Toxic Epidermal Necrolysis Medication
- Author: Victor Cohen, PharmD; Chief Editor: Michael Stuart Bronze, MD more...
Medication Summary
The goals of pharmacotherapy in toxic epidermal necrolysis (TEN) are to reduce morbidity and to prevent complications. No specific treatment modality has been proven effective, but agents such as crystalloids, antibiotics, antihistamines, anticoagulants, analgesics, and antiseptic agents are important for supportive care. Use of corticosteroids is controversial.
Crystalloids
Class Summary
Fluid resuscitation is critical in TEN. In cases of acute skin failure, insensible losses may be enormous, and repletion of water loss is essential.
Isotonic sodium chloride 0.9%
Patients with TEN are at serious risk of dehydration, which may complicate their condition. For example, water losses in a hypercatabolic state result in hypoalbuminemia and reduced renal perfusion. This leads to acute renal failure; therefore, maintaining intravascular volume is paramount. The rate of intravenous repletion should be titrated based on urine output or central venous pressure.
Antibiotics
Class Summary
Patients with TEN lose their epidermis, a major barrier to invading organisms. If patients become infected, morbidity is enhanced. Staphylococcus aureus is the main bacteria present during the first days, with gram-negative strains appearing later.
Case reports of Klebsiella species,[35] Escherichia coli, and Pseudomonas species recovered from patients with TEN have created concern about the possible polymicrobial nature of sepsis associated with this condition. Therefore, good gram-negative coverage may be necessary.
Nafcillin
Nafcillin covers most common skin organisms (eg, Staphylococcus, Streptococcus). If patient has allergy to penicillin or if methicillin-resistant S aureus (MRSA) is present on skin culture, use vancomycin.
Gentamicin
Gentamicin is an aminoglycoside antibiotic for gram-negative coverage. It is used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Third-generation cephalosporins, such as ceftazidime, and others with good gram-negative coverage are suitable alternatives. Adjust dose based on renal insufficiency.
Antihistamines
Class Summary
Hydroxyzine may be used when reepithelialization begins because intense pruritus may occur.
Hydroxyzine (Vistaril)
Hydroxyzine antagonizes H1 receptors in the periphery. It may suppress histamine activity in subcortical region of the central nervous system.
Anticoagulants
Class Summary
Heparin is indicated for prophylaxis of thromboembolic events. Patients with TEN remain nonambulatory until skin begins to heal, and until that time, anticoagulant therapy is imperative.
Heparin
Heparin augments activity of antithrombin III and prevents conversion of fibrinogen to fibrin. It does not actively lyse thrombus but is able to inhibit further thrombogenesis. Heparin prevents reaccumulation of clot after spontaneous fibrinolysis. It is indicated for the prevention of thromboembolic events.
Analgesics
Class Summary
Opiate analgesics are important to alleviate pain and anxiety associated with TEN. Much like treatment of a second-degree burn, the pain must not be ignored.
Morphine sulfate (Duramorph, Astramorph, MS Contin)
Morphine is the drug of choice for pain in patients with TEN. In case of allergy or intolerability, meperidine or fentanyl may be used.
Fentanyl Citrate ( Fentora, Abastral, Duragesic)
A synthetic opioid analgesic that is primarily a mu receptor agonist, fentanyl is 50-100 times more potent than morphine. It has short duration of action (1-2 h) and minimal cardiovascular effects, such as hypotension. Respiratory depression is uncommon, but this effect lasts longer than its analgesic effect. Fentanyl is frequently used in patient-controlled analgesia for relief of pain. Unlike morphine, fentanyl is not commonly associated with histamine release.
Meperidine (Demerol)
Meperidine is a synthetic opioid narcotic analgesic indicated for the relief of severe pain. This analgesic has multiple actions similar to those of morphine. However, meperidine may produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine.
Antiseptics
Class Summary
These agents inhibit growth of gram-positive and gram-negative bacteria.
Chlorhexidine gluconate (PerioGard, Peridex, Hibiclens, Avagard)
Chlorhexidine binds to negatively charged bacterial cell walls and extramicrobial complexes. It has bacteriostatic and bactericidal effects.
Topical Anesthetics
Class Summary
Topical anesthetics can be applied to mucous membranes, especially buccal, to relieve pain.
Benzocaine (Americaine, Anbesol, Chiggerex Plus)
Benzocaine inhibits neuronal membrane depolarization, blocking nerve impulses. It provides oral or mucosal anesthesia, thereby controlling pain.
Corticosteroids
Class Summary
While corticosteroids may be used, their use is highly controversial. Although high-dose corticosteroids used early in the course of TEN (within 24-48 hours of onset) may halt the progression of the reaction, many experts believe that corticosteroids should not be used because they predispose patients to infection, mask early signs of sepsis, encourage GI bleeding, and impair or delay wound healing.
If corticosteroids are used, the initial high dose is titrated down as quickly as possible and tapered off, usually over 7-10 days.
Dexamethasone (Baycadron)
Dexamethasone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability. Other corticosteroids, such as methylprednisolone, prednisone, and hydrocortisone, also may be used.
Methylprednisolone (Solu-Medrol, Medrol, A-Methapred)
Methylprednisolone is a highly potent synthetic glucocorticoid that causes diverse metabolic effects and modifies the body's immune responses to various stimuli.
Prednisone
Prednisone, a synthetic glucocorticoid analog, acts as a potent immunosuppressant. It May inhibit cyclooxygenase, which, in turn, inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Hydrocortisone (A-Hydrocort, Solu-Cortef, Cortef)
Hydrocortisone elicits anti-inflammatory properties and causes profound and varied metabolic effects. This agent modifies the body's immune response to diverse stimuli.
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