Professional Documents
Culture Documents
Key Words
Peer reviewed by: NUH critical care consultants; Critical care cross-town
guidelines group
Evidence base: (1-5)
4
expert committee reports or opinions and / or clinical experiences of respected authorities
5
recommended best practice based on the clinical experience of the guideline developer
Consultation Process
Cross-town guidelines group
Target audience
This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The
interpretation and application of clinical guidelines will remain the responsibility of the individual
clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines
after the review date.
Dr M Levitt
2013
Page 1 of 9
Introduction:
Toxic epidermal necrolysis (TEN) is a rare, potentially life threatening dermatological
condition. It is characterised by widespread detachment of the epidermis from the underlying
dermis as a result of immune mediated keratinocyte death.
TEN is regarded as part of a spectrum of conditions that include Stevens-Johnson syndrome
(SJS), the differentiation being the percentage skin involvement.
The condition is usually precipitated by an adverse reaction to a drug (see table 1) but may
also be associated with infections such as mycoplasma and HSV, and following bone marrow
transplantation.
The overall mortality for TEN is around 30% with the more severe cases having greater than
90% risk of death. For this reason TEN is managed on Critical Care in a similar manner to a
thermal burn injury.
Table 1. Common drug causes of TEN
Sulfonamides
Beta lactam antibiotics
Macrolides
NSAIDS
Allopurinol
Methotrexate
Antiretroviral drugs
Phenobarbitone
Carbamazepine
Sodium valproate
Corticosteroids
Dr M Levitt
2013
Page 2 of 9
Diagnosis
Diagnosis may be suspected from the clinical appearance and temporal association with drug
administration. It is usual for the diagnosis to be made or confirmed by the dermatologists.
Referral is then made to the burns team at Nottingham University Hospital, City Campus for
further management. Skin biopsy is not considered essential, but may be helpful in cases
where there is diagnostic uncertainty and in those uncommon cases that fail to reepithelialize.
Assessment of severity
Although thought of as a cutaneous disease, TEN can affect all mucous membranes.
Typically the eyes and mouth are involved, but involvement of the genitalia, gastro-intestinal
tract and the respiratory epithelium can occur. On admission to Critical Care, the patient
should be examined thoroughly and the extent and location of the skin involvement
documented. Note that the disease may progress following admission.
It is customary to assess the patient using the SCORTEN scoring system (table 2). This was
developed in the 1990s and gives an approximate mortality prediction based upon the
presence or absence of 7 predictive factors at admission . It should be noted that the
confidence intervals are extremely wide and overlapping.
Table 2.
Mortality %
3
12
35
58
90+
Dr M Levitt
2013
Page 3 of 9
Dr M Levitt
2013
Page 4 of 9
Dr M Levitt
2013
Page 5 of 9
12. Intravenous Immunoglobulin: The role of IVIG remains controversial, with little
evidence for benefit and some for potential harm. There is no consensus, so the use
of IVIG remains at the discretion of the dermatology or the burns teams. TEN is listed
in the DOH guidelines for use of IVIG.
13. Infection issues: TEN patients are at high risk of developing infection. Wound
colonization is usual and wound infection common. The use of nano-crystaline silver
dressings may reduce this. Regular surveillance cultures should be performed at each
dressings change. Other sources of infection include lines and VAP.
Persistent fever is common in patients with TEN, and does not always indicate the
presence of infection. The following indices may be used to aid the decision-making
process:
Fever >39C
Hypothermia (<36.5C)
Especially where any of the above occurs in combination with any of:
New hyperglycaemia
New diarrhoea
Dr M Levitt
2013
Page 6 of 9
NSAIDs as antipyretics may only be prescribed at the direction a consultant and must
not be used if there is the possibility that they may have been the initial trigger
15. Patients who recover from TEN must be aware of the potential for re-exposure to the
causative drug and of the risks of cross reactivity, especially with anticonvulsants and
NSAIDS. The potential for a genetic basis for TEN suggests that blood relatives
should avoid exposure to trigger agents.
References:
Toxic epidermal necrolysis: current evidence, practical management and future directions
Chave TA, et al
Toxic Epidermal Necrolysis and Stevens Johnson Syndrome: Our Current Understanding.
French LE
2013
Dr M Levitt
Page 7 of 9
2.
Responsible Manager
Owen Bennett (Clinical Quality, Risk and Safety Manager)
3.
4.
5.
6.
7.
8.
Results of Initial Screening or Full Equality Impact
Assessment:
Equality Group
Assessment of Impact
Age
No Impact Identified
Gender
No Impact Identified
8
Race
No Impact Identified
Sexual Orientation
No Impact Identified
Religion or belief
No Impact Identified
Disability
No Impact Identified
No Impact Identified
Working Patterns
No Impact Identified
Social Deprivation
No Impact Identified
9.
Decisions and/or Recommendations (including
supporting
rationale)
From the information contained in the procedure, and
following the initial screening, it is my decision that a full
assessment is not required at the present time.
10.
11.