A review on toxic epidermal necrolysis-like superficial wound lesions: Issue and challenge on 10 clinical entities

Toxic epidermal necrolysis (TEN) is a severe skin reaction caused by extensive epidermal and mucosal necrosis. This clinical phenomenon is known as an acute syndrome of apoptotic pan-epidermolysis (ASAP). The ASAP phenomenon is observed in conditions that mimic TEN, highlighting the challenge in distinguishing these conditions. While TEN is a well-recognized entity, distinguishing it from other TEN-like conditions presents significant diagnostic and treatment challenges. These conditions include drug rash with eosinophilia and systemic symptoms (DRESS), generalized bullous fixed drug eruption (GBFDE), acute generalized exanthematous pustulosis (AGEP), TEN-like methotrexate toxicity, mustard gas toxicity, pseudoporphyria, mycoplasma-induced rash and mucositis (MIRM), multisystem inflammatory syndrome in children (MIS-C), graft versus host disease (GVHD), and acute cutaneous lupus erythematosus and subacute cutaneous lupus erythematosus. This review explores these ten separate entities and debates their clinical features, pathophysiology, diagnosis and management.

A case of toxic epidermal necrosis-like cutaneous eruption as the first manifestation and clue to the diagnosis of systemic lupus erythematosus: A case report

We present a rare case of a 61-year-old woman presenting with a widespread erosive eruption on her torso and extremities. Although the lesions were histologically compatible with toxic epidermal necrolysis, clinically the patient was hemodynamically stable, had no mucosal involvement and had no relevant medical history or potentially incriminating medications. Further investigations uncovered a new diagnosis of systemic lupus erythematosus, with this toxic epidermal necrolysis-like eruption being the first presentation of the disease. This case highlights the importance of broadening the differential diagnosis in patients presenting with acute widespread cleavage of the epidermis, using the spectrum of acute syndrome of apoptotic pan-epidermolysis as a reference.

Fixed Drug Eruptions: An Update, Emphasizing the Potentially Lethal Generalized Bullous Fixed Drug Eruption

A fixed drug eruption (FDE) is a relatively common reaction associated with more than 100 medications. It is defined as a same-site recurrence with exposure to a particular medication. The primary approach and treatment for all types of FDEs are to identify and remove the causative agent, often accomplished by a thorough history of medication and other chemical exposures, and possibly prior episodes. The most common category of FDE, localized FDE, whether bullous or non-bullous, is self-limited. Although one can confirm the causative agent using oral challenge testing, it is not recommended due to the risk of severe exacerbation or possible generalization; patch testing is now preferred. Bullous FDE may resemble erythema multiforme. Treatment of localized FDE includes medication removal, patient counseling, and symptomatic relief. Failure to remove the causative agent in localized FDE can lead to recurrence, which is associated with increased inflammation, hyperpigmentation, and risk of a potentially lethal generalized bullous FDE (GBFDE), which may resemble Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN). Distinguishing GBFDE from SJS and TEN is salient and will be stressed: GBFDE has more rapid onset in 1-24 h rather than in weeks, less or no mucosal involvement, less or no systemic involvement, and a tendency for a more favorable prognosis; however, recent experience suggests it may be just as life-threatening. This review will provide a comprehensive update and approach to diagnosis and management.

A case of toxic epidermal necrolysis-like skin lesions with systemic lupus erythematosus and review of the literature

Objective

Subepidermal bullous lesions and toxic epidermal necrolysis-like (TEN-like) lesions can occur in patients with systemic lupus erythematosus (SLE). In this report, we describe a case of a patient previously diagnosed with SLE who experienced TEN-like skin lesions with unusual subacute progression in the context of the current literature.

Methods

We present a recent case of TEN-like lupus erythematosus and review of studies published in English identifying SLE cases mimicking TEN, accessed via PubMed and Google Scholar databases. The keywords used in the search were: TEN, SLE, TEN-like SLE, and TEN-like lesions. The search covered all articles from January 1980 to November 2011.

Results

A 52-year-old male presented with fatigue, weakness, and weight loss (23 kg in two months). Skin redness started across nose and cheeks six months before admission. Bilateral pleural effusions were observed in a thorax tomography taken in the referral hospital two months prior to admission. Because of articular involvement, antinuclear antibody (ANA), and anti-dsDNA positivity, the patient was diagnosed with SLE. We initiated a punch skin biopsy, and the findings were consistent with Stevens-Johnson syndrome. There was marked basal layer necrosis in the epidermis, and there was predominantly lymphohistiocytic infiltrate in the dermis. A total of 22 cases, including our case, with TEN-like lupus erythematosus were reported in the literature. In addition, cutaneous lupus had positive ANAs in 18 of 22 patients (81.8%). The patients were aged 12 to 76 years; 21 cases were women and only one patient was male.

Discussion

Skin involvement, including the rare variant of TEN-like acute cutaneous SLE, is very common among SLE patients. The acute syndrome of pan-epidermolysis or apoptotic pan-epidermolysis may become a useful designation when considering a clinical diagnosis of drug-induced TEN or SLE. Further studies are required to verify our findings.

Toxic epidermal necrolysis-like acute cutaneous lupus erythematosus and the spectrum of the acute syndrome of apoptotic pan-epidermolysis (ASAP): a case report, concept review and proposal for new classification of lupus erythematosus vesiculobullous skin lesions

The acute clinical syndrome of toxic epidermal necrolysis (TEN) is currently thought to be a distinct clinical-pathological entity typically resulting from drug hypersensitivity. We describe an adult woman who experienced a fulminate pattern of apoptotic epidermal cell injury following tanning bed exposure while taking naproxen that resulted in a clinical presentation having combined features of drug-induced TEN and an infrequently recognized form of bullous cutaneous lupus erythematosus (LE). This case calls attention to the fact that TEN-like injury can occasionally be seen in settings other than drug hypersensitivity (e.g., LE, acute graft versus host disease) and illustrates the need for a unifying concept in this area. We therefore propose the term 'Acute Syndrome of Apoptotic Pan-Epidermolysis (ASAP)' to designate a clinical syndrome that is characterized by life-threatening acute and massive cleavage of the epidermis resulting from hyperacute apoptotic injury of the epidermis. We also review vesiculobullous skin disorders that can be encountered in LE patients and suggest a new classification scheme for such lesions.