What is the management of Toxic Epidermal Necrolysis (TEN)?

Management of Toxic Epidermal Necrolysis (TEN)

Patients with Toxic Epidermal Necrolysis should be immediately transferred to a burn center or ICU with experience treating TEN and facilities to manage extensive skin loss wound care, as this is critical for reducing mortality. 1, 2

Initial Assessment and Management

• Calculate SCORTEN within the first 24 hours of admission to predict mortality risk and guide management intensity 2, 1
• Immediately discontinue any potential culprit drug (common triggers include allopurinol, carbamazepine, lamotrigine, nevirapine, oxicam NSAIDs, phenobarbital, phenytoin, and sulfonamides) 2, 3
• Document all medications taken over the previous 2 months, including over-the-counter preparations 2
• Transfer patients with >10% body surface area (BSA) epidermal detachment to a specialized burn unit or ICU without delay 2, 1

Multidisciplinary Approach

• Care should be coordinated by a specialist in skin failure (dermatology/plastic surgery) 2
• Include clinicians from intensive care, ophthalmology, and specialist skincare nursing 2
• Arrange ophthalmology consultation within 24 hours of diagnosis to prevent permanent visual impairment 1
• Consider additional input from respiratory medicine, gastroenterology, gynecology, urology, oral medicine, microbiology, pain team, dietetics, physiotherapy, and pharmacy as needed 2

Supportive Care

Environmental Management

• Place patient in a side room controlled for humidity 2
• Use a pressure-relieving mattress to prevent further skin damage 2
• Raise ambient temperature to between 25°C and 28°C to prevent hypothermia 2

Fluid Management

• Monitor fluid balance carefully and catheterize if clinically indicated 2
• Establish adequate intravenous fluid replacement guided by urine output and other end-point measurements 2
• Avoid overaggressive fluid resuscitation which may cause pulmonary, cutaneous, and intestinal edema 1

Nutrition Support

• Provide continuous enteral nutrition throughout the acute phase 2
• Deliver 20–25 kcal/kg daily during the early, catabolic phase, and 25–30 kcal/kg daily during recovery 2

Wound Care Protocol

• 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 (1/5000) 2
• Apply 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
• Use secondary foam or burn dressings to collect exudate 2
• Take swabs for bacterial and candidal culture from three areas of lesional skin, particularly sloughy areas, on alternate days 2

Infection Management

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

Pain Management

• Use validated pain assessment tools at least once daily 2
• Provide adequate analgesia to ensure comfort at rest, with supplementary opiates as required 2
• Consider patient-controlled analgesia where appropriate 1
• Consider sedation or general anesthesia for patient handling, repositioning, and dressing changes 1

Specific Therapies

• Consider cyclosporine as a potential treatment option under specialist supervision 1
• Evidence for systemic corticosteroids, intravenous immunoglobulin (IVIg), and other immunomodulatory therapies remains inconsistent 2, 4
• The decision to use specific therapies should be made by the specialist multidisciplinary team based on individual patient factors 2

Discharge Planning and Follow-up

• Provide written information about drug(s) to avoid and related medications that may cross-react 2
• Encourage wearing a MedicAlert bracelet and document drug allergy in patient's notes 1
• Report the adverse drug reaction to pharmacovigilance authorities 2
• Arrange follow-up with dermatology and ophthalmology within weeks of discharge 1
• Prepare patients for potential fatigue and lethargy for several weeks following discharge 2
• Monitor for potential long-term complications affecting the eyes, skin, and other organ systems 2

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 TEN 1, 4
• Neglecting eye care may result in permanent visual impairment 1