Updates in SJS/TEN: collaboration, innovation, and community

Systematic review, methodological appraisal, and recommendation mapping of clinical practice guidelines for managing patients with Stevens-Johnson syndrome and toxic epidermal necrolysis

PURPOSE

The Appraisal of Guidelines for Research and Evaluation II Instrument (AGREE II) was developed to enhance the methodological rigor of clinical practice guidelines (CPGs), aiming to generate trustworthy recommendations for various clinical scenarios. Despite its importance, there exists a gap in the quality of CPGs pertaining to Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (SJS-TEN). The aim of the study was to evaluate SJS-TEN CPGs to shed light on areas for enhancing SJS-TEN guidelines' quality.

MATERIALS AND METHODS

A systematic review was conducted to identify SJS-TEN CPGs from January 2011 to December 2023 across bibliographic and guideline databases, as well as dermatology association websites. Four reviewers employed the AGREE II instrument to appraise the quality of eligible CPGs. Subsequently, AGREE II domain scores were calculated and their recommendations mapped.

RESULTS AND CONCLUSIONS

Seven eligible SJS-TEN CPGs reviewed, originating from Europe, North America, Asia, and an authorship Group. The highest AGREE II domain scores were observed in scope and purpose (mean: 63%, standard deviation [SD]: 23.195%) and clarity of presentation (mean: 70%, SD: 14.5%). Conversely, the lowest score was noted in the applicability domain (mean: 28%, SD: 17.44%). Only two guidelines by the British Association of Dermatologists (28.6%) met the 'recommend' level. Recommendations from all CPGs were compared in tabular form.

Improving Recruitment Through Social Media and Web-Based Advertising to Evaluate the Genetic Risk and Long-Term Complications in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: Community-Based Survey

Background

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are genetically mediated, life-threatening reactions usually caused by a medication in adults. These genetic associations promise an opportunity for pre-prescription screening, prevention, and understanding influences at a population level. Importantly, older adults disproportionally face more severe SJS/TEN reactions and higher mortality rates. However, the study of genetic risk and long-term sequelae of SJS/TEN across racially diverse populations and age groups is hampered by many factors, including rarity, social disparities, and trust in health care and providers, impacting access to hospital- and clinic-based research studies.

Objective

This paper aims to explore the utility of multiple social media and web-based search tools to increase study enrollment numbers, diversity, and inclusivity of all populations and ages in the SJS Survivor Study.

Methods

The community-based SJS/TEN Survivor Study remotely recruited drug-induced SJS/TEN survivors in the United States. The aims were to help determine genetic risk and long-term outcomes of SJS/TEN. Baseline recruitment included advertisements through the SJS Foundation website and American Burn Association newsletter. Two years into the study, in hopes of improving accessibility and enrollment diversity, social media ads were introduced on the Vanderbilt University Medical Center (VUMC) Facebook and Instagram accounts. Posts were created using flyers and 60-second SJS/TEN survivor video vignettes. Finally, we launched a nationwide Google Ad campaign. To understand the impact of the additional online advertising, we measured the change in registration in both the study interest and the effectiveness of implementation of specific social media and web-based search tools before and after implementation.

Results

With the introduction of social media and Google Ads, we report a 48.6% increase in enrollment overall and a 289.5% increase in participation interest. We noticed the ads were accessible to all age groups and notably reported a more even age distribution of enrolled participants from 18 through 74 years, with an average of 15% enrolled in each age category. The largest increase in any age category was seen in the 65- to 74-year-old patients (n=19), with 16.5% of the age distribution. The most significant increase in enrollment and diversity of responses came from Google Ads, with a total of 201 expressions of interest, from 56 enrolled participants, 33% of which self-identified as non-White. VUMC Facebook ads had an enrollment rate of 15.3%, and VUMC Instagram ads saw an enrollment rate of 14.3%.

Conclusions

Social media and web-based search tools differ in their enrollment effectiveness. Google Ads were found to be the most effective advertisement for recruitment in this community-based study. Each of the social media and web-based strategies used increased enrollment numbers, accessibility to more age ranges, and diversity of enrollment. They show promise as tools to improve inclusion and enrollment in rare disease research such as SJS/TEN.

[Dermatological conditions requiring intensive care treatment]

Some skin conditions may require intensive care treatment. Early diagnosis can be challenging but is crucial to adequate patient management and decision making, since appropriate treatment influences prognosis. The following skin conditions will be reviewed: severe cutaneous drug reactions (drug reaction with eosinophilia and systemic symptoms [DRESS], Stevens-Johnson syndrome/toxic epidermal necrolysis [SJS/TEN]), acute cutaneous graft versus host disease (aGvHD) following allogeneic stem cell transplantation, infectious diseases (staphylococcal scalded skin syndrome [SSSS], toxic shock-syndrome [TSS], necrotizing fasciitis) and vascular disease (acute infectious purpura fulminans). We focus on the course of the diseases, describing clinical presentation and differential diagnosis as well as diagnostic and therapeutic strategies.

[Dermatological conditions requiring intensive care treatment]

Some skin conditions may require intensive care treatment. Early diagnosis can be challenging but is crucial to adequate patient management and decision making, since appropriate treatment influences prognosis. The following skin conditions will be reviewed: severe cutaneous drug reactions (drug reaction with eosinophilia and systemic symptoms [DRESS], Stevens-Johnson syndrome/toxic epidermal necrolysis [SJS/TEN]), acute cutaneous graft versus host disease (aGvHD) following allogeneic stem cell transplantation, infectious diseases (staphylococcal scalded skin syndrome [SSSS], toxic shock-syndrome [TSS], necrotizing fasciitis) and vascular disease (acute infectious purpura fulminans). We focus on the course of the diseases, describing clinical presentation and differential diagnosis as well as diagnostic and therapeutic strategies.

Drug allergy

Drug allergy encompasses a spectrum of immunologically-mediated hypersensitivity reactions (HSRs) with varying mechanisms and clinical presentations. This type of adverse drug reaction (ADR) not only affects patient quality of life, but may also lead to delayed treatment, unnecessary investigations, and increased morbidity and mortality. Given the spectrum of symptoms associated with the condition, diagnosis can be challenging. Therefore, referral to an allergist experienced in the diagnosis and management of drug allergy is recommended if a drug-induced allergic reaction is suspected. Diagnosis relies on a careful history and physical examination and, in some instances, skin testing or in vitro testing and drug challenges. The most effective strategy for the management of allergist-confirmed drug allergy is avoidance or discontinuation of the offending drug. When available, alternative medications with unrelated chemical structures should be substituted. Cross-reactivity among drugs should also be taken into consideration when choosing alternative agents. Additional therapy for drug HSRs may include topical corticosteroids, oral antihistamines and, in severe cases, systemic corticosteroids and other immunomodulators. In the event of anaphylaxis, the treatment of choice is intramuscular epinephrine. If a patient with a history of anaphylaxis requires a specific drug and there is no acceptable alternative, desensitization to that drug may be considered. This article provides a background on drug allergy and strategies for the diagnosis and management of some of the most common drug-induced allergic reactions.

Update on Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: Diagnosis and Management

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the most severe cutaneous adverse reactions that are typically drug-induced in adults. Both SJS and TEN have high morbidity and mortality rates. SJS/TEN imposes clinical challenges for physicians managing patients suffering from this condition, both because it is rare and because it is a rapidly progressing systemic disease with severe cutaneous, mucosal, and systemic manifestations. Although many cases of SJS/TEN have been reported in the literature, there is no consensus regarding diagnostic criteria or treatment. Significant progress has been made in understanding its genetic predisposition and pathogenesis. This review is intended to provide physicians with a comprehensive but practical SJS/TEN roadmap to guide diagnosis and management. We review data on pathogenesis, reported precipitating factors, presentation, diagnosis, and management SJS/TEN focusing on what is new over the last 5 years.

Atypical Rash as a Presentation of Pityriasis Rosea in a 23-Month-Old

Pityriasis rosea is a self-limiting skin disorder that can occur in pediatric patients. We report an atypical presentation of a 23-month-old male with a generalized rash similar in appearance to pityriasis rosea. We then review the literature on pityriasis rosea and its application to pediatrics. Our patient had the rash as the only presentation which was also atypical in appearance as opposed to the regular rashes seen with pityriasis rosea which makes this case further interesting. We only treated the case symptomatically and the patient had spontaneous resolution of symptoms.

Multiomic single-cell sequencing defines tissue-specific responses in Stevens-Johnson syndrome and toxic epidermal necrolysis

Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) is a rare but life-threatening cutaneous drug reaction mediated by human leukocyte antigen (HLA) class I-restricted CD8+ T cells. For unbiased assessment of cellular immunopathogenesis, here we perform single-cell (sc) transcriptome, surface proteome, and T cell receptor (TCR) sequencing on unaffected skin, affected skin, and blister fluid from 15 SJS/TEN patients. From 109,888 cells, we identify 15 scRNA-defined subsets. Keratinocytes express markers indicating HLA class I-restricted antigen presentation and appear to trigger the proliferation of and killing by cytotoxic CD8+ tissue-resident T cells that express granulysin, granzyme B, perforin, LAG3, CD27, and LINC01871, and signal through the PKM, MIF, TGFβ, and JAK-STAT pathways. In affected tissue, cytotoxic CD8+ T cells express private expanded and unexpanded TCRαβ that are absent or unexpanded in unaffected skin, and mixed populations of macrophages and fibroblasts express pro-inflammatory markers or those favoring repair. This data identifies putative cytotoxic TCRs and therapeutic targets.

Novel insights into the heterogeneity of FOXP3 + Treg cells in drug-induced allergic reactions through single-cell transcriptomics

This study uncovers the novel heterogeneity of FOXP3 + regulatory T (Treg) cells and their pivotal role in modulating immune responses during drug-induced allergic reactions, employing cutting-edge single-cell transcriptomics. We established a mouse model for drug-induced allergic reactions and utilized single-cell RNA sequencing (scRNA-seq) to analyze the transcriptomic landscapes of FOXP3 + Treg cells isolated from affected tissues. The study involved both in vitro and in vivo approaches to evaluate the impact of FOXP3 expression levels on the immunoregulatory functions of Treg cells during allergic responses. Techniques included flow cytometry, cluster analysis, principal component analysis (PCA), CCK8 and CSFE assays for cell proliferation, LDH release assays for toxicity, ELISA for cytokine profiling, and CRISPR/Cas9 technology for gene editing. Our findings revealed significant transcriptomic heterogeneity among FOXP3 + Treg cells in the context of drug-induced allergic reactions, with distinct subpopulations exhibiting unique gene expression profiles. This heterogeneity suggests specialized roles in immune regulation. We observed a decrease in the proliferative capacity and cytokine secretion of FOXP3 + Treg cells following allergic stimulation, alongside an increase in reaction toxicity. Manipulating FOXP3 expression levels directly influenced these outcomes, where FOXP3 deletion exacerbated allergic responses, whereas its overexpression mitigated them. Notably, in vivo experiments demonstrated that FOXP3 overexpression significantly reduced the severity of allergic skin reactions in mice. Our study presents novel insights into the heterogeneity and crucial immunoregulatory role of FOXP3 + Treg cells during drug-induced allergic reactions. Overexpression of FOXP3 emerges as a potential therapeutic strategy to alleviate such allergic responses. These findings contribute significantly to our understanding of immune regulation and the development of targeted treatments for drug-induced allergies.

Patient-Reported Outcome Measures in Food and Drug Allergy

A patient-reported outcome is directly reported by the patient without interpretation of the patient's response by anyone else. It refers to the patient's health (symptoms and feelings), quality of life, or functional status associated with health care or treatment. Patient-reported outcome measures (PROMs) are defined as the tools or instruments that are used to measure patient-reported outcomes. Health-related quality of life has been the most studied psychosocial PROM in food allergy, using validated questionnaires. In drug allergy, PROMs are useful in capturing patients' experiences of potential allergic reactions, including subjective symptoms such as headache, dizziness, or fatigue. Patient-reported outcome measures can also help differentiate true allergies from side effects or other nonallergic reactions and inform decisions about drug challenges and de-labeling strategies. Ensuring the chosen tool is validated for the specific allergy context is crucial for accurate data collection. Integrating patient-reported experiences alongside traditional methods can lead to more accurate assessments and personalized care.

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: Analysis of the Russian Database of Spontaneous Reports

(1) Background: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are extremely severe cutaneous adverse drug reactions which are relatively rare in routine clinical practice. An analysis of a national pharmacovigilance database may be the most effective method of obtaining information on SJS and TEN. (2) Methods: Design-a retrospective descriptive pharmacoepidemiologic study of spontaneous reports (SRs) with data on SJS and TEN retrieved from the Russian National Pharmacovigilance database for the period from 1 April 2019 to 31 December 2023. Descriptive statistics was used to assess the demographic data of patients and the structure of suspected drugs. (3) Results: A total of 170 SRs on SJS and TEN were identified, of which 32.9% were SJS and 67.1%-TEN. In total, 30% were pediatric SRs, 21.2%-SRs of the elderly. There were 12 lethal cases, and all cases were TEN. The leading culprit drugs were anti-infectives for systemic use and nervous system agents. The top 10 involved drugs are as follows: lamotrigine (23.5%), ibuprofen (12.9%), ceftriaxone (8.8%), amoxicillin and amoxicillin with beta-lactam inhibitors (8.8%), paracetamol (7.6%), carbamazepine (5.9%), azithromycin (4.1%), valproic acid (4.1%), omeprazole (3.5%), and levetiracetam (3.5%). (4) Conclusions: Our study was the first study in Russia aimed at the assessment of the structure of the drugs involved in SJS and TEN on the national level.

Recent findings on drug hypersensitivity in children

Drug hypersensitivity reactions (DHR) in children have a significant impact on clinical practice and public health. Both under-diagnosis (due to under-reporting) and over-diagnosis (due to the overuse of the term "allergy") are potential issues. The aim of this narrative review is to describe the most recent findings of DHR in children/adolescents and gaps regarding epidemiology, antibiotic allergy, antiepileptic hypersensitivity, vaccine allergy, and severe cutaneous adverse reactions (SCAR) in this age group.

The Role of NLRP3 Inflammasome in the Pathogenesis of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

Stevens Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) are mainly drug-induced severe cutaneous adverse reactions with increased mortality. It also involves the eyes causing ocular surface disease leading to visual impairment and blindness. The role of NLRP3 Inflammasome in causing ocular surface disease and keratinocyte apoptosis is not fully explored. This study is focused on determining the role of NLRP3 Inflammasome in the pathogenesis of Stevens Johnson Syndrome/Toxic Epidermal Necrolysis. The NLRP3 Inflammasome plays a crucial role in the pathogenesis of Stevens Johnson Syndrome/Toxic Epidermal Necrolysis and may correlate with the degree of severity of skin detachment and ocular surface disease. This study looked at the expression of the NLRP3 Inflammasome in the skin of patients with biopsy confirm Stevens Johnson Syndrome/Toxic Epidermal Necrolysis compared to the lichen planus and normal controls by immunohistochemistry as well as observing the mitochondrial function of platelets challenged with plasma from patients with Stevens Johnson Syndrome/Toxic Epidermal Necrolysis and Normal Human Plasma using Agilent Seahorse XF Analyzer. Under a current, Loyola IRB approved protocol, 12 collected and archived unstained slides of skin and blood plasma samples from patients with biopsy confirmed Stevens Johnson Syndrome/Toxic Epidermal Necrolysis was used for this study. Immunohistochemical analysis was performed using anti-NLRP3 antibodies followed by imaging on a Delta Vision microscope. The precise roles of cytokines and chemokine receptors in severity of skin detachment has not been completely studied. The identification of the roles of NLRP3 in Stevens Johnson Syndrome/Toxic Epidermal Necrolysis would bridge the gaps in the basic understanding regarding the pathogenesis of this disease spectrum. NLRP3 Inflammasome is a potential therapeutic target and its inhibition by phytochemicals may be appropriate effective treatment strategies in the management of this condition.