Toxic epidermal necrolysis - Revision history

Danbot: Add reference

2026-03-22T10:06:44Z

Add reference

← Older revision		Revision as of 10:06, 22 March 2026
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	**Lactate		**Lactate
	*Skin biopsy: full-thickness epidermal necrosis (distinguishes from SSSS)		*Skin biopsy: full-thickness epidermal necrosis (distinguishes from SSSS)
	*SCORTEN severity score (assess within first 24 hours):		*SCORTEN severity score (assess within first 24 hours):<ref>Bastuji-Garin S, et al. SCORTEN: a severity-of-illness score for toxic epidermal necrolysis. J Invest Dermatol. 2000;115(2):149-153. PMID 10951229</ref>
	**Age >40, malignancy, HR >120, initial BSA detachment >10%, BUN >28, glucose >252, bicarb <20		**Age >40, malignancy, HR >120, initial BSA detachment >10%, BUN >28, glucose >252, bicarb <20
	**Score ≥3 = mortality >35%; Score ≥5 = mortality >90%		**Score ≥3 = mortality >35%; Score ≥5 = mortality >90%

Danbot: Strip excess bold

2026-03-22T09:28:30Z

Strip excess bold

← Older revision		Revision as of 09:28, 22 March 2026
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	*Severe, life-threatening mucocutaneous reaction characterized by widespread epidermal necrosis and detachment		*Severe, life-threatening mucocutaneous reaction characterized by widespread epidermal necrosis and detachment
	*Represents a spectrum with [[Stevens-Johnson syndrome]] (SJS):		*Represents a spectrum with [[Stevens-Johnson syndrome]] (SJS):
	**~~'''~~SJS~~'''~~: <10% body surface area (BSA) detachment		**SJS: <10% body surface area (BSA) detachment
	**~~'''~~SJS-TEN overlap~~'''~~: 10-30% BSA detachment		**SJS-TEN overlap: 10-30% BSA detachment
	**~~'''~~TEN~~'''~~: >30% BSA detachment		**TEN: >30% BSA detachment
	*Medications are the cause in ~~'''~~80-95% of cases~~'''~~		*Medications are the cause in 80-95% of cases
	**Most common: ~~'''~~sulfonamides~~'''~~, [[anticonvulsants]] (carbamazepine, phenytoin, lamotrigine), ~~'''~~allopurinol~~'''~~, [[NSAIDs]], [[penicillins]]		**Most common: sulfonamides, [[anticonvulsants]] (carbamazepine, phenytoin, lamotrigine), allopurinol, [[NSAIDs]], [[penicillins]]
	**Typically occurs ~~'''~~1-3 weeks~~'''~~ after drug initiation		**Typically occurs 1-3 weeks after drug initiation
	*Other triggers: [[Mycoplasma pneumoniae]] infection (especially in children), HIV, malignancy		*Other triggers: [[Mycoplasma pneumoniae]] infection (especially in children), HIV, malignancy
	*Mortality: ~~'''~~25-35% for TEN~~'''~~, 1-5% for SJS		*Mortality: 25-35% for TEN, 1-5% for SJS
	HLA-B5801 (allopurinol) and HLA-B*1502 (carbamazepine) associated with increased risk		HLA-B5801 (allopurinol) and HLA-B*1502 (carbamazepine) associated with increased risk

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	[[File:Necrolysis epidermalis toxica 02.jpg\|thumb\|Toxic epidermal necrolysis on legs]]		[[File:Necrolysis epidermalis toxica 02.jpg\|thumb\|Toxic epidermal necrolysis on legs]]
	[[File:TENS patient on day 10.jpg\|thumb\|The back of a TENs patient on day 10, at the peak of the condition]]		[[File:TENS patient on day 10.jpg\|thumb\|The back of a TENs patient on day 10, at the peak of the condition]]
	*~~'''~~Prodrome~~'''~~ (1-3 days before skin findings):		*Prodrome (1-3 days before skin findings):
	**[[Fever]], malaise, [[myalgia]]s, [[arthralgia]]s, painful skin, pharyngitis		**[[Fever]], malaise, [[myalgia]]s, [[arthralgia]]s, painful skin, pharyngitis
	*~~'''~~Skin findings~~'''~~:		*Skin findings:
	**Tender erythematous or dusky macules → confluent areas of necrosis		**Tender erythematous or dusky macules → confluent areas of necrosis
	**Flaccid [[vesiculobullous rashes\|bullae]] with full-thickness epidermal detachment		**Flaccid [[vesiculobullous rashes\|bullae]] with full-thickness epidermal detachment
	**~~'''~~Positive Nikolsky sign~~'''~~ (lateral pressure causes epidermal separation)		**Positive Nikolsky sign (lateral pressure causes epidermal separation)
	**~~'''~~Positive Asboe-Hansen sign~~'''~~ (pressure on blister causes lateral extension)		**Positive Asboe-Hansen sign (pressure on blister causes lateral extension)
	**Skin sloughs in sheets, leaving raw denuded dermis		**Skin sloughs in sheets, leaving raw denuded dermis
	*~~'''~~Mucosal involvement~~'''~~ (present in >90% of cases):		*Mucosal involvement (present in >90% of cases):
	**Oral (painful erosions, inability to eat/drink)		**Oral (painful erosions, inability to eat/drink)
	**Ocular ([[conjunctivitis]], corneal erosions — '''ophthalmology emergency''')		**Ocular ([[conjunctivitis]], corneal erosions — '''ophthalmology emergency''')
	**Genitourinary (dysuria, urinary retention)		**Genitourinary (dysuria, urinary retention)
	**Respiratory (tracheobronchial sloughing may cause respiratory failure)		**Respiratory (tracheobronchial sloughing may cause respiratory failure)
	*~~'''~~Systemic complications~~'''~~:		*Systemic complications:
	**[[Sepsis]] (leading cause of death)		**[[Sepsis]] (leading cause of death)
	**[[Hypovolemia]] and [[electrolyte disorders]]		**[[Hypovolemia]] and [[electrolyte disorders]]
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	==Evaluation==		==Evaluation==
	*~~'''~~Clinical diagnosis~~'''~~ based on:		*Clinical diagnosis based on:
	**History of drug exposure within preceding 1-4 weeks		**History of drug exposure within preceding 1-4 weeks
	**Prodrome of fever and malaise		**Prodrome of fever and malaise
	**Positive Nikolsky sign		**Positive Nikolsky sign
	**Mucosal erosions with skin detachment		**Mucosal erosions with skin detachment
	*~~'''~~Labs~~'''~~:		*Labs:
	**CBC (~~'''~~[[leukopenia]]~~'''~~ and ~~'''~~[[thrombocytopenia]]~~'''~~ = poor prognosis)		**CBC ([[leukopenia]] and [[thrombocytopenia]] = poor prognosis)
	**BMP ([[acute kidney injury]], electrolyte derangements)		**BMP ([[acute kidney injury]], electrolyte derangements)
	**LFTs (hepatic involvement in ~10%)		**LFTs (hepatic involvement in ~10%)
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	**Blood cultures (if febrile)		**Blood cultures (if febrile)
	**Lactate		**Lactate
	*~~'''~~Skin biopsy~~'''~~: full-thickness epidermal necrosis (distinguishes from SSSS)		*Skin biopsy: full-thickness epidermal necrosis (distinguishes from SSSS)
	*~~'''~~SCORTEN severity score~~'''~~ (assess within first 24 hours):		*SCORTEN severity score (assess within first 24 hours):
	**Age >40, malignancy, HR >120, initial BSA detachment >10%, BUN >28, glucose >252, bicarb <20		**Age >40, malignancy, HR >120, initial BSA detachment >10%, BUN >28, glucose >252, bicarb <20
	**Score ≥3 = mortality >35%; Score ≥5 = mortality >90%		**Score ≥3 = mortality >35%; Score ≥5 = mortality >90%
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	*'''Discontinue ALL suspected causative medications immediately'''		*'''Discontinue ALL suspected causative medications immediately'''
	**Early drug withdrawal (within 24h of blister onset) improves survival		**Early drug withdrawal (within 24h of blister onset) improves survival
	*Manage as a ~~'''~~burn patient~~'''~~ — transfer to burn center when stable		*Manage as a burn patient — transfer to burn center when stable
	*~~'''~~Fluid resuscitation~~'''~~:		*Fluid resuscitation:
	**Less than typical burn (use 2/3 Parkland formula or ~2-3 mL/kg/%BSA/day)		**Less than typical burn (use 2/3 Parkland formula or ~2-3 mL/kg/%BSA/day)
	**Target UOP 0.5-1 mL/kg/hr		**Target UOP 0.5-1 mL/kg/hr
	*~~'''~~Wound care~~'''~~:		*Wound care:
	**Minimize handling; leave intact bullae when possible		**Minimize handling; leave intact bullae when possible
	**Non-adherent dressings (e.g., Aquacel, petrolatum gauze)		**Non-adherent dressings (e.g., Aquacel, petrolatum gauze)
	**'''Do NOT debride''' attached skin		**'''Do NOT debride''' attached skin
	*~~'''~~Temperature regulation~~'''~~: raise ambient temperature to 30-32°C		*Temperature regulation: raise ambient temperature to 30-32°C

	===Supportive===		===Supportive===
	*~~'''~~Pain control~~'''~~: IV opioids, avoid NSAIDs if suspected trigger		*Pain control: IV opioids, avoid NSAIDs if suspected trigger
	*~~'''~~Nutrition~~'''~~: early enteral nutrition via NG tube if unable to eat		*Nutrition: early enteral nutrition via NG tube if unable to eat
	*~~'''~~DVT prophylaxis~~'''~~		*DVT prophylaxis
	*~~'''~~Eye care~~'''~~: ~~'''~~urgent ophthalmology consult~~'''~~, preservative-free lubricating drops, amniotic membrane grafting for severe involvement		*Eye care: urgent ophthalmology consult, preservative-free lubricating drops, amniotic membrane grafting for severe involvement
	*~~'''~~Mouth care~~'''~~: antiseptic mouthwash, viscous lidocaine		*Mouth care: antiseptic mouthwash, viscous lidocaine
	*~~'''~~Infection monitoring~~'''~~: avoid prophylactic antibiotics (increases resistance); culture if signs of [[sepsis]]		*Infection monitoring: avoid prophylactic antibiotics (increases resistance); culture if signs of [[sepsis]]
	*~~'''~~Foley catheter~~'''~~ if GU involvement		*Foley catheter if GU involvement

	===Specific Therapies (Controversial)===		===Specific Therapies (Controversial)===
	*~~'''~~Cyclosporine~~'''~~ 3-5 mg/kg/day: best available evidence for mortality reduction		*Cyclosporine 3-5 mg/kg/day: best available evidence for mortality reduction
	*~~'''~~IVIG~~'''~~: conflicting data, some protocols use 1-2 g/kg over 3-4 days		*IVIG: conflicting data, some protocols use 1-2 g/kg over 3-4 days
	*~~'''~~Systemic corticosteroids~~'''~~: controversial; short pulse may be considered early		*Systemic corticosteroids: controversial; short pulse may be considered early
	*~~'''~~TNF-α inhibitors~~'''~~ (etanercept): emerging evidence for benefit		*TNF-α inhibitors (etanercept): emerging evidence for benefit

	==Disposition==		==Disposition==
	*~~'''~~All patients require admission~~'''~~, preferably to a ~~'''~~burn center ICU~~'''~~		*All patients require admission, preferably to a burn center ICU
	*Consults: ~~'''~~dermatology, ophthalmology, burn surgery~~'''~~		*Consults: dermatology, ophthalmology, burn surgery
	*Patients may require weeks-months of wound care and rehabilitation		*Patients may require weeks-months of wound care and rehabilitation
	*Long-term complications: skin scarring, ocular sequelae (symblepharon, blindness), genital stenosis		*Long-term complications: skin scarring, ocular sequelae (symblepharon, blindness), genital stenosis
	*~~'''~~Document causative drug allergy prominently~~'''~~ in medical record		*Document causative drug allergy prominently in medical record

	==See Also==		==See Also==

Danbot: Comprehensive expansion: SCORTEN score, detailed management (wound care, cyclosporine, fluid resuscitation), drug causes, mucosal involvement, added peer-reviewed references with PMIDs

2026-03-21T19:34:26Z

Comprehensive expansion: SCORTEN score, detailed management (wound care, cyclosporine, fluid resuscitation), drug causes, mucosal involvement, added peer-reviewed references with PMIDs

Show changes

Rossdonaldson1: /* Background */

2024-12-11T18:17:21Z

Background

← Older revision		Revision as of 18:17, 11 December 2024
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	==Background==		==Background==
			{{Skin anatomy background images}}
	*Explosive dermatosis with tender erythema, bullae, and subsequent exfolliation		*Explosive dermatosis with tender erythema, bullae, and subsequent exfolliation
	*Most commonly caused by medications		*Most commonly caused by medications

Rossdonaldson1: /* References */

2019-11-16T13:50:24Z

References

← Older revision		Revision as of 13:50, 16 November 2019
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	==References==		==References==
	~~<UpToDate>~~

	[[Category:Dermatology]]		[[Category:Dermatology]]
	[[Category:Critical Care]]		[[Category:Critical Care]]

Rossdonaldson1: /* Clinical Features */

2019-11-16T13:25:45Z

Clinical Features

← Older revision		Revision as of 13:25, 16 November 2019
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	==Clinical Features==		==Clinical Features==
	[[File:Necrolysis epidermalis toxica 02.jpg\|thumb\|Toxic epidermal necrolysis on legs]]		[[File:Necrolysis epidermalis toxica 02.jpg\|thumb\|Toxic epidermal necrolysis on legs]]
			[[File:TENS patient on day 10.jpg\|thumb\|The back of a TENs patient on day 10, at the peak of the condition]]
	*Malaise, anorexia, [[myalgia]]s, [[arthralgia]]s, [[fever]], painful skin, GI symptoms		*Malaise, anorexia, [[myalgia]]s, [[arthralgia]]s, [[fever]], painful skin, GI symptoms
	*Extracutaneous manifestations may persist for 1-2 weeks following skin symptoms		*Extracutaneous manifestations may persist for 1-2 weeks following skin symptoms

Rossdonaldson1: /* Clinical Features */

2019-11-16T13:23:34Z

Clinical Features

← Older revision		Revision as of 13:23, 16 November 2019
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	==Clinical Features==		==Clinical Features==
	[[File:Necrolysis epidermalis toxica 02.jpg\|thumb]]\|Toxic epidermal necrolysis on legs]]		[[File:Necrolysis epidermalis toxica 02.jpg\|thumb\|Toxic epidermal necrolysis on legs]]
	*Malaise, anorexia, [[myalgia]]s, [[arthralgia]]s, [[fever]], painful skin, GI symptoms		*Malaise, anorexia, [[myalgia]]s, [[arthralgia]]s, [[fever]], painful skin, GI symptoms
	*Extracutaneous manifestations may persist for 1-2 weeks following skin symptoms		*Extracutaneous manifestations may persist for 1-2 weeks following skin symptoms

Rossdonaldson1: /* Clinical Features */

2019-11-16T13:23:08Z

Clinical Features

← Older revision		Revision as of 13:23, 16 November 2019
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	==Clinical Features==		==Clinical Features==
			[[File:Necrolysis epidermalis toxica 02.jpg\|thumb]]\|Toxic epidermal necrolysis on legs]]
	*Malaise, anorexia, [[myalgia]]s, [[arthralgia]]s, [[fever]], painful skin, GI symptoms		*Malaise, anorexia, [[myalgia]]s, [[arthralgia]]s, [[fever]], painful skin, GI symptoms
	*Extracutaneous manifestations may persist for 1-2 weeks following skin symptoms		*Extracutaneous manifestations may persist for 1-2 weeks following skin symptoms

ClaireLewis at 01:57, 28 September 2019

2019-09-28T01:57:45Z

← Older revision		Revision as of 01:57, 28 September 2019
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	==Clinical Features==		==Clinical Features==
	*Malaise, anorexia, ~~myalgias~~, ~~arthralgias~~, [[fever]], painful skin, GI symptoms		*Malaise, anorexia, [[myalgia]]s, [[arthralgia]]s, [[fever]], painful skin, GI symptoms
	*Extracutaneous manifestations may persist for 1-2 weeks following skin symptoms		*Extracutaneous manifestations may persist for 1-2 weeks following skin symptoms
	*Exam with warm tender erythema with overlying flaccid bullae, erosions with exfoliation		*Exam with warm tender erythema with overlying flaccid [[vesiculobullous rashes\|bullae]], erosions with exfoliation
	*Positive ~~Nikolskly~~'s sign (able to rub off superficial layers of skin with pressure)		*Positive Nikolsky's sign (able to rub off superficial layers of skin with pressure)
	*Mucosal involvement (oral, conjunctival, respiratory, GU)		*Mucosal involvement (oral, conjunctival, respiratory, GU)
	*Systemic toxicity		*Systemic toxicity
	*25-35% Mortality		*25-35% Mortality
	**Death is usually caused by infection, hypovolemia, and electrolyte disorders		**Death is usually caused by [[infection]], [[hypovolemia]], and [[electrolyte disorders]]
	*Predictors of poor prognosis include: age, extent of disease, leukopenia, azotemia, and thrombocytopenia		*Predictors of poor prognosis include: age, extent of disease, [[leukopenia]], azotemia, and [[thrombocytopenia]]

	==Differential Diagnosis==		==Differential Diagnosis==
	*Toxic infectious erythemas		*Toxic infectious erythemas
	*Exfoliative drug eruptions		*Exfoliative [[drug eruptions]]
	*Primary blistering disorders		*Primary blistering disorders
	*[[Stevens-Johnsons syndrome]]		*[[Stevens-Johnsons syndrome]]
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	==Management==		==Management==
	*Monitor cardiopulmonary status closely		*Monitor cardiopulmonary status closely
	*Correct fluid and electrolyte imbalances		*Correct [[IVF\|fluid]] and [[electrolyte imbalances]]
	*Attend to infectious complications		*Attend to infectious complications

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	[[Category:Dermatology]]		[[Category:Dermatology]]
			[[Category:Critical Care]]

Rossdonaldson1: Text replacement - "BSA" to "BSA"

2019-02-12T08:11:15Z

Text replacement - "BSA" to "BSA"

← Older revision		Revision as of 08:11, 12 February 2019
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	*SJS vs TEN		*SJS vs TEN
	**SJS - skin detachment of <10% of BSA		**SJS - skin detachment of <10% of [[BSA]]
	**TEN – skin detachment of >30% of BSA		**TEN – skin detachment of >30% of [[BSA]]

	==Management==		==Management==