What is the treatment for toxic epidermal necrolysis?

Treatment of Toxic Epidermal Necrolysis (TEN)

Patients with toxic epidermal necrolysis should be immediately transferred to a burn center or intensive care unit with experience in treating TEN, where supportive care and specialized wound management can be provided by a multidisciplinary team. 1

Initial Assessment and Management

• Immediately identify and discontinue any potential culprit drugs 1
• Calculate SCORTEN within the first 24 hours to predict mortality and guide management intensity 1
• Perform comprehensive assessment including vital signs, body surface area (BSA) affected, and laboratory investigations (FBC, U&E, LFT, glucose, electrolytes) 1
• Take bacterial swabs from lesional skin for culture and sensitivity 1
• Obtain skin biopsy from lesional skin for histopathological confirmation 1

Care Setting

• Patients with >10% BSA epidermal loss should be admitted to a burn center or ICU with experience in treating TEN 1
• Barrier-nurse in a side room controlled for humidity, on a pressure-relieving mattress, with ambient temperature between 25°C and 28°C 1
• Convene a multidisciplinary team led by a specialist in skin failure (dermatology and/or plastic surgery), including clinicians from intensive care, ophthalmology, and specialist skincare nursing 1

Wound Management

Conservative Approach (First-line for all patients)

• Employ strict barrier nursing to reduce nosocomial infections 1
• Minimize shearing forces when moving/positioning the patient (antishear handling) 1
• Regularly cleanse wounds by gently irrigating with warmed sterile water, saline, or dilute chlorhexidine (1/5000) 1
• Apply greasy emollient (50% white soft paraffin with 50% liquid paraffin) over the whole epidermis, including denuded areas 1
• Leave detached epidermis in situ to act as a biological dressing 1
• Decompress blisters by piercing and expression or aspiration of fluid 1
• Apply non-adherent dressings to denuded dermis (e.g., Mepitel™ or Telfa™) 1
• Use secondary foam or burn dressings to collect exudate (e.g., Exu-Dry™) 1
• Apply topical antimicrobial agents only to sloughy areas (consider silver-containing products/dressings) 1
• Administer systemic antibiotics only if there are clinical signs of infection 1

Surgical Approach (Consider in specific circumstances)

• Consider transfer to a burn center for patients with TEN (>30% BSA epidermal loss) with clinical deterioration, extension of epidermal detachment, subepidermal pus, local sepsis, or delayed healing 1
• Remove necrotic/loose infected epidermis and clean wounds using topical antimicrobial agents under general anesthesia 1
• Consider debridement with specialized equipment (e.g., Versajet™) 1
• Apply physiological closure with biosynthetic materials (Biobrane/allograft/xenograft skin) in patients with early presentation involving non-infected and large confluent areas 1

Supportive Care

Fluid Management

• Site venous lines through non-lesional skin whenever possible 1
• Monitor fluid balance carefully; catheterize if appropriate 1
• Establish adequate IV fluid replacement initially, guided by urine output and other end-point measurements 1
• Adjust fluid management daily on an individualized basis 1
• Progressively increase oral fluid administration as mouth involvement improves 1

Nutritional Support

• Provide continuous enteral nutrition throughout the acute phase 1
• Deliver 20-25 kcal/kg daily during the early catabolic phase, and 25-30 kcal/kg daily during recovery 1
• Insert a nasogastric tube and institute feeding immediately if oral intake is inadequate 1

Pain Management

• Use a validated pain assessment tool at least once daily 1
• Provide adequate analgesia to ensure comfort at rest, with supplementary opiates as required 1
• Consider additional analgesia for procedure-related pain 1

Management of Mucosal Involvement

• For oral involvement: clean mouth every 4 hours with saline-soaked gauze, use anti-inflammatory oral rinse (benzydamine hydrochloride), antiseptic rinse (chlorhexidine), and topical corticosteroid mouthwash 1
• For urogenital involvement: apply white soft paraffin ointment every 4 hours, use potent topical corticosteroid ointment once daily on non-eroded surfaces, and silicone dressings on eroded areas 1
• For respiratory involvement: early discussion with intensivist and consideration of fibreoptic bronchoscopy if respiratory symptoms present 1
• For ocular involvement: early ophthalmology consultation is essential 1

Monitoring and Complications

• Monitor for signs of systemic infection (confusion, hypotension, reduced urine output, reduced oxygen saturation) 1
• Be aware that fever from TEN itself can complicate detection of secondary sepsis 1
• Watch for rising C-reactive protein, neutrophilia, or monoculture on previously mixed-growth skin swabs as signs of developing infection 1
• Consider HSV activation in eroded areas that are slow to heal, particularly in genital and oral sites 1
• Sepsis is the most common cause of death in TEN and requires prompt intervention 1, 2

Follow-up Care

• Provide written information about drugs to avoid 1
• Encourage wearing a MedicAlert bracelet 1
• Document drug allergy in patient's notes and inform all doctors involved in care 1
• Report the episode to national pharmacovigilance authorities 1
• Arrange dermatology and ophthalmology follow-up appointments within weeks of discharge 1

Prognosis and Risk Factors

• Mortality is strongly influenced by age, comorbidities, and extent of skin involvement 2
• Genetic predispositions (certain HLA types) increase risk with specific medications 2, 3
• Delayed transfer to specialized care is associated with increased mortality 1, 4