From the Guidelines
The management of Toxic Epidermal Necrolysis (TEN) requires immediate hospitalization in a burn unit or intensive care setting, with prompt withdrawal of the suspected causative medication and supportive care including fluid resuscitation, temperature regulation, nutritional support, and meticulous wound care with non-adherent dressings, as recommended by the UK guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults 2016 1.
Key Components of Management
- Immediate hospitalization in a burn unit or intensive care setting for patients with large areas of epidermal loss (> 10% BSA) 1
- Prompt withdrawal of the suspected causative medication and supportive care including:
- Pain management with opioid analgesics is essential, with the use of a patient-appropriate validated pain tool to assess pain in all conscious patients at least once daily 1
- Infection prevention is critical, with regular wound cultures and targeted antibiotics only when infection is confirmed, not prophylactically 1
Immunomodulatory Therapy
- Intravenous immunoglobulin (IVIG) at 2-3 g/kg divided over 3-5 days is commonly used, though evidence is mixed 1
- Cyclosporine (3-5 mg/kg/day for 7-10 days) has shown promise in reducing mortality
- Systemic corticosteroids remain controversial but may be considered in early disease (methylprednisolone 1-2 mg/kg/day for 3-5 days)
- TNF-alpha inhibitors like etanercept (50 mg twice weekly) or infliximab (single dose of 5 mg/kg) are emerging options
Ophthalmologic and Other Supportive Care
- Ophthalmologic consultation is mandatory to prevent ocular complications, with aggressive lubrication and topical antibiotics 1
- Daily oral review is necessary during the acute illness, with the application of white soft paraffin ointment to the lips and cleaning of the mouth with warm saline mouthwashes or an oral sponge 1
- Daily urogenital review is necessary during the acute illness, with the application of white soft paraffin ointment to the urogenital skin and mucosae and the use of a potent topical corticosteroid ointment once daily to the involved, but noneroded, surfaces 1
From the Research
Management and Treatment of Toxic Epidermal Necrolysis (TEN)
The management and treatment of TEN involve a combination of supportive care and pharmacological interventions. Some key aspects of TEN management include:
- Discontinuation of the offending drug
- Specialized care in an intensive care unit or burn center
- Supportive therapy, such as wound care and fluid management
- Use of intravenous immunoglobulin (IVIg) as a potential treatment option 2, 3, 4, 5
Role of Intravenous Immunoglobulin (IVIg) in TEN Treatment
IVIg has been shown to interfere with the interaction of Fas and FasL, and can be used as a treatment for TEN 4. Studies have reported varying degrees of success with IVIg treatment, with some showing improved outcomes 2, 5 and others finding no significant benefit 3. The optimal dosage and timing of IVIg administration are still unclear.
Other Treatment Options
Other treatment options that have been explored for TEN include:
- Systemic steroids
- Plasmapheresis
- Cyclosporine
- Biologics However, the effectiveness of these agents is uncertain, and further research is needed to determine their role in TEN treatment 6
Prognosis and Prevention
TEN has a high mortality rate, making early diagnosis and treatment crucial. Pharmacogenetic studies have identified a link between human leukocyte antigen allotype and TEN, and testing for these allotypes may help prevent the development of TEN in susceptible individuals 6.