From the Guidelines
The treatment for tissue epidermal necrosis involves a conservative approach with regular cleansing of wounds and intact skin using warmed sterile water or saline, and application of a greasy emollient and topical antimicrobial agent as needed, as recommended by the most recent guidelines 1. The goal of treatment is to promote healing, prevent infection, and minimize scarring.
- Regular cleansing of wounds and intact skin is essential to remove bacteria and debris, and can be done using warmed sterile water or saline, or an antimicrobial such as chlorhexidine (1/5000) 1.
- Application of a greasy emollient, such as 50% white soft paraffin with 50% liquid paraffin, over the whole epidermis, including denuded areas, can help to protect the skin and promote healing 1.
- Topical antimicrobial agents, such as silver-containing products or dressings, can be applied to sloughy areas to prevent infection, but should be used judiciously due to the risk of absorption 1.
- Nonadherent dressings, such as Mepitel or Telfa, can be applied to denuded dermis to protect the wound and promote healing, and a secondary foam or burn dressing can be used to collect exudate 1. In cases of extensive epidermal loss (> 30% BSA), consideration should be given to transfer to a burn centre for specialized care, including surgical debridement and physiological closure with biosynthetic dressings 1. It is also important to address the underlying cause of the necrosis, whether it's a drug reaction, infection, or other factor, and to provide supportive care, including pain management and nutritional support, to promote healing and prevent complications 1.
From the Research
Treatment for Tissue Epidermal Necrosis
The treatment for tissue epidermal necrosis, also known as toxic epidermal necrolysis (TEN), involves a combination of topical and systemic therapies. The primary goal of treatment is to promote wound healing, prevent infection, and manage symptoms.
- Topical Treatment: Topical treatments are essential in managing TEN, including specific bedding, debridement of epidermal necrosis, applications of bioactive skin substitutes or semi-synthetic and synthetic dressings, as well as antiseptic and antibiotic agents 2.
- Debridement: Debridement is the removal of necrotic material, scabs, and devitalized tissues, which is an essential element of wound healing therapy. Properly performed debridement leads to improvement of microcirculation in the wound, reduction in inflammation, and lowering of the level of metalloproteinases 3.
- Antimicrobial Agents: Antimicrobial agents, such as creams and ointments, are used to prevent infection and promote wound healing. These agents can be used in conjunction with surgical intervention or as a non-operative wound care approach 4.
- Systemic Therapy: Immunomodulating systemic therapy may be necessary in some cases of TEN, particularly in severe cases or those with significant mucosal involvement 5.
- Wound Care: Wound care procedures must be managed according to the skin condition, corresponding to the initial highly exudating/necrotic phase, the secondary moderately exudating stabilized phase, and the later re-epidermization phase. Bedding modalities, debridement procedures, applications of bioactive, semi-synthetic, and synthetic dressings, and antiseptic/antibiotic creams should be adapted accordingly 2.
Diagnosis and Treatment Approach
A fast and accurate diagnosis of TEN is crucial for relevant treatment decision. Ex vivo confocal laser scanning microscopy (CLSM) offers a rapid and reliable approach for morphological TEN emergency screening on fresh skin samples 6. The S3 guideline provides an evidence-based framework for the diagnosis and treatment of epidermal necrolysis, including Stevens-Johnson syndrome and toxic epidermal necrolysis 5.