Sections

Sections Toxic Epidermal Necrolysis (TEN)
Overview
Presentation
DDx
Workup
Treatment
Guidelines
Medication
Questions & Answers
Media Gallery
References

Medication

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.

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.

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 bacterium present during the first days, with gram-negative strains appearing later.

Case reports of Klebsiella species,^[65]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

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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

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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.

Class Summary

Hydroxyzine may be used when reepithelialization begins because intense pruritus may occur.

Hydroxyzine (Vistaril)

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Hydroxyzine antagonizes H1 receptors in the periphery. It may suppress histamine activity in subcortical region of the central nervous system.

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

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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.

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)

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Morphine is the drug of choice for pain in patients with TEN. In case of allergy or intolerability, fentanyl may be used.

Fentanyl Citrate ( Fentora, Abastral, Duragesic)

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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.

Class Summary

These agents inhibit growth of gram-positive and gram-negative bacteria.

Chlorhexidine gluconate (PerioGard, Peridex, Hibiclens, Avagard)

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Chlorhexidine binds to negatively charged bacterial cell walls and extramicrobial complexes. It has bacteriostatic and bactericidal effects.

Class Summary

Topical anesthetics can be applied to mucous membranes, especially buccal, to relieve pain.

Benzocaine (Americaine, Anbesol, Chiggerex Plus)

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Benzocaine inhibits neuronal membrane depolarization, blocking nerve impulses. It provides oral or mucosal anesthesia, thereby controlling pain.

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)

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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)

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Methylprednisolone is a highly potent synthetic glucocorticoid that causes diverse metabolic effects and modifies the body's immune responses to various stimuli.

Prednisone

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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)

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Hydrocortisone elicits anti-inflammatory properties and causes profound and varied metabolic effects. This agent modifies the body's immune response to diverse stimuli.

Questions

Aulakh S, Arora R, Sarangal R, Chopra D. Increased Predisposition of SJS TEN in COVID-19 Patients, Presenting as Post COVID Complication: Report of Two Cases. Indian Dermatol Online J. 2022 Mar-Apr. 13 (2):237-239. [QxMD MEDLINE Link].
Jouhar L, Yahya M, Elsiddiq S. Toxic Epidermal Necrolysis associated with COVID-19 infection: A case report. Clin Case Rep. 2022 Mar. 10 (3):e05565. [QxMD MEDLINE Link].
Mardani M, Mardani S, Asadi Kani Z, Hakamifard A. An extremely rare mucocutaneous adverse reaction following COVID-19 vaccination: Toxic epidermal necrolysis. Dermatol Ther. 2022 May. 35 (5):e15416. [QxMD MEDLINE Link].
Bastuji-Garin S, Rzany B, Stern RS, Shear NH, Naldi L, Roujeau JC. Clinical classification of cases of toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme. Arch Dermatol. 1993 Jan. 129(1):92-6. [QxMD MEDLINE Link].
LYELL A. Toxic epidermal necrolysis: an eruption resembling scalding of the skin. Br J Dermatol. 1956 Nov. 68(11):355-61. [QxMD MEDLINE Link].
LANG R, WALKER J. An unusual bullous eruption. S Afr Med J. 1956 Feb 4. 30(5):97-8. [QxMD MEDLINE Link].
Debre R, Lemy M, Lamotte M. L'erythrodermie bulleuses avec epidermolyse. Bull Soc Pediatr (Paris). 1939;37:231-238:
Lyell A. Toxic epidermal necrolysis (the scalded skin syndrome): a reappraisal. Br J Dermatol. 1979 Jan. 100(1):69-86. [QxMD MEDLINE Link].
Dodiuk-Gad RP, Chung WH, Valeyrie-Allanore L, Shear NH. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: An Update. Am J Clin Dermatol. 2015 Dec. 16 (6):475-93. [QxMD MEDLINE Link].
Pereira FA, Mudgil AV, Rosmarin DM. Toxic epidermal necrolysis. J Am Acad Dermatol. 2007 Feb. 56(2):181-200. [QxMD MEDLINE Link].
Nagy N, McGrath JA. Blistering skin diseases: a bridge between dermatopathology and molecular biology. Histopathology. 2010 Jan. 56(1):91-9. [QxMD MEDLINE Link].
Abe R, Shimizu T, Shibaki A, Nakamura H, Watanabe H, Shimizu H. Toxic epidermal necrolysis and Stevens-Johnson syndrome are induced by soluble Fas ligand. Am J Pathol. 2003 May. 162(5):1515-20. [QxMD MEDLINE Link]. [Full Text].
Posadas SJ, Padial A, Torres MJ, Mayorga C, Leyva L, Sanchez E, et al. Delayed reactions to drugs show levels of perforin, granzyme B, and Fas-L to be related to disease severity. J Allergy Clin Immunol. 2002 Jan. 109(1):155-61. [QxMD MEDLINE Link].
Paul C, Wolkenstein P, Adle H, Wechsler J, Garchon HJ, Revuz J, et al. Apoptosis as a mechanism of keratinocyte death in toxic epidermal necrolysis. Br J Dermatol. 1996 Apr. 134(4):710-4. [QxMD MEDLINE Link].
Nassif A, Moslehi H, Le Gouvello S, Bagot M, Lyonnet L, Michel L, et al. Evaluation of the potential role of cytokines in toxic epidermal necrolysis. J Invest Dermatol. 2004 Nov. 123(5):850-5. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Roujeau JC, Kelly JP, Naldi L, Rzany B, Stern RS, Anderson T, et al. Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. N Engl J Med. 1995 Dec 14. 333(24):1600-7. [QxMD MEDLINE Link].
Das S, Roy AK, Biswas I. A six-month prospective study to find out the treatment outcome, prognosis and offending drugs in toxic epidermal necrolysis from an urban institution in kolkata. Indian J Dermatol. 2013 May. 58(3):191-3. [QxMD MEDLINE Link]. [Full Text].
Thammakumpee J, Yongsiri S. Characteristics of toxic epidermal necrolysis and stevens-johnson syndrome: a 5-year retrospective study. J Med Assoc Thai. 2013 Apr. 96(4):399-406. [QxMD MEDLINE Link].
Pejčić AV. Stevens-Johnson syndrome and toxic epidermal necrolysis associated with the use of macrolide antibiotics: a review of published cases. Int J Dermatol. 2021 Jan. 60 (1):12-24. [QxMD MEDLINE Link].
Moshfeghi M, Mandler HD. Ciprofloxacin-induced toxic epidermal necrolysis. Ann Pharmacother. 1993 Dec. 27(12):1467-9. [QxMD MEDLINE Link].
Ernst ME, Ernst EJ, Klepser ME. Levofloxacin and trovafloxacin: the next generation of fluoroquinolones?. Am J Health Syst Pharm. 1997 Nov 15. 54(22):2569-84. [QxMD MEDLINE Link].
Creamer JD, Whittaker SJ, Kerr-Muir M, Smith NP. Phenytoin-induced toxic epidermal necrolysis: a case report. Clin Exp Dermatol. 1996 Mar. 21(2):116-20. [QxMD MEDLINE Link].
Chahal D, Aleshin M, Turegano M, Chiu M, Worswick S. Vaccine-induced toxic epidermal necrolysis: A case and systematic review. Dermatol Online J. 2018 Jan 15. 24 (1):[QxMD MEDLINE Link].
Lissia M, Mulas P, Bulla A, Rubino C. Toxic epidermal necrolysis (Lyell's disease). Burns. 2010 Mar. 36(2):152-63. [QxMD MEDLINE Link].
Abood GJ, Nickoloff BJ, Gamelli RL. Treatment strategies in toxic epidermal necrolysis syndrome: where are we at?. J Burn Care Res. 2008 Jan-Feb. 29(1):269-76. [QxMD MEDLINE Link].
Ferrell PB Jr, McLeod HL. Carbamazepine, HLA-B*1502 and risk of Stevens-Johnson syndrome and toxic epidermal necrolysis: US FDA recommendations. Pharmacogenomics. 2008 Oct. 9(10):1543-6. [QxMD MEDLINE Link]. [Full Text].
Dunn J. Genetics and Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: What Have We Learned?. JAMA Ophthalmol. 2017 Apr 1. 135 (4):361-362. [QxMD MEDLINE Link].
Wang YH, Chen CB, Tassaneeyakul W, Saito Y, et al. The Medication Risk of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in Asians: The Major Drug Causality and Comparison With the US FDA Label. Clin Pharmacol Ther. 2019 Jan. 105 (1):112-120. [QxMD MEDLINE Link].
Struck MF, Hilbert P, Mockenhaupt M, Reichelt B, Steen M. Severe cutaneous adverse reactions: emergency approach to non-burn epidermolytic syndromes. Intensive Care Med. 2010 Jan. 36(1):22-32. [QxMD MEDLINE Link].
Estrella-Alonso A, Aramburu JA, González-Ruiz MY, Cachafeiro L, Sánchez MS, Lorente JA. Toxic epidermal necrolysis: a paradigm of critical illness. Rev Bras Ter Intensiva. 2017 Oct-Dec. 29 (4):499-508. [QxMD MEDLINE Link].
Revuz J, Roujeau JC, Guillaume JC, Penso D, Touraine R. Treatment of toxic epidermal necrolysis. Créteil's experience. Arch Dermatol. 1987 Sep. 123(9):1156-8. [QxMD MEDLINE Link].
Koh MJ, Tay YK. An update on Stevens-Johnson syndrome and toxic epidermal necrolysis in children. Curr Opin Pediatr. 2009 Aug. 21(4):505-10. [QxMD MEDLINE Link].
Bastuji-Garin S, Fouchard N, Bertocchi M, Roujeau JC, Revuz J, Wolkenstein P. SCORTEN: a severity-of-illness score for toxic epidermal necrolysis. J Invest Dermatol. 2000 Aug. 115(2):149-53. [QxMD MEDLINE Link].
Aziza Y, Harada K, Ueta M, Fukuoka H, Kinoshita S, Sotozono C. Challenges in the management of bilateral eyelid closure in Stevens-Johnson Syndrome. Am J Ophthalmol Case Rep. 2022 Jun. 26:101473. [QxMD MEDLINE Link].
Magina S, Lisboa C, Leal V, Palmares J, Mesquita-Guimarães J. Dermatological and ophthalmological sequels in toxic epidermal necrolysis. Dermatology. 2003. 207(1):33-6. [QxMD MEDLINE Link].
Aziza Y, Harada K, Ueta M, Fukuoka H, Kinoshita S, Sotozono C. Challenges in the management of bilateral eyelid closure in Stevens-Johnson Syndrome. Am J Ophthalmol Case Rep. 2022 Jun. 26:101473. [QxMD MEDLINE Link].
Power WJ, Ghoraishi M, Merayo-Lloves J, Neves RA, Foster CS. Analysis of the acute ophthalmic manifestations of the erythema multiforme/Stevens-Johnson syndrome/toxic epidermal necrolysis disease spectrum. Ophthalmology. 1995 Nov. 102(11):1669-76. [QxMD MEDLINE Link].
Noe MH, Micheletti RG. Diagnosis and management of Stevens-Johnson syndrome/toxic epidermal necrolysis. Clin Dermatol. 2020 Nov - Dec. 38 (6):607-612. [QxMD MEDLINE Link].
Brown CS, Defazio JR, An G, O'Connor A, Whitcomb E, Hart J, et al. Toxic Epidermal Necrolysis with Gastrointestinal Involvement: A Case Report and Review of the Literature. J Burn Care Res. 2017 Jan/Feb. 38 (1):e450-e455. [QxMD MEDLINE Link].
Barrera JE, Meyers AD, Hartford EC. Hypopharyngeal stenosis and dysphagia complicating toxic epidermal necrolysis. Arch Otolaryngol Head Neck Surg. 1998 Dec. 124(12):1375-6. [QxMD MEDLINE Link].
Bachot N, Roujeau JC. Differential diagnosis of severe cutaneous drug eruptions. Am J Clin Dermatol. 2003. 4(8):561-72. [QxMD MEDLINE Link].
Szatkowski J, Schwartz RA. Acute generalized exanthematous pustulosis (AGEP): A review and update. J Am Acad Dermatol. 2015 Nov. 73 (5):843-8. [QxMD MEDLINE Link].
Abadías-Granado I, Palma-Ruiz AM, Cerro PA, Morales-Callaghan AM, et al. Generalized pustular figurate erythema first report in two COVID-19 patients on hydroxychloroquine. J Eur Acad Dermatol Venereol. 2021 Jan. 35 (1):e5-e7. [QxMD MEDLINE Link].
Schwartz RA, Janniger CK. Generalized pustular figurate erythema: A newly delineated severe cutaneous drug reaction linked with hydroxychloroquine. Dermatol Ther. 2020 May. 33 (3):e13380. [QxMD MEDLINE Link].
Patel S, John AM, Handler MZ, Schwartz RA. Fixed Drug Eruptions: An Update, Emphasizing the Potentially Lethal Generalized Bullous Fixed Drug Eruption. Am J Clin Dermatol. 2020 Jun. 21 (3):393-399. [QxMD MEDLINE Link].
Stingeni L, Bianchi L, Tramontana M, Pigatto PD, Patruno C, Corazza M, et al. Skin tests in the diagnosis of adverse drug reactions. G Ital Dermatol Venereol. 2020 Oct. 155 (5):602-621. [QxMD MEDLINE Link].
Avakian R, Flowers FP, Araujo OE, Ramos-Caro FA. Toxic epidermal necrolysis: a review. J Am Acad Dermatol. 1991 Jul. 25(1 Pt 1):69-79. [QxMD MEDLINE Link].
Fromowitz JS, Ramos-Caro FA, Flowers FP. Practical guidelines for the management of toxic epidermal necrolysis and Stevens-Johnson syndrome. Int J Dermatol. 2007 Oct. 46(10):1092-4. [QxMD MEDLINE Link].
Sharma S, Singh S, Basu S, Shanbhag SS. Chronic Ocular Sequelae and Subsequent Surgical Interventions in Stevens-Johnson Syndrome After Amniotic Membrane Transplantation. Cornea. 2022 May 1. 41 (5):632-634. [QxMD MEDLINE Link].
Endorf FW, Cancio LC, Gibran NS. Toxic epidermal necrolysis clinical guidelines. J Burn Care Res. 2008 Sep-Oct. 29(5):706-12. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Palmieri TL, Greenhalgh DG, Saffle JR, Spence RJ, Peck MD, Jeng JC, et al. A multicenter review of toxic epidermal necrolysis treated in U.S. burn centers at the end of the twentieth century. J Burn Care Rehabil. 2002 Mar-Apr. 23(2):87-96. [QxMD MEDLINE Link].
Woolum JA, Bailey AM, Baum RA, Metts EL. A Review of the Management of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Adv Emerg Nurs J. 2019 Jan/Mar. 41 (1):56-64. [QxMD MEDLINE Link].
Papp A, Sikora S, Evans M, Song D, Kirchhof M, Miliszewski M, et al. Treatment of toxic epidermal necrolysis by a multidisciplinary team. A review of literature and treatment results. Burns. 2018 Jun. 44 (4):807-815. [QxMD MEDLINE Link].
Ririe MR, Blaylock RC, Morris SE, Jung JY. Intravenous immune globulin therapy for Stevens-Johnson syndrome/toxic epidermal necrolysis complicated by hemolysis leading to pigment nephropathy and hemodialysis. J Am Acad Dermatol. 2013 May 11. [QxMD MEDLINE Link].
Chaidemenos GC, Chrysomallis F, Sombolos K, Mourellou O, Ioannides D, Papakonstantinou M. Plasmapheresis in toxic epidermal necrolysis. Int J Dermatol. 1997 Mar. 36(3):218-21. [QxMD MEDLINE Link].
Kohanim S, Palioura S, Saeed HN, Akpek EK, et al. Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis--A Comprehensive Review and Guide to Therapy. I. Systemic Disease. Ocul Surf. 2016 Jan. 14 (1):2-19. [QxMD MEDLINE Link].
Seminario-Vidal L, Kroshinsky D, Malachowski SJ, Sun J, et al. Society of Dermatology Hospitalists supportive care guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults. J Am Acad Dermatol. 2020 Jun. 82 (6):1553-1567. [QxMD MEDLINE Link].
Sims JR, Kozlova A, Ostrovsky A. Modified technique for sutureless amniotic membrane transplantation in acute Stevens-Johnson syndrome using fibrin sealant. Ocul Surf. 2022 May 26. [QxMD MEDLINE Link].
Mereniuk A, Jaque A, Jeschke MG, Shear NH. Toxic Epidermal Necrolysis Spectrum Management at Sunnybrook Health Sciences Centre: Our Multidisciplinary Approach After Review of the Current Evidence. J Cutan Med Surg. 2018 Mar/Apr. 22 (2):213-219. [QxMD MEDLINE Link].
McPherson T, Exton LS, Biswas S, Creamer D, Dziewulski P, Newell L, et al. British Association of Dermatologists' guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in children and young people, 2018. Br J Dermatol. 2019 Jul. 181 (1):37-54. [QxMD MEDLINE Link].
O’Brien KF, Saardi KM, Johnson LS, Shupp JW, Rodic N, Pasieka HB. Recommendations for Prevention of Drug Re-Exposure in Toxic Epidermal Necrolysis. J Drugs Dermatol. 2019 Oct 1. 18 (10):1049-1052. [QxMD MEDLINE Link].
Gupta LK, Martin AM, Agarwal N, D'Souza P, Das S, Kumar R, et al. Guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis: An Indian perspective. Indian J Dermatol Venereol Leprol. 2016 Nov-Dec. 82 (6):603-625. [QxMD MEDLINE Link].
Picard E, Gillis D, Klapholz L, Schreiber L, Engelhard D. Toxic epidermal necrolysis associated with Klebsiella pneumoniae sepsis. Pediatr Dermatol. 1994 Dec. 11(4):331-4. [QxMD MEDLINE Link].
Jouhar L, Yahya M, Elsiddiq S. Toxic Epidermal Necrolysis associated with COVID-19 infection: A case report. Clin Case Rep. 2022 Mar. 10 (3):e05565. [QxMD MEDLINE Link].
Mardani M, Mardani S, Asadi Kani Z, Hakamifard A. An extremely rare mucocutaneous adverse reaction following COVID-19 vaccination: Toxic epidermal necrolysis. Dermatol Ther. 2022 May. 35 (5):e15416. [QxMD MEDLINE Link].
Aulakh S, Arora R, Sarangal R, Chopra D. Increased Predisposition of SJS TEN in COVID-19 Patients, Presenting as Post COVID Complication: Report of Two Cases. Indian Dermatol Online J. 2022 Mar-Apr. 13 (2):237-239. [QxMD MEDLINE Link].

Media Gallery

Toxic epidermal necrolysis (TEN) ulcer in great toe (initial infection).
Hemorrhagic crusting of mucous membranes in toxic epidermal necrolysis (TEN).
Maculopapular rash in toxic epidermal necrolysis (TEN).
Diffuse maculopapular rash in toxic epidermal necrolysis (TEN).
Toxic epidermal necrolysis (TEN) blister on the index finger.
Epidermal sloughing in toxic epidermal necrolysis (TEN).

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Author

Samantha P Jellinek-Cohen, PharmD, BCPS (AQ-ID) Associate Clinical Professor, St John's University College of Pharmacy and Health Sciences; Pharmacist, NYC Health + Hospitals/Coney Island

Samantha P Jellinek-Cohen, PharmD, BCPS (AQ-ID) is a member of the following medical societies: American College of Clinical Pharmacy, American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Coauthor(s)

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Professor of Pediatrics, Professor of Medicine, Rutgers New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Victor Cohen, PharmD Clinical Coordinator, Department of Emergency Medicine, Maimonides Medical Center, Assistant Professor, Division of Pharmacy Practice, Schwartz College of Pharmacy and Health Sciences

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, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Theodore J Gaeta, DO, MPH, FACEP Clinical Associate Professor, Department of Emergency Medicine, Joan and Sanford Weill Medical College at Cornell University; Vice Chairman and Program Director of Emergency Medicine Residency Program, Department of Emergency Medicine, New York Methodist Hospital; Academic Chair, Adjunct Professor, Department of Emergency Medicine, St George's University School of Medicine

Theodore J Gaeta, DO, MPH, FACEP is a member of the following medical societies: Alliance for Clinical Education, American College of Emergency Physicians, Clerkship Directors in Emergency Medicine, Council of Emergency Medicine Residency Directors, New York Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Gregory P Garra, DO Clinical Assistant Professor, Department of Emergency Medicine, Stony Brook University School of Medicine; Residency Program Director, Department of Emergency Medicine, Stony Brook University Hospital

Gregory P Garra, DO is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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.

Mark L Plaster, MD, JD Executive Editor, Emergency Physicians Monthly

Mark L Plaster, MD, JD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: M L Plaster Publishing Co LLC Ownership interest Management position

Jennifer Stellke, DO Resident Physician, Department of Emergency Medicine, Stony Brook University Medical Center

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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 GeriatricsSociety, 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 Societyof 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