Combination therapy of intravenous immunoglobulin and corticosteroid in the treatment of toxic epidermal necrolysis and Stevens-Johnson syndrome: a retrospective comparative study in China

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Review of Current Management and Innovative Therapies

There is no consensus regarding the treatment of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Supportive care remains the preferred approach internationally, while the efficacy of topical/systemic therapies is subject to controversy. We reviewed published guidelines and recommendations on SJS/TEN management and assessed supportive care involving topical and systemic therapies in a series of SJS patients. We included several specialty departments from different countries to determine the consensus in the management of SJS/TEN. We also included SJS patients and provided supportive care including silver nitrate at 0.5% sprayed on denuded areas, in conjunction with a single dose of subcutaneous etanercept. Based on our literature review and experience, we propose a management algorithm for SJS/TEN. Our review confirmed the importance of supportive care, including specific topical and systemic treatments, for SJS/TEN. Systemic corticotherapy, cyclosporine A, intravenous immunoglobulin, tumor necrosis factor-alpha (TNF-α) blockers, or combinations are subject to controversies. In our pilot series of seven adult patients with SJS, we obtained good clinical results within 1 week, with mucosal and skin clearance at Week 2, along with a good safety profile. This was achieved by spraying topical silver nitrate at a concentration of 0.5% on denuded areas, following a single dose of etanercept. This consensus led to the recommendation of a combination of supportive care along with several possible topical and systemic therapies for SJS/TEN. Corticosteroids, immunoglobulins, cyclosporine A, and TNF-alpha blockers were used in our centers alone or in combination, with good results associated with 0.5% topical silver nitrate. In our series of SJS patients, silver nitrate at 0.5% associated with etanercept showed a good response.

S3 guideline: Diagnosis and treatment of epidermal necrolysis (Stevens-Johnson syndrome and toxic epidermal necrolysis) - Part 1: Diagnosis, initial management, and immunomodulating systemic therapy

Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are rare, predominantly drug-induced, acute, life-threatening diseases of skin and mucosae. SJS and TEN are nowadays considered variants of one disease entity with varying degrees of severity called epidermal necrolysis (EN). EN is associated with high morbidity and mortality and constitutes a major disease burden for affected patients. The guideline "Diagnosis and treatment of epidermal necrolysis (Stevens-Johnson syndrome and toxic epidermal necrolysis)" was developed under systematic consideration of existing scientific literature and in a formal consensus process according to regulations issued by the Association of Scientific Medical Societies in Germany (AWMF) to establish an evidence-based framework to support clinical decision-making. The interdisciplinary guideline commission consisted of representatives from various specialist societies and patient representatives. The guideline is aimed at specialists in the fields of dermatology, ophthalmology, plastic surgery, intensive care, and pediatrics in hospitals and offices, as well as other medical speciallved in the diagnosis and treatment of EN. The guideline is also aimed at patients, their relatives, insurance funds, and policymakers. This first part focuses on the diagnostic aspects, the initial management as well as the immunomodulating systemic therapy.

Toxic epidermal necrolysis complicated with respiratory failure in children: A case report

Stevens-Johnson syndrome or toxic epidermal necrolysis (TEN) is a severe skin and mucosal reaction that develops rapidly and has a high mortality rate. Its early identification and proper treatment are crucial to lowering the risk of death. Severe TEN can also lead to acute respiratory failure. This study probed the effect of early treatment on chronic airway damage in children with TEN complicated by respiratory failure. Three children diagnosed with TEN complicated by respiratory failure received interventions including high-dose glucocorticoids, gamma-globulin pulse therapy, and plasma exchange. One patient experienced recurrent lung infections, developed secondary chronic obstructive pulmonary disease, and eventually succumbed to respiratory failure despite skin improvement. The other two patients showed improvement after receiving combination treatment with a tumor necrosis factor-α (TNF-α) inhibitor. However, they also had concurrent chronic airway disease during the follow-up period. The exact mechanism underlying TEN remains uncertain. Children with TEN complicated by respiratory failure continue to experience chronic airway damage even after standard treatment. In future, multi-center clinical studies are warranted to investigate the impact of TNF-α inhibitors in children with TEN. Assessing the effectiveness and safety of targeted medications for TEN will provide more evidence regarding the prognosis of this disease.

A retrospective analysis of mortality risk and immunosuppressive therapy for Stevens-Johnson Syndrome and toxic epidermal necrolysis syndrome using the TriNetX research network

Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) exist on a spectrum of autoimmune conditions which cause epidermal detachment and keratinocyte necrosis. Due to the rare incidence of these conditions, a dramatic heterogeneity in treatment algorithms exists. To better appreciate pharmacologic immunosuppressive therapies' impact on survival, the authors queried a multi-institutional data network. Data for this study was extracted from TriNetX Research Network, a platform that contains ICD-9/ICD-10 coding data from a consortium of international healthcare organizations. Seventy-one institutions were queried to identify adult patients diagnosed with SJS, TEN or SJS-TEN Overlap. Cohorts were created based on the therapy received: systemic steroids (SS), diphenhydramine (DH), cyclosporine (CS), intravenous immunoglobulin (IVIG), tumor necrosis factor alpha inhibitors (TNFαi), or a combination of treatments. Cohorts were then propensity matched with patients who received supportive care. Patients who only received one of the above treatments showed no significant reduction in 90-day mortality. Patients who received CS or IVIG as part of their multitherapy showed a significantly increased risk of death when compared to supportive care (CS: RR = 1.583, 95% CI [1.119, 2.240]; IVIG: RR = 2.132, 95% CI [1.485, 3.059]). Despite their frequent utilization, this study's analysis suggests that none of these therapies confer significant 90-day mortality survival over supportive care alone. These results highlight the heterogeneity of therapies and emphasize the need for critical prospective appraisal of their outcomes in SJS and TEN.

Toxic epidermal necrolysis after injection of sclerosing agent and medical adhesive into oesophageal variceal ligation in a patient with a malignant liver tumour: A case report

Chronic liver disease can cause an increase in portal sinus pressure, which may lead to rupture and bleeding of esophageal and gastric varices. Oesophageal variceal ligation, with use of sclerosing agent and tissue glue injection is commonly used in clinical practice to address oesophageal bleeding. A 58-year-old male patient with chronic liver disease was treated with oesophageal variceal ligation, sclerosing agent and tissue glue injection due to oesophageal and gastric variceal bleeding. After 2 days, the skin of the patient exhibited erythema to different degrees. After 10 days of dexamethasone treatment, the whole-body rash worsened, and a severe skin reaction appeared that was suggestive of toxic epidermal necrolysis (TEN). Strict mucosal care was provided, and corticosteroids, γ globulin and adalimumab were concurrently used for treatment. After 20 days, the patient recovered from the skin problems. To the best of our knowledge, TEN after endoscopic surgery has rarely been reported in the relevant literature. Furthermore, when patients being treated with multiple drugs have erythema multiforme, physicians should be alert to the possibility of its development into TEN. The present case report summarizes the treatment methods for patients with TEN, providing a practical clinical basis and direction for the future diagnosis and treatment of the condition.

Management of Toxic Epidermal Necrolysis Using Early Combination Therapy of Intravenous Immunoglobulin and Amniotic Membrane Grafting: A Case Report

Toxic epidermal necrolysis (TEN) is a devastating challenge faced by wound care practitioners. However, surgical management with amniotic membrane graft (AMG) promises better results in scar healing, but there is a lack of additional intervention to reduce the high mortality rate in those patients who are admitted with poor prognosis clinical situation. There is supportive evidence that combination therapy with AMG and early high-dose intravenous immunoglobulin (IVIG) as early management in TEN could improve the prognosis. In this study, the authors present a 61-year-old female who presented with a widespread macular lesion on the trunk, upper extremities, and face. The patient was treated with early amniotic membrane grafting and high-dose IVIG and achieved satisfactory results. Complete wound healing was achieved in 21 days. There were no acute or chronic complications, consisting of infection of the skin areas, gastrointestinal bleeding, pleural effusion, and severe ocular mucous membrane damage.

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.

Intravenous Immunoglobulin Combined With Corticosteroids for the Treatment of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: A Propensity-Matched Retrospective Study in China

Background: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but life-threatening severe adverse drug reactions. The use of corticosteroids and intravenous immunoglobulin (IVIg) in SJS/TEN remains controversial. Methods: In this single-center, observational, propensity-matched, retrospective study, we collected a total of 224 patients with SJS/TEN who were hospitalized in our department from 2008 to 2019; according to treatment with IVIg combined with corticosteroids or with corticosteroids alone, patients were divided into combination therapeutic group (163 patients) and monotherapeutic group (61 patients). Patients from the two groups were matched by their propensity score in blocks of 2:1. Comparisons of the clinical characteristics and prognoses between propensity-matched SJS/TEN patients treated with IVIg combined with corticosteroids and corticosteroids alone were made. Results: After our propensity matching, a total of 145 patients were yielded, including 93 patients treated with IVIg and 52 patients not treated with IVIg. All of the 23 variables reflected good matching between patients treated with/without IVIg, and no significant difference was observed. Although there was no significant difference between the totally predicted and actual mortality in both of our groups, the actual mortality was lower than it was predicted in patients treated with IVIg [p > 0.250, the standardized mortality ratio (SMR) was 0.38, 95% CI 0.00-0.91] and patients treated without IVIg (p = 1.000, the SMR was 0.75, 95% CI 0.00-1.76). IVIg tended toward reducing the time to arrest of progression by 1.56 days (p = 0.000) and the length of hospital stay by 3.37 days (p = 0.000). The mortality rate was 45% lower for patients treated with IVIg combined with corticosteroids than those only treated with corticosteroid therapy, although it was not statistically significant (p = 0.555). The incidence of skin infections was significantly lower in the combined therapy group (p < 0.025), and the total infection rate of patients treated with combination therapy tended to decrease by 67% compared to patients treated with corticosteroids alone (p = 0.047). Conclusion: The actual mortality rate of patients treated with corticosteroids alone or IVIg combined with corticosteroids tended to be lower than those predicted by TEN-specific severity-of-illness score (SCORTEN), although there was no significance. Compared with those treated by corticosteroids alone, combination therapy was prone to bring a better prognosis for SJS/TEN patients.

Critical Review of Gaps in the Diagnosis and Management of Drug-Induced Liver Injury Associated with Severe Cutaneous Adverse Reactions

Drug-induced liver injury (DILI) encompasses the unexpected damage that drugs can cause to the liver. DILI may develop in the context of an immunoallergic syndrome with cutaneous manifestations, which are sometimes severe (SCARs). Nevirapine, allopurinol, anti-epileptics, sulfonamides, and antibiotics are the most frequent culprit drugs for DILI associated with SCARs. Interestingly, alleles HLA-B*58:01 and HLA-A*31:01 are associated with both adverse reactions. However, there is no consensus about the criteria used for the characterization of liver injury in this context, and the different thresholds for DILI definition make it difficult to gain insight into this complex disorder. Moreover, current limitations when evaluating causality in patients with DILI associated with SCARs are related to the plethora of causality assessment methods and the lack of consensual complementary tools. Finally, the management of this condition encompasses the treatment of liver and skin injury. Although the use of immunomodulant agents is accepted for SCARs, their role in treating liver injury remains controversial. Further randomized clinical trials are needed to test their efficacy and safety to address this complex entity. Therefore, this review aims to identify the current gaps in the definition, diagnosis, prognosis, and management of DILI associated with SCARs, proposing different strategies to fill in these gaps.

Comparison of effectiveness of interventions in reducing mortality in patients of toxic epidermal necrolysis: A network meta-analysis

BACKGROUND

Limited evidence is available about effectiveness and choice of immunomodulating treatment modalities for toxic epidermal necrolysis (TEN).

AIMS

To compare the effectiveness of interventions to reduce mortality in patients of toxic epidermal necrolysis through network meta-analysis.

METHODS

Studies were retrieved using PubMed, Google Scholar and Cochrane Database of Systematic Reviews from inception to September 18, 2018. Only English language articles were considered. Observational and randomized controlled studies having ≥ 5 TEN patients in each intervention arm were included. Two investigators independently extracted study characteristics, intervention details and mortality data. Bayesian network meta-analysis was performed using the Markov chain Monte Carlo (MCMC) approach through the random effect model. The ranking analysis was done to provide a hierarchy of interventions. The consistency between direct and indirect evidence was assessed through node spit analysis. The primary outcome was to compare the mortality [Odds ratio OR (95% credibility interval CrI)] among all treatment modalities of TEN.

RESULTS

Twenty-four studies satisfying the selection criteria were included. The network analysis showed improved survival with cyclosporine as compared to supportive care [OR- 0.19 (95% CrI: 0.05, 0.59)] and intravenous immunoglobulin [OR- 0.21 (95% CrI: 0.05, 0.76)]. The hierarchy of treatments based on "surface under the cumulative ranking curves" (SUCRA) value were cyclosporine (0.93), steroid+intravenous immunoglobulin (0.76), etanercept (0.59), steroids (0.46), intravenous immunoglobulin (0.40), supportive care (0.34) and thalidomide (0.02). No inconsistencies between direct and indirect estimates were observed for any of the treatment pairs.

LIMITATIONS

Evidence is mainly based on retrospective studies.

CONCLUSION

The use of cyclosporine can reduce mortality in TEN patients. Other promising immunomodulators could be steroid+intravenous immunoglobulin combination and etanercept.

Recent Dermatological Treatments for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in Japan

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are serious conditions characterized by necrosis of the skin and mucus membranes, and are mainly caused by medication and infections. Although the exact pathomechanism of SJS/TEN remains unclear, keratinocyte death is thought to be triggered by immune reactions to these antigens. While there is no established therapy for SJS/TEN, corticosteroids and intravenous immunoglobulin (IVIG) have been utilized as immunomodulator. We previously conducted a study to evaluate the efficacy of IVIG therapy in Japanese patients with SJS/TEN. IVIG was administered at a dosage of 400 mg/kg/day for 5 consecutive days as an additional therapy with systemic steroids. Prompt amelioration was observed in seven of the eight patients. All patients survived without sequelae. Recently, we retrospectively analyzed 132 cases of SJS/TEN treated in our two hospitals. The mortality rates in the patients treated with methylprednisolone pulse were 0% (0/31) for SJS and 7.0% (3/43) for TEN, and 0% (0/10) in the TEN patients treated with methylprednisolone pulse in combination with IVIG. These results suggest that early treatment with high-dose steroids, including methylprednisolone pulse therapy, and IVIG together with corticosteroids are possible therapeutic options to improve the prognosis of SJS/TEN.

Retrospective Study of Patients With SJS/TEN Treated at a Tertiary Burn Unit in Canada: Overview of 17 Years of Treatment

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are adverse drug reactions.

OBJECTIVES

To learn about the clinical characteristics of patients with SJS/TEN including treatments provided, outcomes, and mortality.

METHODS

We conducted a retrospective chart review of patients who were hospitalized with the diagnosis of SJS/TEN at the Ross Tilley Burn Center between the years 1999 and 2015.

RESULTS

A total of 43 patients were identified with a mean age of 54 ± 19 (58, 18-85). The most common offending medications were allopurinol and carbamazepine. The overall mortality rate in our study is 21% with the most common causes of death being multiorgan failure and sepsis. The majority of our patients had oral (84%), ocular (79%), and genital (60%) involvement during hospitalization. Our data revealed that combination treatment involving oral corticosteroids with intravenous immunoglobulin (IVIG) had the highest mortality rate in our study since 55% (6/11) of patients who were treated in this manner passed away compared to 11% (2/18) of patients passing away who were treated with solely IVIG and 33% (1/3) who were treated with only supportive care. Our study also demonstrates the addition of etanercept and cyclosporine treatment in the second time period we studied: 2008-2015 versus the earlier time period of 1999-2007. None of the patients in our study who were treated with therapies including cyclosporine and/or etanercept passed away.

CONCLUSIONS

Our study sheds light on a possible beneficial role of cyclosporine and etanercept for the treatment of SJS and TEN and reinforces the necessity of a multidisciplinary care team for patients.

Cytokines/Chemokines: Novel Biomarkers Associated with Severe Cutaneous Adverse Reactions

Although the incidence of severe cutaneous adverse reactions (SCARs) is very low, if it is not diagnosed and treated in time, it can not only cause skin and mucous membrane involvement, but can also cause multiple organ failure and even death. The diagnostic criteria and treatment guidelines for severe drug eruptions have not been unified. Many medical centers have used human leukocyte antigen alleles to diagnose SCARs. Some prospective studies have shown that susceptibility gene testing can prevent SCARs as early as possible, but the widespread implementation of its technology is limited by being ethnically specific. With the unique advantages of cytokine detection technology, cytokines are increasingly important for the diagnosis and treatment of SCARs. Related cytokines/chemokines involved in the pathogenesis, adjuvant diagnosis, and treatment of SCARs are discussed.

Association of Early Systemic Corticosteroid Therapy with Mortality in Patients with Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis: A Retrospective Cohort Study Using a Nationwide Claims Database

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe dermatologic disorders with high mortality. The role of systemic corticosteroids as an adjunctive therapy for SJS or TEN remains controversial.

OBJECTIVE

The aim of this study was to determine whether treatment with early systemic corticosteroids impacts the in-hospital mortality of patients hospitalized with SJS or TEN.

METHODS

Using the Japanese Diagnosis Procedure Combination Database, a large nationwide inpatient administrative claims database, we identified inpatients aged ≥ 18 years who were admitted with SJS or TEN. Treatment with early systemic corticosteroids was defined as starting treatment with systemic corticosteroids within 2 days (day 0 or day 1) of admission. The primary outcome was in-hospital mortality. We examined the association between early systemic corticosteroids and in-hospital mortality using propensity score (PS) analyses.

RESULTS

We identified 1846 eligible patients with SJS or TEN, including 793 patients with early systemic corticosteroid use at ≤ 2 mg/kg/day, 558 patients with early systemic corticosteroid use at > 2 mg/kg/day, and 495 patients without early corticosteroid use. PS matching created 235 pairs (> 2 mg/kg/day vs. controls) and 332 pairs (≤ 2 mg/kg/day vs. controls). Early systemic corticosteroid use was not significantly associated with lower in-hospital mortality by PS matching (> 2 mg/kg/day vs. controls: relative risk [RR] 0.83, 95% confidence interval [CI] 0.37-1.85; ≤ 2 mg/kg/day vs. controls: RR 0.61, 95% CI 0.28-1.36) and by inverse probability of treatment weighting (> 2 mg/kg/day vs. controls: RR 0.99, 95% CI 0.45-2.19; ≤ 2 mg/kg/day vs. controls: RR 0.65, 95% CI 0.29-1.47).

CONCLUSION

Early systemic corticosteroid therapy for patients with SJS or TEN was not associated with lower in-hospital mortality. Further studies are needed to define the effect of corticosteroids for patients with SJS or TEN.

Outcomes of Stevens-Johnson syndrome and toxic epidermal necrolysis in HIV-infected patients when using systemic steroids and/or intravenous immunoglobulins in Pietermaritzburg, South Africa

Background

Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe life-threatening mucocutaneous reactions. There is an ongoing controversy regarding the use of systemic corticosteroids and intravenous immunoglobulin (IVIG) in SJS/TEN and their utility in HIV-infected patients.

Objectives

The objective was to assess the outcome of a combination of intensive supportive care with oral corticosteroids in SJS and a combination of systemic steroids and IVIG for 3 consecutive days in HIV-infected patients with TEN. In addition, we assessed management in a general dermatology ward without implementing wound debridement.

Methods

This was a retrospective cohort study of 36 HIV-infected adults with SJS/TEN admitted to a tertiary dermatology unit between 1st January 2010 and 31st July 2011. Standard-of-care protocols included identification and elimination of the possible causative drug, meticulous wound care without debridement, initiation of oral prednisone (1 mg/kg/day) on admission for 3 consecutive days, and the addition of IVIG (1 g/kg/day) for 3 consecutive days to those with TEN.

Results

Of the 36 patients in the study, 32 were female. Nevirapine was the commonest drug implicated. A diagnosis of tuberculosis did not increase the case fatality rate. Complications included infections, anaemia, drug-induced hepatitis, ocular involvement, renal impairment, deep vein thrombosis, respiratory distress, Leucopenia, gastritis and hypernatremia. The overall survival rate was 97%.

Conclusion

HIV-infected SJS and TEN patients were treated in a tertiary dermatology ward with a treatment plan of skin care, and a combination of systemic corticosteroids and IVIG respectively had a survival rate of 97%.

A 10-year retrospective cohort study of the management of toxic epidermal necrolysis and Stevens-Johnson syndrome in a New South Wales state referral hospital from 2006 to 2016

IMPORTANCE

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are life-threatening severe cutaneous drug reactions. There have been no Australian data published since 2007.

OBJECTIVE

To explore whether there is an association between prognosis and the type of systemic immune-modulation treatment administered in a cohort of patients with SJS, SJS-TEN overlap, and TEN at the New South Wales State SJS/TEN referral center - Concord Repatriation General Hospital.

METHODS

This is a retrospective, single center, cohort study of patients admitted with SJS/TEN from January 1, 2006, to December 31, 2016, at Concord Repatriation General Hospital. Data on demographic information, the causative agent, treatment, and final survival outcome were analyzed.

RESULTS

Forty-two patients included: 26 (62%) with TEN, six (14%) with SJS/TEN overlap, and 10 (24%) with SJS. Overall mortality was 19% (n = 8), and seven suffered TEN. The average age of those who died was 60 years. Eighty-one percent of patients were managed within the burn unit. Twenty-nine patients (70%) received IVIG within this group; 13 individuals also received systemic corticosteroids. Seven (17%) were managed with corticosteroid therapy alone. The incidence of death was 0% in the combined IVIG and corticosteroid group.

CONCLUSION

This series of 42 patients contributes valuable information to a serious condition with low global incidence and high mortality. There appears to be an apparent reduced mortality in the group of SJS/TEN patients managed with combined IVIG and corticosteroid. Larger cohorts are required to validate this relationship due to the risk of bias inherent to the retrospective study design and small sample size.

Empirical evaluation of variant calling accuracy using ultra-deep whole-genome sequencing data

In the design of whole-genome sequencing (WGS) studies, sequencing depth is a crucial parameter to define variant calling accuracy and study cost, with no standard recommendations having been established. We empirically evaluated the variant calling accuracy of the WGS pipeline using ultra-deep WGS data (approximately 410×). We randomly sampled sequence reads and constructed a series of simulation WGS datasets with a variety of gradual depths (n = 54; from 0.05× to 410×). Next, we evaluated the genotype concordances of the WGS data with those in the SNP microarray data or the WGS data using all the sequence reads. In addition, we assessed the accuracy of HLA allele genotyping using the WGS data with multiple software tools (PHLAT, HLA-VBseq, HLA-HD, and SNP2HLA). The WGS data with higher depths showed higher concordance rates, and >13.7× depth achieved as high as >99% of concordance. Comparisons with the WGS data using all the sequence reads showed that SNVs achieved >95% of concordance at 17.6× depth, whereas indels showed only 60% concordance. For the accuracy of HLA allele genotyping using the WGS data, 13.7× depth showed sufficient accuracy while performance heterogeneity among the software tools was observed (the highest concordance of 96.9% was observed with HLA-HD). Improvement in HLA genotyping accuracy by further increasing the depths was limited. These results suggest a medium degree of the WGS depth setting (approximately 15×) to achieve both accurate SNV calling and cost-effectiveness, whereas relatively higher depths are required for accurate indel calling.

Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: A Multicenter Retrospective Study of 377 Adult Patients from the United States

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a rare, severe mucocutaneous reaction with few large cohorts reported. This multicenter retrospective study included patients with SJS/TEN seen by inpatient consultative dermatologists at 18 academic medical centers in the United States. A total of 377 adult patients with SJS/TEN between January 1, 2000 and June 1, 2015 were entered, including 260 of 377 (69%) from 2010 onward. The most frequent cause of SJS/TEN was medication reaction in 338 of 377 (89.7%), most often to trimethoprim/sulfamethoxazole (89/338; 26.3%). Most patients were managed in an intensive care (100/368; 27.2%) or burn unit (151/368; 41.0%). Most received pharmacologic therapy (266/376; 70.7%) versus supportive care alone (110/376; 29.3%)-typically corticosteroids (113/266; 42.5%), intravenous immunoglobulin (94/266; 35.3%), or both therapies (54/266; 20.3%). Based on day 1 SCORTEN predicted mortality, approximately 78 in-hospital deaths were expected (77.7/368; 21%), but the observed mortality of 54 patients (54/368; 14.7%) was significantly lower (standardized mortality ratio = 0.70; 95% confidence interval = 0.58-0.79). Stratified by therapy received, the standardized mortality ratio was lowest among those receiving both steroids and intravenous immunoglobulin (standardized mortality ratio = 0.52; 95% confidence interval 0.21-0.79). This large cohort provides contemporary information regarding US patients with SJS/TEN. Mortality, although substantial, was significantly lower than predicted. Although the precise role of pharmacotherapy remains unclear, co-administration of corticosteroids and intravenous immunoglobulin, among other therapies, may warrant further study.

SJS/TEN 2017: Building Multidisciplinary Networks to Drive Science and Translation

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a life-threatening, immunologically mediated, and usually drug-induced disease with a high burden to individuals, their families, and society with an annual incidence of 1 to 5 per 1,000,000. To effect significant reduction in short- and long-term morbidity and mortality, and advance clinical care and research, coordination of multiple medical, surgical, behavioral, and basic scientific disciplines is required. On March 2, 2017, an investigator-driven meeting was held immediately before the American Academy of Dermatology Annual meeting for the central purpose of assembling, for the first time in the United States, clinicians and scientists from multiple disciplines involved in SJS/TEN clinical care and basic science research. As a product of this meeting, this article summarizes the current state of knowledge and expert opinion related to SJS/TEN covering a broad spectrum of topics including epidemiology and pharmacogenomic networks; clinical management and complications; special populations such as pediatrics, the elderly, and pregnant women; regulatory issues and the electronic health record; new agents that cause SJS/TEN; pharmacogenomics and immunopathogenesis; and the patient perspective. Goals include the maintenance of a durable and productive multidisciplinary network that will significantly further scientific progress and translation into prevention, early diagnosis, and management of SJS/TEN.

Treatments for Severe Cutaneous Adverse Reactions

Severe cutaneous adverse reaction (SCAR) is life-threatening. It consists of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), acute generalized exanthematous pustulosis (AGEP), and generalized bullous fixed drug eruptions (GBFDE). In the past years, emerging studies have provided better understandings regarding the pathogenesis of these diseases. These diseases have unique presentations and distinct pathomechanisms. Therefore, theoretically, the options of treatments might be different among various SCARs. However, due to the rarity of these diseases, sufficient evidence is still lacking to support the best choice of treatment for patients with SCAR. Herein, we will provide a concise review with an emphasis on the characteristics and treatments of each SCAR. It may serve as a guidance based on the current best of knowledge and may shed light on the directions for further investigations.

Improving mortality outcomes of Stevens Johnson syndrome/toxic epidermal necrolysis: A regional burns centre experience

INTRODUCTION

Stevens Johnson Syndrome/toxic epidermal necrolysis (SJS/TEN) are rare, potentially fatal desquamative disorders characterised by large areas of partial thickness skin and mucosal loss. The degree of epidermal detachment that occurs has led to SJS/TEN being described as a burn-like condition. These patients benefit from judicious critical care, early debridement and meticulous wound care. This is best undertaken within a multidisciplinary setting led by clinicians experienced in the management of massive skin loss and its sequelae. In this study, we examined the clinical outcomes of SJS/TEN overlap & TEN patients managed by our regional burns service over a 12-year period. We present our treatment model for other burn centres treating SJS/TEN patients.

METHODS

A retrospective case review was performed for all patients with a clinical diagnosis of TEN or SJS/TEN overlap admitted to our paediatric and adult burns centre between June 2004 and December 2016. Patient demographics, percentage total body surface area (%TBSA), mucosal involvement, causation, severity of illness score (SCORTEN), length of stay and survival were appraised with appropriate statistical analysis performed using Graph Pad Prism 7.02 Software.

RESULTS

During the study period, 42 patients (M26; F: 16) with TEN (n=32) and SJS/TEN overlap (n=10) were managed within our burns service. Mean %TBSA of cutaneous involvement was 57% (range 10-100%) and mean length of stay (LOS) was 27 days (range 1-144 days). We observed 4 deaths in our series compared to 16 predicted by SCORTEN giving a standardised mortality ratio (SMR) of 24%.

CONCLUSION

Management in our burns service with an aggressive wound care protocol involving debridement of blistered epidermis and wound closure with synthetic and biological dressings seems to have produced benefits in mortality when compared to predicted outcomes.

Score of Toxic Epidermal Necrosis Predicts the Outcomes of Pediatric Epidermal Necrolysis

BACKGROUND/OBJECTIVES

Epidermal necrolysis (Stevens-Johnson syndrome and toxic epidermal necrolysis) includes immune-mediated, life-threatening inflammatory blistering disorders that can affect children. The Score of Toxic Epidermal Necrosis (SCORTEN) tool has accurately predicted the outcome of these disorders in adults but has not been tested in children.

METHODS

We performed a retrospective chart review to compare the accuracy of the adult SCORTEN tool with that of two modifications tailored to children in predicting disease outcome.

RESULTS

The longer the patient's median length of hospital stay was, the higher the adult and two proposed pediatric SCORTENs were. In addition, all patients who died had SCORTENs greater than 4.

CONCLUSION

The pediatric-modified tools were not superior to the adult SCORTEN, which accurately predicted outcome.

Clinical Case of Toxic Epidermal Necrolysis

Toxic epidermal necrolysis or Lyell’s syndrome is a severe life-threatening adverse drug reaction with a high mortality rate. The drugs most commonly involved are: antibiotics; anticonvulsants; antiretroviral drugs; nonsteroidal anti-inflammatory drugs, allopurinol. Case report: A 68-year-old female, presented with complaints of fever and extensive rashes on the skin of the face, the neck and the trunk, severe itching of the skin, ulcerations and erythema of the conjunctiva and the oral cavity and difficulty in swallowing. She has a period of two or three days of general discomfort and fatigue, rash, fever up to 38°C, sore throat, arthralgia, myalgia, loss of appetite and have been treated with antipyretics, antibiotic – ampicillin, antihistamines, vitamins. Her state worsened during the next 3 days, therefore she was hospitalized in the Toxicology clinic of University Hospital “N. I. Pirogov”. Multiple maculopapular and bullous eruptions, plaques were present all over the body, blisters that cover a substantial portion of the body. The entire skin covering the body surface was denuded and peeled off with minor manipulation – the Nikolsky’s sign. Intraorally, multiple oral ulcers of the buccal mucosa, tongue, palate, labial mucosa, and soft palate were seen. Hemorrhagic erosions were also seen on both the upper and lower lips. Conjunctivitis and ulceration of genitalia were also noted. The lesions got slowly better with serum therapy, fluid and electrolyte replacement, systemic corticosteroids, antihistamines, antibiotic, vitamins, H2 blockers, topical care of mucosal changes. Evolution was satisfactory with epidermization and the patient was discharged from the hospital after 1 month.

Update on the use of immunoglobulin in human disease: A review of evidence

Human immunoglobulin preparations for intravenous or subcutaneous administration are the cornerstone of treatment in patients with primary immunodeficiency diseases affecting the humoral immune system. Intravenous preparations have a number of important uses in the treatment of other diseases in humans as well, some for which acceptable treatment alternatives do not exist. We provide an update of the evidence-based guideline on immunoglobulin therapy, last published in 2006. Given the potential risks and inherent scarcity of human immunoglobulin, careful consideration of its indications and administration is warranted.

The Effect of Intravenous Immunoglobulin Combined with Corticosteroid on the Progression of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Meta-Analysis

Background

Intravenous immunoglobulin (IVIG) treatment is commonly used to treat Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) with controversial therapeutic effect.

Methods

We conducted a comprehensive meta-analysis through combining the published eligible studies to evaluate the effectiveness of IVIG on SJS and TEN treatment.

Results

A total of 26 studies were selected from public available databases. The combination of IVIG and corticosteroid markedly reduced the recovery time (by 1.63 days, 95% CI: 0.83–2.43, P < 0.001), compared with solo corticosteroid group. The favorable effects were greater in Asian (2.19, 95% CI: 1.41–2.97, P < 0.001), TEN (2.56, 95% CI: 0.35–4.77, P = 0.023) and high-dose IVIG treated individuals (1.78, 95% CI: 0.42–3.14, P = 0.010). The hospitalization length reduced by 3.19 days (95% CI: 0.08–6.30, P = 0.045), though the outcome was proven to be unstable. We found heterogeneities, which sources were probably regional factors. Besides, IVIG was inclined to decrease SJS/TEN mortality (SMR: 0.84, 95% CI: 0.66–1.08, P = 0.178). This impact was possibly more profound when patients were treated with high dose IVIG (SMR: 0.74, 95% CI: 0.50–1.08, P = 0.116), or when patients were diagnosed as TEN (SMR: 0.68, 95% CI: 0.45–1.01, P = 0.058).

Conclusions

Our current meta-analysis suggests that IVIG combined with corticosteroid could reduce recovery time for SJS and TEN. This effect is greater among Asian patients. Whereas, its impact on reducing mortality is not significant.

Immunologic Mediators in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are a spectrum of T-cell mediated immune disorders. While the contributory mechanisms leading to the apoptosis of epidermal cells in SJS/TEN remain unproven, the keratinocyte apoptosis seen in SJS/TEN is thought to occur through the T-cell mediated Fas-Fas ligand (FasL), perforin/granzyme B, and other immune mediators. Most recently, emphasis has been placed on the granulysin pathway as being the primary mediator of apoptosis and widespread epidermal necrosis in SJS/TEN. This article aims to review the proposed mechanisms by which these pathways work and the immunomodulatory therapies that have been developed in an attempt to target them.

Variable levels of apoptotic signal-associated cytokines in the disease course of patients with Stevens-Johnson syndrome and toxic epidermal necrolysis

BACKGROUND/OBJECTIVES

Keratinocyte death is a hallmark of Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN). Apoptotic signal-associated cytokines, such as TNF-α, sFasL, granulysin, sTRAIL and IFN-γ have been reported to participate in keratinocyte apoptosis. However, their levels are variable, which hampers the elucidation of the role of these cytokines. We sought to determine whether cytokine levels vary with disease course.

METHODS

The serum cytokine levels of 24 patients and blister fluid of 10 were analysed by enzyme-linked immunosorbent assay on the first day of their admission to hospital and were evaluated at different time points in the disease course. Meanwhile, surface markers (CD3, CD4, CD8, CD1a, CD14, CD16+56 and CD68) of blister fluid cells were measured by flow cytometry.

RESULTS

The concentrations of all cytokines in the serum and blister fluid were higher than those in the controls and were more elevated in the blister fluid than in the serum. Moreover, sTRAIL, IFN-γ and TNF-α quantities were relatively stable, while those of sFasL and granulysin decreased rapidly in the disease course. On the first day, CD8+ T and natural killer cells were predominant in the blister fluid but their relative percentage diminished gradually, while that of CD14+ cells increased.

CONCLUSION

Our study confirmed there are high but variable levels of these cytokines in SJS/TEN, especially in the early phase and different tendencies are manifested in the disease course.

Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis--A Comprehensive Review and Guide to Therapy. I. Systemic Disease

The intent of this review is to comprehensively appraise the state of the art with regard to Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with particular attention to the ocular surface complications and their management. SJS and TEN represent two ends of a spectrum of immune-mediated, dermatobullous disease, characterized in the acute phase by a febrile illness followed by skin and mucous membrane necrosis and detachment. The widespread keratinocyte death seen in SJS/TEN is rapid and irreversible, and even with early and aggressive intervention, morbidity is severe and mortality not uncommon. We have divided this review into two parts. Part I summarizes the epidemiology and immunopathogenesis of SJS/TEN and discusses systemic therapy and its possible benefits. We hope this review will help the ophthalmologist better understand the mechanisms of disease in SJS/TEN and enhance their care of patients with this complex and often debilitating disease. Part II (April 2016 issue) will focus on ophthalmic manifestations.

A clinicotherapeutic analysis of Stevens-Johnson syndrome and toxic epidermal necrolysis with an emphasis on the predictive value and accuracy of SCORe of Toxic Epidermal Necrolysis

BACKGROUND

The SCORTEN scale (SCORe of Toxic Epidermal Necrolysis) is widely used to predict mortality in patients with Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN). Although it is largely a useful tool, the predictive ability of the scale is variable, and modifications to the existing scale have been suggested. In addition, there is controversy regarding the roles of active therapy and conservative management.

OBJECTIVES

This study was conducted to assess outcomes in SJS/TEN patients managed conservatively and to analyze the predictive performance of SCORTEN.

METHODS

Sixty patients were studied prospectively from October 2008 to September 2011. The accuracy of SCORTEN in predicting mortality was analyzed on days 1, 3, and 5 of admission. All patients were managed conservatively.

RESULTS

The discriminative power of SCORTEN was acceptable, being best on day 5. The agreement between actual and predicted mortality was poor, as indicated by a low P-value of the Hosmer-Lemeshow statistic. Only three parameters (heart rate, blood urea, and serum bicarbonate) were found to be significant on multivariate analysis, and all of these represented components within the original SCORTEN scale. The mortality rate was 16.7%. All deaths occurred within the first two weeks (8-12 days).

CONCLUSIONS

Serial analysis using SCORTEN is better than analysis performed only on day 1. Although the scale is largely useful, its performance is influenced by the demographic profile of the study population; minor modifications based on the population studied may increase the predictive accuracy of the original SCORTEN. In addition, conservative management is a valid therapeutic option, is preferable to treatment with steroids and immunosuppressants, and is highly recommended.

Pediatric Toxic Epidermal Necrolysis: Experience of a Tertiary Burn Center

BACKGROUND

Pediatric toxic epidermal necrolysis (TEN) is a rare and potentially fatal skin disease with a multitude of causative factors and no consensus on treatment guidelines and, as a result, it has a variety of short- and long-term outcomes. We present the experience of a large specialty burn center to share our diagnostic and treatment principles.

METHODS

A retrospective review from 1989 to 2010 at the Joseph M. Still Burn Center was performed to find patients with a diagnosis of Steven-Johnson syndrome (SJS) or TEN. Information was obtained on demographic and physiologic parameters such as age, race, total body surface area involved, treatments, hospital stay, and need for ventilator support.

RESULTS

We identified SJS or TEN in 21 patients. Prescription drugs were the most common etiology (in 15 patients), with antibiotics as the most common causative agent. Histology confirmed the clinical diagnosis of TEN in 14 patients. Our treatment plan included a multidisciplinary team, early initiation of intravenous immunoglobulin, bronchoscopy, strict management of electrolyte and fluid balances, and meticulous surgical wound care. Mortality was 9.5%.

CONCLUSION

Our experience in treating this rare but devastating disease affords us the opportunity to share the diagnostic dilemmas we faced and the treatment principles we used to treat this unique patient population successfully.

Efficacy of additional i.v. immunoglobulin to steroid therapy in Stevens-Johnson syndrome and toxic epidermal necrolysis

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.

Occupational toxic epidermal necrolysis associated with dalbergia cochinchinensis: a retrospective comparative study of eight cases in China

BACKGROUND

Occupational toxic epidermal necrolysis (TEN) related to Dalbergia cochinchinensis has seldom been reported in the past. Its clinical characteristic needs to be investigated. This study reports eight cases of such disease in China.

METHODS

Eight patients with occupational TEN admitted from 2003 to 2012 were retrospectively analyzed and compared with 15 patients admitted with TEN caused by drugs as controls. Patients all received combination therapy of corticosteroid and intravenous immunoglobulin. The times for bullous ceasing, tapering of corticosteroid, and total hospitalization were compared between the two groups of patients. SCORTEN, a severity-of-illness scoring system for TEN prognosis, was applied to evaluate clinical outcome.

RESULTS

The three time measurements in occupational TEN were longer than those in control, and the differences were statistically significant (P = 0.0023, 0.026, 0.0017), which means the total dose of corticosteroid needed in occupational TEN was higher than that in the control. There were no deaths in the two groups, although expected deaths were 0.612 and 0.836, respectively.

DISCUSSION

Occupational TEN has a longer progression than TEN caused by drugs, and there is more difficulty in its treatment. Clinicians should pay attention to this disease. However, its mechanism and target therapy remain unclear.

Use of intravenous immunoglobulin in critically ill patients

Intravenous immunoglobulin (IVIG) has been suggested for the treatment of many ailments due to its ability to modulate the immune system and to provide passive immunity to commonly circulating pathogens. Its use as primary and adjunctive therapy for the treatment of conditions affecting critically ill patients is an attractive option, especially when alternative therapy does not exist. The body of literature on the use of IVIG for the treatment of several serious conditions, including sepsis, toxic shock syndrome, acute myocarditis, Stevens-Johnson syndrome, toxic epidermal necrolysis, and H1N1 influenza, were reviewed. Despite advances in treatment of these conditions since they were first described, there remains a paucity of well-designed studies on the use of IVIG for their treatment. Therefore, the use of IVIG for treatment of these conditions remains controversial.

Corticosteroids in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

Objective: To review the evidence for the use of steroids in adults presenting with Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), or overlap. Data Sources: EMBASE (1974 to April 2014), MEDLINE (1946 to April 2014), Cochrane Database of Systematic Reviews, and International Pharmaceutical Abstracts (1970 to January 2014) were searched using the terms: prednisone, methylprednisolone, dexamethasone, prednisolone, steroids, glucocorticoids, corticosteroids, Stevens-Johnson Syndrome, toxic epidermal necrolysis, and SJS/TEN overlap. Study Selection and Data Extraction: English-language, full reports of experimental and observational studies were included. Bibliographies from pertinent publications were reviewed for additional references. Prespecified outcomes included survival, survival to discharge, hospitalization without intensive care, length of intensive care stay, duration of hospitalization, ophthalmological complications, infection rates, and adverse events. Data Synthesis: Six studies that used steroids for SJS, TEN, and/or overlap were included. All studies were retrospective cohort studies with no case-control or cross-sectional studies; 5 studies reported on steroid doses, and 2 studies reported time from disease onset to steroid use (2-4 days). Only 1 of 6 studies reported a statistically significant impact on mortality with steroids use (odds ratio = 0.4; 95% CI = 0.2-0.9). Adverse event rates were not reported in any of the studies. Conclusions: A review of the current evidence reveals a need for prospective, randomized controlled studies to provide more definitive conclusions on steroid use in patients with SJS, TEN, and/or overlap.

Stevens-Johnson syndrome and toxic epidermal necrolysis: a 20-year single-center experience

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening diseases that are most frequently caused by drugs.

OBJECTIVES

The purpose of this study was to summarize 20 years of experience with SJS and TEN in the largest dermatology clinic in Serbia.

METHODS

The study included 38 patients treated during the period 1993-2012. The patients were classified into three groups according to whether they were diagnosed with SJS, a condition representing an overlap of SJS and TEN (SJS/TEN), or TEN. Patients with TEN were also divided into three groups according to the modality of therapy: supportive therapy (ST) only (n = 3); ST plus systemic corticosteroids (SC) (n = 8); and ST plus SC plus IV immunoglobulins (IVIG) (n = 6).

RESULTS

The study population included 13 SJS patients, eight SJS/TEN patients, and 17 TEN patients. The disease had started at a mean ± standard deviation (SD) of 7.1 ± 3.5 days after the commencement of treatment with the offending drug. The disease resulted in three lethal outcomes, all of which occurred in TEN patients. However, the predicted mortality for the whole group was 5.6 in 38 patients, whereas that for the TEN group was 3.97 in 17 patients. The differences between actual and predicted rates of mortality were not significant. Among the three groups of TEN patients, there were no significant differences in the commencement of re-epithelialization or the duration of hospitalization.

CONCLUSIONS

In the present study, nonsteroidal anti-inflammatory and anti-infective drugs were the most frequent causative agents (eight patients in each group). In the group of SJS and SJS/TEN patients treated with ST and SC, the mortality rate was 0%. In TEN patients, the mortality rate was 17.6% (three of 17 patients). There were no significant differences in mortality rate among the three TEN treatment groups, but the results may have been biased by the small number of patients.

Mycoplasma-associated Stevens-Johnson syndrome in children: retrospective review of patients managed with or without intravenous immunoglobulin, systemic corticosteroids, or a combination of therapies

Administration of intravenous immunoglobulin (IVIG) to patients with Stevens-Johnson syndrome (SJS) has been controversial. The objective of this study was to evaluate the effectiveness of IVIG, systemic corticosteroids, or both in treating Mycoplasma pneumoniae-associated SJS (mpSJS). Retrospective series of 10 pediatric mpSJS cases were stratified into four treatment groups: IVIG alone, IVIG and systemic corticosteroids together, systemic corticosteroids alone, and supportive care. The efficacy of therapy was evaluated on the basis of several proxies of disease severity, including hospital length of stay (LOSt ) and number of febrile days (Febt ) after initiation of therapy. Patients treated with IVIG alone had a longer LOSt and more Febt , despite different baseline characteristics, than patients treated with supportive therapy. Of patients who received IVIG, 50% were treated with corticosteroids concurrently and had similar characteristics of disease severity but showed a non-statistically significant trend toward shorter LOSt and fewer Febt than those who received IVIG alone. A patient treated with corticosteroids alone had the shortest LOSt in this series. Therefore treatment with IVIG alone was associated with a more severe disease course than supportive therapy, although causality cannot be inferred given possible confounding by indication. When systemic corticosteroids were used alone or in conjunction with IVIG, hospital LOSt and Febt trended lower than with the use of IVIG alone, although disease severity at baseline was similar between those treated with IVIG and corticosteroids concurrently and those treated with IVIG alone. It was thus concluded that treatment with systemic corticosteroids as monotherapy or in combination with IVIG may be preferable to IVIG alone. Further large-scale studies are warranted to evaluate this hypothesis.

The role of systemic immunomodulatory treatment and prognostic factors on chronic ocular complications in Stevens-Johnson syndrome

PURPOSE

To compare the effect of early systemic immunomodulatory treatment and to identify prognostic factors of chronic ocular complications in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) patients.

DESIGN

Retrospective, comparative, multicenter study.

PARTICIPANTS

Forty-three patients admitted to 1 of 3 University Hospitals (Seoul National University Hospital, Chonnam National University Hospital, and Yonsei University Hospital) with a diagnosis of SJS or TEN who were followed up for at least 6 months in Korea.

METHODS

Patients were divided into 5 groups according to systemic immunomodulatory treatment received: systemic steroids (S), intravenous immunoglobulin (IVIG), combined S plus IVIG, systemic pulse steroids (PS), and supportive care only (C). Best-corrected visual acuity (BCVA) and chronic ocular surface complications score (COCS; range, 0-15) at final follow-up were compared among the 5 groups. Prognostic factors at onset (age, gender, causative drugs, initial visual acuities, acute ocular involvement score [range, 0-3], acute systemic involvement score [range, 0-16], systemic steroid dose, IVIG dose, and amniotic membrane transplantation [AMT]) were analyzed to predict final BCVA or COCS using logistic regression or linear regression analysis.

MAIN OUTCOME MEASURES

Best-corrected visual acuity and COCS at final follow-up.

RESULTS

The mean age and follow-up period of the patients was 30.5±21.0 years and 29.1±30.4 months, respectively. The acute systemic involvement score in the IVIG, S plus IVIG, and PS groups was significantly higher than that in the S and C groups (P < 0.001). However, final BCVA and COCS were not significantly different between groups, even after statistical adjustment. High COCS (≥8 points) was associated with female gender (P = 0.012) and AMT at the acute stage (P = 0.040). High acute ocular and systemic involvement scores were associated with worse COCS (P < 0.001), and COCS showed good correlation with final BCVA (R(2) = 0.7101; P < 0.0001).

CONCLUSIONS

There were no therapeutic benefits of systemic immunomodulatory treatments in final visual outcome and COCS in SJS and TEN patients. Female gender and acute ocular and systemic involvement scores may be prognostic factors predicting chronic ocular complications.

Systematic review of treatments for Stevens-Johnson syndrome and toxic epidermal necrolysis using the SCORTEN score as a tool for evaluating mortality

Epidermal necrolysis, whether involving limited, that is, Stevens-Johnson syndrome (SJS), or large, that is, toxic epidermal necrolysis (TEN), areas of the skin surface, is associated with high mortality. A specific prognosis score (SCORTEN) accurately predicts mortality. Management of SJS and TEN mainly relies on supportive care but several treatments have been proposed, particularly corticosteroids and intravenous immunoglobulins (IVIG), to block the progression of the disease. The aim of this study was a pooled analysis of published series addressing the question of treatment efficacy by comparing the mortality observed to the mortality predicted by the SCORTEN score. A literature search was carried out through PubMed from January 2001 to December 2009. It found 47 original series including at least 10 patients. Among these, 13 containing a clear description of treatment(s) and an evaluation of SCORTEN score were analyzed allowing the calculation of a mortality ratio (MR) for each series and a pooled MR with 95% confidence interval (CI) for each treatment. The analyzed series comprised a total of 439 patients. Supportive care was used only in 199 patients with a pooled MR of 0.89 (CI 0.67-1.16, p = 0.43), corticosteroids were administered to 78 patients with a pooled MR of 0.92 (CI 0.53-1.48, p = 0.84), and IVIG in 162 with a pooled MR of 0.82 (CI 0.58-1.12, p = 0.23). In conclusion, even though this analysis had some limitations, it strongly suggested that neither corticosteroids nor IVIG provide any important reduction in the risk of dying from SJS and TEN.