EM is a self-limited skin condition mainly associated with infections and drugs [53, 54]. Exfoliative dermatitis is also a risk factor for epidemic spread of methicillin-resistant Staphylococcus aureus.6,20. Curr Probl Dermatol. Role of nanocrystalline silver dressings in the management of toxic epidermal necrolysis (TEN) and TEN/StevensJohnson syndrome overlap. 583-587. Targeting keratinocyte apoptosis in the treatment of atopic dermatitis and allergic contact dermatitis. Unlike EMM, SJS and TEN are mainly related to medication use. Annu Rev Pharmacol Toxicol. 2012;51(8):889902. Von Hebra first described erythroderma (exfoliative dermatitis) in 1868. A systematic review of treatment of drug-induced StevensJohnson syndrome and toxic epidermal necrolysis in children. Erythroderma is the term used to describe intense and usually widespread reddening of the skin due to inflammatory skin disease. J Invest Dermatol. The prognosis of cases associated with malignancy typically depends on the outcome of the underlying malignancy. Drug eruptions that initially present as morbilliform, lichenoid or urticarial rashes may progress to generalized exfoliative dermatitis. 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. Its also characterized by a cell-poor infiltrate, where macrophages and dendrocytes with a strong TNF- immunoreactivity predominate [6, 50]. Recombinant granulocyte colony-stimulating factor in the management of toxic epidermal necrolysis. Therefore, it is important to identify and treat any underlying disease whenever possible and to remove any contributing external factors.2, Most published studies of exfoliative dermatitis have been retrospective and thus do not address the issue of overall incidence. For SJS/TEN, corticosteroids are the cornerstone of treatment albeit efficacy remains unclear. Iv bolus of steroid (dexamethasone 100300mg/day or methylprednisolone 2501000mg/day) for 3 consecutive days with a gradual taper steroid therapy is sometimes advised. Arch Dermatol. Clin Exp Dermatol. A marker for StevensJohnson syndrome: ethnicity matters. N Engl J Med. As written before, Sassolas B. et al. HLA-B* 5801 allele as a genetic marker for severe cutaneous adverse reactions caused by allopurinol. PubMed Med J Armed Forces India. 2015;21:13343. Immunoregulatory effector cells in drug-induced toxic epidermal necrolysis. 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. TEN is characterized by full-thickness epidermal necrosis with an evident epidermal detachment and sloughing caused by necrosis of keratinocytes following apoptosis [49, 52]. Blood gas analysis, glucose and creatinine levels together with electrolytes should be evaluated and therapy should be modified accordingly. 2005;136(3):20516. Common acute symptoms include abdominal pain or cramps, nausea, vomiting, and diarrhea, jaundice, skin rash and eyes dryness and therefore could mimic the prodromal and early phase of ED. sharing sensitive information, make sure youre on a federal Exposure to anticonvulsivants (phenytoin, phenobarbital, lamotrigine), non-nucleoside reverse transcriptase inhibitors (nevirapine), cotrimoxazole and other sulfa drugs (sulfasalazine), allopurinol and oxicam NSAIDs [2] confers a higher risk of developing SJS/TEN. Hum Mol Genet. It has a wide spectrum of severity, and it is divided in minor and major (EMM). ADRJ,2015,17(6):464-465. Br J Dermatol. Exfoliative dermatitis is characterized by generalized erythema with scaling or desquamation affecting at least 90% of the body surface area. PubMed Article 2012;43:10115. Australas J Dermatol. 2013;27(5):65961. Frequently reported adverse events of rebamipide compared to other drugs for peptic ulcer and gastroesophageal reflux disease. Contact dermatitis from topical antihistamine . AQUACEL Ag in the treatment of toxic epidermal necrolysis (TEN). Typical target lesions consist of three components: a dusky central area or blister, a dark red inflammatory zone surrounded by a pale ring of edema, and an erythematous halo on the periphery. Joint Bone Spine. Schwartz RA, McDonough PH, Lee BW. Herpes simplex virus (HSV) 1 and 2 are the main triggers in young adults (>80% of cases), followed by Epstein-Barr virus (EBV), and Mycoplasma pneumonia [5558]. 2016 Nov 15;17(11):1890. doi: 10.3390/ijms17111890. Locharernkul C, et al. A recently published meta-analysis by Huang [110] and coworkers on IVIG in SJS/SJS-TEN/TEN reviewed 17 studies with 221 patients and compared the results obtained with high-dosage IVIG (>2g/kg) compared to lower-dosage IVIG (<2g/kg). Br J Dermatol. 2008;53(1):28. (in Chinese) . Ann Pharmacother. Accurate eye cleaning with saline solution is fundamental for the prevention of synechiae and for reducing corneal damage. 1. Kaffenberger BH, Rosenbach M. Toxic epidermal necrolysis and early transfer to a regional burn unit: is it time to reevaluate what we teach? 1999;48(5):21726. eCollection 2018. They found that the inhibition of these molecules could attenuate the cytotoxic effect of lymphocytes toward keratinocytes. 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]. Drug-induced exfoliative dermatitis is usually short-lived once the inciting medication is withdrawn and appropriate therapy is administered. The site is secure. Exfoliative dermatitis has been reported in association with hepatitis, acquired immunodeficiency syndrome, congenital immunodeficiency syndrome (Omenn's syndrome) and graft-versus-host disease.2,1517, In reviews of erythroderma, a significant percentage of patients (about 25 percent) do not receive a specific etiologic diagnosis. Arch Dermatol. Toxic epidermal necrolysis associated with Mycoplasma pneumoniae infection. The long-term prognosis is good in patients with drug-induced disease, although the course tends to be remitting and relapsing in idiopathic cases. Med., 1976, 6, pp. 2012;42(2):24854. FDA Drug information Palynziq Read time: 10 mins Marketing start date: 04 Mar 2023 . The authors declare that they have no competing interests. Wetter DA, Camilleri MJ. J Am Acad Dermatol. MRY, MGS, EN and GC designed the study, selected scientifically relevant information, wrote and revised the manuscript. Chem Immunol Allergy. In addition to all these mechanisms, alarmins, endogenous molecules released after cell damage, were found to be transiently increased in SJS/TEN patients, perhaps amplifying the immune response, including -defensin, S100A and HMGB1 [47]. Initial symptoms could be aspecific, as fever, stinging eyes and discomfort upon swallowing, occurring few days before the onset of mucocutaneous involvement. Bookshelf Exfoliative dermatitis, including Stevens-Johnson syndrome, drug rash with eosinophilia and systemic symptoms, and toxic epidermal necrolysis, has occurred with anti-PD-1/PD-L1 treatments. Guidelines for the management of drug-induced liver injury[J]. Utility of the lymphocyte transformation test in the diagnosis of drug sensitivity: dependence on its timing and the type of drug eruption. A significant number of these patients eventually progress to cutaneous T-cell lymphoma.8, Clinically, the first stage of exfoliative dermatitis is erythema, often beginning as single or multiple pruritic patches, involving especially the head, trunk and genital region. Mortality rate of patients with TEN has shown to be directly correlated to SCORTEN. Some of these patients undergo spontaneous resolution. Infliximab: chimeric IgG monoclonal anti-TNF- antibody. PubMed Detection of a herpes simplex viral antigen in skin lesions of erythema multiforme. 2014;71(5):9417. Considered variables in SCORTEN are shown in Table2. In patients with SJS/TEN increased serum levels of retinoid acid have been found. Roujeau JC, et al. Energy requirements of pediatric patients with StevensJohnson syndrome and toxic epidermal necrolysis. 2011;71(5):67283. Risk factors for the development of ocular complications of StevensJohnson syndrome and toxic epidermal necrolysis. 8600 Rockville Pike Downey A, et al. 1992;11(3):20710. Overall, incidence of SJS/TEN ranges from 2 to 7 cases per million person per year [9, 1820], with SJS the commonest [21]. In a hemodialysis patient with active pulmonary tuberculosis, early withdrawl followed by prompt rechallenging to identify the causative agent and then to achieve cure of pulmonary tuberculosis is an interesting therapeutic challenge. 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). Napoli B, et al. In acute phase it is crucial to assess the culprit agent, in particular when the patient was assuming several drugs at time of DHR. StevensJohnson syndrome and toxic epidermal necrolysis: a review of the literature. -, Schwartz RA, McDonough PH, Lee BW. In the hospital, special attention must be given to maintaining temperature control, replacing lost fluids and electrolytes, and preventing and treating infection. Paulmann M, Mockenhaupt M. Severe drug-induced skin reactions: clinical features, diagnosis, etiology, and therapy. After 24 hours, split formation was evident in hematoxylin and eosin-stained sections of HOSCs treated . 2014;71(2):27883. Mayo Clin Proc. The applications of topical cyclosporine and autologous serum have also been showed to be useful in refractory cases [103]. The fluid of blisters from TEN patients was found to be rich in TNF-, produced by monocytes/macrophages present in the epidermis [42], especially the subpopulation expressing CD16, known to produce higher levels of inflammatory cytokines [43]. Allergol Int. PubMed Fritsch PO. Am Fam Physician. Granulysin as a marker for early diagnosis of the StevensJohnson syndrome. The approach to treatment should include discontinuation of any potentially causative medications and a search for any underlying malignancy. ACE inhibitor-induced cough should be considered in the differential diagnosis of cough. Erythema multiforme and latent herpes simplex infection. Increased peripheral blood flow can result in high-output cardiac failure. 2012;167(2):42432. J Invest Dermatol. Do this 2 to 3 times a week. 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. 2015;13(7):62545. 2004;59(8):80920. Fritsch PO. Temporary tracheostomy may be necessary in case of extended mucosal damage. 1984;101(1):4850. AB, CC, ET, GAR, AN, EDL, PF performed a critical revision on the current literature about the described topic, wrote and revised the manuscript. [117] described a cohort of ten patients affected by TEN treated with a single dose of etanercept 50mg sc with a rapid and complete resolution and without adverse events. Drug reactions are one of the most common causes of exfoliative dermatitis. Exfoliative Dermatitis is a serious skin cell disorder that requires early diagnosis and treatment. The epidermal-dermal junction shows changes, ranging from vacuolar alteration to subepidermal blisters [20]. Fitzpatricks dermatology in general medicine. In patients with this disorder, the mitotic rate and the absolute number of germinative skin cells are higher than normal. Ayangco L, Rogers RS 3rd. Infliximab was used in cases refractory to high-dosage steroid therapy and/or IVIG. Hypothermia can result in ventricular flutter, decreased heart rate and hypotension. Association of HLA-B*1502 allele with carbamazepine-induced toxic epidermal necrolysis and StevensJohnson syndrome in the multi-ethnic Malaysian population. TNF- has a dual role: interacts with TNF-R1 activating Fas pathway and activates NF-B leading to cell survival. Painkiller therapy. Perforin/granzyme B pathway: Nassif and colleagues have proposed a role for perforin/grazyme B in keratinocyte death [37]. A useful sign for differential diagnosis is the absence of mucosal involvement, except for conjunctiva. GULIZ KARAKAYLI, M.D., GRANT BECKHAM, M.D., IDA ORENGO, M.D., AND TED ROSEN, M.D. Gonzalez-Delgado P, et al. 2011;20(5):103441. Mortality rate of patients with TEN has shown to be directly correlated to SCORTEN, as shown in Fig. Aminoglutethimide: Aminoglutethimide may lead to a loss of corticosteroid-induced adrenal suppression. Yamada H, Takamori K. Status of plasmapheresis for the treatment of toxic epidermal necrolysis in Japan. 2009;145(2):15762. 2018 Feb;54(1):147-176. doi: 10.1007/s12016-017-8654-z. [80], which consists of the determination of IFN and IL4 by ELISpot (Enzyme-linked immunospot assay), allowing to increase the sensitivity of LTT during acute DHR (82 versus 50% if compared to LPA). Erythema multiforme: a review of epidemiology, pathogenesis, clinical features, and treatment. Patients present an acute high-grade of skin and mucosal insufficiency that obviously leads to great impairment in the defenses against bacteria that normally live on the skin, increasing the high risk of systemic infections.
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