What causes mucosal sloughing during sleep?

Mucosal Sloughing During Sleep: Causes and Clinical Context

Mucosal sloughing during sleep is most commonly caused by severe drug reactions (particularly Stevens-Johnson syndrome/toxic epidermal necrolysis), bullous dermatoses affecting mucosal surfaces, or esophageal conditions like esophagitis dissecans superficialis, rather than normal physiological processes. 1, 2

Primary Pathological Causes

Severe Cutaneous Adverse Reactions (SCAR)

• Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) cause skin and mucosal sloughing covering variable body surface area with erythema, purpura, and epidermal detachment 1
• These reactions involve T-cell immune-directed toxicity leading to full-thickness epidermal necrosis 1
• Mucosal involvement includes oral, ocular, genital, and respiratory tract surfaces 1
• Bronchial mucosal sloughing in TEN can cause life-threatening airway obstruction requiring bronchoscopic aspiration 3

Bullous Dermatoses with Esophageal Involvement

• Pemphigus and pemphigoid can cause sloughing/blistering of esophageal tissues, erythema, erosions, and dislodgement of epithelium during endoscopy (similar to skin Nikolsky's sign) 1
• Lichen planus affecting the esophagus presents with pale, edematous mucosa with peeling/sloughing often upon contact with the endoscope, and thick white exudates 1
• These conditions require upper endoscopy with biopsies for routine H&E staining and direct immunofluorescence 1

Esophagitis Dissecans Superficialis (EDS)

• EDS is characterized by esophageal mucosal sloughing and is associated with medications, chemical irritants, hot drinks, autoimmune diseases, and post-viral states including COVID-19 2
• This benign condition typically resolves without residual pathology and responds to high-dose proton pump inhibitors 2
• Patients present with dysphagia and odynophagia 2

Sleep-Related Physiological Factors That May Contribute

Reduced Protective Mechanisms During Sleep

• During sleep, salivation, swallowing rate, upper esophageal sphincter pressure, and primary esophageal contractions are all markedly reduced 4
• These reductions impair mucosal protection and clearance mechanisms 4
• Gastroesophageal reflux during sleep causes prolonged acid exposure because gravity doesn't assist clearance in the supine position, salivation is decreased, and primary esophageal contractions are infrequent 4, 5

REM Sleep-Specific Changes

• During REM sleep, muscle tone reaches its nadir and upper airway muscles become atonic (except nasal and laryngeal dilators), contributing to autonomic instability 6
• Gastric emptying is faster during REM sleep, which may affect reflux patterns 4

Other Causes of Mucosal Sloughing

Radiation-Induced Changes

• Radiation colitis causes acute mucosal sloughing manifested by diarrhea, mucus discharge, and tenesmus 7
• Up to 25% of patients receiving pelvic radiation develop mild symptoms 7

Infectious and Medication-Related

• Candidal esophagitis presents with whitish nummular lesions and can cause mucosal changes 1
• Medication-induced ulceration (e.g., doxycycline) can cause well-marked esophageal ulcerations 1

Clinical Approach

When to Suspect Serious Pathology

• Recent medication changes, particularly antibiotics, immunosuppressants, or drugs known to cause SCAR reactions 1
• History of bullous dermatoses (pemphigus, pemphigoid, lichen planus) affecting oral, dermatologic, or genital areas 1
• Recent COVID-19 infection or other viral illnesses 2
• Immunosuppression increasing risk of infectious esophagitis 1

Diagnostic Workup

• Total body skin examination with attention to ALL mucous membranes and complete review of systems 1
• Upper endoscopy with biopsies for routine H&E staining; additional biopsies for direct immunofluorescence if bullous dermatoses suspected 1
• Rule out infection with appropriate cultures and brushings 1
• CBC with differential, liver and kidney function tests to assess for systemic involvement 1

Critical Pitfall

Do not assume mucosal sloughing during sleep is a benign or normal finding—it typically indicates significant underlying pathology requiring urgent evaluation, particularly if associated with skin changes, medication use, or systemic symptoms. 1, 2