What is the treatment for toxic epidermal necrolysis (TEN) caused by Lamotrigine (lamotrigine)?

Treatment of Toxic Epidermal Necrolysis Caused by Lamotrigine

Patients with toxic epidermal necrolysis (TEN) caused by lamotrigine should be immediately transferred to a burn center or ICU with experience treating SJS/TEN, with immediate discontinuation of lamotrigine and implementation of intensive supportive care. 1

Immediate Management

• Discontinue lamotrigine immediately as it is one of the most common drugs causing SJS/TEN 2
• Calculate SCORTEN within the first 24 hours of admission to predict mortality risk 2, 1
• Transfer patients with >10% body surface area (BSA) epidermal detachment to a specialized burn unit or ICU 2, 1
• Establish a multidisciplinary team led by a specialist in skin failure (dermatology/plastic surgery) including clinicians from intensive care, ophthalmology, and specialist skincare nursing 2, 1

Supportive Care (Critical for Survival)

Environmental Control

• Place patient in a side room controlled for humidity 2
• Use a pressure-relieving mattress 2
• Raise ambient temperature to between 25°C and 28°C 2, 1

Fluid Management

• Establish adequate intravenous fluid replacement guided by urine output 1
• Avoid overaggressive fluid resuscitation which may cause pulmonary, cutaneous, and intestinal edema 1
• Consider using formula based on body weight/% BSA epidermal detachment to determine replacement volumes 1

Wound Care

• Handle skin carefully to minimize shearing forces and further epidermal detachment 2, 1
• Regularly cleanse wounds by gently irrigating with warmed sterile water, saline, or chlorhexidine 1
• Apply greasy emollient (50% white soft paraffin with 50% liquid paraffin) over the whole epidermis 2, 1
• Apply nonadherent dressings to denuded dermis and secondary foam or burn dressings to collect exudate 1
• Take swabs for bacterial and candidal culture from lesional skin, particularly sloughy areas 1

Pain Management

• Use validated pain assessment tools at least once daily 1
• Administer adequate analgesia using intravenous opioid infusions for those not tolerating oral medication 1
• Consider patient-controlled analgesia where appropriate 1
• Consider sedation or general anesthesia for patient handling, repositioning, and dressing changes 1

Infection Prevention and Management

• Monitor for signs of systemic infection (confusion, hypotension, reduced urine output, reduced oxygen saturation) 1
• Do not administer prophylactic systemic antibiotics as this may increase skin colonization 1
• Only institute antimicrobial therapy if there are clinical signs of infection 1
• Watch for monoculture of organisms on culture swabs from multiple sites, which indicates increased likelihood of invasive infection 1

Specialized Consultations

• Arrange ophthalmology consultation within 24 hours of diagnosis to prevent permanent visual impairment 1
• Monitor for respiratory symptoms and hypoxemia which may require urgent ICU transfer 2
• Consider fibreoptic bronchoscopy to identify bronchial involvement and evaluate prognosis 2

Potential Active Therapies

While supportive care remains the cornerstone of management, several active therapies have been studied:

• Cyclosporine has shown promising results in recent studies and may be considered as a treatment option under specialist supervision 1, 3, 4
• Corticosteroids have been used historically but remain controversial; some case reports suggest benefit when combined with broad-spectrum antibiotics 5
• Intravenous immunoglobulin (IVIg) has mixed evidence - high-dose IVIg may be more effective than low-dose, but overall mortality benefit is uncertain 2

Monitoring and Follow-up

• Daily assessment of vital signs and organ function 1
• Regular monitoring for infection, the most common cause of mortality 1
• Daily review of mucosal sites (oral, ocular, urogenital) to prevent complications 1
• Upon discharge, provide written information about lamotrigine to avoid, encourage wearing a MedicAlert bracelet 1
• Arrange follow-up with dermatology and ophthalmology within weeks of discharge 1

Common Pitfalls to Avoid

• Delayed transfer to a specialized unit increases mortality risk 1
• Overaggressive fluid resuscitation can cause complications 1
• Indiscriminate use of prophylactic antibiotics may increase skin colonization 1
• Failure to recognize and treat sepsis, which is the most common cause of death in SJS/TEN 1
• Inadequate eye care leading to permanent visual impairment 1
• Continued exposure to sunlight may worsen the condition in some cases 6