What is the most common cause of Toxic Epidermal Necrolysis (TEN) in children?

Toxic Epidermal Necrolysis in Children is Most Commonly Related to Infections and Medications, Not Bacteria

In the pediatric population, toxic epidermal necrolysis (TEN) is most commonly related to medications (particularly anticonvulsants and antibiotics) and infections (especially Mycoplasma pneumoniae), not any of the bacterial options listed in the question. 1

Etiology of TEN in Children

• Infections are a common cause of TEN in the pediatric population, with up to 50% of cases triggered by infectious agents 1
• Mycoplasma pneumoniae is particularly significant, accounting for up to 50% of infection-related cases 1
• Herpes simplex virus (HSV) is another important infectious trigger in children 1
• Among medications, anticonvulsants and antibiotics are the most commonly implicated drugs in pediatric TEN 1
• Other medications that can trigger TEN include NSAIDs, paracetamol, and newer anti-cancer medications 1, 2

Distinguishing TEN from Staphylococcal Scalded Skin Syndrome (SSSS)

• TEN must be distinguished from SSSS, which is caused by Staphylococcus aureus exotoxins 3
• The key clinical difference is that TEN typically presents with prominent mucosal involvement (eyes, mouth, nose, genitalia), while SSSS characteristically lacks mucosal involvement 3
• Histologically, TEN shows subepidermal cleavage, whereas SSSS demonstrates intraepidermal cleavage at the granular layer 3
• A skin biopsy or frozen section of a blister roof can definitively distinguish between these conditions 3

Clinical Features and Diagnosis

• TEN is characterized by widespread epidermal necrosis and profound toxic systemic reaction 4
• The condition involves separation of the epidermis at the dermal-epidermal junction of both skin and mucous membranes 4
• TEN exists on a spectrum with Stevens-Johnson Syndrome (SJS), with TEN defined as epidermal detachment greater than 30% BSA 1
• Diagnosis relies on clinical features, detailed medication history, and sometimes skin biopsy 5
• The primary differential diagnosis in children is reactive infectious mucocutaneous eruption, which has disproportionate mucous membrane involvement relative to skin lesions 5

Management Considerations

• Immediate discontinuation of any suspected culprit medication is essential and decreases mortality risk 1
• Children with TEN should be managed in age-appropriate specialist units with an appropriate multidisciplinary team 1
• More extensive cases require management in a specialized dermatology service PICU or a pediatric burn center with on-site PICU 1
• Supportive care focusing on wound management, fluid and electrolyte balance, temperature maintenance, and nutritional support is crucial 4, 6
• Early ophthalmologic consultation is important due to the high frequency of ocular involvement (90% in some series) 6

Prognosis

• Mortality in pediatric TEN appears to be lower than in adults 1
• In one series, despite high rates of infectious complications, all children survived with appropriate management 6
• Long-term morbidities can include keratitis sicca (20%), finger nail deformities (30%), and variegated skin pigment changes (50%) 6
• Recurrence is more common in children (up to 18% of cases), likely because infections, which may recur, are more common triggers than drugs, which can be avoided 1