From the Guidelines
If you suspect toxic epidermal necrolysis (TEN) from Lamictal, discontinue the medication immediately and seek emergency medical care. Lamictal (lamotrigine) can cause TEN, a rare but severe and potentially life-threatening skin reaction [ 1 ]. Signs of TEN include widespread skin redness, blistering, peeling, fever, and mucosal involvement (mouth, eyes, genitals). The risk of this reaction is highest during the first 8 weeks of treatment, especially if the dose is increased too rapidly or if taken concurrently with valproate.
Initial Assessment and Management
According to the UK guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults 2016 [ 1 ], if SJS/TEN is suspected, any potential culprit drug should be discontinued immediately. The patient should undergo an evaluation of the critical disease components, including a clinical examination and assessments specific to SJS/TEN. Institution of an immediate management protocol is necessary as soon as the patient has been assessed.
Treatment and Care
Treatment of TEN requires hospitalization, often in burn units, with supportive care including:
- Fluid management
- Wound care
- Pain control
- Prevention of secondary infections The use of an appropriate dressing on exposed dermis can reduce fluid and protein loss, limit microbial colonization, and help with pain control [ 1 ]. A surgical approach involving debridement of detached epidermis may be considered in cases of clinical deterioration or failure of conservative management.
Prevention of Secondary Infections
It is essential to monitor patients carefully for signs of systemic infection, such as confusion, hypotension, reduced urine output, and reduced oxygen saturation [ 1 ]. Antimicrobial therapy should only be instituted if there are clinical signs of infection, as indiscriminate administration of prophylactic systemic antibiotics may increase skin colonization with Candida albicans.
From the FDA Drug Label
LAMICTAL XR can cause serious rashes requiring hospitalization and discontinuation of treatment. The incidence of these rashes, which have included Stevens-Johnson syndrome, is approximately 0.8% (8 per 1,000) in pediatric patients (aged 2 to 16 years) receiving immediate-release lamotrigine as adjunctive therapy for epilepsy and 0. 3% (3 per 1,000) in adults on adjunctive therapy for epilepsy. In worldwide postmarketing experience, rare cases of toxic epidermal necrolysis and/or rash-related death have been reported in adult and pediatric patients, but their numbers are too few to permit a precise estimate of the rate.
Toxic Epidermal Necrolysis from lamictal is a rare but potentially life-threatening condition.
- The exact rate of Toxic Epidermal Necrolysis is unknown due to the limited number of reported cases.
- Risk factors that may increase the risk of severe rash include coadministration of lamictal with valproate, exceeding the recommended initial dose, or exceeding the recommended dose escalation.
- Nearly all cases of life-threatening rashes have occurred within 2 to 8 weeks of treatment initiation, but isolated cases have occurred after prolonged treatment.
- Due to the potential risk of Toxic Epidermal Necrolysis, lamictal should be discontinued at the first sign of rash, unless the rash is clearly not drug-related 2.
From the Research
Toxic Epidermal Necrolysis from Lamictal
- Toxic Epidermal Necrolysis (TEN) is a life-threatening, typically drug-induced, mucocutaneous disease 3
- Lamotrigine, an anti-epileptic drug, has been associated with TEN, as reported in a case study where a patient developed TEN secondary to lamotrigine and was managed symptomatically with intravenous immunoglobulins (IVIG) 4
- The management of TEN ranges from nutritional support, care of denuded skin and mucosa, to IVIG, and the discontinuation of the offending drug is crucial 3, 4
- TEN is characterized clinically by blistering and widespread exfoliation, and pathologically by apoptosis of keratinocytes and epidermal necrosis 4, 5
- Early recognition and diagnosis of TEN are essential, and oral and maxillofacial surgeons play a crucial role in its diagnosis and management 5
Treatment and Management
- The mainstay of treatment for TEN involves discontinuation of the offending drug, specialized care in an intensive care unit or burn center, and supportive therapy 3
- IVIG has been used in the treatment of TEN, and its effectiveness has been reported in some cases 4, 6
- Other treatments, such as systemic steroids, cyclosporine, and biologics, have been used, but their effectiveness is uncertain 3, 6
- Infliximab has been reported to be effective in the treatment of TEN, especially in cases of rapid progression 6
Prognosis and Prevention
- TEN has a high mortality rate, making early diagnosis and treatment of paramount importance 3, 7
- Pharmacogenetic studies have established a link between human leukocyte antigen allotype and TEN, and human leukocyte antigen testing should be performed on patients of East Asian descent before the initiation of certain drugs 3