple myeloma and many conditions like erythema nodosum leprosum, graft versus host disease, recurrent aphthous ulcers etc.[ncbi.nlm.nih.gov]
  • Here, we report a case of a 9-year-old girl who presented with blisters associated with an extensive vesicular rash and multiple ulcerations on the lips and oral cavity.[ncbi.nlm.nih.gov]
  • Given the extensive cutaneous involvement and the frequent mucosal ulcerations associated with GBFDE, it is challenging to discern these lesions from Steven-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN).[ncbi.nlm.nih.gov]
  • She had poorly controlled ulcerative colitis and was treated with high doses of prednisolone, infliximab, acetaminophen and lansoprazole.[ncbi.nlm.nih.gov]
Nikolsky's Sign
  • A 63-year-old woman treated with trimethoprim-sulfamethoxazole for Pneumocystis jirovecii infection developed a generalized maculopapular rash with herpetiform lesions, rosette-like lesions, and tense bullae with Nikolsky sign.[ncbi.nlm.nih.gov]
  • She presented targetoid lesions affecting approximately 25-30% of her body surface, large erosions with mucosal lesions and positive Nikolsky sign.[ncbi.nlm.nih.gov]
  • Nikolsky's sign is positive in perilesional skin. SJS and TEN are considered to be two ends of the spectrum of one disease, differing only by their extent of skin detachment.[ncbi.nlm.nih.gov]
  • Facts : Generally seen in adults History / PE : Erythematous morbilliform eruption Exfoliation of skin Positive Nikolsky's sign (skin falls off with slightest touch/pressure) Diagnosis : Biopsy shows full-thickness eosinophilic epidermal necrosis Greater[medlibes.com]
  • In severe cases of toxic epidermal necrolysis, large sheets of epithelium slide off the entire body at pressure points (Nikolsky sign), exposing weepy, painful, and erythematous skin.[merckmanuals.com]
Exanthema
  • Five days later, she developed a maculopapulous exanthema and small flaccid blisters, which spread over the common integument predominantly located on the dorsal trunk.[ncbi.nlm.nih.gov]
  • Subsequently, the exanthema progression stopped and resolution of the lesions happened in a few days.[ncbi.nlm.nih.gov]
  • Maculopapular Exanthema The group with maculopapular exanthema consisted of 106 subjects: 57 who were recruited through the Liverpool collaborators and 49 who were recruited through the EPIGEN consortium.[doi.org]
  • Here, we extended our genetic study to different types of CBZ-cADRs (91 patients, including 60 patients with SJS/TEN, 13 patients with hypersensitivity syndrome and 18 with maculopapular exanthema versus 144 tolerant controls).[ncbi.nlm.nih.gov]

Workup

The diagnosis of toxic epidermal necrolysis is based on both clinical and histological findings. A recent history of drug reactions can indicate a high risk for this disorder. Skin examination shows painful, burning, erythematous macules that coalesce and form large fluid-filled blisters all over the skin. The Nikolsky sign is positive in such patients.

The laboratory tests that help confirm the diagnosis include the following.

  • Complete blood count: Leukopenia, thrombocytopenia and neutropenia are present in severe infections
  • Hematologic studies: These include erythrocyte sedimentation rate and circulating immune complexes. They are found to be raised in chronic infections and sepsis.
  • Coagulation studies: These include prothrombin time and activated partial thromboplastin time. These help assess the degree of severity of the disorder. 
  • Skin biopsy: It is usually required to confirm the clinical diagnosis. A frozen section specimen is taken to exclude Staphylococcal Scalded Skin Syndrome and other generalized rashes with blisters. 
  • Histology: The histopathology suggests full thickness epidermal necrosis with keratinocyte death. It often shows scant inflammatory infiltrate in the papillary dermis. Epidermal detachment and sloughing may also be evident. 
  • Serum biomarkers: It is a new technique for early diagnosis of toxic epidermal necrolysis. Serum granulysin and serum high-mobility group protein B1 are among a few of the markers being used in early research.
  • To assess fluid and electrolyte losses, blood urea nitrogen, albumin and total protein should be assessed. Chest radiography should be performed in severe cases with respiratory distress. Patch testing also identifies the case and is often recommended.
Atelectasis
  • […] limitations in mastication and predisposition to dental caries. [8] Pulmonary Respiratory involvement can occur in up to 40% of patients. [8] Pulmonary complications can include the following: Epidermal sloughing of the bronchial epithelium Pulmonary edema Atelectasis[emedicine.com]

Treatment

The management of toxic epidermal necrolysis requires prompt diagnosis of the disorder and cessation of all causative agents. The patient should be hospitalized immediately in burn unit or intensive care center [14]. The supportive measures include isolation of the patient with fluid and electrolyte replacement, nutritional support, temperature maintenance, pain management and protective dressing. Crystalloids are given by intravenous or nasogastric routes. On average, 3-4 liters are needed in patients with 50% of the body surface area affected. Parenteral feeding should be advised. Opiate analgesics for pain relief are essential for comforting patients. Proper skin care should be provided by daily skin examination, skin culture, use of topical anesthetics, for example silver nitrate or chlorhexidine and sterile dressings such as gauze with petroleum. Other supportive measures include frequent use of eye-drops, mouthwashes, aerosols, bronchial aspiration and urinary catheterization. Regular assessment for infection including skin, mucous membrane and catheter sites is essential. Psychiatric support and physiotherapy to maintain joint movements may also be helpful.

Drug therapy should be initiated within the first 24-48 hours of illness. This includes:

Prognosis

The mortality for toxic epidermal necrolysis is 25-30%. With early diagnosis and good care, the outlook is very good. However, the untreated cases become vulnerable to chronic infections from fungi and bacteria, and can result in sepsis and death of the patient. Mortality rates are higher in elderly patients than in children and adults. The various complications include hypopigmentation, hypohidrosis, scarring, alopecia, chronic xerostomia, phimosis and nail dystrophy.

A disease severity score (SCORTEN) is used to predict outcome [7] [8] [9]. It includes various factors such as age > 40 years, heart rate > 120 beats/min, hematological malignancies, involved body surface area > 10%, blood urea > 10mmol/L, serum bicarbonate <20mmol/L and blood glucose >14mmol/L. The mortality rates increase up to 90% if more than 5 factors are present. Other negative prognostic factors include respiratory failure, lymphopenia, neutropenia, multiple drugs intake and sepsis.

Etiology

More than 85-90% cases of toxic epidermal necrolysis have been reported to be caused by drug reactions [1]. Numerous drug groups have been implicated in this case. Antibacterial drugs associated with toxic epidermal necrolysis include sulfonamides, penicillins, macrolides, quinolones and chloramphenicol. The anticonvulsants associated with the disorder include phenobarbital, phenytoin, carbamazepine, valproic acid and lamotrigine. NSAIDs include sulindac, tolmetin, indomethacin, ibuprofen, phenylbutazone, oxybutazone and oxicams [2] [3] [4]. The genetic factors, for example certain HLA-types and HIV-positive individuals are at increased risk of toxic epidermal necrolysis. Moreover, certain infectious agents such as mycoplasma pneumoniae, herpes simplex virus, hepatitis A, dengue virus, various immunizations, contrast agents used in imaging studies and bone marrow transplantations have also been associated with toxic epidermal necrolysis.

Epidemiology

The incidence of toxic epidermal necrolysis is 1-2 cases per million population a year. In the HIV-positive population, the incidence increases to 1 case per thousand a year. It can affect people of all age groups but is more common in the elderly. There is a genetic predilection towards individuals with HLA-types. The mean age of patients with this disorder is reported to be between 46 and 63 years. The female to male ratio is 1.5:1. Toxic epidermal necrolysis is a severe form of Stevens-Johnson syndrome. The condition is called toxic epidermal necrolysis when >30% of the body surface is involved. However, it is called Stevens-Johnson syndrome when <10% of body surface is involved.

Sex distribution
Age distribution

Pathophysiology

Toxic epidermal necrolysis is usually caused by drugs or a bacterial infection. Usually 1-4 weeks after drug commencement, the patient becomes systemically unwell and often runs a fever. Soon after, erythema and blistering develop, initially on the trunk but rapidly involving all skin. The toxic drug reactions weaken the immune system of the body. Certain type of immune cells including cytotoxic CD8 and helper T cells are primarily responsible for keratinocyte death and subsequent skin detachment [5] [6]. Drug induced secretion of granulysin and the release of destructive proteins from cytotoxic T lymphocytes involves an immunopathologic pathway that leads to keratinocyte apoptosis. CD8 immune cells become overactive by stimulation from drug metabolites. Other agents, including tumor necrosis factor alpha and fas ligand also appear to be involved in the pathogenesis of toxic epidermal necrolysis.

Prevention

The most effective way to prevent toxic epidermal necrolysis and its recurrence is by proper skin care and avoid taking the causative drugs and related medications. Cross reactions have been reported between different anti-convulsant agents or non-steroidal anti-inflammatory drugs, such as the oxicams. Specialized nursing care is essential in people who have survived the lethal disorder. It should be predicted early using genetic screening, as specific at-risk HLA alleles have been recognized in certain populations. The first degree relatives of the patient should be alerted to their elevated risk of such reactions to the same drug. Patients requiring management should be monitored carefully in sterile environment. Areas of skin erosion should be covered with non-adherent protective dressings such as petroleum gauze. The patients with respiratory distress should be facilitated with endotracheal intubation and proper ventilation. The long term complications such as dry eyes, photophobia, symblepharon, corneal scarring, xerosis, vulvovaginal stenosis and skin eruptive lesions should also be treated immediately. In patients with worsening renal functions, allopurinol should be prescribed for good indications and commenced at low doses.

Summary

Toxic epidermal necrolysis is a rare, life-threatening skin disorder associated with a high mortality rate. The disease is characterized by extensive mucocutaneous blistering that causes rash, skin peeling and soreness on the mucous membranes. It is usually drug-induced, particularly associated with anticonvulsants, sulphonamides, sulphonylureas, anxiolytics, beta-lactams, barbiturates, NSAIDs, allopurinol and antiretroviral therapy. Typical symptoms for disease include flu-like prodrome with a cough, runny nose, fever, body-aches, decreased appetite, malaise and a flat red rash. It usually co-exists with Stevens-Johnson syndrome. Treatment involves discontinuing the use of causative agents, and supportive care in the intensive care unit of a hospital. Untreated cases of toxic epidermal necrolysis often suffer long-term complications affecting the skin and eyes.

Patient Information

Toxic epidermal necrolysis is a life-threatening skin disorder that is usually caused by a reaction to drugs. It causes rash, skin peeling and sores on the mucous membrane. The patients usually presents with fever, cough, body aches, generalized weakness, a flat red rash and blisters all over the skin. It affects the face and trunk, and later spreads to the rest of the body. It is a medical emergency and the patient requires proper treatment in burn unit. With early diagnosis and supportive care, the prognosis is good.

References

Article

  1. Roujeau JC, Guillaume JC, Fabre JP, Penso D, Flechet ML, Girre JP. Toxic epidermal necrolysis (Lyell syndrome). Incidence and drug etiology in France, 1981-1985. Archives of dermatology. Jan 1990;126(1):37-42.
  2. Faninger A. [Contribution to the knowledge of the etiology of "toxic epidermal necrolysis (Lyell)"]. Der Hautarzt; Zeitschrift fur Dermatologie, Venerologie, und verwandte Gebiete. Dec 1961;12:554-555.
  3. Mockenhaupt M. Stevens-Johnson syndrome and toxic epidermal necrolysis: clinical patterns, diagnostic considerations, etiology, and therapeutic management. Seminars in cutaneous medicine and surgery. Mar 2014;33(1):10-16.
  4. Schwartz RA, McDonough PH, Lee BW. Toxic epidermal necrolysis: Part I. Introduction, history, classification, clinical features, systemic manifestations, etiology, and immunopathogenesis. Journal of the American Academy of Dermatology. Aug 2013;69(2):173 e171-113; quiz 185-176.
  5. Khalili B, Bahna SL. Pathogenesis and recent therapeutic trends in Stevens-Johnson syndrome and toxic epidermal necrolysis. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology. Sep 2006;97(3):272-280; quiz 281-273, 320.
  6. Downey A, Jackson C, Harun N, Cooper A. Toxic epidermal necrolysis: review of pathogenesis and management. Journal of the American Academy of Dermatology. Jun 2012;66(6):995-1003.
  7. Collin B, Marshall T, Heagerty A. Scoring with SCORTEN. Archives of dermatology. Sep 2003;139(9):1215; author reply 1215-1216.
  8. Bastuji-Garin S, Fouchard N, Bertocchi M, Roujeau JC, Revuz J, Wolkenstein P. SCORTEN: a severity-of-illness score for toxic epidermal necrolysis. The Journal of investigative dermatology. Aug 2000;115(2):149-153.
  9. Cartotto R, Mayich M, Nickerson D, Gomez M. SCORTEN accurately predicts mortality among toxic epidermal necrolysis patients treated in a burn center. Journal of burn care & research : official publication of the American Burn Association. Jan-Feb 2008;29(1):141-146.
  10. Soloshenko EN, Brailovskii A. [Clinical picture and pathogenesis of toxic epidermal necrolysis (Lyell's syndrome)]. Vestnik dermatologii i venerologii. 1971;45(4):72-74.
  11. van Gijn J, Gijselhart JP. [Nikolsky and his sign]. Nederlands tijdschrift voor geneeskunde. 2011;155:A2846.
  12. Doubleday CW. Who is Nikolsky and what does his sign mean? Journal of the American Academy of Dermatology. May 1987;16(5 Pt 1):1054-1055.
  13. Goodman H. Nikolsky sign; page from notable contributors to the knowledge of dermatology. A.M.A. archives of dermatology and syphilology. Sep 1953;68(3):334-335.
  14. Hensen E. [Pathogenesis and treatment of toxic epidermal necrolysis]. Tijdschrift voor ziekenverpleging. Jun 23 1981;34(13):563-567.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2019-07-11 20:28