Treatment for Toxic Epidermal Necrolysis (TEN)
Patients with TEN should be immediately transferred to a burn center or ICU with experience in managing TEN, where supportive care, wound management, and multidisciplinary treatment can be provided under specialist supervision. 1, 2
Initial Assessment and Management
Immediate actions:
- Discontinue all potential culprit drugs immediately
- Calculate SCORTEN score to assess mortality risk
- Transfer to specialized center with TEN experience
- Isolate in a barrier-controlled room with humidity control
- Provide anti-shear mattress with ambient temperature 25-28°C
SCORTEN parameters (1 point each, predicting mortality):
- Age >40 years
- Heart rate >120 bpm
- Cancer/hematological malignancy
- Epidermal detachment >10% body surface area
- Serum urea >10 mmol/L
- Serum glucose >14 mmol/L
- Serum bicarbonate <20 mmol/L
Wound Management
Conservative Approach (First-Line)
- Gently cleanse wounds using warmed sterile water, saline or dilute antimicrobial solution
- Apply greasy emollient (50% white soft paraffin with 50% liquid paraffin) over entire epidermis
- Leave detached epidermis in situ as biological dressing
- Decompress blisters by piercing and expressing fluid
- Apply non-adherent dressings (Mepitel™ or Telfa™) to denuded areas
- Use secondary foam dressings to collect exudate
Surgical Approach (For Failed Conservative Management)
Consider when there is:
- Clinical deterioration
- Extension of epidermal detachment
- Local sepsis/subepidermal pus
- Delayed healing
- Wound conversion
Surgical intervention includes:
Infection Management
- Take swabs from three areas of lesional skin on alternate days
- Do not administer prophylactic systemic antibiotics
- Only use antimicrobials when clinical signs of infection present
- Apply topical antimicrobials only to sloughy areas
- Consider silver-containing products for infected wounds
- Monitor for signs of sepsis (confusion, hypotension, reduced urine output, reduced oxygen saturation)
Supportive Care
Fluid management:
- Site venous lines through non-lesional skin when possible
- Monitor fluid balance carefully; catheterize if necessary
- Establish adequate IV fluid replacement initially
- Transition to oral fluids as mouth involvement improves
Nutrition:
- Provide continuous enteral nutrition throughout acute phase
- Deliver 20-25 kcal/kg daily during catabolic phase
- Increase to 25-30 kcal/kg daily during recovery phase
Pain management:
- Assess pain using validated tools at least daily
- Provide adequate analgesia for comfort at rest
- Add supplementary opiates as required
Multidisciplinary Care
- Team coordination by specialist in skin failure (dermatology/plastic surgery)
- Team members should include specialists in:
- Intensive care
- Ophthalmology (for ocular involvement)
- Specialized nursing care
- Other specialists as needed (pulmonology, gastroenterology)
Monitoring and Complications Management
- Monitor for systemic infection (most common cause of death)
- Address anemia, leucopenia, renal insufficiency, and hepatic dysfunction
- Provide specialized mucosal care (ocular, oral, genital)
- Watch for respiratory tract involvement (cough, dyspnea, bronchial hypersecretion)
Special Considerations
- High-risk patients (epidermal loss >70%, high SCORTEN score, drug cause, underlying malignancy) require more aggressive management
- Corticosteroids have shown mixed results and should be used with caution 4, 5
- Biobrane has shown promising results for early wound coverage 3
Prognosis
- Mortality rates correlate with SCORTEN score (1% with score of 0, up to 99% with score of 7)
- Sepsis is the most common cause of death
- Surviving patients typically heal completely in 3-4 weeks
- Up to 50% may have residual ocular complications 5