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Senda A, Fushimi K. Effectiveness of early treatment with plasma exchange in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis. Sci Rep 2024; 14:2893. [PMID: 38316978 PMCID: PMC10844598 DOI: 10.1038/s41598-024-53653-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 02/03/2024] [Indexed: 02/07/2024] Open
Abstract
Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are potentially fatal medical conditions that lack established treatment. Therapeutic plasma exchange (PE) is a potential treatment option; however, its effectiveness is unclear. We aimed to evaluate the effectiveness of PE in patients with SJS/TEN. A retrospective cohort study was conducted using data from the Japanese National Administrative Claims database from 2016 to 2021. The analysis included 256 patients diagnosed with SJS/TEN who were admitted to the intensive care unit, of whom 38 received PE and 218 did not. The outcomes of patients who did and did not receive PE within the first 24 h of admission were compared. The risk ratios and 95% confidence intervals of the PE group compared with those of the no-PE group were as follows: in-hospital mortality, 0.983 (0.870-1.155); 30-day mortality rate, 1.057 (0.954-1.217); 50-day mortality rate, 1.023 (0.916-1.186); and length of hospital stay, 1.163 (0.762-1.365). This study does not provide evidence of a benefit of PE in reducing mortality or length of hospital stay in patients with severe SJS/TEN.
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Affiliation(s)
- Atsushi Senda
- Department of Acute Critical Care and Disaster Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8510, Japan.
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8510, Japan
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2
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A Review of the Systemic Treatment of Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis. Biomedicines 2022; 10:biomedicines10092105. [PMID: 36140207 PMCID: PMC9495335 DOI: 10.3390/biomedicines10092105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 08/10/2022] [Accepted: 08/24/2022] [Indexed: 11/28/2022] Open
Abstract
Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are uncommon but life-threatening diseases mostly caused by drugs. Although various systemic immunomodulating agents have been used, their therapeutic efficacy has been inconsistent. This study aimed to provide an evidence-based review of systemic immunomodulating treatments for SJS/TEN. We reviewed 13 systematic review and meta-analysis articles published in the last 10 years. The use of systemic corticosteroids and IVIg is still controversial. An increasing number of studies have suggested the effectiveness of cyclosporine and biologic anti-TNF-α in recent years. There were also some promising results of combination treatments. Further large-scale randomized controlled trials are required to provide more definitive evidence of the effectiveness of these treatments. The pathogenesis of SJS/TEN has been elucidated in recent years and advances in the understanding of SJS/TEN may inspire the discovery of potential therapeutic targets.
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Strużyna J, Surowiecka A, Korzeniowski T, Piszczek J, Korulczyk P, Drozd L, Stachura A, Torres K, Krajewski A. Immunomodulatory treatment of Lyell's syndrome - a simultaneous plasmapheresis and IVIGs therapy. J Burn Care Res 2022; 43:1394-1398. [PMID: 35396849 DOI: 10.1093/jbcr/irac046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Lyell's syndrome, or toxic epidermal necrolysis (TEN) is a rare but life-threatening condition. It manifests with blistering of skin and mucous due to subepidermal bullae and keratinocyte necrosis. In most cases it is an immune response to drugs or their metabolites. The mortality in TEN is high despite optimal infection and wound control. There are no unequivocal treatment guidelines in TEN. Immunosuppressive treatment may increase the wound infection risk and mortality. The aim of the study was to evaluate a 10-year experience with immunomodulatory therapy in TEN. We perform a combination of plasmapheresis and IVIGs to control the disease. There were 35 patients in the group and we performed a post hoc evaluation. 28 patients received the full protocol and there were 7 patients who did not complete the treatment (single therapy group). The mortality in the test group was 14,29%, and the difference reached statistical significance in comparison with the single therapy group (p<0.05). Our protocol reduced the mortality risk 5 times. Our study proved that simultaneous plasmaphereses with IVIGs administration was safe and improved patients' outcome in TEN.
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Affiliation(s)
- Jerzy Strużyna
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland.,Department of Plastic Surgery, Reconstructive Surgery and Burn Treatment, Medical University of Lublin, Poland
| | - Agnieszka Surowiecka
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland
| | - Tomasz Korzeniowski
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland.,West Pomeranian Burns and Plastic Surgery Center, Gryfice, Poland
| | - Joanna Piszczek
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland.,Department of Plastic Surgery, Reconstructive Surgery and Burn Treatment, Medical University of Lublin, Poland
| | - Patrycja Korulczyk
- Chair and Department of Didactics and Medical Simulation, Medical University of Lublin, Poland
| | - Lukasz Drozd
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland
| | - Aldona Stachura
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland
| | - Kamil Torres
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland.,Chair and Department of Didactics and Medical Simulation, Medical University of Lublin, Poland
| | - Andrzej Krajewski
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland.,West Pomeranian Burns and Plastic Surgery Center, Gryfice, Poland
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Naik PP. A contemporary snippet on clinical presentation and management of toxic epidermal necrolysis. Scars Burn Heal 2022; 8:20595131221122381. [PMID: 36118413 PMCID: PMC9476246 DOI: 10.1177/20595131221122381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Toxic epidermal necrolysis (TEN) is one of the most severe cutaneous adverse reactions with a mortality rate of 30%. Due to a lack of consensus regarding the treatment and management of TEN, therapy is individualized on a case-to-case basis. Purpose The scientific literature about Stevens-Johnson Syndrome (SJS) and TEN is summarized and assessed to aid and assist in determining the optimal course of treatment. Methods PubMed and Google Scholar, among others, were searched with the keywords: “Toxic Epidermal Necrolysis”, “corticosteroids”, “cyclosporine”, “etanercept”, “intravenous immunoglobulin”, “Stevens-Johnson syndrome” and filtered by year. The research articles generated by the search, and their references, were reviewed. Results TEN is a severe dermatological condition that is mainly caused by medicines. World-wide guidelines differ in care plans. As there is no consensus on the management of TEN, this article aims to summarize the efficacy and feasibility of the management aspect of TEN from previous studies. Supportive care is highly accepted, along with early discontinuation of all medicines (hydration & electrolytes). Corticosteroids and cyclosporine have been used in therapy. Intravenous immunoglobulin (IVIG) is currently being administered; however, their efficacy by themselves and in combination remains uncertain. Conclusion Current evidence predominantly from retrospective studies suggests no individual treatment has sufficient efficacy and a multi-faceted regimen stands to be favored. Therapeutic regimens from corticosteroids to IVIG are under constant evaluation. The life-threatening nature of TEN warrants further confirmation with more extensive, robust randomized, controlled trials. Lay Summary Toxic epidermal necrolysis (TEN) is a serious skin reaction with a 30% chance of mortality. Commonly TEN is caused by medicines and results in a burn like appearance and sensation in patients. Usually administered medicine is cleared effectively by the human body but when the clearance of few metabolites from medicine is disrupted due to few genes, it leads to an ominous response by the body. This response involves several intermediate chemicals that primarily attack skin cells. Treatment guidelines differ globally. Supportive care is highly accepted, along with early discontinuation of all medicine. Currently, a multi-faceted treatment regimen is favored. Treatments like corticosteroids to immunoglobulins are under constant evaluation. Identification of the perfect combination of treatment needs confirmation from robust randomized controlled trials.
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Affiliation(s)
- Piyu Parth Naik
- Department of Dermatology, Saudi German Hospital and Clinic, Dubai, United Arab Emirates
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Zhang J, Lei Z, Xu C, Zhao J, Kang X. Current Perspectives on Severe Drug Eruption. Clin Rev Allergy Immunol 2021; 61:282-298. [PMID: 34273058 PMCID: PMC8286049 DOI: 10.1007/s12016-021-08859-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 12/16/2022]
Abstract
Adverse drug reactions involving the skin are commonly known as drug eruptions. Severe drug eruption may cause severe cutaneous adverse drug reactions (SCARs), which are considered to be fatal and life-threatening, including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), acute generalized exanthematous pustulosis (AGEP), and drug reaction with eosinophilia and systemic symptoms (DRESS). Although cases are relatively rare, approximately 2% of hospitalized patients are affected by SCARs. There is an incidence of 2 to 7 cases/million per year of SJS/TEN and 1/1000 to 1/10,000 exposures to offending agents result in DRESS. However, the mortality rate of severe drug eruptions can reach up to 50%. SCARs represent a real medical emergency, and early identification and proper management are critical to survival. The common pathogenesis of severe drug eruptions includes genetic linkage with HLA- and non-HLA-genes, drug-specific T cell-mediated cytotoxicity, T cell receptor restriction, and cytotoxicity mechanisms. A multidisciplinary approach is required for acute management. Immediate withdrawal of potentially causative drugs and specific supportive treatment is of great importance. Immunoglobulins, systemic corticosteroids, and cyclosporine A are the most frequently used treatments for SCARs; additionally, new biologics and plasma exchange are reasonable strategies to reduce mortality. Although there are many treatment methods for severe drug eruption, controversies remain regarding the timing and dosage of drug eruption. Types, dosages, and indications of new biological agents, such as tumor necrosis factor antagonists, mepolizumab, and omalizumab, are still under exploration. This review summarizes the clinical characteristics, risk factors, pathogenesis, and treatment strategies of severe drug eruption to guide clinical management.
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Affiliation(s)
- Jingzhan Zhang
- Department of Dermatology, People's Hospital of Xinjiang Uygur Autonomous Region, Tianshan District, No. 91, Tianchi Road, Urumqi, 830001, Xinjiang, China.,Xinjiang Key Laboratory of Dermatology Research, Urumqi, Xinjiang, China
| | - Zixian Lei
- Department of Dermatology, People's Hospital of Xinjiang Uygur Autonomous Region, Tianshan District, No. 91, Tianchi Road, Urumqi, 830001, Xinjiang, China.,Xinjiang Key Laboratory of Dermatology Research, Urumqi, Xinjiang, China
| | - Chen Xu
- Department of Dermatology, People's Hospital of Xinjiang Uygur Autonomous Region, Tianshan District, No. 91, Tianchi Road, Urumqi, 830001, Xinjiang, China.,Xinjiang Key Laboratory of Dermatology Research, Urumqi, Xinjiang, China
| | - Juan Zhao
- Department of Dermatology, People's Hospital of Xinjiang Uygur Autonomous Region, Tianshan District, No. 91, Tianchi Road, Urumqi, 830001, Xinjiang, China.,Xinjiang Key Laboratory of Dermatology Research, Urumqi, Xinjiang, China
| | - Xiaojing Kang
- Department of Dermatology, People's Hospital of Xinjiang Uygur Autonomous Region, Tianshan District, No. 91, Tianchi Road, Urumqi, 830001, Xinjiang, China. .,Xinjiang Key Laboratory of Dermatology Research, Urumqi, Xinjiang, China.
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6
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Therapeutic plasma exchange combined with continuous venovenous hemofiltration in a series of pediatric patients with toxic epidermal necrolysis. Eur J Dermatol 2021; 31:413-415. [PMID: 34309529 PMCID: PMC8354840 DOI: 10.1684/ejd.2021.4042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Arora R, Pande RK, Panwar S, Gupta V. Drug-related Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Review. Indian J Crit Care Med 2021; 25:575-579. [PMID: 34177178 PMCID: PMC8196388 DOI: 10.5005/jp-journals-10071-23826] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, life-threatening, allergic reactions affecting the skin and mucous membranes. SJS is considered to be a milder form with less than 10% of body surface area (BSA) involvement. We report successful management of two cases of SJS and TEN. Firstly, a case of a 24-year-old female who presented with rashes over face, chest, and upper limbs after the oral intake of ciprofloxacin and local application of moxifloxacin eye drops. She developed high-grade fever and difficulty in breathing requiring intubation and lung-protective mechanical ventilation and was treated with high-dose methylprednisolone, azithromycin, soframycin skin dressings, and topical ocular antibiotics. Secondly, another case of a 16-year-old female who developed bullous eruptions over the trunk, arms, hands, face, and sole involving 60% of BSA, after oral intake of albendazole. She was diagnosed as TEN and successfully managed with sterile silver nitrate, soframycin dressings, and antibiotics. Key message Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening, allergic reactions affecting the skin and mucous membranes. Early identification, withdrawal of the suspected drug, and early transfer to a specialized center decrease mortality. How to cite this article Arora R, Pande RK, Panwar S, Gupta V. Drug-related Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Review. Indian J Crit Care Med 2021;25(5):575-579.
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Affiliation(s)
- Rohini Arora
- Department of Critical Care, D BL Kapur Superspeciality Hospital, New Delhi, India
| | - Rajesh K Pande
- Department of Critical Care, D BL Kapur Superspeciality Hospital, New Delhi, India
| | - Shikha Panwar
- Department of Critical Care, D BL Kapur Superspeciality Hospital, New Delhi, India
| | - Vivek Gupta
- Department of Pharmacology, D BL Kapur Superspeciality Hospital, New Delhi, India
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8
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Hasegawa A, Abe R. Recent advances in managing and understanding Stevens-Johnson syndrome and toxic epidermal necrolysis. F1000Res 2020; 9. [PMID: 32595945 PMCID: PMC7308994 DOI: 10.12688/f1000research.24748.1] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2020] [Indexed: 12/15/2022] Open
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening diseases characterized by detachment of the epidermis and mucous membrane. SJS/TEN are considered to be on the same spectrum of diseases with different severities. They are classified by the percentage of skin detachment area. SJS/TEN can also cause several complications in the liver, kidneys, and respiratory tract. The pathogenesis of SJS/TEN is still unclear. Although it is difficult to diagnose early stage SJS/TEN, biomarkers for diagnosis or severity prediction have not been well established. Furthermore, optimal therapeutic options for SJS/TEN are still controversial. Several drugs, such as carbamazepine and allopurinol, are reported to have a strong relationship with a specific human leukocyte antigen (HLA) type. This relationship differs between different ethnicities. Recently, the usefulness of HLA screening before administering specific drugs to decrease the incidence of SJS/TEN has been investigated. Skin detachment in SJS/TEN skin lesions is caused by extensive epidermal cell death, which has been considered to be apoptosis via the Fas-FasL pathway or perforin/granzyme pathway. We reported that necroptosis, i.e. programmed necrosis, also contributes to epidermal cell death. Annexin A1, released from monocytes, and its interaction with the formyl peptide receptor 1 induce necroptosis. Several diagnostic or prognostic biomarkers for SJS/TEN have been reported, such as CCL-27, IL-15, galectin-7, and RIP3. Supportive care is recommended for the treatment of SJS/TEN. However, optimal therapeutic options such as systemic corticosteroids, intravenous immunoglobulin, cyclosporine, and TNF-α antagonists are still controversial. Recently, the beneficial effects of cyclosporine and TNF-α antagonists have been explored. In this review, we discuss recent advances in the pathophysiology and management of SJS/TEN.
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Affiliation(s)
- Akito Hasegawa
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Riichiro Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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9
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Abstract
Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are immunologic reactions to several stimuli, mostly medications, which present as a spectrum of primarily widespread mucocutaneous lesions, but also with other organ involvement. Pathology is characterized by full thickness necrosis of the epithelial layer of the involved organ due to immune-mediated apoptosis of the resident keratinocytes. High suspicion for early detection and quick withdrawal of the culprit medication are the most important steps in stopping this reaction. Aggressive supportive care is often necessary as the patient recovers. Steroids, other immunosuppressants, and plasmapheresis have all been studied as treatments, but high-quality evidence supporting their contributions, either together or separately, in decreasing length of hospital stay or prolonging survival have not been consistently demonstrated. Further studies of the mechanism of action and novel treatment modalities are still needed to improve outcomes in patients with this rare but often fatal condition.
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Affiliation(s)
- Joseph L. Nates
- Department of Critical Care and Respiratory Care, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Kristen J. Price
- Division of Anesthesiology, Critical Care and Pain Medicine, Department of Critical Care and Respiratory Care, The University of Texas MD Anderson Cancer Center, Houston, TX USA
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A Retrospective Cohort Study of the Management and Outcomes of Children Hospitalized with Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:244-250.e1. [PMID: 29859332 DOI: 10.1016/j.jaip.2018.05.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 05/13/2018] [Accepted: 05/17/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Severe cutaneous adverse reactions are rare yet life-threatening conditions. The current management and outcomes of these conditions in US children are unclear. OBJECTIVE To characterize the current management and outcomes of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) across US children's hospitals. METHODS We performed a retrospective cohort study of children younger than 18 years hospitalized with a primary diagnosis of SJS or TEN at 47 US freestanding children's hospitals. We compared treatment (intravenous immunoglobulin [IVIG], steroids, antibiotics, and others) and outcomes (length of stay [LOS], hospital mortality, readmission, recurrence, related complications, and adjusted hospital costs) across hospitals and by SJS versus TEN diagnoses. RESULTS We identified 898 pediatric patients hospitalized with a primary diagnosis of SJS or TEN. Of these patients, 167 (18.6%) were prescribed steroids only, 229 (25.5%) IVIG only, and 153 (17.04%) both IVIG and steroids. Median LOS was 8 days (interquartile range, 5-13) with median hospital-adjusted costs of $16,265. Readmissions were common, with 88 (9.9%) patients readmitted within 30 days of discharge and a recurrence rate of 2.7%. Overall hospital mortality in children was low at 0.56%. TEN was associated with higher mortality (3.23%) compared with SJS (0.13%). There was no association between the use of IVIG, systemic steroids, or IVIG and steroids during the first 2 days of hospitalization and decreased LOS or mechanical ventilation. Complex chronic conditions and TEN diagnoses were associated with increased LOS and increased odds of mechanical ventilation. CONCLUSION Survival in children with SJS and TEN is significantly better than that observed in adults. However, there is variability in the management and outcomes in children diagnosed with these severe cutaneous reactions. Further studies are needed to determine the most effective treatment strategies given the extent of health care utilization and high rate of readmissions observed in this population.
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Waldman R, Whitaker-Worth D, Grant-Kels JM. Cutaneous adverse drug reactions: Kids are not just little people. Clin Dermatol 2017; 35:566-582. [DOI: 10.1016/j.clindermatol.2017.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Han F, Zhang J, Guo Q, Feng Y, Gao Y, Guo L, Hou Y, An J, Wang X, Yan B, Zheng Y, Song J, Li M, Wang G. Successful treatment of toxic epidermal necrolysis using plasmapheresis: A prospective observational study. J Crit Care 2017; 42:65-68. [PMID: 28688239 DOI: 10.1016/j.jcrc.2017.07.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 06/27/2017] [Accepted: 07/01/2017] [Indexed: 01/29/2023]
Abstract
Toxic epidermal necrolysis (TEN) is a rare, severe, life-threatening skin disease and it requires urgent critical care, including admission to the intensive care unit (ICU). It is characterized by fatal sequelae and high mortality. Currently, insufficient evidence exists to support the use of any systemic adjuvant therapy, such as cyclophosphamide, intravenous immunoglobulin (IVIg), or corticosteroids. However, plasmapheresis has been increasingly valued by clinicians due to its significant efficacy and little adverse side effects. To assess the efficacy of such treatment, 28 patients who were diagnosed with TEN or SJS/TEN overlap were continuously recruited in the ICU from February 2009 to August 2016. These patients including both children and adults were randomly divided into two groups based on whether or not plasmapheresis therapy was performed after admission, which resulted in a plasmapheresis group (n=13) and a non-plasmapheresis group (n=15). Severity of the disease and the efficacy of treatments were evaluated by the severity-of-illness score for TEN. The results indicated that plasmapheresis may be superior to conventional therapies, such as IVIg or corticosteroids. Furthermore, plasmapheresis combined with other treatments might not be advantageous compared to the effect of plasmapheresis alone.
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Affiliation(s)
- Feng Han
- Intensive Care Unit, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Jingjing Zhang
- Department of Emergency Medicine, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Qi Guo
- Department of Cardiology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Yanjing Feng
- Department of Emergency Medicine, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Ya Gao
- Department of Emergency Medicine, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Litao Guo
- Intensive Care Unit, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Yanli Hou
- Intensive Care Unit, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Jingang An
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xiaopeng Wang
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Bin Yan
- Department of Emergency Medicine, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Yan Zheng
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Jingchun Song
- Intensive Care Unit, The 94th PLA Hospital, Nanchang, China
| | - Manxiang Li
- Department of Respiratory Medicine, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China.
| | - Gang Wang
- Department of Emergency Medicine, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China.
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Schneider JA, Cohen PR. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Concise Review with a Comprehensive Summary of Therapeutic Interventions Emphasizing Supportive Measures. Adv Ther 2017; 34:1235-1244. [PMID: 28439852 PMCID: PMC5487863 DOI: 10.1007/s12325-017-0530-y] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are two of the most severe dermatologic conditions occurring in the inpatient setting. There is a lack of consensus regarding appropriate management of SJS and TEN. PURPOSE The scientific literature pertaining to SJS and TEN (subsequently referred to as SJS/TEN) is summarized and assessed. In addition, an interventional approach for the clinician is provided. METHODS PubMed was searched with the key words: corticosteroids, cyclosporine, etanercept, intravenous immunoglobulin, Stevens-Johnson syndrome, and toxic epidermal necrolysis. The papers generated by the search, and their references, were reviewed. RESULTS Supportive care is the most universally accepted intervention for SJS/TEN. Specific guidelines differ from the care required for patients with thermal burns. Adjuvant therapies are utilized in most severe cases, but the data are thus far underwhelming and underpowered. Using systemic corticosteroids as sole therapy is not supported. A consensus regarding combined corticosteroids and intravenous immunoglobulin (IVIG) has not been reached. Data regarding IVIG, currently the standard of care for most referral centers, is conflicting. Newer studies regarding cyclosporine and tumor necrosis factor inhibitors are promising, but not powered to provide definitive evidence of efficacy. Data regarding plasmapheresis is equivocal. Thalidomide increases mortality. CONCLUSION Clinicians who manage SJS/TEN should seek to employ interventions with the greatest impact on their patients' condition. While supportive care measures may seem an obvious aspect of SJS/TEN patient care, providers should understand that these interventions are imperative and that they differ from the care recommended for other critically ill or burn patients. While adjuvant therapies are frequently discussed and debated for hospitalized patients with SJS/TEN, a standardized management approach is not yet clear based on the current data. Therefore, until further data are available, decisions regarding such treatments should be made on a case-by-case basis.
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Affiliation(s)
- Jeremy A Schneider
- Department of Dermatology, University of California, San Diego, La Jolla, CA, USA
| | - Philip R Cohen
- Department of Dermatology, University of California, San Diego, La Jolla, CA, USA.
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14
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Nunes JM, Santareno S, Guerreiro L, Margalho AF. Lyell's Syndrome and Antimalarials: A Case Report and Clinical Review. J Glob Infect Dis 2017; 9:23-30. [PMID: 28250622 PMCID: PMC5330040 DOI: 10.4103/0974-777x.199994] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Toxic epidermal necrolysis (TEN) or Lyell's syndrome is a rare, however, life-threatening mucocutaneous disorder with an epidermal detachment of a total body surface area (TBSA) of >30%. It is triggered by an idiosyncratic immune-allergic reaction to a drug, with many possible drugs implicated. Treatment success relies on early diagnosis and withdrawal of suspected/causative drug(s) and supportive care. Clinical evidence for specific therapies is still sparse. It is described a case of Lyell syndrome by sulfonamides for chemoprophylaxis of malaria. The patient presented with an extensive, rapidly evolving skin detachment, which progressed, despite supportive therapy, involving about 80% of TBSA. This led us to initiate a course of immunoglobulin with good clinical response. The aim of this work is to provide a discussion of the case and simultaneously make a practical literature review of TEN.
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Affiliation(s)
| | - Sofia Santareno
- Department of Plastic Surgery and Burn Unit, North Lisbon Hospital Centre, Lisboa University Medical School, Lisboa, Portugal
| | - Lina Guerreiro
- Department of Anesthesiology, Pain and Emergency Medicine, North Lisbon Hospital Centre, Lisboa University Medical School, Lisboa, Portugal
| | - Ana Filipa Margalho
- Department of Plastic, Reconstructive and Aesthetic Surgery, Oncology Portuguese Institute Francisco Gentil, Lisboa, Portugal
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Bai M, Yu Y, Huang C, Liu Y, Zhou M, Li Y, Ma F, Jing R, Zhao L, Li L, Wang P, He L, Sun S. Continuous venovenous hemofiltration combined with hemoperfusion for toxic epidermal necrolysis: a retrospective cohort study. J DERMATOL TREAT 2016; 28:353-359. [PMID: 27653468 DOI: 10.1080/09546634.2016.1240326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIM The current treatments of toxic epidermal necrolysis (TEN) are limited to the discontinuation of a suspect medication and supportive measures. We conducted a retrospective study to evaluate the efficacy of adding continuous venovenous hemofiltration (CVVH) and hemoperfusion (HP) to the conventional treatment for TEN. METHODS TEN patients who were admitted to our center between January 2008 and May 2016 were considered as candidates. The included patients were divided into the CVVH&HP group (n = 34) and the conventional group (n = 34) according to their accepted therapies during hospital stay. RESULTS The patients in the conventional group had a significantly reduced 28-day survival proportion compared with patients in the CVVH&HP group (73.5 versus 91.2%, p = .047). The adjusted results demonstrated that the conventional group had a significantly higher risk of 28-day mortality as well. Moreover, patients in the CVVH&HP group were associated with significantly shorter hospital stay, rash, fever, and antibiotic durations. However, the addition of CVVH&HP to conventional treatment did not significantly increase the in-hospital cost. CONCLUSIONS In conclusion, CVVH&HP might be a safe and effective adjuvant therapy for TEN. Further well-designed studies are warranted to obtain robust evidence.
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Affiliation(s)
- Ming Bai
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Yan Yu
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Chen Huang
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Yirong Liu
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Meilan Zhou
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Yangping Li
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Feng Ma
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Rui Jing
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Lijuan Zhao
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Li Li
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Pengbo Wang
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Lijie He
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Shiren Sun
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
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Linenberger ML, Price TH. Use of Cellular and Plasma Apheresis in the Critically Ill Patient: Part II: Clinical Indications and Applications. J Intensive Care Med 2016; 20:88-103. [PMID: 15855221 DOI: 10.1177/0885066604273479] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Apheresis is the process of separating the blood and removing or manipulating a cellular or plasma component for therapeutic benefit. Such procedures may be indicated in the critical care setting as primary or adjunctive therapy for certain hematologic, neurologic, renal, and autoimmune/rheumatologic disorders. In part I of this series, the technical aspects of apheresis were described and the physiologic rationale and clinical considerations were discussed. This review highlights the pathophysiologic basis, specific clinical indications, and treatment parameters for disorders that more commonly require management in the intensive care unit. The choice of plasma or cellular apheresis in these cases is guided by wellaccepted, evidence-based clinical treatment guidelines. For some disorders, such as liver failure, severe sepsis, and multiple-organ dysfunction syndrome, apheresis treatment approaches remain experimental. Ongoing studies are investigating the potential utility of conventional plasma exchange, ex vivo plasma manipulation, and newer technologies for these and other disorders in severely ill patients.
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Affiliation(s)
- Michael L Linenberger
- Apheresis and Cellular Therapy, Seattle Cancer Care Alliance, Seattle, WA 98109, USA.
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Watari T, Sato S, Uojima H, Tokuda Y. Successful Combination Therapy Including Plasma Exchange for Severe Toxic Epidermal Necrolysis. J Gen Fam Med 2016. [DOI: 10.14442/jgfm.17.3_232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Zhang F, Zhou J. Toxic epidermal necrolysis: 13 years of experience in the management at a Department of Dermatology in China. Cutan Ocul Toxicol 2016; 36:19-24. [PMID: 27079364 DOI: 10.3109/15569527.2016.1141416] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The study aimed to investigate the efficacy of our therapeutic options on toxic epidermal necrolysis (TEN) patients. METHODS After giving informed consent, patients affected by TEN were included in the study between January 2001 and December 2013. Suspected causative drugs, onset to hospitalization, complications, management, outcome, laboratory investigations of blood tests and therapeutic options were recorded and analyzed. SCORTEN scoring system was used to evaluate the complications and the survival rate. Therapeutic interventions included immediate withdrawal of any potentially fatal drug, nursing care, supportive therapy, high-dose corticosteroids, antibiotics, plasma therapy, intravenous immunoglobulins (IVIG) and traditional Chinese medicine (TCM). Blood tests were taken as a result of clinical outcome. RESULTS Total 21 consecutive patients (10 males and 11 females, mean age 33 years) were included in the study. Cefalexin, paracetamol, quick cold capsules, compound aminopyrine phenacetin tablets, carbamazepine, propylthiouracil, sulfonamide, ampicillin, and phenylbutazone were suspected to be the causative agents. All patients received high-dose dexamethasone or methylprednisolone therapy. Eighteen patients received the administration of antibiotics. Twelve patients received plasma infusions, and 11 patients were given albumin. Only 2 patients applied IVIG. Additionally, 3 and 14 cases were intravenously injected with QKL and Xiyanping, respectively. The average score of SCORTEN was 2.52 and the average percentage of total body surface area was 68.8%. The mortality rate in our study was 19%. CONCLUSION The therapeutic options in our study, including nursing care, corticosteroid, anti-inflammatory and TCM are effective for the treatment of TEN.
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Affiliation(s)
- Feng Zhang
- a Department of Dermatology , The First Affiliated Hospital of Harbin Medical University , Harbin , PR China and
| | - Jin Zhou
- b Department of Hematology , The First Affiliated Hospital of Harbin Medical University , Harbin , PR China
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Yamane Y, Matsukura S, Watanabe Y, Yamaguchi Y, Nakamura K, Kambara T, Ikezawa Z, Aihara M. Retrospective analysis of Stevens-Johnson syndrome and toxic epidermal necrolysis in 87 Japanese patients--Treatment and outcome. Allergol Int 2016; 65:74-81. [PMID: 26666483 DOI: 10.1016/j.alit.2015.09.001] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 07/25/2015] [Accepted: 07/28/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but severe adverse drug reactions with high mortality. METHODS To present the clinical characteristics of SJS and TEN in Japan and evaluate the efficacy of treatments, we retrospectively analyzed cases of SJS and TEN treated in 2 university hospitals during 2000-2013. RESULTS Fifty-two cases of SJS (21 males and 31 females; average age, 55.1 years) and 35 cases of TEN (17 males and 18 females; average age, 56.6 years) were included in this study. Twenty-eight cases of SJS (53.8%) and all cases of TEN were caused by drugs. Hepatitis was the most common organ involvement in both SJS and TEN. Renal dysfunction, intestinal disorder, and respiratory disorder were also involved in some cases. The major complication was pneumonia and sepsis. All cases except for 3 cases were treated systemically with corticosteroids. Steroid pulse therapy was performed in 88.6% of TEN. Plasmapheresis and/or immunoglobulin therapy was combined with steroid therapy mainly in TEN after 2007. The mortality rate was 6.9% and the rates for SJS and TEN were 1.9% and 14.3%, respectively. These were much lower than predicted mortality according to a severity-of-illness scoring system for TEN prognosis (SCORTEN) score. When comparing the mortality rate between 2000-2006 and 2007-2013, it was decreased from 4.5% to 0.0% in SJS and from 22.2% to 5.3% in TEN. CONCLUSIONS Treatment with steroid pulse therapy in combination with plasmapheresis and/or immunoglobulin therapy seems to have contributed to prognostic improvement in SJS/TEN.
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Watanabe H, Kamiyama T, Sasaki S, Kobayashi K, Fukuda K, Miyake Y, Aruga T, Sueki H. Toxic epidermal necrolysis caused by acetaminophen featuring almost 100% skin detachment: Acetaminophen is associated with a risk of severe cutaneous adverse reactions. J Dermatol 2015; 43:321-4. [DOI: 10.1111/1346-8138.13073] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 07/10/2015] [Indexed: 12/29/2022]
Affiliation(s)
- Hideaki Watanabe
- Department of Dermatology; Showa University School of Medicine; Tokyo Japan
| | - Taisuke Kamiyama
- Department of Dermatology; Showa University School of Medicine; Tokyo Japan
| | - Shun Sasaki
- Department of Dermatology; Showa University School of Medicine; Tokyo Japan
| | - Kae Kobayashi
- Department of Dermatology; Showa University School of Medicine; Tokyo Japan
| | - Kenichiro Fukuda
- Department of Emergency and Critical Care Medicine; Showa University; Tokyo Japan
| | - Yasufumi Miyake
- Department of Emergency and Critical Care Medicine; Showa University; Tokyo Japan
| | - Tohru Aruga
- Department of Emergency and Critical Care Medicine; Showa University; Tokyo Japan
| | - Hirohiko Sueki
- Department of Dermatology; Showa University School of Medicine; Tokyo Japan
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Aihara M, Kano Y, Fujita H, Kambara T, Matsukura S, Katayama I, Azukizawa H, Miyachi Y, Endo Y, Asada H, Miyagawa F, Morita E, Kaneko S, Abe R, Ochiai T, Sueki H, Watanabe H, Nagao K, Aoyama Y, Sayama K, Hashimoto K, Shiohara T. Efficacy of additional i.v. immunoglobulin to steroid therapy in Stevens-Johnson syndrome and toxic epidermal necrolysis. J Dermatol 2015; 42:768-77. [PMID: 25982480 DOI: 10.1111/1346-8138.12925] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 03/25/2015] [Indexed: 01/11/2023]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare and life-threatening cutaneous adverse drug reactions. While there is no established therapy for SJS/TEN, systemic corticosteroids, plasma exchange and i.v. immunoglobulin (IVIG) have been used as treatment. The efficacy of IVIG is still controversial because total doses of IVIG used vary greatly from one study to another. The aim of this study was to evaluate the efficacy of IVIG, administrated for 5 days consecutively, in an open-label, multicenter, single-arm study in patients with SJS or TEN. IVIG (400 mg/kg per day) administrated for 5 days consecutively was performed as an additional therapy to systemic steroids in adult patients with SJS or TEN. Efficacy on day 7 of IVIG was evaluated. Parameters to assess clinical outcome were enanthema including ophthalmic and oral lesions, cutaneous lesions and general condition. These parameters were scored and recorded before and after IVIG. We enrolled five patients with SJS and three patients with TEN who did not respond sufficiently to systemic steroids before IVIG administration. All of the patients survived and the efficacy on day 7 of the IVIG was 87.5% (7/8 patients). Prompt amelioration was observed in skin lesions and enanthema in the patients in whom IVIG therapy was effective. Serious side-effects from the use of IVIG were not observed. IVIG (400 mg/kg per day) administrated for 5 days consecutively seems to be effective in patients with SJS or TEN. IVIG administrated together with steroids should be considered as a treatment modality for patients with refractory SJS/TEN. Further studies are needed to define the therapeutic efficacy of IVIG.
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Affiliation(s)
- Michiko Aihara
- Department of Dermatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Yoko Kano
- Department of Dermatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Hiroyuki Fujita
- Department of Dermatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Takeshi Kambara
- Department of Dermatology, Yokohama City University Medical Center, Yokohama, Japan
| | - Setsuko Matsukura
- Department of Dermatology, Yokohama City University Medical Center, Yokohama, Japan
| | - Ichiro Katayama
- Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroaki Azukizawa
- Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Miyachi
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuichiro Endo
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hideo Asada
- Department of Dermatology, Nara Medical University, Kashihara, Japan
| | - Fumi Miyagawa
- Department of Dermatology, Nara Medical University, Kashihara, Japan
| | - Eishin Morita
- Department of Dermatology, Shimane University Faculty of Medicine, Izumo, Japan
| | - Sakae Kaneko
- Department of Dermatology, Shimane University Faculty of Medicine, Izumo, Japan
| | - Riichiro Abe
- Department of Dermatology, Hokkaido University School of Medicine, Sapporo, Japan
| | - Toyoko Ochiai
- Department of Dermatology, Nihon University School of Medicine, Tokyo, Japan
| | - Hirohiko Sueki
- Department of Dermatology, Showa University School of Medicine, Tokyo, Japan
| | - Hideaki Watanabe
- Department of Dermatology, Showa University School of Medicine, Tokyo, Japan
| | - Keisuke Nagao
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Yumi Aoyama
- Department of Dermatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Koji Sayama
- Department of Dermatology, Ehime University School of Medicine, Ehime, Japan
| | - Koji Hashimoto
- Ehime Prefectural University of Health Sciences, Ehime, Japan
| | - Tetsuo Shiohara
- Department of Dermatology, Kyorin University School of Medicine, Tokyo, Japan
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Mawson AR, Eriator I, Karre S. Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN): could retinoids play a causative role? Med Sci Monit 2015; 21:133-43. [PMID: 25579087 PMCID: PMC4301467 DOI: 10.12659/msm.891043] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are overlapping manifestations on a spectrum of acute drug-induced conditions associated with severe blistering, skin peeling, and multi-organ damage. TEN is an eruption resembling severe scalding, with ≥30% skin detachment. SJS is a mild form of TEN, characterized histologically by epidermal keratinocyte apoptosis with dermo-epidermal separation and extensive small blisters with <10% body surface skin detachment. The syndrome can be induced by numerous medications and typically occurs 1–4 weeks after the initiation of therapy. Granulysin is found in the lesions of patients with SJS/TEN and plays a significant pathogenic role in the condition, but the overall mechanisms linking medications, granulysin, and disease manifestations remain obscure. This paper reviews evidence suggesting that the different medications implicated in SJS/TEN have the common property of interacting and synergizing with endogenous retinoids (vitamin A and its congeners), in many instances causing the latter to accumulate in and damage the liver, the main storage organ for vitamin A. It is hypothesized that liver damage leads to the spillage of toxic retinoid compounds into the circulation, resulting in an endogenous form of hypervitaminosis A and cytotoxicity with widespread apoptosis, mediated by granulysin and recognized as SJS/TEN. Subject to testing, the model suggests that symptom worsening could be arrested at onset by lowering the concentration of circulating retinoids and/or granulysin via phlebotomy or plasmapheresis or by pharmacological measures to limit their expression.
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Affiliation(s)
- Anthony R Mawson
- Behavioral and Environmental Health Unit, School of Health Sciences, College of Public Service, Jackson State University, Jackson, MS, USA
| | - Ike Eriator
- Department of Anesthesiology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Sridhar Karre
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
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Cytotoxic proteins and therapeutic targets in severe cutaneous adverse reactions. Toxins (Basel) 2014; 6:194-210. [PMID: 24394640 PMCID: PMC3920257 DOI: 10.3390/toxins6010194] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 12/20/2013] [Accepted: 12/27/2013] [Indexed: 11/16/2022] Open
Abstract
Severe cutaneous adverse reactions (SCARs), such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrosis (TEN), are rare but life-threatening conditions induced mainly by a variety of drugs. Until now, an effective treatment for SJS/TEN still remains unavailable. Current studies have suggested that the pathobiology of drug-mediated SJS and TEN involves major histocompatibility class (MHC) I-restricted activation of cytotoxic T lymphocytes (CTLs) response. This CTLs response requires several cytotoxic signals or mediators, including granulysin, perforin/granzyme B, and Fas/Fas ligand, to trigger extensive keratinocyte death. In this article, we will discuss the cytotoxic mechanisms of severe cutaneous adverse reactions and their potential applications on therapeutics for this disease.
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Schwartz RA, McDonough PH, Lee BW. Toxic epidermal necrolysis: Part II. Prognosis, sequelae, diagnosis, differential diagnosis, prevention, and treatment. J Am Acad Dermatol 2013; 69:187.e1-16; quiz 203-4. [PMID: 23866879 DOI: 10.1016/j.jaad.2013.05.002] [Citation(s) in RCA: 174] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 05/06/2013] [Accepted: 05/10/2013] [Indexed: 02/01/2023]
Abstract
Toxic epidermal necrolysis (TEN) is a life-threatening, typically drug-induced, mucocutaneous disease. TEN has a high mortality rate, making early diagnosis and treatment of paramount importance. New but experimental diagnostic tools that measure serum granulysin and high-mobility group protein B1 (HMGB1) offer the potential to differentiate early TEN from other, less serious drug reactions, but these tests have not been validated and are not readily available. The mainstay of treatment for TEN involves discontinuation of the offending drug, specialized care in an intensive care unit or burn center, and supportive therapy. Pharmacogenetic studies have clearly established a link between human leukocyte antigen allotype and TEN. Human leukocyte antigen testing should be performed on patients of East Asian descent before the initiation of carbamezapine and on all patients before the initiation of abacavir. The effectiveness of systemic steroids, intravenous immunoglobulins, plasmapheresis, cyclosporine, biologics, and other agents is uncertain.
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Affiliation(s)
- Robert A Schwartz
- Dermatology, Preventive Medicine, and Pathology, Rutgers University New Jersey Medical School, Newark, New Jersey 07103-2714, USA.
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Knowles SR, Dewhurst N, Shear NH. Anticonvulsant hypersensitivity syndrome: an update. Expert Opin Drug Saf 2012; 11:767-78. [DOI: 10.1517/14740338.2012.705828] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Toxic epidermal necrolysis: Review of pathogenesis and management. J Am Acad Dermatol 2012; 66:995-1003. [DOI: 10.1016/j.jaad.2011.09.029] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 09/17/2011] [Accepted: 09/24/2011] [Indexed: 12/29/2022]
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Abstract
OBJECTIVES The aims of this review are to summarize the definitions, causes, and clinical course as well as the current understanding of the genetic background, mechanism of disease, and therapy of toxic epidermal necrolysis and Stevens-Johnson syndrome. DATA SOURCES PubMed was searched using the terms toxic epidermal necrolysis, Stevens-Johnson syndrome, drug toxicity, drug interaction, and skin diseases. DATA SYNTHESIS Toxic epidermal necrolysis and Stevens-Johnson syndrome are acute inflammatory skin reactions. The onset is usually triggered by infections of the upper respiratory tract or by preceding medication, among which nonsteroidal anti-inflammatory agents, antibiotics, and anticonvulsants are the most common triggers. Initially the diseases present with unspecific symptoms, followed by more or less extensive blistering and shedding of the skin. Complete death of the epidermis leads to sloughing similar to that seen in large burns. Toxic epidermal necrolysis is the most severe form of drug-induced skin reaction and includes denudation of >30% of total body surface area. Stevens-Johnson syndrome affects <10%, whereas involvement of 10%-30% of body surface area is called Stevens-Johnson syndrome/toxic epidermal necrolysis overlap. Besides the skin, mucous membranes such as oral, genital, anal, nasal, and conjunctival mucosa are frequently involved in toxic epidermal necrolysis and Stevens-Johnson syndrome. Toxic epidermal necrolysis is associated with a significant mortality of 30%-50% and long-term sequelae. Treatment includes early admission to a burn unit, where treatment with precise fluid, electrolyte, protein, and energy supplementation, moderate mechanical ventilation, and expert wound care can be provided. Specific treatment with immunosuppressive drugs or immunoglobulins did not show an improved outcome in most studies and remains controversial. The mechanism of disease is not completely understood, but immunologic mechanisms, cytotoxic reactions, and delayed hypersensitivity seem to be involved. CONCLUSION Profound knowledge of exfoliative skin diseases is needed to improve therapy and outcome of these life-threatening illnesses.
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Worswick S, Cotliar J. Stevens-Johnson syndrome and toxic epidermal necrolysis: a review of treatment options. Dermatol Ther 2011; 24:207-18. [DOI: 10.1111/j.1529-8019.2011.01396.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Valeyrie-Allanore L, Wolkenstein P, Brochard L, Ortonne N, Maître B, Revuz J, Bagot M, Roujeau JC. Open trial of ciclosporin treatment for Stevens-Johnson syndrome and toxic epidermal necrolysis. Br J Dermatol 2011; 163:847-53. [PMID: 20500799 DOI: 10.1111/j.1365-2133.2010.09863.x] [Citation(s) in RCA: 176] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)are acute mucocutaneous reactions associated with poor prognosis. The treatment is mainly symptomatic, based on supportive care. Until now, several curative treatments have been proposed without evidence of effectiveness.Objectives To evaluate the effect of ciclosporin on SJS and TEN after a short series had suggested a benefit.Methods We conducted an open, phase II trial to determine the safety and possible benefit of ciclosporin. Among the 45 consecutive patients admitted for SJS /TEN from March 2005 to September 2007, 29 fulfilled inclusion criteria. Ciclosporin was administered orally (3 mg kg)1 daily for 10 days) and tapered over a month. Clinical and biological evaluations were performed sequentially. Predicted death rate was estimated with a validated prognostic score (SCORTEN).Results Twenty-nine patients were included at a mean +/- SD of 2.8 +/- 1.8 days after onset. The final diagnosis was SJS (n = 10), SJS ⁄TEN overlap (n = 12) and TEN(n = 7). One month of treatment was completed in 26. Ciclosporin was stopped after more than 10 days in three cases for side-effects including posterior leucoencephalopathy (n = 1), neutropenia (n = 1) and nosocomial pneumopathy(n = 1). Ciclosporin dosage was tapered earlier than scheduled in two cases for alteration in renal function. The prognostic score predicted 2.75 deaths; none occurred (P = 0.1). Mean epidermal detachment remained stable in 18 of 29 cases (62%). The mean ± SD hospital stay was 16.2 +/- 9.1 days.Conclusions Both the death rate and the progression of detachment seemed lower than expected, suggesting a possible usefulness of ciclosporin in SJS and TEN that needs to be confirmed.
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Affiliation(s)
- L Valeyrie-Allanore
- Department of Dermatology, Reference Centre for Toxic and Autoimmune Blistering Diseases, Universite´ Paris XII, F-94010 Cre´teil, France
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Narita YM, Hirahara K, Mizukawa Y, Kano Y, Shiohara T. Efficacy of plasmapheresis for the treatment of severe toxic epidermal necrolysis: Is cytokine expression analysis useful in predicting its therapeutic efficacy? J Dermatol 2011; 38:236-45. [PMID: 21342225 DOI: 10.1111/j.1346-8138.2010.01154.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Toxic epidermal necrolysis (TEN) is a life-threatening, drug-induced disorder characterized by severe epidermal injury. Although there is no standard therapeutic intervention in TEN, plasmapheresis (PP) is being used increasingly to treat extremely ill TEN patients. In addition to conventional PP, double-filtration PP (DFPP) has been recently used for severe and refractory TEN. In this review, we focus on the clinical usefulness of PP by both demonstrating three cases of TEN refractory to conventional therapies, who were successfully treated with conventional PP or DFPP, and evaluating its therapeutic efficiency. We also provide evidence to suggest the mechanisms of action of PP by investigating the correlation between disease intensity and serum cytokine levels before and after treatment with PP or DFPP in these patients with TEN. At present, PP is a much more effective option for treatment of severe and/or recalcitrant TEN than any other treatment, such as pulsed corticosteroids and i.v. immunoglobulin.
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Affiliation(s)
- Yoko M Narita
- Department of Dermatology, Kyorin University, Tokyo, Japan.
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Paquet P, Piérard GE. New insights in toxic epidermal necrolysis (Lyell's syndrome): clinical considerations, pathobiology and targeted treatments revisited. Drug Saf 2010; 33:189-212. [PMID: 20158284 DOI: 10.2165/11532540-000000000-00000] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Drug-induced toxic epidermal necrolysis (TEN), also known as Lyell's syndrome, is a life-threatening drug reaction characterized by extensive destruction of the epidermis and mucosal epithelia. The eyes are typically involved in TEN. At present, the disease has a high mortality rate. Conceptually, TEN and the Stevens-Johnson syndrome are closely related, although their severity and outcome are different. Distinguishing TEN from severe forms of erythema multiforme relies on consideration of aetiological, clinical and histological characteristics. The current understanding of the pathomechanism of TEN suggests that keratinocytes are key initiator cells. It is probable that the combined deleterious effects on keratinocytes of both the cytokine tumour necrosis factor (TNF)-alpha and oxidative stress induce a combination of apoptotic and necrotic events. As yet, there is no evidence indicating the superiority of monotherapy with corticosteroids, ciclosporin (cyclosporine) or intravenous immunoglobulins over supportive care only for patients with TEN. However, the current theory of TEN pathogenesis supports the administration of a combination of antiapoptotic/antinecrotic drugs (e.g. anti-TNF-alpha antibodies plus N-acetylcysteine) targeting different levels of the keratinocyte failure machinery.
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Affiliation(s)
- Philippe Paquet
- Department of Dermatopathology, University Hospital of Liège, CHU Sart Tilman, Liège, Belgium.
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Rieder MJ. Immune mediation of hypersensitivity adverse drug reactions: implications for therapy. Expert Opin Drug Saf 2010; 8:331-43. [PMID: 19505265 DOI: 10.1517/14740330902933736] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Adverse drug reactions are among the top causes of death in the developed world, and among the spectrum of adverse drug reactions, drug hypersensitivity is a principal contributor to serious adverse drug events. The pathophysiology of drug hypersensitivity remains incompletely understood, but seems to involve the initial recognition of a drug or metabolite by the immune system followed by an immune response that determines the clinical manifestations. At present, there are two competing theories for how immune recognition occurs: the Hapten Hypothesis in which drug hapten-carrier association is the key driver for immune recognition and the Pharmacological Interference Concept that postulates direct recognition of drugs by low affinity association with the T cell receptor. The Danger Hypothesis provides a potentially important addition to the Hapten Hypothesis. Therapy for drug hypersensitivity has traditionally involved excellent supportive care. Although corticosteroids and intravenous immunoglobulin have both been used as immunomodulatory therapy, there is no robust evidence supporting the efficacy of their therapy for drug hypersensitivity. Recent advances in molecular biology and genomic pharmacology offer previously unappreciated opportunities to clarify the controversies surrounding drug hypersensitivity and to better diagnose, treat and, it is hoped, prevent drug hypersensitivity in the future.
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Affiliation(s)
- Michael J Rieder
- University of Western Ontario, Children's Health Research Institute, Schulich School of Medicine & Dentistry, Ontario, Canada.
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Lissia M, Mulas P, Bulla A, Rubino C. Toxic epidermal necrolysis (Lyell's disease). Burns 2010; 36:152-63. [DOI: 10.1016/j.burns.2009.06.213] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2008] [Revised: 04/21/2009] [Accepted: 06/03/2009] [Indexed: 10/20/2022]
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Szczeklik W, Nowak I, Seczynska B, Sega A, Krolikowski W, Musial J. Beneficial Therapeutic Effect of Plasmapheresis After Unsuccessful Treatment With Corticosteroids in Two Patients With Severe Toxic Epidermal Necrolysis. Ther Apher Dial 2010; 14:354-7. [DOI: 10.1111/j.1744-9987.2009.00800.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Shahverdian DE, Anastassiades CP, Charles JC. 60-year-old man with rash. Mayo Clin Proc 2009; 84:838-41. [PMID: 19720782 PMCID: PMC2735434 DOI: 10.4065/84.9.838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Affiliation(s)
| | | | - Joseph C. Charles
- Advisor to residents and Consultant in Hospital Internal Medicine, Mayo Clinic Arizona, Scottsdale, AZ
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Knowles S, Shear NH. Clinical risk management of Stevens-Johnson syndrome/toxic epidermal necrolysis spectrum. Dermatol Ther 2009; 22:441-51. [DOI: 10.1111/j.1529-8019.2009.01260.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Abstract
Toxic epidermal necrolysis, a unique rapidly developing mucocutaneous reaction pattern, characterized by sheets of erythema, necrosis and bullous detachment of the epidermis, closely resembling that of scalding of the skin and rapidly fatal, was described by Lyell, and is now recognized as toxic epidermal necrolysis (TEN) Lyell's syndrome. The condition is indistinguishable from staphylococcal scalded skin syndrome (SSSS), and generalized fixed drug eruption. Hence, there has always been controversy as regards terminology. It is well conceived that TEN is equivalent to Stevens-Johnson syndrome (SJS), at its greatest severity. TEN, therefore, is a great challenge and warrants instant attention based on a thorough knowledgeable background covering several related facets including the recent advances in pathogenesis and management strategies. The details contained in the following text should prove very useful in the comprehension of a largely intractable entity.
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Affiliation(s)
- Virendra N Sehgal
- Dermato-Venereology (Skin/VD) Centre, Sehgal Nursing Home, Panchwati, Azadpur, Skin Institute and School of Dermatology, Greater Kailash, New Delhi, India.
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Toxic Epidermal Necrolysis in Children: Medical, Surgical, and Ophthalmologic Considerations. J Burn Care Res 2009; 30:437-49. [DOI: 10.1097/bcr.0b013e3181a28c82] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Karaoui LR, Chahine-Chakhtoura C. Fatal Toxic Epidermal Necrolysis Associated with Minoxidil. Pharmacotherapy 2009; 29:460-7. [DOI: 10.1592/phco.29.4.460] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Palmieri TL. Initial ICU Management of Skin Sloughing Diseases: Toxic Epidermal Necrolysis and Stevens-Johnson Syndrome. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-77383-4_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Yamada H, Takamori K. Status of Plasmapheresis for the Treatment of Toxic Epidermal Necrolysis in Japan. Ther Apher Dial 2008; 12:355-9. [DOI: 10.1111/j.1744-9987.2008.00609.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Simsek I, Cinar M, Erdem H, Pay S, Meric C, Dinc A. Efficacy of plasmapheresis in the treatment of refractory toxic epidermal necrolysis–like acute cutaneous lupus erythematosus. Lupus 2008; 17:605-6. [DOI: 10.1177/0961203308089341] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- I Simsek
- Division of Rheumatology, Gulhane Military School of Medicine, Ankara, Turkey
| | - M Cinar
- Department of Internal Medicine, Gulhane Military School of Medicine, Ankara, Turkey
| | - H Erdem
- Division of Rheumatology, Gulhane Military School of Medicine, Ankara, Turkey
| | - S Pay
- Division of Rheumatology, Gulhane Military School of Medicine, Ankara, Turkey
| | - C Meric
- Department of Internal Medicine, Gulhane Military School of Medicine, Ankara, Turkey
| | - A Dinc
- Division of Rheumatology, Gulhane Military School of Medicine, Ankara, Turkey
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Carr DR, Houshmand E, Heffernan MP. Approach to the acute, generalized, blistering patient. ACTA ACUST UNITED AC 2008; 26:139-46. [PMID: 18070680 DOI: 10.1016/j.sder.2007.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
This article discusses the approach to the acute, generalized, blistering patient from the perspective of the dermatologic consultant. Initially, a case is presented, followed by a discussion of the relevant evaluation, differential diagnosis, and treatment options.
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Affiliation(s)
- David R Carr
- Division of Dermatology, Wright State University, Dayton, OH 45408-1445, USA
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Yamane Y, Aihara M, Ikezawa Z. Analysis of Stevens-Johnson syndrome and toxic epidermal necrolysis in Japan from 2000 to 2006. Allergol Int 2007; 56:419-25. [PMID: 17713361 DOI: 10.2332/allergolint.o-07-483] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Accepted: 04/16/2007] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe adverse drug reactions with high mortality. METHODS To present the current clinical characteristics and treatment of SJS and TEN in Japan, we retrospectively analyzed reports of SJS and TEN published in medical journals from 2000 to 2006. RESULTS Fifty-two cases of SJS (19 males and 33 females; mean age, 45.2 years) and 65 cases of TEN (31 males and 34 females; mean age, 45.7 years) were reported. Thirty-six cases of SJS (69.2%) and all cases of TEN were caused by drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics, and anticonvulsant drugs. Hepatitis was the most common organ involvement in both SJS and TEN. Renal dysfunction and respiratory disorders were also involved in some cases. The major complication was sepsis, but in only 1.9% of SJS and 10.8% of TEN. Most cases were treated systemically with corticosteroids, and 42 cases (80.8%) of SJS and 39 cases (60.0%) of TEN were treated with corticosteroids alone. Plasmapheresis and/or immunoglobulin therapy was combined with corticosteroid therapy in some cases. The mortality rates for patients with SJS and TEN were 1.9% and 6.2%, respectively. The mortality in TEN decreased remarkably from 21.6% (58/269) during the previous 17 years (1981 to 1997). CONCLUSIONS Improvement of treatment may be one of the reasons for the decrease in mortalities of both SJS and TEN.
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Affiliation(s)
- Yumiko Yamane
- Department of Environmental Immuno-Dermatology, Yokohama City University Graduate School of Medicine, Kanagawa, Japan.
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Stella M, Clemente A, Bollero D, Risso D, Dalmasso P. Toxic epidermal necrolysis (TEN) and Stevens–Johnson syndrome (SJS): Experience with high-dose intravenous immunoglobulins and topical conservative approach. Burns 2007; 33:452-9. [PMID: 17475410 DOI: 10.1016/j.burns.2006.08.014] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2006] [Accepted: 08/15/2006] [Indexed: 01/07/2023]
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Miller DD, Warshaw EM. Adverse cutaneous reactions to antimicrobials in patients with human immunodeficiency virus infection. Dermatitis 2007; 18:8-25. [PMID: 17303040 DOI: 10.2310/6620.2007.05041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Adverse reactions to medication are significant contributors to morbidity and mortality in patients with human immunodeficiency virus (HIV) infection. Cutaneous events not only constitute a significant portion of these reactions, they may also herald developing systemic reactions such as hemato-, nephro-, and hepatotoxicity. The identification of cutaneous adverse reactions and drug culprits and the proper management of reactions are of paramount importance for these patients. This review focuses specifically on adverse cutaneous reactions to antimicrobials that are commonly used in the management of patients with HIV infection.
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