Approach Considerations

TEN is a clinical diagnosis, confirmed by histopathologic analysis of lesional skin. Early involvement of a dermatologist and dermatopathologist is recommended. Skin biopsy, harvested at the earliest possible stage, is important in establishing an accurate diagnosis and directing specific therapeutic modalities.

Necrotic keratinocytes with full-thickness epithelial necrosis and detachment is consistent with the diagnosis of TEN. Perivascular and scattered lymphocytic infiltration of the dermis is sometimes demonstrated, although the underlying dermis is not greatly altered.

No definitive or specific emergent laboratory tests are indicated for TEN. Basic laboratory tests may be helpful in planning symptomatic or supportive therapy. Surveillance cultures of blood, skin, and urine should be obtained.

Imaging studies are not indicated for the diagnosis of TEN. Chest radiography should be performed in the setting of respiratory distress because tracheobronchial inflammation may predispose to diffuse interstitial pulmonary disease or pneumonia.

Blood Studies

Hematology studies include the following:

Complete blood count (CBC) and differential
Circulating immune complexes
Erythrocyte sedimentation rate

Leukopenia is common, whether a result of TEN itself or of bacteremia, as is a normochromic normocytic anemia. Eosinophilia may be present. Less often, thrombocytopenia, neutropenia, and bandemia may occur. Neutropenia is an unfavorable prognostic sign.

In the acute phase, there are transient decreases of peripheral CD4⁺ T lymphocytes and reduced allogeneic and natural killer cell cytotoxicity, which returns to normal in 7-10 days.

Coagulation studies may include prothrombin time/international normalized ratio (INR) and activated partial thromboplastin time.

Chemistry to assess fluid and electrolyte losses include the following:

Albumin
Blood urea nitrogen
Total protein

As toxic epidermal necrolysis progresses, multiple organs are affected, causing other abnormalities in laboratory test results. Diffuse skin involvement may cause significant fluid loss and electrolyte abnormalities.

Biopsy

A skin biopsy specimen must be obtained. In experienced hands, a frozen section specimen expedites matters. Results are very useful in differentiating TEN from other dermatologic disorders.

Histologically, TEN is characterized by full-thickness epidermal necrosis with little evidence of epidermal or dermal inflammation. Epidermal detachment and sloughing may be evident. Satellite cell necrosis may be visible early, progressing to extensive eosinophilic necrosis.

Other Tests

Patch testing may be used to identify the culprit drugs.^[47] Patch tests show an acceptable sensitivity, yielding positive results in 50% of patients with acute generalized exanthematous pustulosis and in 50% of patients with maculopapular exanthema.

Treatment & Management

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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].
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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).

of 6

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