Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis

Association of antibiotics with Stevens-Johnson syndrome and toxic epidermal necrolysis: a real-world pharmacovigilance study

BACKGROUND

Recent reports suggest antibiotics may cause severe allergic reactions, such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), exacerbating concerns about antibiotic safety.

OBJECTIVE

Given the limited real-world evidence, this study aims to analyze the FDA Adverse Event Reporting System (FAERS) to investigate the association between various antibiotics and SJS/TEN risk.

METHODS

Reports from infected patients (Q1 2014-Q4 2023) were extracted from the FAERS. Disproportionality analysis using information component (IC) identified risk signals of antibiotics associated with SJS/TEN. Subgroup analyses investigated the impact of age and gender on antibiotic-associated SJS/TEN. Also a time of onset analysis was performed.

RESULTS

Among 78,593 infected patients, 1,221 cases of SJS/TEN were identified from 30,369 antibiotic administrations. The median age of patients with SJS was 63 years, and with TEN was 60 years. Eleven positive signal drugs were detected through disproportionality analysis. Amoxicillin, piperacillin, ceftriaxone, cefuroxime, cefotaxime, azithromycin, sulfamethoxazole, trimethoprim, vancomycin, doxycycline, and gentamicin exhibited significant risk associations with SJS/TEN. Sulfamethoxazole had the highest risk. Patients with pneumonia, urinary tract infections, and sepsis had higher risks than those with respiratory tract infections. Male patients using specific antibiotics may have a higher risk than females, with no significant age difference.

CONCLUSION

Antibiotics including penicillins, cephalosporins, azithromycin, sulfamethoxazole, trimethoprim, vancomycin, doxycycline, and gentamicin are associated with an increased risk of SJS/TEN, with sulfamethoxazole presenting the highest risk. Patients with pneumonia, urinary tract infections, and sepsis are particularly vulnerable. These findings highlight the need for personalized antibiotic regimens based on infection site and patient gender.

Updates in immunomodulator therapy in ocular surface inflammatory diseases

PURPOSE OF REVIEW

Ocular surface inflammatory disorders (OSIDs), including allergic conjunctivitis, ocular graft-versus-host disease (oGVHD), and cicatrizing conjunctivitis, present significant clinical challenges due to complex immune modulation. Traditional therapies like corticosteroids have limitations, prompting the need for alternative treatments. This review explores novel, steroid-sparing immunomodulatory options.

RECENT FINDINGS

In recent years, immunomodulatory therapies have evolved from corticosteroids and broad-spectrum T-cell inhibitors such as cyclosporine and tacrolimus to more selective pathway-targeting agents like JAK inhibitors (e.g., ruxolitinib). Biologic agents, including dupilumab and upadacitinib, have demonstrated efficacy in severe allergic conjunctivitis. In oGVHD, JAK inhibitors and combination therapies are emerging as promising strategies. For cicatrizing conjunctivitis, rituximab and IVIg have shown encouraging outcomes. Additionally, novel therapeutic targets such as chemokine receptor blockers (e.g., CCL20 locked dimer), T regulatory cell (Treg) modulation, and transcriptional modification via micro-RNA are shaping the future of ocular surface disease management.

SUMMARY

The future of immunomodulatory therapy for ocular surface diseases lies in refining current treatment approaches and advancing targeted biologic agents that modulate specific immune pathways, offering improved efficacy and safety for patients with these sight-threatening conditions.

Pharmacogenomics predictors of aromatic antiepileptic drugs-induced SCARs in the Iraqi patients

Introduction

Severe cutaneous adverse reactions (SCARs) are life-threatening and often linked to antiepileptic drugs (AEDs). Common types of SCARs include Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS). Immune-mediated mechanisms involving human leukocyte antigen (HLA) alleles have been implicated in the pathogenesis of this reaction. This study examines the association between specific HLA alleles (HLA-A, -B, and -DRB1) and AED-induced SCARs in the Iraqi population.

Methodology

A total of 50 patients diagnosed with SCARs and 90 tolerant controls were recruited from Dr. Saad Al-Wattari Hospital for Neurological Sciences and Baghdad Hospital - Medical City. HLA genotyping was performed using PCR-SSO method from peripheral blood samples. Statistical comparisons were made using the t-test or chi-square test, while univariate logistic regression with Bonferroni's correction (p < 0.05) were used to assess associations between HLA alleles and SCARs.

Results

Among the patients, SJS was the most prevalent type of SCARs observed. Analysis of HLA allele frequencies revealed significant associations between specific alleles. HLA-A∗02:01 was found to be significantly associated with a lower risk of AED-induced SJS (OR = 0.36; 95 % CI: 0.13-0.97), while HLA-A∗24:02 and HLA-B∗15:02 were associated with an increased risk of AED-induced SJS (OR = 3.60; 95 % CI: 1.21-10.72 and OR = 4.41; 95 % CI: 1.18-16.47, respectively). For AED-induced TEN, HLA-A∗01:02, HLA-B∗15:02, and HLA-B∗52:01 showed significant associations (OR = 6.92; 95 % CI: 1.39-34.37 and OR = 6.55; 95 % CI: 1.62-26.52, respectively), with HLA-DRB1∗03:01 being highly significant (OR = 5.09; 95 % CI: 1.72-15.00). Additionally, HLA-B∗40:02 was strongly associated with AED-induced DRESS (OR = 29.33; 95 % CI: 3.50-245.32).

Conclusion

This study identifies key HLA alleles associated with AED-induced SCARs in the Iraqi population. These findings could facilitate personalized medicine approaches, aiding in better prediction and prevention of SCARs in AED therapy.

Epidemiological Characteristics and Prognostic Scoring in Toxic Epidermal Necrolysis and Stevens-Johnson Syndrome: Insights from a 17-Year Burn Center Experience

Background and Objectives: Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are rare yet life-threatening dermatologic conditions characterized by severe skin and mucous membrane involvement. Accurate prognostic systems are crucial for clinical management to assess disease severity and predict outcomes. The primary objective of this study was to assess the epidemiological characteristics and clinical outcomes of patients with Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS/TEN overlap over a 17-year period at a specialized burn center. The secondary objectives were to evaluate the performance of existing prognostic scoring systems (SCORTEN, Re-SCORTEN, and ABCD-10) in predicting mortality and to propose a novel classification tree model to improve mortality prediction. Materials and Methods: A 17-year retrospective study at a burn center included 68 patients with SJS, SJS/TEN overlap, or TEN. Demographic, clinical, laboratory data, and prognostic scores (SCORTEN, Re-SCORTEN, ABCD-10) were collected and analyzed for associations with mortality. A classification tree was created to detect unknown determinants of SJS/TEN mortality. Results: The drug most frequently associated with the occurrence of SJS/TEN was metamizole. The mortality rate was 51%. Affected body surface area, platelet count, and serum blood urea nitrogen differed significantly between survivors and non-survivors. Regarding the scoring systems, only the Re-SCORTEN showed reliable differentiation for these groups. A classification tree model achieved an accuracy of 89% in predicting the mortality risk. In the ROC curve analysis, the AUC values were 0.88 for the classification tree, 0.66 for Re-SCORTEN, 0.61 for SCORTEN, and 0.56 for ABCD-10. Conclusions: This study explores mortality predictors in SJS/TEN via a classification tree model, highlighting potential factors for further investigation. While cautioning against immediate clinical application due to data constraints, the findings underscore the need for larger studies to validate and refine prediction models in this context.

Immune checkpoint inhibitor-induced severe epidermal necrolysis mediated by macrophage-derived CXCL10 and abated by TNF blockade

Immune checkpoint inhibitors (ICI) represent new anticancer agents and have been used worldwide. However, ICI can potentially induce life-threatening severe cutaneous adverse reaction (SCAR), such as Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), hindering continuous ICI therapy. We examine 6 cohorts including 25 ICI-induced SJS/TEN patients and conduct single-cell RNA sequencing (scRNA-seq) analysis, which shows overexpression of macrophage-derived CXCL10 that recruits CXCR3+ cytotoxic T lymphocytes (CTL) in blister cells from ICI-SJS/TEN skin lesions. ScRNA expression profiles and ex vivo blocking studies further identify TNF signaling as a pathway responsible for macrophage-derived CXCL10 and CTL activation. Based on the trajectory analysis, ICI-activated T cells from whole blood are proposed to serve as the initial cells involved in inflammation, that lead to monocytes differentiating into macrophages and increasing their susceptibility to migrate to the lesion sites. Compared with systemic corticosteroids treatment, ICI-induced SJS/TEN patients treated with biologic TNF blockade showed a significantly rapid recovery and no recurrence of SCAR with continuous ICI therapy. Our findings identify that macrophage-eliciting CTL contribute to the pathogenesis of ICI-induced epidermal necrolysis and provide potential therapeutic targets for the management and prevention of SCAR induced by ICI therapy.

Lamotrigine Emerging as a Driver of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: An 8-Year Retrospective Study

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) represent severe manifestations of a potentially life-threatening spectrum defined by a desquamating rash of the skin and mucous membranes. This study was prompted by the observed increase in the off-label use of lamotrigine as a causal agent in SJS/TEN in our regional burn center.

METHODS

A retrospective cohort of 48 patients presenting to the Connecticut Burn Center from 2015-2022 with suspicion for SJS/TEN were reviewed for age, sex, causative drug, presenting symptoms, hospital course, biopsy confirmation, length of stay, comorbidities, and 30-day mortality. Descriptive statistical analysis was conducted to identify trends in causative agent, clinical presentation, and mortality.

RESULTS

Thirty patients in our cohort received a final diagnosis of SJS/TEN. While antibiotics remain the most frequent cause of SJS/TEN across the study period (33.3 %, n = 10), the incidence of cases attributable to lamotrigine increased from 1 case between 2015 and 2018 (6.7 %) to 6 cases between 2019 and 2022 (40 %). In 2020 alone, 50 % of all cases were attributable to lamotrigine (n = 4). Of the patients where lamotrigine was implicated, 71.4 % (n = 5) were prescribed lamotrigine for off-label use in the treatment of non-bipolar mood disorders. The average lamotrigine-associated SJS/TEN patient was younger (p < 0.001), had fewer comorbidities, and was more likely to be female than the general SJS/TEN population.

CONCLUSION

Off-label use of lamotrigine is emerging as a major driver of SJS/TEN with notable changes in patient demographics. Further research is necessary to understand how changing trends in the patient population will impact clinical course and optimal management.

Osimertinib-Induced Toxic Epidermal Necrolysis - A Case Report

PURPOSE

To investigate the rare side effects of Osimertinib in a case of toxic epidermal necrosis.

CASE PRESENTATION

We report on a case of a 44-year old woman with lung adenocarcinoma harboring an EGFR-sensitizing mutation who was treated with Osimertinib as the second-line treatment. Ten days after Osimertinib initiation, a diffuse erythematous rash rapidly spread over the patient's trunk along with vesicles and purpuric macules; furthermore, she developed erythema and exfoliation on the face and trunk and severe mucositis. Toxic epidermal necrolysis (TEN) is life-threatening dermatologic adverse event, caused by a delayed-type drug hypersensitivity reaction. Although skin toxicity is common during treatment with epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs), Osimertinib-associated TEN is very rare.

RESULTS

Treatment with systemic steroids and immunoglobulin as well as supportive treatment led to an improvement of her general wellbeing, followed by a remarkable recovery.

CONCLUSIONS

Although the clinical use of Osimertinib is becoming widespread, the side effects may not be fully understood. Clinicians should indeed pay more attention to the occurrence of side effects and be prepared to deal with them in timely manner.

Clinical Features of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Induced by Immune Checkpoint Inhibitor versus Non-Immune Checkpoint Inhibitor Drugs in China: A Cross-Sectional Study and Literature Review

Purpose

Immune checkpoint inhibitors (ICIs) can cause life-threatening Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Large-scale original research on ICI-induced SJS/TEN is limited. This study aimed to explore the unique clinical characteristics and potential pathophysiological mechanisms of SJS/TEN induced by ICIs.

Methods

This cross-sectional study compared the clinical features of SJS/TEN induced by ICIs and non-ICIs, and reviewed the case characteristics of ICI-induced SJS/TEN. Clinical features were analyzed using independent t-tests, Mann-Whitney U-tests, and multivariable regression models.

Results

This study enrolled 41 cases of ICI-induced SJS/TEN and 107 non-ICI-induced cases from January 22, 2015, to May 28, 2024. ICI-induced SJS/TEN patients exhibited a trend towards a longer latency period (β: 17, 95% CI: -1.49 to 35.48), a smaller affected body surface area (BSA) (β: -40.68, 95% CI: -71.59 to -9.77), and milder oral and ocular mucositis than non-ICI-induced cases. A literature review identified PD-1 inhibitors as the primary ICIs involved and systemic corticosteroids as the most frequent intervention. No statistically significant difference in mortality rate was observed between patients treated with systemic corticosteroids alone and those receiving combination therapies (P= 0.85). The mortality rate for ICI-induced SJS/TEN was 24.5%.

Conclusion

This study offered the largest comparative analysis to date, highlighting the unique clinical features of ICI-induced SJS/TEN, including a smaller affected BSA, a prolonged latency period trend, and milder oral and ocular mucositis. We described the epidemiology, clinical presentation, and therapeutic strategies for ICI-induced SJS/TEN. These findings not only contribute to a deeper understanding of the complex immune-inflammatory pathways in severe immune-related cutaneous adverse events (ircAEs) but also may inform the development of more targeted and effective treatments.

Comparison of incidence, causes and prognosis of adult and paediatric epidermal necrolysis: a French population-based study

BACKGROUND

Epidermal necrolysis (EN), comprising Stevens-Johnson syndrome and toxic EN, is a rare and severe blistering reaction, mainly induced by drugs. Differences between paediatric and adult patients regarding incidence, causes and outcomes have been discussed but are based on a limited number of patients from small case series.

OBJECTIVES

To directly compare the incidence, cause and prognosis of adult and paediatric EN.

METHODS

We used data from the French Health System Database (1 January 2013-31 December 2022). We identified adult and paediatric patients hospitalized for EN using the International Classification of Diseases, 10th Revision codes combined with validated algorithms. Outcomes were the incidence of EN; the presence of a suspected drug before EN onset (defined as a new drug dispensation from 5 to 56 days prehospitalization); and in-hospital mortality. To estimate the association between paediatric EN and the presence of a suspect drug, we computed a multivariable logistic regression with odd ratios (ORs). To estimate the association with mortality, we computed a multivariable Cox proportional hazard ratio (HR) model.

RESULTS

A total of 1440 patients [799 (55.5%) female] with EN were included, comprising 219 children and 1221 adults. Among children, the incidence of EN was 1.5 cases [95% confidence interval (CI) 1.3-1.7] per 1 million person-years vs. 2.6 cases (95% CI 2.5-2.7) in adults. Moreover, children had less chance of being given a culprit drug before the onset of EN [n = 93/219 (42.5%) vs. n = 829/1221 (67.9%)], with an adjusted OR of 0.43 (95% CI 0.32-0.59; P < 0.001), together with a better prognosis: the mortality rate in paediatric patients was 1.4% (95% CI 0.4-3.7) vs. 19.4% (95% CI 17.3-21.7) in adults. The adjusted HR for in-hospital mortality in children was 0.12 (95% CI 0.04-0.38; P < 0.001).

CONCLUSIONS

Paediatric EN appears to be rarer, with less chance of being caused by drugs and has a better prognosis than adult EN. These results suggest the existence of different underlying pathophysiological mechanisms and clinical particularities between adult and paediatric patients with EN.

Awareness, knowledge, attitude, and practice of adverse drug reaction reporting among health workers in primary health centres participating in seasonal malaria chemoprevention campaign in Nigeria in 2022: a cross-sectional survey

BACKGROUND

Evaluating health workers' knowledge and practice of adverse drug reaction (ADR) reporting is an important step in identifying gaps in quality ADR reporting during public health interventions like the seasonal malaria chemoprevention (SMC) campaign. Pharmacovigilance (PV) monitoring is vital in SMC due to the number of children exposed to malaria medicines for a period of 4 or 5 months during the campaign. In Nigeria more than 10 million children are exposed to SMC medicines every year. The scale of this intervention emphasised the need for efficient and effective safety monitoring during the campaign. Thus, the objective of this study was to evaluate healthcare workers' (HCW) awareness, knowledge, attitude and practice (KAP) of ADR reporting in health facilities participating in SMC campaign to identify pharmacovigilance gaps which may suggest possible ways to ensure safety during the campaign.

METHODS

World Health Organization's service availability and readiness assessment (SARA) recommendations were used to sample 2,598 out of 5,195 used as supervising health facilities (HFs) during the 2022 SMC campaign across nine states of the country. Out of the sampled HFs, 2,144 eligible and consented health facility workers (HFWs) were assessed for awareness, and KAP of ADR using the validated 45-item self-administered questionnaire. The data was analysed using descriptive statistics and correlation analysis at p < 0.05.

RESULTS

The majority of the respondents are males (n = 1,333, 62.2%). The HFWs showed good awareness (n = 2,037, 95.0%) of pharmacovigilance (PV). However, only 809 (37.7%) of them had good knowledge scores. The mean ADR reporting attitude score (85.0 ± 15.3%) was good with many of the respondents (n = 1,548, 72.2%) having a good score. However, the respondents' ADR practice was suboptimal, only 1,356 (63.2%) of them had encounters with ADR, and a lot of negative perceived barriers to ADR reporting were identified in the study. For example, 493 (23%) believed that ADRs were not reported because they were not serious and life-threatening while 248 (11.6%) reported a fear of liability. Correlation analysis revealed female gender (r = 0.163, p < 0.001), older age (r = 0.207, p < 0.001) and years of practice (r = 0.050, p = 0.021) as factors significantly associated with ADR knowledge and attitude scores.

CONCLUSION

The study indicated that HCWs across health facilities participating in SMC campaigns have ADR reporting knowledge and practice gaps. The study suggest training alone may not be effective in addressing gaps in ADR reporting. In addition to PV training, implementers can include continuous mentoring of health care workers or other similar interventions as part of strategy to improve ADR reporting. Also, context specific strategies to improve ADR reporting among health care worker needs to be implemented to address under-reporting of ADRs during SMC campaigns and other malaria public health interventions.

Greater mechanistic understanding of the cutaneous pathogenesis of Stevens-Johnson syndrome/toxic epidermal necrolysis can shed light on novel therapeutic strategies: a comprehensive review

PURPOSE OF REVIEW

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) are severe cutaneous adverse drug reactions (SCARs) characterized by widespread epithelial detachment and blistering, which affects the skin and mucocutaneous membranes. To date, therapeutic interventions for SJS/TEN have focused on systematic suppression of the inflammatory response using high-dose corticosteroids or intravenous immunoglobulin G (IgG), for example. No targeted therapies for SJS/TEN currently exist.

RECENT FINDINGS

Though our understanding of the pathogenesis of SJS/TEN has advanced from both an immunological and dermatological perspective, this knowledge is yet to translate into the development of new targeted therapies.

SUMMARY

Greater mechanistic insight into SJS/TEN would potentially unlock new opportunities for identifying or repurposing targeted therapies to limit or even prevent epidermal injury and blistering.

Stevens-Johnson syndrome-toxic epidermal necrolysis overlap in a patient taking quetiapine and famotidine: a case report

BACKGROUND

Stevens-Johnson syndrome-toxic epidermal necrolysis (SJS-TNE) overlap is a rare skin disorder characterized by erythema, blisters, extensive exfoliation, epidermal detachment, the involvement of multiple mucosae, and positive Nikolsky's sign. SJS-TEN has a high mortality rate. Our case involves a rare occurrence of drug-induced Stevens-Johnson syndrome-toxic epidermal necrolysis overlap with a delayed onset in the setting of quetiapine and famotidine therapy.

CASE PRESENTATION

An 82-year-old Taiwanese female was admitted to our hospital for decreased urine output, generalized edema, and multiple skin blisters and bedsores. With further spread of the lesions, multiple ruptured bullae with shallow erosions on the face, trunk, and limbs and mucosal involvement affected 20% of the total body surface area. Nikolsky's sign was positive. A diagnosis of Steven-Johnson syndrome was highly suspected. One month prior, she had started famotidine and quetiapine. Intravenous methylprednisolone treatment was initiated, which ameliorated the skin lesions after 3 days. However, new lesions developed after only 1 day of methylprednisolone tapering. The patient died 12 days after admission.

CONCLUSION

Stevens-Johnson syndrome-toxic epidermal necrolysis is a rare skin disorder. Although it is mainly acute and has a high mortality rate, delayed onset can still occur. Quetiapine and famotidine are generally safe and effective for treating geriatric and gastrointestinal problems, but rare drug hypersensitivity reactions can lead to debilitating consequences. Therefore, increased clinical awareness and the initiation of supportive care are imperative. Optimal management guidelines are still lacking, and confirmation of developed guidelines through randomized controlled trials is needed. Collaboration for better management strategies is warranted.

The Completion of Postoperative Radiotherapy After Breast-Conserving Surgery in a Patient With Recurrent Erythema Multiforme: A Case Report

Radiotherapy (RT) can induce dermatitis and exacerbate a patient's preexisting skin conditions. We present a case of RT in a 61-year-old Japanese woman with a history of erythema multiforme (EM). She was diagnosed with a nodule on her right breast during therapy for EM. EM was noticed on the anterior chest and upper and lower extremities. RT was initially postponed due to exacerbation of EM before postoperative RT for right breast cancer. However, considering that EM tends to recur every one to two months, RT was commenced during a period of less active dermatitis, and a total dose of 50 Gy of conventional irradiation was successfully administered. One year after RT, there was no EM recurrence, dermatitis development, obvious late effects, or radiation pneumonitis. Our experience suggests that RT can be administered relatively safely to patients with recurrent EM but should be administered with caution.

Neutrophil-driven and interleukin-36γ-associated ocular surface inflammation in chronic Stevens-Johnson syndrome

PURPOSE

This study aims to elucidate the tear proteome and understand the underlying molecular mechanisms involved in the ocular complications following Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN).

METHODS

Mass spectrometry (MS) was performed to quantify the tear fluid proteins from chronic SJS/TEN patients (n = 22 eyes) and age- and gender-matched controls (n = 22 eyes). The candidate proteins were validated using ELISA (n = 80 eyes) in tear samples and immunohistochemistry (IHC; n = 12) in eyelid margin specimens. These proteins were compared for significant differences based on age, gender, disease duration, and ocular severity.

RESULTS

A total of 1692 tear fluid proteins were identified, of which 470 were significantly differentially regulated in chronic SJS/TEN. The top 10 significantly upregulated proteins were neutrophil secretions including neutrophil elastase (p < .0001), defensin (p < .0001), and matrix metalloproteinase 8 (p < .0001). The presence of neutrophils was confirmed by the upregulation of IL-8 (p < .001) in tears, a key cytokine known for recruiting neutrophils. Additionally, positive expression of myeloperoxidase was observed in the keratinized eyelid margins of SJS/TEN to validate the presence of neutrophils. Among 41 unique proteins identified by MS, IL-36γ (p < .01) was expressed in three SJS/TEN patients and was confirmed in SJS/TEN tears and eyelid margins by ELISA and IHC, respectively. IL-36γ was specifically expressed in the superficial layers of eyelid margin keratinized conjunctiva. The majority of the significantly downregulated proteins were lacrimal gland secretions such as lacritin (p < .0001) and opiorphin (p < .002). Neutrophil elastase (p < .02) was significantly elevated in patients with severe eyelid margin keratinization.

CONCLUSION

Our observations indicate a clear correlation between eyelid margin keratinization and the expression of IL-36γ, potentially mediated by neutrophils recruited via IL-8. Future experimental studies are needed to test the role of therapies targeting IL-8 and/or IL-36γ in reducing eyelid margin keratinization and its associated ocular complications in SJS/TEN.

Severe cutaneous adverse reactions

Severe cutaneous adverse reactions (SCARs), which include Stevens-Johnson syndrome and toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms (also known as drug-induced hypersensitivity syndrome), acute generalized exanthematous pustulosis, and generalized bullous fixed drug eruption, are life-threatening conditions. The pathogenesis of SCARs involves T cell receptors recognizing drug antigens presented by human leukocyte antigens, triggering the activation of distinct T cell subsets. These cells interact with keratinocytes and various immune cells, orchestrating cutaneous lesions and systemic manifestations. Genetic predisposition, impaired drug metabolism, viral reactivation or infections, and heterologous immunity influence SCAR development and clinical presentation. Specific genetic associations with distinct SCAR phenotypes have been identified, leading to the implementation of genetic screening before prescription in various countries to prevent SCARs. Whilst systemic corticosteroids and conventional immunomodulators have been the primary therapeutic agents, evolving strategies, including biologics and small molecules targeting tumour necrosis factor, different cytokines, or Janus kinase signalling pathways, signify a shift towards a precision management paradigm that considers individual clinical presentations.

Cutaneous adverse drug reactions

Cutaneous adverse drug reactions (ADRs) represent a heterogeneous field including various clinical patterns without specific features suggesting drug causality. Maculopapular exanthema and urticaria are the most common types of cutaneous ADR. Serious cutaneous ADRs, which may cause permanent sequelae or have fatal outcome, may represent 2% of all cutaneous ADR and must be quickly identified to guide their management. These serious reactions include bullous manifestations (epidermal necrolysis i.e. Stevens-Johnson syndrome and toxic epidermal necrolysis), drug reaction with eosinophilia and systemic symptoms (DRESS) and acute generalized exanthematous pustulosis (AGEP). Some risk factors for developing cutaneous ADRs have been identified, including immunosuppression, autoimmunity or genetic variants. All drugs can cause cutaneous ADRs, the most commonly implicated being antibiotics (especially aminopenicillins and sulfonamides), anticonvulsants, allopurinol, antineoplastic drugs, non-steroidal anti-inflammatory drugs and iodinated contrast media. Pathophysiology is related to immediate or delayed "idiosyncratic" immunologic mechanisms, i.e., usually not related to dose, and pharmacologic/toxic mechanisms, commonly dose-dependent and/or time-dependent. If an immuno-allergic mechanism is suspected, allergological explorations (including epicutaneous patch testing and/or intradermal test) are often possible to clarify drug causality, however these have a variable sensitivity according to the drug and to the ADR type. No in vivo or in vitro test can consistently confirm the drug causality. To determine the origin of a rash, a logical approach based on clinical characteristics, chronologic factors and elimination of differential diagnosis (especially infectious etiologies) is required, completed with a literature search. Reporting to pharmacovigilance system is therefore essential both to analyze drug causality at individual level, and to contribute to knowledge of the drug at population level, especially for serious cutaneous ADRs or in cases involving newly marketed drugs.

Drug-induced hypersensitivity reactions in a Lebanese outpatient population: A decade-long retrospective analysis (2012-2021)

Background

Drug hypersensitivity reactions (DHRs) are becoming more common as a result of increasing prevalence and case complexity. Allergists and clinical immunologists worldwide are challenged daily to adequately diagnose and manage these reactions. Data in the literature regarding DHR outpatient consultations are scarce worldwide, limited in the Middle East, and currently unavailable in Lebanon.

Objective

This retrospective study aimed to evaluate the characteristics of all reported DHRs over 10 years in a tertiary-care allergy clinic in Lebanon.

Methods

We conducted a decade-long (2012-21) retrospective analysis of the archived medical records of patients with a history of DHRs. Demographics, clinical history, diagnostic tools, and characteristics of the DHRs were collected and analyzed.

Results

A total of 758 patients experienced DHRs to therapeutic molecules provided for ambulatory care. Our results identified 72 medications. The most frequently implicated drug classes included β-lactam antibiotics (53.8%), followed closely by nonsteroidal anti-inflammatory drugs (48.9%). Of the 758 patients, 32.6% reported DHRs to multiple molecules, and 11.8% reported concomitant DHRs to 1 or several molecules provided in the perioperative setting. Of those, opioids and neuromuscular blocking agents were the 2 most common therapeutic classes. Furthermore, we evaluated the cross-reactivity between molecules of the same class. In neuromuscular blocking agents, rocuronium and cisatracurium were the most commonly cross-reactive, and for opioids, the most common association we recorded was with morphine and pethidine.

Conclusion

Our findings constitute the first step toward a more comprehensive evaluation of the clinical characteristics of DHRs in Lebanon.

Etanercept treatment for pediatric toxic epidermal necrolysis induced by deflazacort: a case report and literature review

Toxic epidermal necrolysis (TEN) is a life-threatening mucocutaneous disorder commonly caused by drugs. TEN is often treated with corticosteroids, intravenous immunoglobulin (IVIG), or cyclosporine; however, the efficacy of these treatments is controversial. Etanercept (a TNF-α antagonist) was proven to decrease skin-healing time in a randomized clinical trial. Herein, we report the case of a 44-month-old boy who developed TEN due to deflazacort as the probable culprit drug and was successfully treated with etanercept. The patient presented to the emergency department complaining of erythematous maculopapular rashes and vesicles all over the face and body, with vesicles on the hands, feet, and trunk. Symptoms started 4 days before presentation, with edema of the upper lip, which progressed to erythematous macules over the body. He was started on deflazacort for nephrotic syndrome 21 days before the visit. Approximately 20% of the body surface area (BSA) was covered by vesicular lesions. Under the diagnosis of Steven Johnson syndrome/TEN, deflazacort was discontinued, and intravenous dexamethasone (1.5 mg/kg/day), a 5-day course of IVIG (0.4 mg/kg/day), and cyclosporine (3 mg/kg/day) were administered. The lesions seemed to be stationary for 3 days, but on the 6th day of hospitalization, when IVIG was discontinued, the vesicular lesions progressed to approximately 60% of the BSA. Etanercept 0.8 mg/kg was administered subcutaneously. Lesions stopped progressing, and bullous lesions started epithelialization. However, on the 15th day, around 30% of the BSA was still involved; thus, a second dose of etanercept was administered. No acute or sub-acute complications were observed. In conclusion, the use of etanercept in children with TEN that is not controlled with conventional therapy is both effective and safe.

Signal mining study of severe cutaneous adverse events of valaciclovir or acyclovir based on the FAERS database

OBJECTIVE

This study aimed to explore a comprehensive empirical investigation and assess SCARs related to valaciclovir or acyclovir based on FAERS database from FDA, thus providing a theoretical foundation for the rational application of drugs in clinic.

METHODS

SCARs reports relevant to valaciclovir or acyclovir were searched in FAERS database from the 2004 Q1 to 2023 Q2. These data were further mined by a proportional analysis and Bayesian approach to detect signals of SCARs caused by two drugs. Meanwhile, the clinical characteristics, onset time, correlation, and stratification analysis of the two drugs in SCARs were analyzed.

RESULTS

Both drugs exhibited positive signals for drug reaction with DRESS, AGEP, TEN, SJS-TEN overlap and SJS. The median onset time of SCARs caused by valaciclovir or acyclovir was 30 days vs 10 day for DRESS, 11 days vs 9 days for AGEP, 17 days vs 12 days (TEN) and 12 days vs 8 days (SJS). Excluding the effect of combinational drugs, there was an association between the two antiviral drugs and SCARs.

CONCLUSION

By analyzing the FAERS database, the risk trends of SCARs caused by valaciclovir or acyclovir have been identified, providing valuable insights to recognize various types of SCARs in clinics.

Medication Associations With Severe Cutaneous Adverse Reactions: A Case/Non-Case Analysis Using the FDA Adverse Event Reporting System

BACKGROUND

Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP) are potentially life-threatening severe cutaneous adverse reactions (SCARs). Although the classical causal agents of SCARs (antibiotics, anticonvulsants, nonsteroidal anti-inflammatory drugs, and allopurinol) are well characterized, there has been little update to this list to account for newly marketed medications.

OBJECTIVE

To provide an updated and stratified list of medications with significant reporting odds ratios (RORs) of SCARs.

METHODS

A case/non-case analysis using the United States FDA Adverse Event Reporting System was performed.

RESULTS

As expected, the prototypical medication classes made up the majority of reported cases of SJS, TEN, AGEP, and DRESS (77%, 64%, 75%, and 72%, respectively). In addition, several infrequently or previously undescribed classes/medications implicated in SCARs were identified to have significant ROR signals, including acetylcysteine, anticoagulants, diuretics, immunotherapies, proton pump inhibitors, antivirals, and antifungals. Among these reported for SJS were acetylcysteine (ROR: 64.38) and fluconazole (ROR: 17.13). For TEN, we identified furosemide (ROR: 26.32), spironolactone (ROR: 14.45), fluconazole (ROR: 30.21), amphotericin B (39.06), and acetylcysteine (ROR: 93.12). For AGEP, we identified acyclovir (ROR: 61.72), valacyclovir (ROR: 30.76), and enoxaparin (ROR: 27.37). For DRESS, we identified vemurafenib (ROR: 17.35), acyclovir (ROR: 30.63), abacavir (ROR: 26.62), raltegravir (ROR: 23.27), and valacyclovir (ROR: 21.77) to have strong reporting odds.

CONCLUSION

Our analysis provides an updated tool for physicians to reference when identifying suspected SCARs and a basis for future studies to investigate atypical medication causality.

Update on HLA-B*15:02 allele associated with adverse drug reactions

HLA alleles, part of the major histocompatibility complex, are strongly associated with adverse drug reactions (ADRs). This review focuses on HLA-B*15:02 and explores its association with ADRs in various ethnic populations and with different drugs, aiming to provide insights into the safe clinical use of drugs and minimize the occurrence of ADRs. Furthermore, the review explores the potential mechanisms by which HLA-B*15:02 may be associated with ADRs, aiming to gain new insights into drug modification and identification of haptens. In addition, it analyzes the frequency of the HLA-B*15:02, genotyping methods, cost-effectiveness and treatment measures for adverse reactions, thereby providing a theoretical basis for formulating clinical treatment plans.

Antibiotic prophylaxis in immunosuppressed patients - Missed opportunities from trimethoprim-sulfamethoxazole allergy label

Trimethoprim-sulfamethoxazole (TMP-SMX) is a broad spectrum antibiotic in use for more than 50 years. It has an important indication as first line agent in the prophylaxis of opportunistic infections, particularly Pneumocystis jirovecii pneumonia (PJP), in immunosuppressed patients. For those who have a history of allergy or severe intolerance to TMP-SMX, pentamidine, dapsone or atovaquone may be substituted; however there is evidence that TMP-SMX offers superior coverage for PJP, toxoplasmosis, and nocardiosis. Compared to pentamidine, it has the added benefit of cost-effectiveness and self-administration as opposed to required hospital attendance for administration. Many patients who report a history of allergy or adverse reaction to TMP-SMX (or "sulfur allergy") will be found not to be allergic; and even those who are allergic may be able to be desensitized. The evaluation and, where appropriate, removal of TMP-SMX allergy label enables the use of TMP-SMX for prophylaxis against opportunistic infections. This is a cost-effective intervention to optimize antimicrobial prescribing and reduce the risk of opportunistic infections in immunosuppressed patients.

Risk of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Associated With Antibiotic Use: A Case-Crossover Study

BACKGROUND

Evidence is lacking on the association between antibiotic use and risk of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) in Asians.

OBJECTIVE

We assessed the risk of SJS/TEN associated with different antibiotic classes in Japanese.

METHODS

We conducted a case-crossover study using a claims database. Firth conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of SJS/TEN associated with antibiotic use in a 56-day hazard period versus 3 control periods. We created 18 cohorts for each antibiotic class and calculated 56-day cumulative incidence per 100,000 new users. The association between antibiotic class and SJS/TEN was also evaluated in each case using the ALgorithm of Drug causality for Epidermal Necrolysis (ALDEN).

RESULTS

Our case-crossover study included 170 SJS/TEN cases. Increased ORs were observed for lincomycins (OR, 33.00 [95% CI, 3.74-4332.05]), trimethoprim-sulfamethoxazole (21.20 [6.73-105.98]), penicillins (14.39 [6.95-34.21]), glycopeptides (14.37 [3.17-136.10]), cephalosporins (7.06 [4.25-12.21]), aminoglycosides (6.55 [1.97-26.84]), quinolones (5.98 [3.34-11.20]), fosfomycin (5.40 [1.20-30.97]), carbapenems (5.09 [1.85-15.64]), tetracyclines (4.95 [1.78-15.27]), and macrolides (3.78 [2.13-6.83]). Cumulative incidence of SJS/TEN was 67.4 for trimethoprim-sulfamethoxazole, 86.2 for glycopeptides, and below 10.0 for the others. Despite the high incidence, only 2 cases had a probable causal relationship with glycopeptides.

CONCLUSION

Some antibiotic classes, including lincomycins, glycopeptides, aminoglycosides, fosfomycin, and carbapenems, were newly suggested to be associated with risk of SJS/TEN; considered together with the high incidence for trimethoprim-sulfamethoxazole and glycopeptides, these findings warrant caution in clinical practice.

Reality of drug-induced erythema multiforme: A French pharmacovigilance study

BACKGROUND

Since the 2002 SCAR study, erythema multiforme (EM), a post-infectious disease, has been distinguished from Stevens-Johnson syndrome (SJS), drug-induced. Nevertheless, EM cases are still reported in the French pharmacovigilance database (FPDB).

OBJECTIVES

To describe EM reported in the FPDB and to compare the quality and the characteristics of the reports.

METHODS

This retrospective observational study selected all EM cases reported in the FPDB over two periods: period 1 (P1, 2008-2009) and period 2 (P2, 2018-2019). Inclusion criteria were 1) a diagnosis of clinically typical EM and/or validated by a dermatologist; 2) a reported date of onset of the reaction; and 3) a precise chronology of drug exposure. Cases were classified confirmed EM (typical acral target lesions and/or validation by a dermatologist) and possible EM (not-otherwise-specified target lesions, isolated mucosal involvement, doubtful with SJS). We concluded possible drug-induced EM when EM was confirmed, with onset ranging from 5 to 28 days without an alternative cause.

RESULTS

Among 182 selected reports, 140 (77%) were analyzed. Of these, 67 (48%) presented a more likely alternative diagnosis than EM. Of the 73 reports of EM cases finally included (P1, n=41; P2, n=32), 36 (49%) had a probable non-drug cause and 28 (38%) were associated with only drugs with an onset time ≤4 days and/or ≥29 days. Possible drug-induced EM was retained in 9 cases (6% of evaluable reports). Etiological work-up was more often performed in period 2 than 1 (53.1% vs 29.3%, P=0.04), and the time to onset from 5 to 28 days was more frequent in period 2 (59.2% vs 40%, P=0.04).

CONCLUSIONS

This study suggests that possible drug-induced EM is rare. Many reports describe "polymorphic" rashes inappropriately concluded as EM or post-infectious EM with unsuitable drug accountability subject to protopathic bias.

TMP-SMX induced type 4 hypersensitivity with multi-organ involvement

Trimethoprim-sulfamethoxazole (TMP-SMX), also referred to as co-trimazole, is a common antibiotic used to treat a wide range of infections ranging from simple skin and soft tissue infections to opportunistic infections such as Pneumocystis jirovecii. Generally, this medication is well-tolerated, but severe adverse reactions, such as myelosuppression and hepatitis, can occur, albeit rarely. In this case report, we describe a patient who presented to the hospital with symptoms of rash, elevated liver enzymes, thrombocytopenia, and acute kidney injury 2 weeks after completing a course of TMP-SMX for a skin infection. We highlight the difficulties in diagnosing adverse events associated with this drug due to the variability in its presentation and the unpredictable onset of symptoms. By excluding common differential diagnoses including thrombotic thrombocytopenic purpura (TTP) and glucose-6-phosphate- dehydrogenase (G6PD) deficiency, we concluded that the patient was suffering from TMP-SMX-induced multi-organ dysfunction and treated him supportively. Through this case report, we aim to elucidate the importance of early recognition and treatment of the adverse effects of TMP-SMX.

Impact on carbamazepine usage and cutaneous adverse reactions before and after the reimbursement of HLA-B*1502 genotyping in Taiwan, 2000-2017: A nationwide longitudinal study

OBJECTIVE

The HLA-B*1502 allele is strongly associated with carbamazepine (CBZ)-induced Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) in the Han Chinese population. This study investigated the impact of HLA-B*1502 screening on CBZ utilization and rates of severe cutaneous allergic reactions (SCARs) and SJS/TEN over time in Taiwan, where screening for HLA-B*1502 genotyping before prescribing CBZ was reimbursed in June 2010.

METHODS

Using the Taiwan National Health Insurance Research Database, we analyzed 13 277 457 episodes of seeking treatment for epilepsy or neuralgia between 2000 and 2017. Episodes were categorized into quarters based on treatment time. Propensity score-based stabilized weighting (PSSW) ensured well-balanced covariates. The difference in 3-month SCAR and SJS/TEN rates between phase 2 (2011-2017) and phase 1 (2000-2009) was examined using a one-sample Z-test. Pearson correlation coefficients assessed the association between screening rate, the number of CBZ users and nonusers, and SCAR and SJS/TEN rates after HLA-B*1502 genotyping.

RESULTS

CBZ prescriptions reduced from 7% (2000-2003) to 6% (2004-2010) and 4% (2011-2017). The screening rates of CBZ nonusers and CBZ users increased from 0%, .5% in 2011 to .8%, 16% in 2017, respectively. After PSSW, the mean 3-month SCAR incidence rates (per 10 000 episodes) significantly decreased from phase 1 to phase 2 for CBZ users (6.91 vs. 3.09, p < .0001) and nonusers (1.96 vs. 1.65, p < .0001). SJS/TEN incidence rates (per 10 000 episodes) significantly decreased from phase 1 to phase 2 for CBZ users (2.94 vs. 1.93, p < .0001) but not for nonusers (.71 vs. .74, p = .1492). In phase 2, SCAR incidence rates were significantly and negatively correlated with the screening rate for both CBZ users (r = -.38, p = .0342) and nonusers (r = -.80, p < .001). No significant correlation was found between SJS/TEN incidence rates and screening rates.

SIGNIFICANCE

Recognizing HLA-B*1502 allele and avoiding CBZ therapy in HLA-B*1502-positive patients is critical for preventing CBZ-induced severe adverse events.

Assessment of Need for Improved Identification of a Culprit Drug in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

Importance

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a severe hypersensitivity reaction. Identifying a culprit drug is critical for patient care, yet identification is based on clinical judgment. Data are limited on the accuracy in or approach to identifying a culprit drug.

Objective

To evaluate patient allergy list outcomes, current approaches in identifying culprit drugs, and potential methods of improving culprit drug identification.

Design, Setting, and Participants

This retrospective cohort study spanned 18 years (January 2000 to July 2018), was conducted at Brigham and Women's Hospital and Massachusetts General Hospital (Boston), and included patients with clinically and histologically confirmed cases of SJS/TEN overlap and TEN.

Main Outcomes and Measures

This study descriptively analyzed potential culprits to SJS/TEN, patients' allergy lists, and currently used approaches that led to those lists. It then tested the theoretical contribution of incorporating various parameters to allergy list outcomes.

Results

Of 48 patients (29 women [60.4%]; 4 Asian [8.3%], 6 Black [12.5%], 5 Hispanic [10.4%], and 25 White [52.1%] individuals; median age, 40 years [range, 1-82 years]), the mean (SD) number of drugs taken per patient at disease onset was 6.5 (4.7). Physicians labeled 17 patients as allergic to a single culprit drug. Comparatively, 104 drugs were added to allergy lists across all patients. Physicians' approaches relied largely on heuristic identification of high-notoriety drugs and the timing of drug exposure. Use of a vetted database for drug risk improved sensitivity. Algorithm for Drug Causality for Epidermal Necrolysis scoring was discordant in 28 cases, labeling an additional 9 drugs missed by physicians and clearing 43 drugs labeled as allergens by physicians. Human leukocyte antigen testing could have potentially affected 20 cases. Consideration of infection as a culprit was limited.

Conclusions and Relevance

The results of this cohort study suggest that currently used approaches to identify culprit drugs in SJS/TEN are associated with overlabeling patients allergic to likely nonculprit drugs and less commonly missed possible culprit drugs. Incorporation of a systematized unbiased approach could potentially improve culprit drug identification, although ultimately a diagnostic test is necessary.

Relationship between Atopic Disease and Acute Ocular and Systemic Outcomes in Patients with Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

OBJECTIVE

To describe the relationship between history of atopic disease on systemic and ocular manifestations of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN).

METHODS

Retrospective chart review of patients with SJS/TEN patients. Those with and without prior atopic diagnosis were compared.

RESULTS

In total, 200 patients with SJS/TEN were identified. A total of 23 patients also had an atopic diagnosis. Four, 10, and 18 had atopic dermatitis, allergic rhinitis, and asthma respectively. Acute ocular severity was significantly worse in the atopic cohort. No significant differences in overall systemic severity of SJS or mortality were found between the atopic and non-atopic cohorts. Compared to our hospital system's general population, prevalence of an atopic diagnosis was significantly higher in those with SJS/TEN.

CONCLUSION

Patients with a history of an atopic diagnosis appear to have more significant acute ocular involvement during their SJS/TEN hospitalization. Atopic conditions appear to occur more frequently in the SJS/TEN population compared to the general population.

TFOS Lifestyle: Impact of elective medications and procedures on the ocular surface

The word "elective" refers to medications and procedures undertaken by choice or with a lower grade of prioritization. Patients usually use elective medications or undergo elective procedures to treat pathologic conditions or for cosmetic enhancement, impacting their lifestyle positively and, thus, improving their quality of life. However, those interventions can affect the homeostasis of the tear film and ocular surface. Consequently, they generate signs and symptoms that could impair the patient's quality of life. This report describes the impact of elective topical and systemic medications and procedures on the ocular surface and the underlying mechanisms. Moreover, elective procedures performed for ocular diseases, cosmetic enhancement, and non-ophthalmic interventions, such as radiotherapy and bariatric surgery, are discussed. The report also evaluates significant anatomical and biological consequences of non-urgent interventions to the ocular surface, such as neuropathic and neurotrophic keratopathies. Besides that, it provides an overview of the prophylaxis and management of pathological conditions resulting from the studied interventions and suggests areas for future research. The report also contains a systematic review investigating the quality of life among people who have undergone small incision lenticule extraction (SMILE). Overall, SMILE refractive surgery seems to cause more vision disturbances than LASIK in the first month post-surgery, but less dry eye symptoms in long-term follow up.

Aripiprazole-Induced Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: A Case Study

OBJECTIVES

The use of medications in management of disease is an integral part of treatment to patients in both the inpatient and outpatient setting; however, these medications often have risk of adverse effects associated with their benefits of use. Adverse cutaneous reactions are one of the most frequent types of adverse drug reactions. Two major phenotypes of cutaneous adverse drug reactions are toxic epidermal necrolysis (TEN), and Stevens-Johnson syndrome (SJS). Aripiprazole is an antipsychotic drug with a well-documented profile of adverse effects for physicians to be aware of; however, SJS/TEN is not known to be included in that profile.

METHODS

The authors encountered a case of aripiprazole-induced SJS/TEN and used the electronic medical records from this encounter to summarize this novel case in detail. Existing literature was reviewed using public databases for evaluation of similar cases.

RESULTS

We present a case of SJS/TEN induced by aripiprazole use for bipolar disorder, type 1, which is not an adverse effect of the drug that has been documented in the literature. We include patient history, hospital course, images, and treatment of disease throughout admission as well as a thorough discussion of the topic.

CONCLUSIONS

We present a case of an adverse drug reaction that has not previously been documented in the literature with the goal of informing readers of the potential for this life-threatening atypical effect and the severity of disease it may cause.

Dermatologic complications in transplantation and cellular therapy for acute leukemia

Adoptive cellular immunotherapy, mainly hematopoietic stem cell transplant and CAR-T cell therapy have revolutionized treatment of patients with acute leukemia. Indications and inclusion criteria for these treatments have expanded in recent years. While these therapies are associated with significant improvements in disease response and overall survival, patients may experience adverse events from associated chemotherapy conditioning, engraftment, cytokine storm, supportive medications, and post-transplant maintenance targeted therapies. Supportive oncodermatology is a growing specialty to manage cutaneous toxicities resulting from the anti-cancer therapies. In this review, we summarize diagnosis and management of the common cutaneous adverse events including drug eruptions, graft-versus-host disease, neoplastic and paraneoplastic complications in patients undergoing cellular therapies.

Shabana SK. Case Reports of Stevens Johnson Syndrome (SJS) Induced by Chemically Unrelated Drugs

Stevens-Johnson syndrome (SJS) is considered as serious mucocutaneous autoimmune disease which is potentially fatal. It may be initiated by medical treatment or infection and sometimes both may be triggering factors. Skin reactions involving loss of skin and mucus membrane and in severe cases, systemic symptoms may be appeared in SJS. In most of the cases medication is the causative factor. Toxic Epidermal Necrolysis (TEN) is a severe form of SJS, as it involves more than 30% of the skin surface with extensive damage to the mucous membranes. SJS and TEN are distinguished based on the extent of the detached skin surface area. It starts with flu-like symptoms, rashes with pain; the upper layer of affected skin dies, sheds and begins to heal after several days. In severe cases, it may leads to life threatening condition. Here we are presenting drug induced SJS in three different cases with different drugs. In first case, a 40-years male treated with Phenytoin 400mg for epilepsy, in second case, a 50-years male was given Amoxicillin + clavulanic acid-625 for some skin lesions and in third case, 50-years old female was given Methotrexate 7.5mg for Rheumatoid arthritis. In all the three cases, SJS symptoms were started within a period of 5-10days. All the symptoms and reactions were noticed and assessed for the confirmations of SJS.

Black-Box Warnings of Antiseizure Medications: What is Inside the Box?

Antiseizure medications can cause serious adverse reactions and have deleterious drug interactions that often complicate the clinical management of patients. When the US Food and Drug Administration (FDA) wants to alert healthcare providers and patients about the risk of potentially serious or fatal drug reactions, the FDA requires the manufacturers of these medications to format these warnings within a "black-box" border, and prominently display this box on the first section of the package insert; such warnings are called "black-box warnings (BBWs)". The BBW is a way for the FDA to urge physicians to evaluate patients more rigorously and carefully weigh the risks and benefits, before prescribing medication that has the potential to cause serious adverse reactions, and to formulate a plan for close monitoring during therapy. The FDA BBW provides the extra layer of safety but many healthcare providers fail to comply with these warnings. Currently, there are 26 FDA-approved antiseizure medications in the US market, 38% of which have received BBWs, and most of the antiseizure medications with BBWs are older-generation drugs. Some antiseizure medications have multiple BBWs; for example, valproic acid has three BBWs including hepatotoxicity, fetal risk, and pancreatitis, carbamazepine has BBWs of serious skin and hematological reactions, and felbamate also has two BBWs including hepatic failure and aplastic anemia. The purpose of this review is to provide insight into each BBW received by antiseizure medications and discuss the FDA recommendations for evaluating the drug benefit/risk, and for monitoring parameters before the initiation of and during treatment.

A Peculiar Case of Idiopathic Herpes-Zoster-Like Stevens-Johnson Syndrome (SJS)

Epidermal necrolysis is a severe dermatological condition usually associated with adverse drug reactions involving the mucosa. Stevens-Johnson syndrome (SJS) is clinically diagnosed when an epidermal detachment of less than 10% of body surface area (BSA) is involved. In contrast, toxic epidermal necrolysis (TEN) is characterized when there is an epidermal detachment of more than 30% BSA. Epidermal necrolysis can be described as ulcerated, painful, and erythematous lesions typically appearing on the skin. Typical clinical presentations of SJS include epidermal detachment of less than 10% of BSA and mucosal involvement with prodromal flu-like symptoms. Atypical presentations of focal epidermal necrolysis include the presence of lesions in a dermatomal pattern, associated itching, and idiopathic cause. We report a rare case of suspected herpes-zoster virus (HZV)-like SJS with negative HZV serum PCR and negative varicella-zoster virus (VZV) biopsy immunostaining. This rare case of SJS was resolved with the administration of IV acyclovir and Benadryl.

DNA methylation of ITGB2 contributes to allopurinol hypersensitivity

BACKGROUNDS

HLA-B*58:01 allele was strongly associated with allopurinol induced severe cutaneous adverse drug reaction (SCAR). However, HLA-B genotype is not sufficient to predict the occurrence of allopurinol-induced SCAR.

OBJECTIVE

To discover DNA methylation markers for allopurinol-induced SCAR which may improve the prediction accuracy of genetic testing.

STUDY DESIGN

The study was designed as a retrospective case-control clinical study in multicenter hospitals across Taiwan, Mainland China, Malaysia and Canada. 125 cases of allopurinol-induced SCAR patients and 139 cases of allopurinol tolerant controls were enrolled in this study during 2005 to 2021.

RESULTS

The results of genome-wide DNA methylation assay of 62 patients revealed that ITGB2 showed strong discriminative ability of allopurinol-induced SCAR in both HLA-B*58:01 positive and negative patients with AUC value of 0.9364 (95% CI 0.8682-1.000). In validation study, significant hypermethylation of ITGB2 were further validated in allopurinol-induced SCAR patients compared to tolerant controls, especially in those without HLA-B*58:01(AUC value of 0.8814 (95% CI 0.7121-1.000)). Additionally, the methylation levels of 2 sites on ITGB2 were associated with SCAR phenotypes. Combination of HLA-B*58:01 genotyping and ITGB2 methylation status could improve the prediction accuracy of allopurinol-induced SCAR with the AUC value up to 0.9387 (95% CI 0.9089-0.9684), while the AUC value of HLA-B*58:01 genotyping alone was 0.8557 (95% CI 0.8030-0.9083).

CONCLUSIONS

Our study uncovers differentially methylated genes between allopurinol-induced SCAR patients and tolerant controls with positive or negative HLA-B*58:01 allele and provides the novel epigenetic marker that improves the prediction accuracy of genetic testing for prevention of allopurinol-induced SCAR.

A comparison of international treatment guidelines for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are rare and life-threatening mucocutaneous diseases that occur almost exclusively as a result of adverse drug reactions, although there are rare cases attributed to infection, immunization, or malignancy.^1,2 Given the low incidence of these diseases as well as the high level of morbidity and mortality, randomized controlled clinical trials are difficult to perform, making it difficult to establish a "gold-standard" treatment. To date, there are only five published articles in the literature detailing evidence-based guidelines for the treatment of SJS and TEN, one of which is specifically tailored to pediatric and young adult patients.^3-7 These guidelines have significant overlap in regards to the importance of prompt discontinuation of the offending drug and the need for supportive care, but there are differences in regards to the ideal supportive care measures. Additionally, there is still no clear consensus agreement on the pharmacological treatment of SJS and TEN.^4-7 Herein, we aim to compare the international treatment guidelines for management of SJS and TEN as well as promote continued discussion and a multidisciplinary approach to establish consensus recommendations for these mucocutaneous emergencies.

Updates on the immunopathology and genomics of severe cutaneous adverse drug reactions

Severe cutaneous adverse reactions (SCARs) such as Stevens-Johnson syndrome, toxic epidermal necrolysis (SJS/TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS)/drug-induced hypersensitivity syndrome (DIHS) cause significant morbidity and mortality and impede new drug development. HLA class I associations with SJS/TEN and drug reaction with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome have aided preventive efforts and provided insights into immunopathogenesis. In SJS/TEN, HLA class I-restricted oligoclonal CD8+ T-cell responses occur at the tissue level. However, specific HLA risk allele(s) and antigens driving this response have not been identified for most drugs. HLA risk alleles also have incomplete positive and negative predictive values, making truly comprehensive screening currently challenging. Although, there have been key paradigm shifts in knowledge regarding drug hypersensitivity, there are still many open and unanswered questions about SCAR immunopathogenesis, as well as genetic and environmental risk. In addition to understanding the cellular and molecular basis of SCAR at the single-cell level, identification of the MHC-restricted drug-reactive self- or viral peptides driving the hypersensitivity reaction will also be critical to advancing premarketing strategies to predict risk at an individual and drug level. This will also enable identification of biologic markers for earlier diagnosis and accurate prognosis, as well as drug causality and targeted therapeutics.

Association of Human Leukocyte Antigen Alleles with Carbamazepine- or Lamotrigine-Induced Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in an Iranian Population: A Case-control Study

Background

Genetic diversity in human leukocyte antigen (HLA) alleles across populations is a significant risk factor for drug-induced severe cutaneous adverse reactions (SCARs), e.g., carbamazepine (CBZ)- and lamotrigine (LTG)-induced Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN). The present study aimed to investigate the frequency of different HLA alleles in Iranian patients with CBZ- and LTG-induced SJS/TEN.

Methods

A case-control study was conducted from 2011 to 2018 at various hospitals affiliated with Shiraz University of Medical Sciences (Shiraz, Iran). A total of 31 patients receiving anticonvulsant drugs (CZB or LTG) were recruited and divided into two groups. The drug-induced group (n=14) included hospitalized patients due to CBZ- or LTG-induced SJS/TEN. The drug-tolerant group (n=17) included individuals receiving CBZ or LTG for at least three months with no adverse effects. In addition, 46 healthy individuals (control group) were recruited. The frequency of HLA-A, -B, and -DRB1 alleles in patients with CZB- or LTG-induced SJS/TEN was investigated. HLA typing was performed using the allele-specific polymerase chain reaction method. The Chi square test and Fisher's exact test were used to determine a potential association between SJS/TEN and HLA alleles. P<0.05 was considered statistically significant.

Results

CBZ- or LTG-induced SJS/TEN was not significantly associated with HLA alleles. However, HLA-DRB1*01 showed a significantly higher frequency in patients with CBZ-induced SJS/TEN than the CBZ-tolerant patients (30% vs. 9%, P=0.07).

Conclusion

Overall, no significant association was found between CBZ- or LTG-induced SJS/TEN and HLA alleles. Further large-scale studies are required to substantiate our findings.

Cost-effectiveness analysis of HLA-B*13:01 screening for the prevention of co-trimoxazole-induced severe cutaneous adverse reactions among HIV-infected patients in Thailand

Studies found a strong association between HLA-B*13:01 allele and co-trimoxazole-induced severe cutaneous adverse reactions (SCARs). Genetic screening before initiation of co-trimoxazole may decrease the incidence of co-trimoxazole-induced SCARs. This study aims to evaluate the cost-effectiveness of HLA-B*13:01 screening before co-trimoxazole initiation in HIV-infected patients in Thailand. A combination of a decision tree model and a Markov model was used to estimate lifetime costs and outcomes of two strategies including 1) HLA-B*13:01 screening before co-trimoxazole initiation and 2) usual practice from a societal perspective. Alternative drugs are not considered because dapsone (the second-line drug) also presents a genetic risk. Input parameters were obtained from literature, government documents, and part of the TREAT Asia HIV Observational Database (TAHOD). One-way sensitivity analyses and probabilistic analyses were performed to determine robustness of the findings. HLA-B*13:01 screening resulted in 0.0061 quality-adjusted life years (QALYs) loss with an additional cost of 370 THB ($11.84). At the cost-effectiveness threshold of 160,000 THB ($5,112.85), the probability of the genetic screening strategy being cost-effective is 9.54%. This analysis demonstrated that HLA-B*13:01 allele screening before initiation of co-trimoxazole among HIV-infected patients is unlikely to be cost-effective in Thailand. Our findings will help policymakers make an evidence-informed decision making.

Risk factors and drugs that trigger the onset of Stevens-Johnson syndrome and toxic epidermal necrolysis: A population-based cohort study using the Shizuoka Kokuho database

Background

Evidence of factors associated with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) from population-based studies is scarce.

Objective

We aimed to identify the incidence, risk factors, and drugs that trigger the development of SJS/TEN in the general population.

Methods

A regional, population-based, longitudinal cohort with 2,398,393 Japanese individuals was analyzed using the Shizuoka Kokuho Database from 2012 to 2020.

Results

Among 1,909,570 individuals, 223 (0.01%, 2.3 cases/100,000 person-years) patients were diagnosed with SJS/TEN during the observational period of a maximum of 7.5 years. In a multivariable analysis, the risks of SJS/TEN were an older age, and the presence of type 2 diabetes, peripheral vascular disease, and systemic autoimmune diseases. The administration of drugs, such as immune checkpoint inhibitors, insulin, and type 2 diabetes agents, triggered the onset of SJS/TEN.

Limitations

The results may apply only to the Japanese population.

Conclusion

In this cohort population from a database representing the general population, the risks of developing SJS/TEN were old age and a history of type 2 diabetes, peripheral vascular disease, and systemic autoimmune disease. Furthermore, in addition to previously reported drugs, the administration of immune checkpoint inhibitors, insulin, and type 2 diabetes agents, may trigger the development of SJS/TEN.

Steven Johnson Syndrome in a 102-Year-Old Woman in Saudi Arabia: A Case Report

Medicines often cause serious immune-mediated mucocutaneous reactions including Steven-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN). In the acute phase of SJS and TEN, a febrile illness is followed by cutaneous erythema with blister formation, skin and mucous membrane necrosis, and separation of the skin and mucous membranes. The patient swiftly becomes in danger of dying, necessitating immediate medical attention. In this case report, we described a case of Steven-Johnson Syndrome in a 102-year-old female who was receiving palliative care and had stage 5 chronic renal disease. Although the agent that caused SJS in this patient is unknown, the patient was managed with topical medication, bandages for the lesions, and oral antihistamines. Skin biopsy, abdomen ultrasound, and sezary cell test were advised for the patient. Such presentations at that age have not, to our knowledge, been documented before.

Odynophagia as the first manifestation of toxic epidermal necrolysis

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are infrequent mucocutaneous diseases, rapidly progressive and life-threatening. The clinical aspects and the management of TEN are exposed following a case.A man in his 40s presented to the emergency department with severe odynophagia, poor general condition and fever. His medical history was significant for HIV stage AIDS, and the treatment was discontinued 5 years before the present diagnosis. He was admitted for cerebral toxoplasmosis and discharged the previous 14 days with sulfadiazine. Erythematous-bullous lesions in the oral cavity, diffuse erythematous maculopapular rashes over his neck and chest, acute bilateral conjunctivitis and purulent urethritis was observed. The diagnostic suspicion was SJS/TEN due to sulfadiazine in immunosuppressed patients.This entity is infrequent but is a life-threatening dermatological emergency that requires immediate medical attention. Its diagnosis is mainly clinical, with a new drug history, prodromal symptoms and characteristic cutaneous-mucous lesions. Early diagnosis and rapid withdrawal of the drug improve the prognosis.

Review of culprit drugs associated with patients admitted to the burn unit with the diagnosis of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Syndrome

PURPOSE

Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis Syndrome (TENS) are severe and potentially lethal adverse drug reactions characterized by acute inflammation of the skin, mucous membranes, and ocular surface that typically occurs within weeks of a culprit drug ingestion. The purpose of this study is to report a retrospective trend analysis of SJS spectrum diagnoses and associated culprit drugs in patients admitted to the Loyola University Medical Center (LUMC) Burn Unit, the major referral center in the Chicagoland region for patients with SJS disease spectrum.

METHODS

The electronic medical records (EMR) of 163 patients with a diagnosis of SJS/TENS admitted to the LUMC Burn Unit from 2000 to 2019 were reviewed. Clinical data in addition to the well-established algorithm of drug causality for epidermal necrolysis (ALDEN) allowed us to identify the single most probable culprit drug in 131 cases.

RESULTS

From 2000 to 2019, the most common spectrum classification was TENS (48.1%), followed by SJS (33.6%) and SJS-TEN Overlap Syndrome (18.3%). Anticonvulsants were found to be the most probable culprit class in 30% of cases followed by Trimethoprim-Sulfamethoxazole in 19% of cases. Beta-lactams were the most probable culprit class in 11% of cases while NSAIDs and allopurinol were each the most probable culprit class/drug in 8.4% of cases.

CONCLUSIONS

This is one of the largest single center series of SJS/TENS cases in the United States. Further study into culprit drug distribution by region as well as continuous monitoring of trends is crucial in order to advise prescribing practices.

Toxic Epidermal Necrolysis: A Case Report on a Drug-Induced Phenomenon

Toxic epidermal necrolysis (TEN) is a group of severe forms of several life-threatening conditions. As a co-infection of this group, Stevens-Johnson syndrome (SJS) is a rare though severe disease of the skin and mucous membranes. Intake of some drugs could cause reactions such as SJS and TEN. A form of severe connective tissue disorder, TEN is also known as Lyell's syndrome and is a common cause of significant skin and mucous membrane disintegration. Adverse medication reactions are the most prevalent and contribute highly to the incidence rates of the major etiological variables for TEN. Erythema, epidermal detachment that manifests as blisters, and denuded skin patches are the defining features of this pathology. In the majority of cases, the administration of pharmaceutical drugs is thought to be the primary cause of SJS/TEN. In this article, we report a case of a 33-year-old male patient who presented with complaints of lower left facial pain and thus was prescribed carbamazepine. Following this, the patient presented with an adverse reaction to the administration of carbamazepine and was taken off the drug immediately. The treatment included the administration of hydration therapy and appropriate antibiotics for treating the fluid-filled vesicles. The treatment regimen continued for three weeks and was stopped when the skin lesions were scarce and there was an improvement in the overall health of the patient.

Iodinated contrast-induced Stevens-Johnson syndrome: A report of a rare complication for a common imaging agent

Steven-Johnson syndrome (SJS) is a rare condition commonly associated with exposure to antibiotics. We have presented the case of a 76-year-old man with end-stage renal disease who had developed SJS after endovascular thrombectomy of hemodialysis access. He had developed epithelial erosions of the mucosal membranes, hemorrhagic bullae to the palmar and plantar surfaces, and erosions of the genitalia. The findings from biopsies of the lip and palm were suggestive of a drug reaction. He developed SJS three times after exposure to iodinated contrast. The one time he did not develop SJS, he had undergone open thrombectomy with no contrast exposure.

A Review of the Systemic Treatment of Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis

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.

Chronic kidney disease is potentially an independent prognostic factor for death in Stevens-Johnson syndrome and toxic epidermal necrolysis patients

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are mucocutaneous conditions associated with high mortality and morbidity. Although several prognostic factors have been proposed, some may have yet to be identified. A 14-year retrospective cohort study of patients with SJS/TEN was conducted at a university-based hospital in Bangkok, Thailand, to explore additional prognostic factors for mortality of patients with SJS/TEN. Medical records of all patients aged ≥18 years who were diagnosed with SJS, SJS-TEN overlap, or TEN between 2007 and 2020 were reviewed. Univariate and multivariate analyses were performed to examine associations between death and potential prognostic factors. A total of 76 patients with a mean age of 52 years were enrolled. Among them, 46, 15, and 15 patients were diagnosed with SJS, SJS-TEN overlap, and TEN, respectively. Overall, 10 patients deceased, marking a mortality rate of 13.2%. Based on an algorithm for assessment of drug causality for epidermal necrolysis, drug was the major cause of disease (96.1%). Allopurinol and trimethoprim/sulfamethoxazole were the most frequent culprit drugs. Univariate analysis revealed nine prognostic factors related to death, i.e., age, malignancy, chronic kidney disease (CKD), coronary artery disease, heart rate >120 beats/min, diagnoses of SJS-TEN overlap and TEN, blood urea nitrogen (BUN) >10 mmol/L, hemoglobin <10 g/dL, and serum albumin <2 g/dL. Causality with regard to drug, drug notoriety, time interval from drug intake to onset of reaction, and timing of culprit drug withdrawal were not significantly associated with death. Four independent prognostic factors for mortality were identified from multivariate analysis, i.e., TEN (risk ratio [RR] 8.29, 95% confidence interval [CI]: 2.71–25.38), malignancy (RR 3.34, 95% CI: 1.68–6.69), BUN >10 mmol/L (RR 3.02, 95% CI: 1.28–7.14), and early-stage CKD (RR 4.81, 95% CI: 2.49–9.28). Our findings suggest that CKD is an independent prognostic factor for mortality of patients with SJS/TEN besides those from the SCORTEN.

Stevens-Johnson syndrome and toxic epidermal necrolysis: A systematic review of PubMed/MEDLINE case reports from 1980 to 2020

Background

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, life-threatening immunologic reactions. Prior studies using electronic health records, registries or reporting databases are often limited in sample size or lack clinical details. We reviewed diverse detailed case reports published over four decades.

Methods

Stevens-Johnson syndrome and toxic epidermal necrolysis-related case reports were identified from the MEDLINE database between 1980 and 2020. Each report was classified by severity (i.e., SJS, TEN, or SJS-TEN overlap) after being considered a “probable” or “definite” SJS/TEN case. The demographics, preconditions, culprit agents, clinical course, and mortality of the cases were analyzed across the disease severity.

Results

Among 1,059 “probable” or “definite” cases, there were 381 (36.0%) SJS, 602 (56.8%) TEN, and 76 (7.2%) SJS-TEN overlap cases, with a mortality rate of 6.3%, 24.4%, and 21.1%, respectively. Over one-third of cases had immunocompromised conditions preceding onset, including cancer (n = 194,18.3%), autoimmune diseases (n = 97, 9.2%), and human immunodeficiency virus (HIV) (n = 52, 4.9%). During the acute phase of the reaction, 843 (79.5%) cases reported mucous membrane involvement and 210 (19.8%) involved visceral organs. Most cases were drug-induced (n = 957, 90.3%). A total of 379 drug culprits were reported; the most frequently reported drug were antibiotics (n = 285, 26.9%), followed by anticonvulsants (n = 196, 18.5%), analgesics/anesthetics (n = 126, 11.9%), and antineoplastics (n = 120, 11.3%). 127 (12.0%) cases reported non-drug culprits, including infections (n = 68, 6.4%), of which 44 were associated with a mycoplasma pneumoniae infection and radiotherapy (n = 27, 2.5%).

Conclusion

An expansive list of potential causative agents were identified from a large set of literature-reported SJS/TEN cases, which warrant future investigation to understand risk factors and clinical manifestations of SJS/TEN in different populations.

Review of Urate-Lowering Therapeutics: From the Past to the Future

We reviewed all currently available ULT, as well as any medications in development using following databases: United States Food and Drug Administration (FDA), European Medicines Agency (EMA), Japanese Pharmaceutical and Medical Devices Agency (PMDA), and ClinicalTrials.gov. We identified a total of 36 drugs, including 10 approved drugs, 17 in clinical testing phases, and 9 in preclinical developmental phases. The 26 drugs currently undergoing testing and development include 5 xanthine oxidase inhibitors, 14 uricosurics, 6 recombinant uricases, and one with multiple urate-lowering mechanisms of action. Herein, we reviewed the benefit and risk of each drug summarizing currently available drugs. New trials of uricosuric agents are underway to develop the new indication. New drugs are going on to improve the potency of recombinant uricase and to develop the new route administration of such as oral formulation. This review will provide valuable information on the properties, indications, and limitations of ULTs.

Managing the ADR of Stevens-Johnson syndrome/toxic epidermal necrolysis

INTRODUCTION

Stevens-Johnson syndrome and toxic epidermal necrolysis are severe, life-threatening adverse drug reactions that are collectively known as epidermal necrolysis. The abrupt detachment of the skin and mucositis results in systemic complications such as fluid and electrolyte disturbances, hypothermia, sepsis, organ failure, and death. Management is multidisciplinary and complex.

AREAS COVERED

This present article reviews the principles and best practices in the care of patients with epidermal necrolysis. These include having prompt admissions to optimal care facilities, coordinated specialized care during the acute phase, as well as long-term follow-up to manage chronic sequelae.

EXPERT OPINION

Patients with epidermal necrolysis should be managed in specialized/reference centers that are experienced with the management of the disease. Multi-disciplinary supportive care remains the cornerstone. Current evidence precludes definitive recommendation on any immunomodulatory agent as treatment. Long-term follow-up is required in order to diagnose and treat any chronic sequelae.