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Dermatologic Manifestations of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

  • Author: Daniel L Croom, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Dec 06, 2015
 

Overview

The dermatologic manifestations of either toxic epidermal necrolysis or Stevens-Johnson syndrome may constitute a true emergency. Toxic epidermal necrolysis, an acute disorder, is characterized by widespread erythematous macules and targetoid lesions; full-thickness epidermal necrosis, at least focally; and involvement of more than 30% of the cutaneous surface. Commonly, the mucous membranes are also involved. Nearly all cases of toxic epidermal necrolysis are induced by medications, and the mortality rate can approach 40%.[1]

Manifestations of Stevens-Johnson syndrome include purpuric macules and targetoid lesions; full-thickness epidermal necrosis, although with lesser detachment of the cutaneous surface; and mucous membrane involvement. As with toxic epidermal necrolysis, medications are important inciting agents, although Mycoplasma infections may induce some cases. The mortality rate is much lower than in toxic epidermal necrolysis, approaching 5% of cases.

The prognosis in these diseases is largely a function of the degree of skin sloughing. As the percentage of skin sloughing increases, the mortality rate dramatically worsens. For unknown reasons, however, the disease process in some patients simply stops progressing, and rapid epithelialization ensues. For patients experiencing sloughing over a large area of their skin surface, the mortality rate is much higher. (See the images below.)

Note early cutaneous slough with areas of violaceo Note early cutaneous slough with areas of violaceous erythema.
Extensive sloughing on the face. Extensive sloughing on the face.
Extensive sloughing on the back. Extensive sloughing on the back.

Together, Stevens-Johnson syndrome and toxic epidermal necrolysis may represent a spectrum of a single disease process. Stevens-Johnson syndrome may also have features of the dermatologic condition erythema multiforme (which has led to confusion in nosology).

Treatment

Only early transfer to and care in a burn unit has been demonstrated to decrease mortality. Coupled with early withdrawal of offending agents, this intervention is the best treatment that can be offered at this time.[2, 3]

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Patient History and Physical Examination

Constitutional symptoms, such as fever, cough, or sore throat, may appear 1-3 days prior to any cutaneous lesions. Patients may complain of a burning sensation in their eyes, photophobia, and a burning rash that begins symmetrically on the face and the upper part of the torso. Delineation of a drug exposure timeline is essential, especially in the 1-3 weeks preceding the cutaneous eruption.

Primary lesions

The initial skin lesions of Stevens-Johnson syndrome/toxic epidermal necrolysis are poorly defined, erythematous macules with darker, purpuric centers. The lesions differ from classic target lesions of erythema multiforme by having only 2 zones of color: a central, dusky purpura or a central bulla, with a surrounding macular erythema. A classic target lesion has 3 zones of color: a central, dusky purpura or a central bulla; a surrounding pale, edematous zone; and a surrounding macular erythema. (See the image below.)

Note the presence of both 2-zoned atypical targeto Note the presence of both 2-zoned atypical targetoid lesions and bullae.

Lesions, with the exception of central bullae, are typically flat. (Lesions of erythema multiforme are more likely to be palpable.) Less frequently, the initial eruption may be scarlatiniform. Flaccid blisters are typically present with full-thickness epidermal necrosis. (See the images below.)

Extensive blistering and sloughing on the back. Extensive blistering and sloughing on the back.
Low-power view showing full-thickness epidermal ne Low-power view showing full-thickness epidermal necrosis.

Nondenuded areas have a wrinkled paper appearance. A Nikolsky sign is easily demonstrated by applying lateral pressure to a bulla. With regard to the arrangement of lesions, individual macules are found surrounding large areas of confluence. (See the image below.)

Note extensive sloughing. Note extensive sloughing.

Distribution

Lesions begin symmetrically on the face and the upper part of the torso and extend rapidly, with maximal extension in 2-3 days. In some cases, maximal extension can occur rapidly over hours. Lesions may predominate in sun-exposed areas.

Full detachment is more likely to occur in areas subjected to pressure, such as the shoulders, the sacrum, or the buttocks. Painful, edematous erythema may appear on the palms and the soles. The hairy scalp typically remains intact, but the entire epidermis, including the nail beds, may be affected. (See the image below.)

Sheetlike desquamation on the foot in a patient wi Sheetlike desquamation on the foot in a patient with toxic epidermal necrolysis. Courtesy of Robert Schwartz, MD.

A classification proposes that epidermal detachment in Stevens-Johnson syndrome is limited to less than 10% of the body surface area (BSA). Overlapping Stevens-Johnson syndrome/toxic epidermal necrolysis has more extensive confluence of erythematous and purpuric macules, leading to epidermal detachment of 10-30% of the BSA. Classic toxic epidermal necrolysis has epidermal detachment of more than 30%.

An uncommon form of toxic epidermal necrolysis (toxic epidermal necrolysis without spots) lacks targetoid lesions, and blisters form on confluent erythema. Greater than 10% epidermal detachment is required for diagnosis of these cases.

In contrast, bullous erythema multiforme, which was previously grouped with Stevens-Johnson syndrome, may have epidermal detachment of less than 10% of the BSA, but typical target lesions or raised atypical targets are localized primarily in an acral distribution.

Areas of denuded epidermis in Stevens-Johnson syndrome/toxic epidermal necrolysis are dark red with an oozing surface. Mucous membrane involvement is present in nearly all patients and may precede skin lesions, appearing during the prodrome.

Additional findings

Other findings in Stevens-Johnson syndrome/toxic epidermal necrolysis include the following:

  • Painful oral erosions cause severe crusting of the lips, increased salivation, and impaired alimentation
  • Lesions have been reported in the oropharynx, tracheobronchial tree, esophagus, gastrointestinal tract, genitalia, and anus
  • Involvement of the genitalia may lead to painful micturition
  • Intact expectorated cylindrical casts of bronchial epithelium have been reported
  • Patients may develop a profuse, protein-rich diarrhea
  • Internal involvement is not necessarily limited to patients with extensive cutaneous involvement

Ocular lesions are especially problematic because they have a high risk of sequelae. Initially, the conjunctivae are erythematous and painful. The lids are often stuck together, with efforts to loosen them resulting in tearing of the epidermis. Pseudomembranous conjunctival erosions may form synechiae between the eyelids and the conjunctivae. Keratitis, corneal erosions, and a siccalike syndrome may develop.

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Pharmacologic Therapy

Corticosteroid therapy

The use of corticosteroids in the management of the Stevens-Johnson syndrome/toxic epidermal necrolysis spectrum is one of the most controversial areas in Dermatology. Administration early in the course of disease has been advocated, but multiple retrospective studies demonstrate no benefit or higher rates of morbidity and mortality related to sepsis. This risk is probably proportional to the area of sloughed skin.

Halebian et al advised against the use of steroids based on 2 open, nonrandomized prospective studies of corticosteroids in 30 patients admitted to a burn unit with Stevens-Johnson syndrome or toxic epidermal necrolysis.[4] Fifteen patients received corticosteroids and 15 did not. The groups were statistically similar in terms of age, morbid days before burn center admission, and the amount of skin sloughed. Thirty-three percent of the steroid group survived, versus 66% of the nonsteroid group. Sepsis occurred with similar frequency in both groups, but 91% of patients with sepsis in the steroid group died, versus 56% of the infected patients in the nonsteroid group.

Steroids are suggested to predispose patients to gram-negative sepsis by impairing host resistance and by ultimately leading to late clinical recognition of sepsis through suppression of symptoms. Because multiple studies, albeit uncontrolled, have demonstrated a higher morbidity and mortality in patients receiving corticosteroids, most authorities do not recommend their use.

Intravenous immunoglobulin

The use of intravenous immunoglobulin (IVIG) has been studied in the treatment of toxic epidermal necrolysis with mixed results. Viard et al suggested that keratinocyte apoptotic cell death occurs via activation of a cell-surface death receptor by Fas ligand (FasL).[5] In vitro, target cell death was blocked by a receptor-ligand blocking antibody and by antibodies present in pooled human IVIG.  An open trial of IVIG in 10 patients with toxic epidermal necrolysis resulted in a halt of progression within 24-48 hours, with no mortality. Subsequent studies in the early 2000s would substantiate this benefit. A review by French et al in 2006 highlighted eight studies, six of which demonstrated a benefit for IVIG.[6] Analysis suggested a possible dose dependence with a trend towards a benefit for IVIG at doses larger than 2 g/kg on the mortality of toxic epidermal necrolysis.

Further analysis, however, has brought into question the proposed therapeutic mechanism and clinical benefit of IVIG therapy. An in vitro study suggested granulysin, not FasL, is the key cytotoxic molecule leading to keratinocyte cell death, raising the possibility of a new therapeutic target.[7] Clinical studies have also shown mixed benefit. In 2012, Huang et al performed a meta-analysis of 17 clinical studies containing at least eight patients to assess the efficacy of IVIG in toxic epidermal necrolysis.[8] While 12 of 17 of these studies concluded IVIG was effective in the treatment of toxic epidermal necrolysis, meta-analysis did not support a clinical benefit of IVIG. However, this analysis did suggest high-dose IVIG exhibited a trend towards improved mortality. A subsequent meta-analysis in 2015 by Barron supported a decrease in mortality at IVIG doses greater than 2 g/kg.[9] While these analyses support a dose-dependent benefit, it should be noted that conflicting data regarding dose dependence exist, including a retrospective, noncontrolled study of 64 patients treated with IVIG, which demonstrated no mortality benefit between patients receiving high- (>3 g/kg) or low-dose (<3 g/kg) IVIG.[10]

Given the potentially fatal nature of toxic epidermal necrolysis and the ethical issues involved, a randomized, controlled trial will likely never be performed. Given the suggestion of a therapeutic benefit, many centers are incorporating IVIG into their treatment protocols.

Cyclosporine

An open study from the trauma literature demonstrated the efficacy of cyclosporine in the treatment of toxic epidermal necrolysis. Arevalo et al presented 11 patients admitted consecutively to a burn unit, with toxic epidermal necrolysis involving a large BSA (83% ± 17%).[11] Each patient received 3 mg/kg of cyclosporine daily, with the drug administered enterally every 12 hours. This group was compared to a series of six historical control subjects treated with cyclophosphamide and corticosteroids. In the study, the time from the onset of skin signs to arrest of disease progression and to complete reepithelialization was significantly shorter in the cyclosporine group. All patients in the cyclosporine group survived versus 50% surviving in the cyclophosphamide group.

An open-label phase II trial of adults and a retrospective chart review of patients with Stevens-Johnson syndrome/toxic epidermal necrolysis treated with cyclosporine have also demonstrated a decrease in death and the progression of detachment in adults.[12, 13]

Given a mortality rate of approximately 30% in patients not infected with human immunodeficiency virus (HIV) with toxic epidermal necrolysis, cyclosporine may prove to be a life-saving therapy, but randomized, controlled trials are needed to make definitive recommendations.

Other medications

The tumor necrosis factor-alpha (TNF-a)‒blocking agent etanercept has demonstrated promising results in case reports and a case series. A single subcutaneous injection of 50 mg of etanercept was administered to 10 patients with toxic epidermal necrolysis, resulting in prompt response in all patients with a median time to healing of 8.5 days.[14]

Cyclophosphamide, N-acetylcysteine, and monoclonal antibodies directed against cytokines have been used in isolated case reports and in small, uncontrolled studies. Thalidomide has been shown to have a deleterious effect on patients' outcomes.[15]

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Contributor Information and Disclosures
Author

Daniel L Croom, MD Undersea Medical Officer, Naval Special Warfare Center

Disclosure: Nothing to disclose.

Coauthor(s)

Kristina Marie Dela Rosa, MD Dermatologist, Naval Hospital Camp Pendleton

Kristina Marie Dela Rosa, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Jeffrey P Callen, MD Professor of Medicine (Dermatology), Chief, Division of Dermatology, University of Louisville School of Medicine

Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, American College of Rheumatology

Disclosure: Received income in an amount equal to or greater than $250 from: XOMA; Biogen/IDEC; Novartis; Janssen Biotech, Abbvie, CSL pharma<br/>Received honoraria from UpToDate for author/editor; Received honoraria from JAMA Dermatology for associate editor and intermittent author; Received royalty from Elsevier for book author/editor; Received dividends from trust accounts, but I do not control these accounts, and have directed our managers to divest pharmaceutical stocks as is fiscally prudent from Stock holdings in various trust accounts include some pharmaceutical companies and device makers for i inherited these trust accounts; for: Celgene; Pfizer; 3M; Johnson and Johnson; Merck; Abbott Laboratories; AbbVie; Procter and Gamble; Amgen.

Peter A Klein, MD Associate Professor, Department of Dermatology, University Hospital, State University of New York at Stony Brook

Disclosure: Nothing to disclose.

James J Nordlund, MD Professor Emeritus, Department of Dermatology, University of Cincinnati College of Medicine

James J Nordlund, MD is a member of the following medical societies: American Academy of Dermatology, Sigma Xi, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Acknowledgements

The view(s) expressed herein are those of the authors and do not reflect the official policy or position of Naval Special Warfare Center, the U.S. Navy Medical Department, the U.S. Navy Office of the Surgeon General, the Department of the Navy, Department of Defense, or the U.S. Government.

References
  1. Halevy S, Ghislain PD, Mockenhaupt M, Fagot JP, Bouwes Bavinck JN, Sidoroff A. Allopurinol is the most common cause of Stevens-Johnson syndrome and toxic epidermal necrolysis in Europe and Israel. J Am Acad Dermatol. 2008 Jan. 58(1):25-32. [Medline].

  2. Garcia-Doval I, LeCleach L, Bocquet H, Otero XL, Roujeau JC. Toxic epidermal necrolysis and Stevens-Johnson syndrome: does early withdrawal of causative drugs decrease the risk of death?. Arch Dermatol. 2000 Mar. 136(3):323-7. [Medline].

  3. Guegan S, Bastuji-Garin S, Poszepczynska-Guigne E, Roujeau JC, Revuz J. Performance of the SCORTEN during the first five days of hospitalization to predict the prognosis of epidermal necrolysis. J Invest Dermatol. 2006 Feb. 126(2):272-6. [Medline].

  4. Halebian PH, Corder VJ, Madden MR, Finklestein JL, Shires GT. Improved burn center survival of patients with toxic epidermal necrolysis managed without corticosteroids. Ann Surg. 1986 Nov. 204(5):503-12. [Medline].

  5. Viard I, Wehrli P, Bullani R, et al. Inhibition of toxic epidermal necrolysis by blockade of CD95 with human intravenous immunoglobulin. Science. 1998 Oct 16. 282(5388):490-3. [Medline].

  6. French LE, Trent JT, Kerdel FA. Use of intravenous immunoglobulin in toxic epidermal necrolysis and Stevens-Johnson syndrome: our current understanding. Int Immunopharmacol. 2006 Apr. 6(4):543-9. [Medline].

  7. Chung WH, Hung SI, Yang JY, Su SC, Huang SP, Wei CY, et al. Granulysin is a key mediator for disseminated keratinocyte death in Stevens-Johnson syndrome and toxic epidermal necrolysis. Nat Med. 2008 Dec. 14 (12):1343-50. [Medline].

  8. Huang YC, Li YC, Chen TJ. The efficacy of intravenous immunoglobulin for the treatment of toxic epidermal necrolysis: a systematic review and meta-analysis. Br J Dermatol. 2012 Aug. 167 (2):424-32. [Medline].

  9. Barron SJ, Del Vecchio MT, Aronoff SC. Intravenous immunoglobulin in the treatment of Stevens-Johnson syndrome and toxic epidermal necrolysis: a meta-analysis with meta-regression of observational studies. Int J Dermatol. 2015 Jan. 54 (1):108-15. [Medline].

  10. Lee HY, Lim YL, Thirumoorthy T, Pang SM. The role of intravenous immunoglobulin in toxic epidermal necrolysis: a retrospective analysis of 64 patients managed in a specialized centre. Br J Dermatol. 2013 Dec. 169 (6):1304-9. [Medline].

  11. Arevalo JM, Lorente JA, Gonzalez-Herrada C, Jimenez-Reyes J. Treatment of toxic epidermal necrolysis with cyclosporin A. J Trauma. 2000 Mar. 48(3):473-8. [Medline].

  12. Valeyrie-Allanore L, Wolkenstein P, Brochard L, Ortonne N, Maître B, Revuz J, et al. Open trial of ciclosporin treatment for Stevens-Johnson syndrome and toxic epidermal necrolysis. Br J Dermatol. 2010 Oct. 163 (4):847-53. [Medline].

  13. Kirchhof MG, Miliszewski MA, Sikora S, Papp A, Dutz JP. Retrospective review of Stevens-Johnson syndrome/toxic epidermal necrolysis treatment comparing intravenous immunoglobulin with cyclosporine. J Am Acad Dermatol. 2014 Nov. 71 (5):941-7. [Medline].

  14. Paradisi A, Abeni D, Bergamo F, Ricci F, Didona D, Didona B. Etanercept therapy for toxic epidermal necrolysis. J Am Acad Dermatol. 2014 Aug. 71 (2):278-83. [Medline].

  15. Wolkenstein P, Latarjet J, Roujeau JC, et al. Randomised comparison of thalidomide versus placebo in toxic epidermal necrolysis. Lancet. 1998 Nov 14. 352(9140):1586-9. [Medline].

 
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Note early cutaneous slough with areas of violaceous erythema.
Extensive sloughing on the face.
Note the presence of both 2-zoned atypical targetoid lesions and bullae.
Extensive blistering and sloughing on the back.
Extensive sloughing on the back.
Sheetlike desquamation on the foot in a patient with toxic epidermal necrolysis. Courtesy of Robert Schwartz, MD.
Note extensive sloughing.
Low-power view showing full-thickness epidermal necrosis.
 
 
 
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