Improving mortality outcomes of Stevens Johnson syndrome/toxic epidermal necrolysis: A regional burns centre experience. Burns. 2018;44:603-611. [PMID: 29029855 DOI: 10.1016/j.burns.2017.09.015]

To Debride or Not to Debride: A Review of Wound Management for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are immune-mediated skin reactions with high mortality as a result of severely compromised skin barrier function. Currently, there is no consensus on the topical management of these conditions. Some advocate for surgical debridement of affected skin as a means of preventing infection and facilitating reepithelialization with synthetic and biological wound coverage. Others prefer a conservative approach that relies on leaving the blistered skin in situ. A consensus is lacking, primarily due to the rarity of the disease and the lack of high-quality evidence supporting one particular form of management. The goal of this review is to explore and compare the two treatment approaches for SJS and TEN, namely conservative management and surgical debridement.

An individual patient data meta-analysis of wound care in patients with toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) involves extensive mucocutaneous loss, and care is supportive. The approach to wound care includes surgical debridement or using dressings while leaving the epidermis intact. Robust evidence for either approach is lacking. We compared surgical debridement to the use of dressings while leaving the epidermis in situ (referred to hereon as dressings) in adult patients with TEN. The primary outcome assessed was mortality. The secondary outcome was time to re-epithelialisation. The impact of medications was evaluated. An individual patient data (IPD) systematic review and meta-analysis was undertaken. A random effects meta-analysis and survival analysis for IPD data examined mortality, re-epithelisation time and the effect of systemic medications. The quality of evidence was rated per the Grading of Recommendations Assessment, Development and Evaluation (GRADE). PROSPERO: CRD42021266611 Fifty-four studies involving 227 patients were included in the systematic review and meta-analysis, with a GRADE from very low to moderate. There was no difference in survival in patients who had surgical debridement or dressings (univariate: p = 0.91, multivariate: p = 0.31). Patients who received dressings re-epithelialised faster than patients who underwent debridement (multivariate HR: 1.96 [1.09-3.51], p = 0.023). Intravenous immunoglobulin (univariate HR: 0.21 [0.09-0.45], p < 0.001; multivariate HR: 0.22 [0.09-0.53], p < 0.001) and cyclosporin significantly reduced mortality (univariate HR: 0.09 [0.01-0.96], p = 0.046; multivariate HR: 0.06 [0.01-0.73], p = 0.028) irrespective of the wound care. This study supports the expert consensus of the dermatology hospitalists, that wound care in patients with TEN should be supportive with the epidermis left intact and supported with dressings, which leads to faster re-epithelialisation.

Desmoplakin I/II immunohistochemical staining may be a helpful tool in differentiating cutaneous graft versus host disease from the erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis spectrum disorders

Cutaneous graft versus host disease (cGVHD) has substantial clinical and histopathologic overlap with erythema multiforme (EM), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN). This overlap can make it difficult to distinguish these disorders in patients who have received hematopoietic transplants. We sought to evaluate the utility of Dp I/II immunohistochemical stain in differentiating EM/SJS/TEN and cGVHD in a large cohort. Skin biopsy specimens from patients with cGVHD (n = 58) and EM/SJS/TEN (n = 60) were evaluated for Dp I/II expression by immunohistochemistry. We found a statistically significant difference in Dp I/II staining between cGVHD (all grades) and EM/SJS/TEN (mean scores 1.62 and 2.14, respectively; p < 0.005), as well as between Grades 2 + 3 cGVHD and EM/SJS/TEN (mean scores 2.26 and 1.62, respectively; p < 0.005), while we did not find a significant difference between Grade 4 cGVHD and EM/SJS/TEN (mean scores 1.69 and 1.62, respectively; p = 0.71). Dp I/II immunostain may be useful for differentiating EM/SJS/TEN from Grade 2 and Grade 3 cGVHD, especially in clinically ambiguous cases without extracutaneous GVHD.

Role of Silver Nitrate Spray for Skin Wound Care in Patients with Toxic Epidermal Necrolysis: Our Experience in 4 Patients

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are examples of severe cutaneous adverse reactions to drugs (SCARs) with several international recommendations for global medical management, ranging from pharmacological systemic therapy to skin wound care. There is no defined best management of the skin wounds in SJS/TEN. The care of wounds is essential to initiate re-epithelialization. Our objective is to improve the cicatrization process, avoiding scarring due to deepening of the wounds, as well as prevent infections, achieve pain control, and avoid loss of serum proteins, fluids, and electrolytes. In this retrospective case series, we highlight the value of systemic therapy and the use of silver nitrate for wound management in four patients with TEN.

RDW-SD and PCT Are Potential Prognostic Factors for In-hospital Death in Patients With Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

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.

Autologous Skin Cell Suspension in Toxic Epidermal Necrolysis: A Case Series

Toxic epidermal necrolysis (TEN) is a dermatological process which has lacked both clear pathophysiological definition and efficacious medical treatment. This leads to metabolic dysfunction due to the inability to regulate fluid and electrolytes after the loss of skin. It is a deadly and costly disease which is associated with long lengths of stay and high-mortality rates. The depth of TEN mimics that of a partial-thickness burn. There has been documentation of successful usage of autologous skin cell suspension (ASCS) in TEN. This study expands upon our previous experience using ASCS in TEN to a series of three. Dermatology is consulted for biopsy along with the burn surgery team for wound care, where a Score for TEN is performed for risk stratification. Aggressive operative debridement is performed in the operative suite and a healthy, uninvolved donor site is harvested and processed per standard protocol. Dressings are taken down at postoperative day 4 for evaluation. The average length of stay when compared to historical data in literature is a reduction by 48%. ICU days were reduced by 64%. Cost was reduced by 54%. There was no mortality in our population of three. ASCS is both therapeutically and cost effective at treating TEN. The question of type of dressing and decision to operate is mitigated by this intervention. As an efficacious intervention, it reduces hospital stay, reduces wound cares, speeds healing, and provides a cosmetically acceptable outcome.

Scoring Assessments in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

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.

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

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.

Improvement of Mortality Prognostication in Patients With Epidermal Necrolysis: The Role of Novel Inflammatory Markers and Proposed Revision of SCORTEN (Re-SCORTEN)

IMPORTANCE

Epidermal necrolysis is a severe cutaneous adverse reaction in which severe systemic inflammation results in extensive epithelial keratinocyte necrosis. The most commonly used prognostic score in epidermal necrolysis, the Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN), was recently found to overestimate mortality in contemporary cohorts. Identification of independent prognostic markers may help to stratify risk more accurately.

OBJECTIVE

This study evaluates the association between novel inflammatory markers and in-hospital mortality in patients with epidermal necrolysis to study the incremental prognostic value of these markers in combination with SCORTEN.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted over a 17-year period from 2003 to 2019. Patients were enrolled from Singapore General Hospital, the national referral center for epidermal necrolysis. A total of 196 patients with epidermal necrolysis were recruited, 4 (2%) of whom were excluded owing to incomplete data.

MAIN OUTCOMES AND MEASURES

The main outcome assessed was the in-hospital mortality rate. Discrimination and calibration of risk scores were assessed using the area under the receiver operating characteristic curve (AUC) and calibration plot, respectively. Evaluation of the incremental prognostic value of these markers was done by comparing the AUC between the old and new risk score, and the use of net reclassification improvement (NRI) and integrated discrimination improvement (IDI).

RESULTS

Among 192 total patients (median [IQR] age 56 [42-70] years; 114 [59.4%] women), there were 43 (22.4%) who did not survive to discharge. Of the novel inflammatory markers, only red cell distribution width to hemoglobin ratio was significant in predicting in-hospital mortality (odds ratio [OR] 3.55; 95% CI, 1.76-7.16; P < .001) after adjusting for SCORTEN. The RDW/Hb as applied in 4 risk groups showed similar discrimination to SCORTEN (AUC [95% CI]: RDW/Hb in 4 groups, 0.76 [0.69-0.84], vs SCORTEN, 0.78 [0.70-0.85], P = .89). When RDW/Hb was added to SCORTEN, the composite score Re-SCORTEN showed significantly better discrimination than SCORTEN alone (AUC [95% CI]: Re-SCORTEN, 0.83 [0.77-0.89], vs SCORTEN, 0.78 [0.70-0.85], P = .02). The overall NRI was 0.94 (95% CI, 0.68-1.20), P < .001. The IDI was 0.06 (95% CI 0.03-0.08), P < .001. Re-SCORTEN showed good calibration based on the calibration plot.

CONCLUSIONS AND RELEVANCE

In this cohort of patients, RDW/Hb, an inexpensive and readily available marker, showed similar predictive accuracy with SCORTEN. Furthermore, when used in combination with SCORTEN, it also helped augment prognostic ability.

Stevens–Johnson syndrome and toxic epidermal necrolysis: 11-year demographic clinical and prognostic characteristics

Background:

Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are acute, life-threatening, severe drug reactions. Randomized studies on these diseases are difficult to perform.

Aims and Objectives:

The purpose of this study was to summarize the demographic and clinical characteristics of patients with SJS and TEN in a tertiary hospital in Turkey.

Materials and Methods:

We evaluated the records of 33 patients with SJS and TEN who were followed in our clinic or examined between January 2008 and June 2019, retrospectively. Age, sex, time of admission to hospital, causative drug, presence of concomitant disease, skin findings, mucosal involvement, the severity-of-illness score for TEN, the medication used, antibiotic use, transfer to intensive care, development of complications, and death or discharge status were noted.

Results:

Of the 33 patients, 11 (33.3%) had SJS, 3 (9.1%) had SJS/TEN overlap, and 19 (57.6%) had TEN. The majority (60.6%) of the patients were female. Nineteen (57.6%) patients had one, and 13 (39.4%) had more than one suspected drug exposure in their history. The most commonly suspected drugs were antibiotics. Twelve (36.4%) patients had intensive care unit hospitalization. Ten (30.3%) patients died.

Conclusion:

The demographic data of our study were consistent with the literature. Similar to the literature, antibiotics were the most common reaction-causing drugs. However, antiepileptic drugs, which were more frequently reported in other studies, were identified as suspicious in only one patient. We believe that our study will contribute to the determination of characteristics of this rare disease with real-life data.

Autologous skin cell suspension application for toxic epidermal necrolysis: a case report

Toxic epidermal necrolysis is a drug-mediated disease process which mimics a partial thickness thermal injury. It has long been treated with frequent wound dressing changes and supportive care. There has been minimal efficacious system therapy. The pathophysiology is poorly understood but causes necrosis of keratinocytes at the dermal-epidermal junction leading to sloughing of the epidermis. The disease is rare with high mortality rates associated with long hospital stays. This case report describes the application of autologous skin cell suspension to a patient with toxic epidermal necrolysis after antihypertensive and hyperglycemic therapy. This was associated with minimal wound care and efficacious arrest of patient disease process and timely closure of wound.

Assessment and Comparison of Performance of ABCD-10 and SCORTEN in Prognostication of Epidermal Necrolysis

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.

Autologous scalp skin grafting to treat toxic epidermal necrolysis in a patient with a large skin injury: A case report

BACKGROUND

Toxic epidermal necrolysis (TEN) is often associated with skin wounds affecting large areas. Healing of this type of wound is difficult because of pressure, infection and other factors. It can increase the length of hospital stay and result in wound sepsis and even death.

CASE SUMMARY

A 49-year-old woman developed a skin lesion covering 80% of the total body surface area after using a kind of Chinese medicinal ointment on a burn wound on her back; she developed life-threatening wound sepsis and septic shock. Methicillin-resistant Staphylococcus aureus, carbapenem-resistant Acinetobacter baumannii, carbapenem-resistant Pseudomonas aeruginosa and other bacteria were cultured from wound tissue, deep venous catheter and blood samples. Imipenem cilastatin sodium, tigecycline and teicoplanin were used for anti-infection therapy. Finally, the patient was transferred to the burn department because of severe wound sepsis. In the burn intensive care unit, pain-free dressing changes and autologous scalp skin grafting were performed to heal the wound in addition to reasonable and effective antibacterial treatment according to microbial susceptibility test results. After three operations within 2 wk, the wound healed and sepsis resolved.

CONCLUSION

TEN patients with large areas of skin injury may develop wound infection and life-threatening wound sepsis. Autologous scalp skin grafting may be beneficial for rapid wound healing and reducing the risk of sepsis in TEN patients, and it leaves no scar at the donor site.

Intensive care needs and long-term outcome of pediatric toxic epidermal necrolysis - A 10-year experience

BACKGROUND

Toxic epidermal necrolysis (TEN) is a life-threatening severe cutaneous adverse reaction. Data on pediatric TEN is limited.

METHODS

Case records of 44 children, 1 month-12 years with a diagnosis of TEN (>30% body surface area [%BSA] detachment) admitted to a tertiary pediatric intensive care unit (PICU) between 2009 and 2018 were analyzed retrospectively. The primary outcome was mortality, and secondary outcomes were organ dysfunction, length of stay (LOS), and long-term sequelae.

RESULTS

Median (IQR) age was 6.5 (3.6, 8.0) years, and 25 (57%) were boys. Median (IQR) %BSA involved, SCORTEN score, and PRISM-III were 65% (45, 80); 2 (2, 3) and 13 (10, 16), respectively. Antiepileptics (n = 24, 54.6%) and antimicrobials (n = 8, 18.2%) were the most common offending agents. Twenty-four (54.5%) children had culture positive sepsis. Immunomodulatory therapy was provided in 35 (79.5%) and conservative management in nine (20.5%) children. Intravenous immunoglobulin (IVIG) was given in 22 (50%), steroids in three (6.8%), and both IVIG and steroids in 10 (22.7%) children. Respiratory failure (n = 14, 31.8%) was the commonest organ failure. Mortality was 15.9% (n = 7), and median (IQR) PICU-LOS in survivors was 8 (4, 11.75) days. There was no association between IVIG, steroids, or conservative management with mortality or LOS. Ocular sequelae (n = 20, 54.1%) were the most common long-term complication followed by skin (18, 40.1%).

CONCLUSION

Immunomodulation with IVIG or steroids was not associated with any mortality benefit as compared to conservative management alone. Further research is required to determine the most effective treatment in pediatric TEN.

Epidemiology and Risk Factors for Severe Delayed Drug Hypersensitivity Reactions

Severe delayed drug hypersensitivity reactions comprise different clinical entities and can involve different immune-mediated mechanisms. Common examples are severe cutaneous adverse reactions and druginduced internal organ injuries. The incidence of such reactions is overall low but seems to be on the rise reaching numbers as high as 9 per million individuals-years in the case of SJS/TEN and DRESS. Such conditions carry an important associated morbidity, and mortality can attain 40% in SJS/TEN patients, making these hypersensitivity reactions important targets when implementing preventive measures. Several risk factors have been identified for reaction severity; some are transverse, such as older age and underlying chronic diseases. The recent advances in pharmacogenetics allowed the identification of specific populations with higher risk and permitted strategic avoidance of certain drugs being HLA-B*57:01 screening in patients initiating abacavir the best successful example. In this work, we reviewed the epidemiology of SCARs and liver/kidney/lung drug-induced immune-mediated reactions. We focus on particular aspects such as prevalence and incidence, drugs involved, mortality and risk factors.

Society of Dermatology Hospitalists supportive care guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening conditions with high morbidity and mortality. Supportive care management of SJS/TEN is highly variable. A systematic review of the literature was performed by dermatologists, ophthalmologists, intensivists, and gynecologists with expertise in SJS/TEN to generate statements for supportive care guideline development. Members of the Society of Dermatology Hospitalists with expertise in SJS/TEN were invited to participate in a modified, online Delphi-consensus. Participants were administered 9-point Likert scale questionnaires regarding 135 statements. The RAND/UCLA Appropriateness Method was used to evaluate and select proposed statements for guideline inclusion; statements with median ratings of 6.5 to 9 and a disagreement index of ≤1 were included in the guideline. For the final round, the guidelines were appraised by all of the participants. Included are an evidence-based discussion and recommendations for hospital setting and care team, wound care, ocular care, oral care, urogenital care, pain management, infection surveillance, fluid and electrolyte management, nutrition and stress ulcer prophylaxis, airway management, and anticoagulation in adult patients with SJS/TEN.

Toxic Epidermal Necrolysis Therapy with TPE and IVIG-10 Years of Experience of the Burns Treatment Center

Toxic epidermal necrolysis (TEN) is a potentially life-threatening, exfoliative disease. It is described as idiosyncratic, severe, skin reaction to drugs. With Stevens-Johnson's Syndrome, it presents as a continuum of a disease being categorized relating to the percentage of affected skin. Without any multicenter trials comparing TEN treatment modalities, there is dearth of strong evidence-based guidelines of care. Total plasma exchange with intravenous immunoglobulin (IVIG) is one among plethora of possible treatment strategies. In our 10-year experience, we have observed 21 patients admitted to our burns center due to TEN. All of them were placed under intensive care with daily plasmapheresis (TPE) and IVIG. We have observed 52% mortality, with observed severe concomitant diseases in every patient in nonsurvivor group (average Acute Physiology and Chronic Health Evaluation II score at admission: 31.5%). We consider that TPE with IVIG might be of use in selected group of patients with TEN without any severe comorbidities. However, further multicenter trials are needed because in some cases it may raise mortality.

The Role of Biological Skin Substitutes in Stevens-Johnson Syndrome: Systematic Review

Stevens-Johnson syndrome (SJS) is a disease that causes skin exfoliative lesions, characterized by fever, necrosis, and epidermal detachment. Biological skin substitutes may be considered interesting options for the treatment of this disease. This study aims at identifying in the literature the evidence on the current role of these biomaterials in the treatment of SJS and its related diseases. A systematic review with a search period between 2003 and 2017 was carried out, consulting the Lilacs, BVS, and PubMed databases. The quality of the included studies was evaluated by the Oxford Center for Evidence-Based Medicine Classification, for evaluating levels of evidence from the scientific publications. Ninety-five publications were found, and after applying inclusion and exclusion criteria, they resulted in 9 articles. In total, 20 patients with 73.87% average of body surface affected received SJS skin treatment with some biological substitutes, among them are cutaneous allograft, amnion, and xenograft. Mortality rate was 10%, and in these situations, literature indicates mortality rates ranging from 25% to 70%. Effectiveness of the use of biological dressings may be a possible explanation for this finding. Findings indicate the use of these biomaterials may favor reepithelialization, reduce water loss, decrease the chance of infection, and, consequently, improve the survival of patients with SJS and toxic epidermal necrolysis. Biological skin substitutes have characteristics that make them very promising in the topical treatment of these wounds, but their use remains very restricted in the treatment of SJS.