Biobrane wound dressing used in the treatment of toxic epidermal necrolysis: a case report

Toxic epidermal necrolysis results in skin sloughing that resembles a partial-thickness thermal injury. If the exposed dermis can be protected from infection and desiccation, regeneration can occur from the skin appendages. Biobrane, a synthetic wound dressing, has been used with good results on donor sites and outpatient partial-thickness burns in our institution. We report a case of a 12-year-old boy with toxic epidermal necrolysis, whose skin lesions were dressed with Biobrane temporary wound dressing. The Biobrane dressings prevented infection, decreased wound pain, and allowed uncomplicated healing in this patient.     

Nursing care for patients with toxic epidermal necrolysis

Toxic Epidermal Necrolysis (TEN) is a severe skin disorder characterised by separation of the dermal-epidermal junction, as it is observed in second degree superficial burns, and it may also involve any mucosal surface area (otic, buccal, conjunctival, respiratory, genital). This condition is generally induced by the ingestion of drugs, particularly certain antibiotics, nonsteroidal antiinflammatory drugs, and antiepileptic drugs. Mortality has decreased over the last decades, from 80% to about 25% in recent series. This improvement in survival rate has been related to early diagnosis, management in specialized burn units, proper immunosuppressive treatment and intensive specialised nursing care. The main nursing diagnosis include abnormalities in the skin and mucose membranes integrity, risk of infection, loss of blood volume, risk of hypothermia, acute pain, upper airway insufficiency and anxiety. We here review the nursing care of patients with TEN. We emphasize the daily skin and mucose membranes care, and the prevention of conjunctival sinequiae, including daily conjunctival cleaning and debridement of necrotic tissue and fibrin debris using a handle needle.     

Plasma exchange in patients with toxic epidermal necrolysis.

We describe our experience with plasma exchange (PE) therapy in 13 patients with drug-induced toxic epidermal necrolysis (TEN), 4 of whom had malignant disorders. Skin lesions covered 17% to 100% of total body surface area and 1 to 4 mucous membranes were involved. None of the patients was hospitalized in a burn unit. The patients underwent from 2 to 5 PE sessions (mean 3.4 +/- 0.2 standard error of mean [SEM], median 3) exchanging 6.6 to 17.6 L of plasma (mean 10.1 +/- 0.7 SEM, median 10). PE sessions were carried out every other day in 8 patients and daily in 5. Three patients died (23%) while the remaining 10 (77%) had a full recovery. Plasmapheresis may be an effective treatment in patients with drug-induced TEN hospitalized outside a burn unit.     

Topical treatment of toxic epidermal necrolysis with Iodoplex

Toxic epidermal necrolysis (TEN) is characterized by extensive exfoliation of the epidermis, mucosal ulcerations and fever, after a recent intake of a new drug. TEN developed in an 8-year-old girl after she ingested sulfonamides and sustained skin injuries of 90% total body surface area. In addition to her critical care management, local treatment consisted of Iodoplex cream (Biosearch Laboratories, Haifa, Israel), a long-acting antimicrobial agent from which iodine is slowly released over 48 hours. Healing was observed within 8 to 17 days after initial application. Iodoplex cream is an additional topical agent for the local treatment of TEN when porcine heterografts or allografts might not be feasible.     

29例中毒性表皮坏死松解症患者的护理

总结了29例中毒性表皮坏死松解症(TEN)患者的护理体会.本组TEN患者采用了大剂量糖皮质激素联合大剂量静脉注射人免疫丙种球蛋白冲击治疗,并积极保护创面,合理营养,预防和控制感染,严密观察病情变化,加强皮肤黏膜护理、基础护理、生活护理、心理护理,28例治愈出院,1例死亡.     

Current concepts of toxic epidermal necrolysis.

Toxic epidermal necrolysis consists of two distinct clinical entities. The Ritter type, seen mostly in children under age 10, is the severest manifestation of staphylococcal disease. A toxin has been isolated which is postulated to be the cause for clinical lesions. High epidermal necrosis occurs. Treatment is with one of the penicillinase-resistant penicillins, and prognosis is good. The Lyell type is seen mostly in adults, is drug-related, and may be the severest form of the Stevens-Johnson syndrome. Full-thickness epidermal necrosis occurs. Treatment consists of withdrawing the offending drug. Good nursing care is essential. Prognosis is guarded.     

Trimethoprim/sulfamethoxazole-induced toxic epidermal necrolysis.

OBJECTIVE: To report a case of toxic epidermal necrolysis (TEN) associated with trimethoprim/sulfamethoxazole (TMP/SMX). CASE SUMMARY: A 34-year-old Asian woman developed a severe, desquamating mucocutaneous reaction (TEN) after six days of taking TMP/SMX to treat a presumed urinary tract infection (UTI). DISCUSSION: TMP/SMX is often recommended as first-line therapy for UTIs, sinusitis, bronchitis, and as prophylaxis and treatment for Pneumocystis carinii pneumonia. TEN is a rare, but severe condition associated with sulfonamide use. This article describes a typical case and offers an opportunity for review of this potentially serious reaction. CONCLUSIONS: Sulfonamides are often implicated in the majority of drug-induced cases of TEN. This case report illustrates the typical presentation of sulfonamide-induced TEN with a prodrome, characteristic rash, mucous membrane lesions, and systemic involvement. Practitioners should be aware of this rare adverse effect and closely observe patients for cutaneous manifestations or complaints. Any suspected drug should be discontinued if clinical evaluation leads to the suspicion of Stevens-Johnson syndrome or TEN.     

Bronchopulmonary distress associated with toxic epidermal necrolysis

We describe here a patient with severe TEN and respiratory distress and we review the subject of bronchopulmonary symptoms in TEN. Even if pseudostratified ciliated involvement is uncommon, bronchial lesions in the absence of other known causes, should be specifically related to TEN. The mechanisms of pulmonary involvement and ARDS associated with TEN are discussed.     

Treatment of toxic epidermal necrolysis with intravenous immunoglobulin

Toxic epidermal necrolysis (TEN) is a rare severe reaction of the skin resulting in full thickness damage to the epidermis. The condition has significant morbidity as a result of dehydration, protein loss, thermoregulatory difficulties, and renal, lung, liver and heart failure. The mortality rate approaches 30%, most commonly from bacterial sepsis. Management of this condition is cessation of the suspected causative agent and supportive care on a burns or intensive care unit. There have been recent reports of treatment using intravenous immunoglobulin (IVIG) therapy, though its efficacy is yet to be established. It has been proposed that IVIG inhibits the Fas-FasL mediated apoptosis of keratinocytes affected by TEN. We describe a case of extensive drug-induced TEN in a 33-year-old woman who showed rapid improvement with IVIG therapy at a dose of 0.75 g/kg/day given for four consecutive days.     

儿童重症中毒性大疱性表皮松解症的护理

目的:探讨11例重症中毒性大疱性表皮松解症患儿的临床护理方法。方法:通过创造相对的无菌环境,有效的创面保护,严密的病情观察,特殊的心理护理,足够的营养供给,以促进创面愈合,减少感染和死亡率的发生。结果:11例重症中毒性大疱性表皮松解症患儿病情痊愈,无溃疡疤痕形成。结论:加强皮肤黏膜护理,保护其不受损伤及继发感染是护理成败关键。     

A 10-year experience with toxic epidermal necrolysis

Toxic epidermal necrolysis is a devastating medication-induced desquamation disorder with a reported mortality rate of 30% to 60% in adults. Data from previously reported series suggest that age, delay in referral to a burn center, total body surface area (TBSA) involvement, and systemic steroid treatment are poor prognostic indicators. We reviewed the records of 39 patients treated in our burn center over the past 10 years and found that the mortality rate was significantly correlated with age, thrombocytopenia, and delay in presentation. Steroid treatment and TBSA involvement were not significantly related to the mortality rate. Thirty-nine adult patients with greater than 20% TBSA epithelial necrosis were cared for in our center from January 1987 to March 1998. Wounds were treated with topical antimicrobial medications and porcine xenografts in a bacteria-controlled nursing unit. We reviewed the records of these patients for 28 clinical characteristics and looked for clinical correlates of mortality by single analysis of variance. The mortality rate was 44% (17 of 39 patients); the cause of death was most commonly multiple-organ dysfunction syndrome, for which a microbial etiologic agent was not always identified. Autopsies were performed on 11 of the 17 patients who died; there was evidence of multiple-organ damage. The patients who survived and the patients who died did not differ significantly in TBSA epithelial necrosis (66%+/-6% vs 72%+/-5%, respectively), admission platelets, number of nosocomial infections, number of complications, preadmission exposure to steroids, or extent of mucosal involvement. When compared with the patients who died, the patients who survived were (1) 20 years younger (47.5+/-4.2 years vs 64.5+/-5.3 years), (2) admitted to the hospital sooner after the onset of their rash (3.5+/-0.4 days vs 5.9+/-1.0 days), (3) much less likely to experience early thrombocytopenia (platelet nadir, 154+/-24 vs 70+/-18), (4) more likely to be febrile on presentation, and (5) less likely to have been treated with antibiotics before referral to our unit. These differences were statistically significant. The most common etiologic agents were antibiotics, anticonvulsants, and nonsteroidal anti-inflammatory drugs. Our results for a group of older patients with toxic epidermal necrolysis with extensive skin involvement suggest that age, delay in hospitalization, thrombocytopenia, and early empiric antibiotic treatment are associated with a poor prognosis.     

Rehabilitative considerations for patients with severe Stevens-Johnson syndrome or toxic epidermal necrolysis. A case report

Stevens-Johnson syndrome and toxic epidermal necrolysis are dermatologic disorders that demonstrate pathophysiologic similarities to partial-thickness burn injury and benefit from treatment in a multidisciplinary burn center. Although burn therapists frequently participate in the care of these patients, guidelines for rehabilitative intervention have not been previously identified. A case report highlights the potential rehabilitative complications and treatment interventions indicated for patients with severe forms of these conditions.     

A study of the efficacy of plasmapheresis for the treatment of drug induced toxic epidermal necrolysis.

The efficacy of plasmapheresis for the treatment of toxic epidermal necrolysis (TEN) in our patient and related reports in the literature were examined. The patient, a 41-year-old female, was diagnosed as having drug (Sedes-G [isopropylantipyrin, arylisopropylacetoureid, and phenacetinum]) induced TEN. Upon admission to our hospital, extensive corticostroid therapy was initiated. After 6 days, because more than 90% of the patient's body surface was affected by TEN, it was concluded that the patient was unresponsive to corticosteroid therapy. Double filtration plasmapheresis (DFPP) was therefore begun. After 2 sessions of DFPP, extensive reepithelialization rapidly occurred, and after 3 sessions of DFPP, the improvement was dramatic. The patient's condition had almost healed during 1 month's hospitalization. It has been reported in the literature that 22 patients with drug induced TEN have been treated with plasmapheresis. The mortality rate of 23 patients, including our patient, was 17.4%. The rate of effectiveness of plasmapheresis on drug induced TEN is 82.6%. It appears that some kind of necrolytic factors were removed by the plasmapheresis. This suggests that plasmapheresis may be an effective treatment for drug induced TEN.     

Interleukin-2-induced dermatotoxicity resembling toxic epidermal necrolysis.

Interleukin-2 is a promising new immunotherapeutic antineoplastic agent, but it can cause severe multiorgan toxicity. Although dermatologic toxicity is seen in most patients receiving IL-2 therapy, it is usually manifested as pruritus and an erythematous macular rash, which resolve quickly once infusion is terminated. We have described a patient who was allergic to multiple drugs and who had sloughing of large sheets of epidermis over 75% of body surface area during IL-2 therapy. Clinically, this was indistinguishable from toxic epidermal necrolysis, but the findings on skin biopsy were nonspecific for any dermatitides. The skin healed after cessation of IL-2 infusion, but the rash recurred upon resuming infusion at a lesser dose, indicting IL-2 as the probable causative agent. This unique dermatologic sensitivity to IL-2 suggests that IL-2 could act directly as a promoter in dermatologic disease. Patients with a history of allergic reactions to other unrelated drugs should be monitored carefully for unusual bullous dermatologic changes during IL-2 therapy.     

中毒性表皮坏死松解型药疹患者的护理

报告了1例中毒性表皮坏死松解型药疹患者的护理方法。对患者皮肤创面和黏膜进行专科护理,并配合病情观察、环境准备、饮食护理、心理护理等护理措施,患者病情得以控制,经过1个月的临床治疗痊愈出院。     

重症多形红斑与中毒性表皮坏死松解症的临床分析

目的探讨重症多形红斑(SJS)与中毒性表皮坏死松解症(TEN)的致病因素、发生规律、临床特点和治疗措施。方法对42例SJS和20例TEN住院患者的临床资料进行回顾性分析。结果 SJS组和TEN组患者中,药物为最常见病因。致敏药物中排在前三位的分别是抗癫痫药(29.03%)、别嘌呤醇(16.13%)及抗生素(16.13%)。SJS与TEN的黏膜损害率均为100%,TEN组的皮损范围、损害程度、黏膜病变均较SJS组更广泛、更严重,TEN的日、最大糖皮质激素用量均高于SJS。结论药物是SJS和TEN发病最主要的原因。TEN患者较SJS患者病变广泛且严重。别嘌呤醇与卡马西平应用需谨慎,激素联合免疫球蛋白IVIG治疗有效。