Okuläre Beteiligung bei Stevens-Johnson-Syndrom und Toxisch epidermaler Nekrolyse

Ophthalmic Aspects of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Narrative Review

The aim of our review article was to summarize the current literature on Stevens-Johnson syndrome (SJS) and its severe form, toxic epidermal necrolysis (TEN). SJS/TEN is a serious, rare multi-system, immune-mediated, mucocutaneous disease with a significant mortality rate that can lead to severe ocular surface sequelae and even to bilateral blindness. Restoration of the ocular surface in acute and chronic SJS/TEN is challenging. There are only limited local or systemic treatment options for SJS/TEN. Early diagnosis, timely amniotic membrane transplantation and aggressive topical management in acute SJS/TEN are necessary to prevent long-term, chronic ocular complications. Although the primary aim of acute care is to save the life of the patient, ophthalmologists should regularly examine patients already in the acute phase, which should also be followed by systematic ophthalmic examination in the chronic phase. Herein, we summarize actual knowledge on the epidemiology, aetiology, pathology, clinical appearance and treatment of SJS/TEN.

[Severe skin reactions due to new medications]

Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN) and a specific form of hypersensitivity syndrome which is nowadays called "drug reaction with eosinophilia and systemic symptoms" (DRESS) are severe, mainly drug-induced skin reactions. Whereas SJS/TEN is considered one reaction entity of different severity, DRESS has to be distinguished from SJS/TEN but also from other severe exanthems due to multiorgan involvement. Although SJS/TEN is generally referred to as drug reaction, in total only about three quarters of the cases are actually caused by drugs. After the clinical diagnosis is made, identification of the potential inducing factor is most important. In case medications are considered as causal, their withdrawal plays a key role in management. In order to identify and withdraw the inducing agent, a detailed and thorough medication history must be obtained. Agents identified or confirmed as inducers of SJS/TEN by pharmacoepidemiological studies are allopurinol, antibacterial sulfonamides, various antiepileptics, nevirapine and nonsteroidal anti-inflammatory drugs of the oxicam-type. Among drugs inducing DRESS are also various antiepileptics, but in addition allopurinol, sulfonamides and minocycline. Some cases of SJS/TEN and DRESS associated with the use of new medication, including targeted therapies and biologicals, have been observed.

Severe drug-induced skin reactions: clinical features, diagnosis, etiology, and therapy

Drugs can induce severe skin reactions that differ in clinical presentation, prognosis, and therapy. The spectrum of these reactions not only includes bullous reactions such as Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and generalized bullous fixed drug eruption (GBFDE) but also acute generalized exanthematous pustulosis (AGEP) and drug reaction with eosinophilia and systemic symptoms (DRESS). If AGEP or DRESS is suspected, the diagnosis should be confirmed by thorough clinical examination, a skin biopsy, and specific laboratory tests. Crucial for the patient's prognosis, the causative agent should be rapidly identified and discontinued. It is therefore important to know the most frequent triggers of severe drug reactions, some of which may induce various reaction patterns. Depending on the clinical diagnosis, symptomatic and adequate supportive therapy, as well as systemic immunomodulatory treatments are used. The prognosis in SJS/TEN is often poor and depends on the patient's age and underlying conditions as well as the extent of skin detachment. The prognosis of GBFDE is somewhat better, but recurrences may lead to more severe disease manifestations. In DRESS, protracted and recurrent courses have been described, whereas AGEP usually resolves without problems.