Toxic Epidermal Necrolysis (TEN) Differential Diagnoses

Updated: Jun 07, 2022
  • Author: Samantha P Jellinek-Cohen, PharmD, BCPS (AQ-ID); Chief Editor: Michael Stuart Bronze, MD  more...
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Diagnostic Considerations

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are considered to be a single disease entity differing in severity. There is debate whether TEN and SJS are part of a spectrum of disorders including erythema multiforme major (EMM); however, it is widely accepted that SJS and TEN are distinct entities differing in etiology, clinical manifestations, histopathology, treatment, and prognosis.

EMM is characterized by typical target lesions (at least 3 concentric rings) with or without blister formation in a symmetric, predominantly acral distribution. In contrast, the skin lesions of SJS and TEN are predominately central (trunk and face), consisting of blisters that arise on erythematous or purpuric macules and involve 2 or more mucosal surfaces.

Histopathologic examination is necessary in differentiating these disorders from other severe bullous skin diseases, including the following [42] :

TEN and SJS are characterized by apoptotic keratinocyte cell death in the epidermis with dermal-epidermal separation that results in bullae formation.

Other problems to be considered in the differential diagnosis of TEN include the following:

  • Cauterization burns
  • Caustic agents
  • Drug reaction with eosinophilia
  • Generalized pustular figurate erythema [44, 45] ; sometimes seen with pustulosis and atypical targetoid erythema multiforme-like plaques with cutaneous sloughing and excoriations with blisters or erosions that may suggest TEN.
  • Generalized bullous fixed eruption [46]
  • Kerosene and paraffin burns

Differential Diagnoses