Toxic Epidermal Necrolysis

Toxic epidermal necrolysis
  • It is a potentially life-threatening dermatologic disorder characterized by widespread erythema, necrosis, and bullous detachment of the epidermis and mucous membranes, resulting in exfoliation and possible sepsis and/or death .
  • Stevens-Johnson syndrome (also known as erythema multiforme major) is a manifestation of the same process involved in TEN, with the latter involving more extensive necrotic epidermal detachment. TEN involves more than 30% of the body surface, whereas SJS involves less than 10% 
  • TEN is most commonly drug induced.
The most commonly implicated agents include the following:
  • Sulfonamide antibiotics
  • Antiepileptic drugs
  • Oxicam nonsteroidal anti-inflammatory drugs
  • Allopurinol
  • Nevirapine
  • Abacavir
  • Lamotrigine.
  • Infectious agents (ie, Mycoplasma pneumoniae, herpes virus, hepatitis A), immunizations, and bone marrow or solid organ transplantation have also been associated with TEN. Patients with toxic epidermal necrolysis (TEN) may describe an influenza like prodrome lasting from 1 day to as long as 3 weeks characterized by the following: Malaise,rash,fever,cough,rhinitis,myalgia,etc
  • The cutaneous eruption begins as a poorly defined, erythematous macular rash with purpuric centers.
  • Over a period of hours to days, the rash coalesces to form flaccid blisters and sheetlike epidermal detachment.
  • The lesions predominate on the torso and face, sparing the scalp.
  • The epidermis sloughs in sheets, leaving a characteristic moist, denuded dermis .
  • A positive Nikolsky sign is evident when the application of slight lateral pressure to the epidermal surface results in the epidermis easily separating from its underlying surface. Mucous membrane erosions (seen in 90% of cases) generally precede the skin lesions by 1-3 days.
  • The most frequently affected mucosal membrane is the oropharynx, followed by the eyes and genitalia.
  • The mainstay of treatment is supportive care until the epithelium regenerates. Supportive measures include isolation, fluid and electrolyte balance, nutritional support, pain management, and protective dressings. Withdraw the offending agent, if one is identified, as soon as possible.
Exam Question
  • Skin involvement in toxic epidermal necrolysis?> 30%.
  • Lesions are similar in appearance to partial thickness bums in toxic epidermal necrolysis.
  • The process develops at the dermoepidermal junction in toxic epidermal necrolysis.
  • TEN is believed to be an immunologic problem.
  • Corticosteroid use is not a primary part of therapy
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