What is the management of mild toxic epidermal necrolysis (TEN)?

Management of Mild Toxic Epidermal Necrolysis (TEN)

Patients with mild TEN (epidermal detachment <10% BSA) should be managed with immediate discontinuation of the suspected culprit drug, careful monitoring, and supportive care, but do not require transfer to a burn center unless clinical deterioration occurs. 1, 2

Initial Assessment and Triage

• Calculate SCORTEN within 24 hours of admission to predict mortality risk 1
• Document extent of epidermal detachment and erythema separately on a body map 1
• Identify high-risk patients (underlying malignancy, previous stem cell transplant) 1
• Take a detailed medication history covering all drugs taken in the previous 2 months 1, 2
• Perform bacterial swabs from three areas of lesional skin 1

Immediate Management Steps

1. Discontinue suspected culprit drug immediately 1, 2
2. Investigate potential infectious triggers (especially mycoplasma in mild cases with predominant mucositis) 1
3. Arrange ophthalmology examination within 24 hours to assess and manage ocular involvement 1
4. Barrier nurse the patient in a side room with controlled humidity and temperature (25-28°C) 1, 2

Skin Management

• Conservative approach for mild cases:

  • Gently cleanse wounds using warmed sterile water, saline or dilute chlorhexidine (1/5000) 1
  • Apply greasy emollient (50% white soft paraffin with 50% liquid paraffin) over the entire epidermis 1, 2
  • Leave detached epidermis in situ as a biological dressing 1
  • Decompress blisters by piercing and expressing fluid 1
  • Apply non-adherent dressings (Mepitel™ or Telfa™) to denuded areas 1, 2
  • Use secondary foam dressings to collect exudate 1

• Do not use prophylactic antibiotics - administer only if clinical signs of infection develop 1, 2

Supportive Care

• Fluid management: Monitor fluid balance carefully; establish adequate IV fluid replacement initially 1
• Pain control: Use validated pain assessment tools and provide adequate analgesia 1
• Nutrition: Provide continuous enteral nutrition throughout the acute phase 1
• Thromboprophylaxis: Administer low molecular weight heparin for immobile patients 1

Monitoring for Complications

• Daily assessment of vital signs and skin progression 1
• Regular monitoring of electrolytes, renal function, and liver function 1
• Daily examination of mucous membranes (eyes, mouth, genitalia) 1
• Watch for signs of sepsis, which is the most common cause of death 1, 2

Escalation Criteria

Transfer to a burn center or specialized ICU if any of the following occur 1, 2:

• Clinical deterioration
• Extension of epidermal detachment beyond 10% BSA
• Development of subepidermal pus
• Local sepsis
• Wound conversion
• Delayed healing

Follow-up Care

• Arrange follow-up with dermatology within 4-6 weeks 1
• Provide patient with documentation of the culprit drug to avoid future exposure 1
• Consider MedicAlert bracelet/amulet 1
• Arrange ophthalmology follow-up to monitor for late ocular complications 1

Common Pitfalls to Avoid

• Delayed diagnosis: Early recognition and intervention are critical to reducing mortality 3
• Continued exposure to culprit drug: Immediately stop all non-essential medications 1, 2
• Prophylactic antibiotics: These may lead to resistant organisms and should be avoided unless infection is confirmed 1, 2
• Inadequate temperature control: Patients lose thermoregulatory function and require careful environmental temperature management 1, 4
• Overlooking ocular involvement: Even mild cases require ophthalmology assessment to prevent long-term sequelae 1

By following these guidelines, mild TEN can be managed effectively with good outcomes. However, vigilance for progression to more severe disease is essential, as early transfer to specialized care when needed significantly improves survival.