From the Guidelines
TEN skin infection management should prioritize supportive care, including wound management, fluid replacement, and nutritional support, as outlined in the UK guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults 2016 1.
Key Considerations
- Initial assessment should include a detailed history, physical examination, and investigations such as FBC, U&E, LFT, and skin biopsy 1.
- Patients with >10% BSA epidermal loss should be admitted to a burn centre or ICU with experience in managing SJS/TEN 1.
- Skin management regimen should include strict barrier nursing, regular wound cleansing, and application of a greasy emollient and topical antimicrobial agent as needed 1.
- Fluid replacement should be guided by urine output and other endpoint measurements, with individualized management adjusted daily 1.
- Nutritional support should provide up to 20-25 kcal/kg/day during the catabolic phase and 25-30 kcal/kg/day during the anabolic phase 1.
Wound Care
- Wounds should be cleansed regularly with warmed sterile water or saline, and a greasy emollient applied to the whole epidermis, including denuded areas 1.
- Topical antimicrobial agents should be applied to sloughy areas only, with the choice guided by local microbiological advice 1.
- Nonadherent dressings should be applied to denuded dermis, and a secondary foam or burn dressing used to collect exudate 1.
Infection Management
- Systemic antibiotics should only be administered if there are clinical signs of infection 1.
- Prophylactic systemic antibiotics should be avoided due to the risk of increasing skin colonization with Candida albicans 1.
Multidisciplinary Team (MDT) Involvement
- An MDT should be convened, coordinated by a specialist in skin failure, and including clinicians from intensive care, ophthalmology, and skincare nursing 1.
- The MDT should provide a defined management plan, including supportive care, wound management, and surgical intervention as needed 1.
From the Research
TEN Skin Infection Overview
- Toxic epidermal necrolysis (TEN) is a severe cutaneous adverse drug reaction with a high mortality rate, as reported in studies 2, 3.
- The condition is typically drug-induced and requires early diagnosis and treatment, with the mainstay of treatment involving discontinuation of the offending drug and supportive therapy 3.
Treatment Options
- Intravenous immunoglobulin (IVIg) is widely used as a specific treatment for TEN, although evidence of its benefit is conflicting, as shown in studies 2, 4.
- Corticosteroids have also been used to treat TEN, but their effectiveness is uncertain, with some studies suggesting that combination therapy with IVIg may be more effective 4, 5.
- Other treatment options, such as infliximab, have been reported to be effective in individual cases, but more research is needed to confirm their efficacy 6.
Prognosis and Management
- The severity-of-illness score for TEN (SCORTEN) is a useful tool for predicting mortality and guiding treatment decisions, as demonstrated in studies 2, 4.
- Intensive care unit (ICU) management is often required for patients with TEN, with attention to pain therapy, positioning, and prevention of complications such as infection and kidney failure 6.
- Pharmacogenetic studies have identified a link between human leukocyte antigen allotype and TEN, highlighting the importance of genetic testing in preventing the condition 3.