eMedicine Specialties > Infectious Diseases > Skin and Soft-Tissue Infections

Toxic Epidermal Necrolysis: Follow-up

Author: Victor Cohen, PharmD, Clinical Pharmacy Manager, Department of Emergency Medicine, Maimonides Medical Center, Assistant Professor, Division of Pharmacy Practice, Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University
Coauthor(s): Samantha P Jellinek, PharmD, BCPS, Clinical Coordinator of Pharmacy Practice Residency Program, Manager of Medication Reconciliation and Safety, Maimonides Medical Center; Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Contributor Information and Disclosures

Updated: Feb 12, 2009

Follow-up

Further Inpatient Care

  • Plasmapheresis may enhance elimination of the agent or agents responsible for toxic epidermal necrolysis (TEN).12
  • Place the patient in a warm environment to enhance reepithelialization. Avoid dehydration.
  • Blood transfusion may be needed if anemia occurs.
  • Anti-TNF-α treatment has been reported to rapidly resolve skin lesions due to toxic epidermal necrolysis. TNF-α is strongly expressed in keratinocytes and macrophages of lesional skin, and high concentrations are found in cutaneous blister fluid.

Further Outpatient Care

  • Avoid exposure to the causative agent by ensuring that all health care team members are aware of the initial reaction.
  • Cross-reactivity may occur with agents that chemically resemble the causative agent.

Transfer

  • Most patients with toxic epidermal necrolysis require transfer to a burn or intensive care unit, with specialized consultation by dermatologists, pulmonologists, gastroenterologists, plastic surgeons, and others with advanced knowledge.

Deterrence/Prevention

  • Educate patients about which substances to avoid.

Complications

  • Complications of toxic epidermal necrolysis include stomatitis and mucositis, which are painful and hinder oral intake; therefore, patients with these complications are at risk for dehydration and malnutrition.
  • Cutaneous complications of toxic epidermal necrolysis include the following:
    • Bacterial wound infections
    • Changes in skin pigment (hypopigmentation or hyperpigmentation) (Sun exposure must be avoided for several months because ultraviolet light can worsen hyperpigmentation. Sunblock is recommended.)
    • Nail loss and nail dystrophy
    • Hypohidrosis (inability to sweat)
    • Scarring, alopecia, and hypertrophic scarring
    • Dermal desiccation, causing deep dermal wounds
  • Mucosal complications: Barrera and colleagues (1998) reported a case of hypopharyngeal stenosis and dysphagia with recurrent aspiration.14 Toxic epidermal necrolysis occurred after the patient ingested naproxen sodium (Aleve) and aspirin. Other complications include the following:
  • A study by Power and colleagues (1995) found that 50% of patients with toxic epidermal necrolysis developed ocular complications.15 Patients treated with steroids fared no better than those treated without steroids. Therefore, toxic epidermal necrolysis remains a common cause of visual loss in a significant number of patients. Complications include the following:
    • Conjunctivitis, ranging from mild hyperemia to purulent, crusting, or ulcerative conjunctivitis is usually painful and may result in formation of a pseudomembrane.
    • Photophobia may occur.
    • Ectropion or entropion with subsequent trichiasis may occur.
    • Symblepharon formation may occur.
    • Vascularization of the cornea may occur.
    • Corneal opacities, punctate corneal lesions, corneal ulcerations, and scarring have also been observed. Note that corticosteroid ophthalmologic drops are not effective in preventing the activity of corneal lesions.
    • Chronic dry eyes are a complication of scar formation in the conjunctiva and the resultant lacrimal duct destruction. These patients are no longer able to produce tears. Artificial tears and lubricants are often prescribed.
    • Ankylo-symblepharon results in conjunctival scarring and destruction, which causes complete fusion of the eyelids and leads to blindness.
    • Ultimately, 5-9% of patients can become blind as a result of some of these complications.
  • Pulmonary complications may occur. Mucous retention and sloughing of tracheobronchial mucosa may occur, with aspiration of mucosal debris. Pneumonia and pneumonitis are common and sometimes fatal complications of toxic epidermal necrolysis.
  • Hematologic complications: Leukopenia is common, whether a result of toxic epidermal necrolysis itself or of a bacteremia, as is a normochromic normocytic anemia. Less often, thrombocytopenia, neutropenia, and bandemia may occur.
  • Sepsis: This can be a disastrous complication, causing more than 50% of deaths in individuals with toxic epidermal necrolysis.
  • Miscellaneous complications include hypovolemia, massive gut bleeding, and pulmonary emboli.

Prognosis

  • Age, area of necrosis, and serum urea level are said to be the most important prognostic factors in toxic epidermal necrolysis.16 Elderly patients have a poor prognosis.
  • Other major prognostic factors include the following: 
    • Extent of necrolysis
    • Elevated serum blood urea nitrogen and creatinine levels
    • Respiratory failure
    • Multiple drugs
    • Thrombocytopenia
    • Lymphopenia
    • Neutropenia
    • Leukopenia
    • Sepsis

Patient Education

  • Counsel patients on what drugs they cannot take.
  • Genetic factors are suspected in drug-induced blistering disorders, and blood relatives of the patient should not use the suspected drug.
  • Patients must call a pharmacist whenever they start a new prescription.
  • For excellent patient education resources, visit eMedicine's Skin, Hair, and Nails Center. Also, see eMedicine's patient education article Life-Threatening Skin Rashes.

Miscellaneous

Medicolegal Pitfalls

  • Failure to warn patients that an agent that induced a previous episode of toxic epidermal necrolysis may also be used in a combination product is a potential pitfall. For example, a patient with a history of toxic epidermal necrolysis induced by a sulfonamide may not know that one component of Bactrim is a sulfonamide.
  • Not recognizing the severity of disease
  • Failure to withdraw the causative agent in time
  • Failure to treat the patient with antibiotics when indicated
  • Failure to monitor hemodynamics effectively
  • Prescribing an agent that is structurally similar to the agent that caused the original toxic epidermal necrolysis reaction
  • Failure to institute anticoagulation for prevention of thromboembolism
 


More on Toxic Epidermal Necrolysis

Overview: Toxic Epidermal Necrolysis
Differential Diagnoses & Workup: Toxic Epidermal Necrolysis
Treatment & Medication: Toxic Epidermal Necrolysis
Follow-up: Toxic Epidermal Necrolysis
Multimedia: Toxic Epidermal Necrolysis
References
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References

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Further Reading

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Keywords

toxic epidermal necrolysis, TEN, toxic epidermal necrosis, acute disseminated epidermal necrosis, acute skin failure, Lyell syndrome, Lyell’s syndrome, Stevens-Johnson syndrome, SJS-TEN

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Contributor Information and Disclosures

Author

Victor Cohen, PharmD, Clinical Pharmacy Manager, Department of Emergency Medicine, Maimonides Medical Center, Assistant Professor, Division of Pharmacy Practice, Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University
Victor Cohen, PharmD is a member of the following medical societies: American Association of Colleges of Pharmacy, American College of Clinical Pharmacy, American Society of Health-System Pharmacists, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Samantha P Jellinek, PharmD, BCPS, Clinical Coordinator of Pharmacy Practice Residency Program, Manager of Medication Reconciliation and Safety, Maimonides Medical Center
Samantha P Jellinek, PharmD, BCPS is a member of the following medical societies: American College of Clinical Pharmacy and American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Fred A Lopez, MD, Associate Professor and Vice Chair, Department of Medicine, Assistant Dean for Student Affairs, Louisiana State University School of Medicine
Fred A Lopez, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, Infectious Diseases Society of America, and Louisiana State Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Charles V Sanders, MD, Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine at New Orleans; Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans; Consulting Staff, Ochsner Medical Center
Charles V Sanders, MD is a member of the following medical societies: Alliance for the Prudent Use of Antibiotics, Alpha Omega Alpha, American Association for the Advancement of Science, American Association of University Professors, American Clinical and Climatological Association, American College of Physician Executives, American College of Physicians, American Federation for Medical Research, American Foundation for AIDS Research, American Geriatrics Society, American Lung Association, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Association for Professionals in Infection Control and Epidemiology, Association of American Medical Colleges, Association of American Physicians, Association of Professors of Medicine, Infectious Disease Society for Obstetrics and Gynecology, Infectious Diseases Society of America, Louisiana State Medical Society, Orleans Parish Medical Society, Royal Society of Medicine, Sigma Xi, Society of General Internal Medicine, Southeastern Clinical Club, Southern Medical Association, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD, Professor, Stewart G Wolf Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center
Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Association of Professors of Medicine, Association of Program Directors in Internal Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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