Allergol Immunopathol (Madr). Careers. 2001;108(5):83946. While nearly any medication can, in theory, cause a reaction if you're sensitive, medications linked to exfoliative dermatitis include: sulfa drugs; penicillin and certain other antibiotics . Hung S-I, et al. The authors wish to thank Dr. Gary White for the picture of EM showed in Fig. Am J Dermatopathol. It is necessary to obtain as soon as possible a central venous access and to start a continuous monitoring of vital signs. Effects of treatments on the mortality of StevensJohnson syndrome and toxic epidermal necrolysis: a retrospective study on patients included in the prospective EuroSCAR Study. Antipyretic therapy. Topical treatment. Plasmapheresis. Fitzpatricks dermatology in general medicine. It is recommended to use 1.5mg/kg hydrocortisone. Mawson AR, Eriator I, Karre S. StevensJohnson syndrome and toxic epidermal necrolysis (SJS/TEN): could retinoids play a causative role? Adapted from Ref. Arch Dermatol. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Toxic epidermal necrolysis treated with cyclosporin and granulocyte colony stimulating factor. Gastrointestinal: pancreatitis, glossitis, dyspepsia. Soak for 5 to 10 minutes and rinse off before patting dry. J Invest Dermatol. HHS Vulnerability Disclosure, Help The velocity of infusion should be regulated according to patients arterial pressure with the aim of 30mL/h urinary output (1mL/kg/h in case of a child). Epidemiological studies on EM, SJS and TEN syndromes report different results, probably related to several biases, such as ethnical differences, diagnostic criteria and drug consumption patterns in different socio-economic systems. Int J Dermatol. In more severe cases antiviral therapies should be given together with intravenous immunoglobulins [93]. Clinical clues of a drug-induced etiology include: Abrupt onset, previous morbilliform eruption, multiple, varied cutaneous morphologic lesions present together Extensive erythema is followed in 2-6 days by exfoliative scaling Pruritus can be severe, leading to scratching and lichenification in more chronic processes Systemic and potentially life-threatening complications include fluid and electrolyte imbalance, thermoregulatory disturbance, fever, tachycardia, high-output failure, hypoalbuminemia, and septicemia. (adult rickets), anticonvulsant-induced rickets and osteomalacia, osteoporosis, renal osteodystrophy . Interferon alfa (Roferon-A, Intron A, Alferon N), Isoniazid (Laniazid, Nydrazid; also in Rifamate, Rimactane), Isosorbide dinitrate (Isordil, Sorbitrate), Para-amino salicylic acid (Sodium P.A.S. Toxic epidermal necrolysis: Part I Introduction, history, classification, clinical features, systemic manifestations, etiology, and immunopathogenesis. A marker for StevensJohnson syndrome: ethnicity matters. Targeting keratinocyte apoptosis in the treatment of atopic dermatitis and allergic contact dermatitis. Oral hygiene with antiseptic and painkiller mouthwash (chlorhexidine+lidocaine+aluminum hydroxide) together with aerosol therapy with saline and bronchodilators can reduce upper airways symptoms. 585600. 2011;128(6):126676. official website and that any information you provide is encrypted Hum Mol Genet. Rifampin, paracetamol, metronidazole, paclitaxel, erythromycin, and ibuprofen have all been reported to cause bullous FDE. doi: 10.4103/0019-5154.39732. 2008;59(5):8989. Descamps V, Ranger-Rogez S. DRESS syndrome. Tohyama M, Hashimoto K. Immunological mechanisms of epidermal damage in toxic epidermal necrolysis. The taper of steroid therapy should be gradual [93]. Background: Panitumumab is an EGFR inhibitor used for the treatment of metastatic colorectal cancer (mCRC), even if its use is related to skin toxicity. EM usually occurs in young adults of 2040years of age [13], with women affected more frequently than men (1.5:1.0) [14]. Efficacy of plasmapheresis for the treatment of severe toxic epidermal necrolysis: is cytokine expression analysis useful in predicting its therapeutic efficacy? Google Scholar. 1991;127(6):8318. 1996;135(2):3056. Etanercept therapy for toxic epidermal necrolysis. Chang CC, et al. Other clinical findings include lymphadenopathy, hepatomegaly, splenomegaly, edema of the foot or ankle4,6 and gynecomastia.19, The scaling that occurs in exfoliative dermatitis can have severe metabolic consequences, depending on the intensity and the duration of the scaling. Grosber M, et al. Albumin is recommended only is albumin serum level is <2.5mg/dL. These molecules may play a role in amplifying the immune response and in increasing the release of other toxic metabolites from inflammatory cells [48]. Gynecologist consultation is required for avoiding the appearance of vaginal phimosis or sinechias. 2010;62(1):4553. J Eur Acad Dermatol Venereol. Fritsch PO. ADRJ,2015,17(6):464-465. d. Cysts and tumors. Indian J Dermatol. Possible involvement of CD14+CD16+monocyte lineage cells in the epidermal damage of StevensJohnson syndrome and toxic epidermal necrolysis. Role of nanocrystalline silver dressings in the management of toxic epidermal necrolysis (TEN) and TEN/StevensJohnson syndrome overlap. Nayak S, Acharjya B. New York: McGraw-Hill; 2003. pp. A slow acetylator genotype is a risk factor for sulphonamide-induced toxic epidermal necrolysis and StevensJohnson syndrome. erythroderma, exfoliative dermatitis, and fixed drug reactions) 4, 5 and . Adverse cutaneous drug reaction. If it is exfoliative dermatitis that's drug induced, it's easy to treat . CAS volume14, Articlenumber:9 (2016) Grieb G, et al. oboda J, Dudzik A, Chomyszyn-Gajewska M. Ramirez GA, Ripa M, Burastero S, Benanti G, Bagnasco D, Nannipieri S, Monardo R, Ponta G, Asperti C, Cilona MB, Castagna A, Dagna L, Yacoub MR. Microorganisms. 2013;57(4):58396. Gonzalez-Delgado P, et al. EM is a self-limited skin condition mainly associated with infections and drugs [53, 54]. Generalized. Google Scholar. [49] confirmed these results and even suggested that higher dosage regimen with 2.74g/kg seem to be more effective in survival outcome. Granulysin: Granulysin is a pro-apoptotic protein that binds to the cell membrane by means of charge interaction without the need of a specific receptor, producing a cell membrane disruption, and leading to possible cell death. 1984;101(1):4850. Neoplastic conditions (renal and gastric carcinoma), autoimmune disease (inflammatory bowel disease), HIV infection, radiation, and food additives/chemicals have been reported to be predisposing factor [59]. 2019 Jan 6;59:463-486. doi: 10.1146/annurev-pharmtox-010818-021818. Ned Tijdschr Geneeskd. Skin testing and patch testing in non-IgE-mediated drug allergy. Bourgeois GP, et al. AR 40-501 14 June 2017 33 e. Dermatitis herpetiformis. Pathophysiology DIP. Wolkenstein P, et al. A catabolic state thus ensues, which is often responsible for significant weight loss. . When it precedes cutaneous T-cell lymphoma lesions, exfoliative dermatitis becomes the presenting sign of the underlying malignancy. 2008;49(12):208791. 2005;136(3):20516. It is a clinical manifestation and usually associated with various underlying cutaneous disorders, drug induced reactions and malignancies. Toxic epidermal necrolysis: Part II Prognosis, sequelae, diagnosis, differential diagnosis, prevention, and treatment. The dermo-epidermal junction and epidermis are infiltrated mostly by CD8+ T lymphocytes whereas dermal infiltrate, mainly made from CD4+ T lymphocytes, is superficial and mostly perivascular [20, 51]. 2012;27(4):21520. The authors concluded that they couldnt demonstrate corticosteroids efficacy in monotherapy, but the use of steroid alone is not linked to an increased risk of mortality due to infective complications [108, 109]. J Dermatol Sci. A systematic review of treatment of drug-induced StevensJohnson syndrome and toxic epidermal necrolysis in children. Von Hebra first described erythroderma (exfoliative dermatitis) in 1868. Cutaneous drug eruptions are one of the most common types of adverse reaction to medications, with an overall incidence of 23% in hospitalized patients [1]. 2010;2(3):18994. Dermatologist and/or allergist should confirm the diagnosis, individuate the culprit agent, give indications about skin management and necessity to obtain theconsultationofthe ENT specialist, the gynecologist/urologist, the ophthalmologist and/or the pulmonologist in the case of mucosal involvement. In serious cases invasive ventilation can be necessary for ARDS. Analysis of StevensJohnson syndrome and toxic epidermal necrolysis using the Japanese Adverse Drug Event Report database. In: Eisen AZ, Wolff K, editors. Early sites of skin involvement include trunk, face, palms and soles and rapidly spread to cover a variable extension of the body. Drug rashes are the body's reaction to a certain medicine. Garza A, Waldman AJ, Mamel J. J Am Acad Dermatol. Smith SD, et al. 2013;69(2):173174. Nassif A, et al. doi: 10.1111/dth.15416. Dent Clin North Am. Erythema multiforme StevensJohnson syndrome and toxic epidermal necrolysis. N Engl J Med. Cho YT, et al. Lymphocyte transformation test (LTT) performed as described by Pichler and Tilch [77] shows a lower sensitivity in severe DHR compared to less severe DHR [78] but, if available, should be performed within 1week after the onset of skin rash in SJS and TEN [79]. GULIZ KARAKAYLI, M.D., GRANT BECKHAM, M.D., IDA ORENGO, M.D., AND TED ROSEN, M.D. Prevalence is low, with mortality of roughly 512.5% for SJS and 50% for TEN [1, 2]. 2004;428(6982):486. CAS Wolkenstein P, et al. The time interval between the appearance of exfoliative dermatitis and the appearance of cutaneous T-cell lymphoma lesions can vary from months to years or even decades. Valeyrie-Allanore L, et al. Erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. Strom BL, et al. Also, physicians should be vigilant about possible secondary infection, whether cutaneous, pulmonary or systemic. Carrozzo M, Togliatto M, Gandolfo S. Erythema multiforme. SSSS is characterized by periorificial face scabs, de-epithelialization of friction zones and conspicuous desquamation after initial erythroderma. Erythema multiforme (EM), Stevens- Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. 2018 Jan 28;2018:9095275. doi: 10.1155/2018/9095275. Rare dermatological side effects such as alopecia, exfoliative dermatitis, xeroderma, pruritus have been reported. Erythema multiforme (photo reproduced with permission of Gary White, MD): typical target lesions (white arrows) together with atypical two-zoned lesions (black arrows). In patients who develop complications (i.e., infection, fluid and electrolyte abnormalities, cardiac failure), the rate of mortality is often high. 2014;71(2):27883. J Allergy Clin Immunol. The relative risk of leukemia inducing erythroderma is highly variable, ranging from 11 to 50 percent.11, Internal (visceral) malignancies cause about 1 percent of all cases of exfoliative dermatitis.11 Frequently, erythroderma is the presenting sign of the malignancy. Contact dermatitis from topical antihistamine . Incidence of toxic epidermal necrolysis and StevensJohnson Syndrome in an HIV cohort: an observational, retrospective case series study. Clinical, etiologic, and histopathologic features of StevensJohnson syndrome during an 8-year period at Mayo Clinic. b. Atopic dermatitis. The most common causes of death in patients with exfoliative dermatitis are pneumonia, septicemia and heart failure. A patch testing and cross-sensitivity study of carbamazepine-induced severe cutaneous adverse drug reactions. Verma R, Vasudevan B, Pragasam V. Severe cutaneous adverse drug reactions. Bastuji-Garin S, et al. Interleukin (IL)-1, IL-2, IL-8, intercellular adhesion molecule 1 (ICAM-1), tumor necrosis factor and interferon gamma are the cytokines that may have roles in the pathogenensis of exfoliative dermatitis.2. PubMed Paradisi A, et al. J Invest Dermatol. Drug-induced LPP. Hospitalization is usually necessary for initial evaluation and treatment. Pharmacogenet Genom. Kostal M, et al. [81]. Nassif A, et al. 2013;168(3):55562. Exfoliative dermatitis is a dangerous form of CADR which needs immediate withdrawl of all the four drugs. Drug specific cytotoxic T-cells in the skin lesions of a patient with toxic epidermal necrolysis. The prognosis of cases associated with malignancy typically depends on the outcome of the underlying malignancy. Article Int Arch Allergy Immunol. Toxic epidermal necrolysis and StevensJohnson syndrome. ), Phenolphthalein (Agoral, Alophen, Modane), Rifampin (Rifadin, Rimactane; also in Rifamate), Trimethoprim (Trimpex; also in Bactrim, Septra). An epidemiologic study from West Germany. Article If cutaneous pathology also mimics cutaneous T-cell lymphoma, it can be very difficult to differentiate a drug-induced skin condition from exfoliative dermatitis associated with a malignancy.2,9. J Pharm Health Care Sci. EMs mortality rate is not well reported. 2007;48(5):10158. Since the earliest descriptions of exfoliative dermatitis, medications have been known to be important causative agents. Br J Dermatol. Rabelink NM, Brakman M, Maartense E, Bril H, Bakker-Wensveen CA, Bavinck JN. 2012;43:10115. The most notable member of this group is mycosis fungoides. Exfoliative dermatitis, also known as erythroderma, is an uncommon but serious skin disorder that family physicians must be able to recognize and treat appropriately. Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involving skin and usually occurring from days to several weeks after drug exposure. Toxic epidermal necrolysis: Part I Introduction, history, classification, clinical features, systemic manifestations, etiology, and immunopathogenesis. 2003;21(1):195205. Patients with underlying skin disorders may respond much more slowly to therapy, but clearing almost always occurs eventually. The exact source of FasL production has not been yet identified as different groups have postulated that the production might be sought in keratinocytes themselves [33] or in peripheral blood mononuclear cells [34]. Drug reactions are one of the most common causes of exfoliative dermatitis. Australas J Dermatol. Med., 1976, 6, pp. 2015;21:13343. The SCORTEN scale is based on a minimal set of parameters as described in the following table. government site. J Am Acad Dermatol. Clinical features; Delayed type hypersensitivity; Drug hypersensitivity; Erythema multiforme; Exfoliative dermatitis; Lyells syndrome; Pathogenesis; StevensJohnson syndrome; Therapy; Toxic epidermal necrolysis. In EMM lesions typically begin on the extremities and sometimes spread to the trunk. Patmanidis K, et al. 12 out of 17 studies concluded for a positive role of IVIG in ED. J Dermatol. (See paras 3 - 42 and 3- 43.) Although the etiology is. In SJS and TEN mucosal erosions on the lips, oral cavity, upper airways, conjunctiva, genital tract or ocular level are frequent [60, 6870]. Once ED has occurred, it has to be managed in the adequate setting with a multidisciplinary approach, and every effort has to be made to identify and avoid the trigger and to prevent infectious and non-infectious complications. Growth-factors (G-CSF). It often precedes or is associated with exfoliation (skin peeling off in scales or layers), when it may also be known as exfoliative dermatitis (ED). Chemicals and Drugs 61. The SJS histology is characterized by a poor dermal inflammatory cell infiltrate and full thickness necrosis of epidermis [20, 49]. AQUACEL Ag in the treatment of toxic epidermal necrolysis (TEN). Sekula P, et al. Add 1 cup (about 236 milliliters) of vinegar to a bathtub filled with warm water. The site is secure. If necessary, it can be repeated every 68h. NSAIDs should be avoided as they can induce ED as well. The erythrodermic form of mycosis fungoides and the Szary syndrome may also be difficult to distinguish from benign erythroderma. Beneficial effect of plasma exchange in the treatment of toxic epidermal necrolysis: a series of four cases. Google Scholar. In case of a respiratory failure, oxygen should be administrated and a NIMV may be required. A severity-of-Illness score for toxic epidermal necrolysis (SCORTEN) has been proposed and validated to predict the risk of death at admission [81]. 2015;13(7):62545. Temporary tracheostomy may be necessary in case of extended mucosal damage. Moreover, transpiration and thermoregulation are greatly impaired with an elevated loss of fluids, proteins and electrolytes through the damaged skin and mucosae. Unfortunately, the clinical picture does not contribute to an understanding of the underlying cause. De Araujo E, et al. Half-life of the drug is approximately 54 h. Modification of nitisinone in liver and renal dysfunction is yet to be studied. 2023 BioMed Central Ltd unless otherwise stated. statement and N.Z. Clinical practice. Immunophenotypic studies with the use of advanced antibody panels may be useful in the differential diagnosis of these two forms.10 Reticulum cell sarcoma is another form of cutaneous T-cell lymphoma that may cause exfoliative dermatitis. HLA-B1502, HLA-B5701, HLA-B5801 and carbamazepine, abacavir, and allopurinol, respectively). Next vol/issue Huang SH, et al. Fas-FasL interaction: Fas is a membrane-bound protein that after interaction with Fas-ligand (FasL) induces a programmed cell death, through the activation of intracellular caspases. Barbaud A. Antiviral therapy. In: Eisen AZ, Wolff K, editors. Jang E, Park M, Jeong JE, Lee JY, Kim MG. Sci Rep. 2022 May 12;12(1):7839. doi: 10.1038/s41598-022-11505-0. 00 Comments Please sign inor registerto post comments. Drugs such as paracetamol, other non-oxicam NSAIDs and furosemide, bringing a relatively low risk of SJS/TEN a priori, are also highly prevalent as putative culprit agents in large SJS/TEN registries, due to their widespread use in the general population [63, 64] (Table1). Yacoub, MR., Berti, A., Campochiaro, C. et al. Diclofenac sodium topical solution, like other NSAIDs, can cause serious systemic skin side effects such as exfoliative dermatitis, SJS, and TEN, which may result in hospitalizations . J Invest Dermatol. Fluid balance is a main focus. Exfoliative dermatitis accounts for about 1 percent of all hospital admissions for dermatologic conditions.3, Although the disease affects both men and women, it is more common in men, with an average male-to-female ratio of 2.3:1. Acute interstitial nephritis associated with hepatitis, exfoliative dermatitis, fever and eosinophilia is uncommon. Arch Dermatol. -. Samim F, et al. (in Chinese) . J Am Acad Dermatol. SCORTEN: a severity-of-illness score for toxic epidermal necrolysis. Proc Natl Acad Sci USA. New York: McGraw-Hill; 2003. p. 54357. Other patients may warrant PUVA (psoralen plus ultraviolet A) phototherapy, systemic steroids (if psoriasis has been ruled out), retinoids (for exfoliative dermatitis secondary to psoriasis and pityriasis rubra pilaris), or immunosuppressive agents such as methotrexate (Rheumatrex) and azathioprine (Imuran).2527, When used as adjunctive therapy, behavior modification designed to eliminate persistent scratching has been successful in reducing the rate of excoriation and increasing the rate of healing.28. 2004;59(8):80920. Avoid rubbing and scratching. Anti-Allergic Agents Immunoglobulin E Allergens Cetirizine Histamine H1 Antagonists, Non-Sedating Histamine H1 Antagonists Loratadine Emollients Nasal Decongestants Dermatologic Agents Leukotriene Antagonists Antigens, Dermatophagoides Ointments Histamine Antagonists Eosinophil Cationic Protein Adrenal Cortex Hormones Terfenadine Antipruritics Antigens, Plant . The EuroSCAR-study. Takahashi R, et al. CAS Recombinant granulocyte colony-stimulating factor in the management of toxic epidermal necrolysis. Etoricoxib-induced toxic epidermal necrolysis: successful treatment with infliximab. Curr Opin Allergy Clin Immunol. Google Scholar. J Immunol. Exfoliative dermatitis, also known as erythroderma, is an uncommon but serious skin disorder that family physicians must be able to recognize and treat appropriately. 2015;56(4):298302. Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involving skin and usually occurring from days to several weeks after drug exposure. J Dtsch Dermatol Ges. Nat Med. A pseudolymphoma reaction with fever, arthralgias, lymphadenopathy, hepatosplenomegaly, anemia and erythroderma may develop as a result of hypersensitivity to dapsone or antiepileptic drugs. The former is usually a recurring, localized eruption of the skin characterized by pathognomonic target or iris lesions, with minimal or no mucosal involvement (Fig. Narita YM, et al. For SJS/TEN, corticosteroids are the cornerstone of treatment albeit efficacy remains unclear. PubMed Chung WH, Hung SI. A drug eruption may start as a rash but eventually progress to more generalized exfoliative dermatitis. 19 Key critical interactions are discussed below for each mpox antiviral. Four cases are described, two of which were due to phenindione sensitivity. It was used with success in different case reports [114116]. Mucosal involvement could achieve almost 65% of patients [17]. Utility of the lymphocyte transformation test in the diagnosis of drug sensitivity: dependence on its timing and the type of drug eruption. To confirm ATT induced erythroderma and narrow down the offending agents, sequential rechallenge with ATT was done and again these patients had similar lesions erupt all over the body only with isoniazid and pyrazinamide. Minerva Stomatol. A rare case of toxic epidermal necrolysis with unexpected Fever resulting from dengue virus. Patients with carcinoma of the colon, lung, prostate and thyroid have presented with erythroderma. Frequently reported adverse events of rebamipide compared to other drugs for peptic ulcer and gastroesophageal reflux disease. Wu PA, Cowen EW. Death ligand TRAIL, secreted by CD1a+and CD14+cells in blister fluids, is involved in killing keratinocytes in toxic epidermal necrolysis. 1995;5(4):2558. 1997;22(3):1467. Drugs.com provides accurate and independent information on more than . Still, treatment indication, choice and dosage remain unclear, and efficacy yet unproven. Acute and chronic leukemia may also cause exfoliative dermatitis. Int J Dermatol. . A heterogeneous pathologic phenotype. Rarely, Mycoplasma pneumoniae, dengue virus, cytomegalovirus, and contrast media may be the causative agent of SJS and TEN [22, 6567]. Tang YH, et al. Tohyama M, et al. Roujeau JC, Stern RS. It recommended to used G-CSF in patients with febrile neutropenia [94, 95]. Usually the amount of calories is 15002000kcal/day and the velocity of infusion is gradually increased based on patients tolerability [92]. The authors declare that they have no competing interests. Copyright 2023 American Academy of Family Physicians. In this study, 965 patients were reviewed. . Retrospective review of StevensJohnson syndrome/toxic epidermal necrolysis treatment comparing intravenous immunoglobulin with cyclosporine. Springer Nature.