What is the management of toxic epidural necrolysis?

Management of Toxic Epidermal Necrolysis

Patients with toxic epidermal necrolysis (TEN) should be immediately transferred to a burn center or intensive care unit with experience in treating TEN and facilities to manage extensive skin loss wound care. 1, 2

Initial Assessment and Management

• Immediately discontinue any potential culprit drug (especially antibiotics, anticonvulsants, NSAIDs, allopurinol) 2, 3
• Calculate SCORTEN within the first 24 hours of admission to predict mortality risk 1, 2
• Transfer patients with >10% body surface area (BSA) epidermal detachment to a specialized burn unit or ICU 1
• Convene a multidisciplinary team led by a specialist in skin failure (dermatology/plastic surgery) that includes clinicians from intensive care, ophthalmology, and specialist skincare nursing 1
• Additional clinical input may be required from respiratory medicine, gastroenterology, gynecology, urology, oral medicine, microbiology, pain team, dietetics, physiotherapy, and pharmacy 1

Care Setting

• Barrier nurse in a side room controlled for humidity 1
• Use a pressure-relieving mattress 1, 2
• Maintain ambient temperature between 25°C and 28°C 1
• For children, ensure care is developmentally appropriate with facilities to support both the patient and their carers 1

Fluid Management

• Monitor fluid balance carefully and catheterize if clinically indicated 1, 2
• Establish adequate intravenous fluid replacement guided by urine output and other end-point measurements 1, 2
• In severely affected cases, use continuous invasive hemodynamic monitoring through a central or arterial line to guide fluid resuscitation 1
• Avoid overaggressive fluid resuscitation which may cause pulmonary, cutaneous, and intestinal edema 2, 4

Wound Care

• Handle skin carefully to minimize shearing forces and further epidermal detachment 1, 2
• Apply bland emollient frequently to the whole skin to support barrier function, reduce transcutaneous water loss, and encourage re-epithelialization 1
• Consider greasy emollient (50% white soft paraffin with 50% liquid paraffin) over the whole epidermis, including denuded areas 2
• Apply nonadherent dressings (such as Mepitel™ or Telfa™) to denuded dermis 2, 4
• Use secondary foam or burn dressings to collect exudate 2
• Take swabs for bacterial and candidal culture from lesional skin, particularly sloughy areas 2
• Consider a surgical approach involving debridement of detached epidermis followed by wound closure using biosynthetic xenograft or allograft if conservative management fails 1

Infection Prevention and Management

• Monitor for signs of systemic infection (confusion, hypotension, reduced urine output, reduced oxygen saturation) 2, 5
• Do not administer prophylactic systemic antibiotics as this may increase skin colonization, particularly with Candida albicans 2, 1
• Only institute antimicrobial therapy if there are clinical signs of infection 2, 5
• Watch for monoculture of organisms on culture swabs from multiple sites, which indicates increased likelihood of invasive infection 2
• Be aware that septicemia is the most frequent cause of death in TEN 1, 5

Mucosal Care

Ocular Management

• Arrange ophthalmology consultation within 24 hours of diagnosis 2
• Consider amniotic membrane transplantation for severe eye disease 1

Oral Care

• Examine the mouth as part of the initial assessment and conduct daily oral reviews 1
• Apply white soft paraffin ointment to the lips every 2 hours 1
• Use mucoprotectant mouthwash three times daily 1
• Clean the mouth daily with warm saline mouthwashes or an oral sponge 1
• Use an anti-inflammatory oral rinse or spray containing benzydamine hydrochloride every 3 hours 1

Urogenital Care

• Perform early assessment by a vulval specialist for women to consider dilators to prevent vaginal synechiae 1
• Apply white soft paraffin ointment to the urogenital skin and mucosae every 4 hours 1
• Use Mepitel dressings for eroded areas in the vulva and vagina 1
• Consider applying a potent topical corticosteroid ointment once daily to involved, noneroded urogenital surfaces 1
• Catheterize patients to prevent strictures forming in the urethra 1

Nutritional Support

• Assess whether the patient can maintain adequate hydration and nutrition orally 1
• If oral intake is not possible, insert a nasogastric tube and institute nasogastric feeding immediately 1, 4

Pain Management

• Use validated pain assessment tools at least once daily 2
• Administer adequate analgesia using intravenous opioid infusions for those not tolerating oral medication 2
• Consider patient-controlled analgesia where appropriate 2
• Consider sedation or general anesthesia for patient handling, repositioning, and dressing changes 2

Special Considerations for Children

• Children with TEN appear to have lower mortality rates than adults but may have a higher risk of recurrence 1
• In children, TEN is more commonly precipitated by infections rather than drugs 1
• Transfer children with >10% BSA epidermal involvement, relevant comorbidities, or requiring ventilation to a PICU or burn center with on-site PICU 1
• Consider transfer to a specialist center for children with confirmed TEN (>30% skin detachment), SJS/TEN overlap with poor prognostic factors, severe eye disease, or conditions where conservative skin care may be supplemented with a surgical approach 1

Common Pitfalls to Avoid

• Delayed transfer to a specialized unit increases mortality risk 1, 2
• Overaggressive fluid resuscitation can cause complications 2
• Indiscriminate use of prophylactic antibiotics may increase skin colonization 2, 1
• Failure to recognize and treat sepsis, which is the most common cause of death in TEN 1, 5
• Neglecting eye care may result in permanent visual impairment 2