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Treatment of toxic epidermal necrolysis in North America

2015; Elsevier BV; Volume: 73; Issue: 5 Linguagem: Inglês

10.1016/j.jaad.2015.08.008

1097-6787

Roni P. Dodiuk‐Gad, C Olteanu, Marc G. Jeschke, Robert Cartotto, Joel Fish, Neil H. Shear,

Contact Dermatitis and Allergies

To the Editor: There is no consensus regarding the optimal management of patients with toxic epidermal necrolysis (TEN). The latest treatment protocol recommended by the American Burn Association (ABA) was published in 2008.1Endorf F.W. Cancio L.C. Gibran N.S. Toxic epidermal necrolysis clinical guidelines.J Burn Care Res. 2008; 29: 706-712Crossref PubMed Scopus (62) Google Scholar However, since then, new data have accumulated in the literature on the lack of survival benefits with intravenous immunoglobulin (IVIG)2Lee H.Y. Lim Y.L. Thirumoorthy T. et al.The role of intravenous immunoglobulin in toxic epidermal necrolysis: a retrospective analysis of 64 patients managed in a specialized centre.Br J Dermatol. 2013; 169: 1304-1309Crossref PubMed Scopus (84) Google Scholar and on the effectiveness of cyclosporine,3Valeyrie-Allanore L. Wolkenstein P. Brochard L. et al.Open trial of ciclosporin treatment for Stevens-Johnson syndrome and toxic epidermal necrolysis.Br J Dermatol. 2010; 163: 847-853Crossref PubMed Scopus (191) Google Scholar anti-tumor necrosis factor (TNF) agents,4Fernando S.L. The management of toxic epidermal necrolysis.Aust J Dermatol. 2012; 53: 165-171Crossref PubMed Scopus (57) Google Scholar and pulse corticosteroids4Fernando S.L. The management of toxic epidermal necrolysis.Aust J Dermatol. 2012; 53: 165-171Crossref PubMed Scopus (57) Google Scholar in adults. In order to evaluate the management of patients with TEN in North America, we conducted this study. Directors of burn centers (130) and dermatology departments and clinics (17) in North America were requested by email to complete a 16-question survey (Supplemental Appendix, available at http://www.jaad.org) on their management of patients with TEN. The study was conducted from September to October 2013. Categorical variables were reported using counts and percentages. Thirty-seven surveys were completed (25% response rate); 24 responses (65%) were from the United States and 13 (35%) were from Canada. The cohort is detailed in Table I.Table ICohort characteristicsCharacteristicNumberPercentage (%)Type of Center Burn center2875.7 Dermatology departments410.8 Dermatology clinics513.5Workplace University affiliated2875.7 Community hospital616.2 Other38.1Types of populations treated Both adult and pediatric2362.2 Adult1027.0 Pediatric410.8Patients treated with TEN in the last 5 years >102464.9 6-10718.9 1-5513.5 012.7 Open table in a new tab Only 51% reported that their center/department has assessment guidelines for patients with TEN (35% use their center's version while 16% use the ABA1Endorf F.W. Cancio L.C. Gibran N.S. Toxic epidermal necrolysis clinical guidelines.J Burn Care Res. 2008; 29: 706-712Crossref PubMed Scopus (62) Google Scholar or other published guidelines), and only 54% reported that their center/department has treatment guidelines (46% use their center's version while 8% use the ABA1Endorf F.W. Cancio L.C. Gibran N.S. Toxic epidermal necrolysis clinical guidelines.J Burn Care Res. 2008; 29: 706-712Crossref PubMed Scopus (62) Google Scholar or other published guidelines). Thirty percent reported that they never use SCORTEN (severity-of-illness score for TEN), 22% frequently use this measure, 22% always use it, 19% rarely use it, and 8% are not familiar with this measure. Forty-three percent never use ALDEN (Algorithm for the Assessment of Drug Causality in TEN), 43% are not familiar with this measure, 5% rarely use it, and only 3% always use it. The most common systemic treatment reported was IVIG at 81%, followed by systemic corticosteroids (24%), cyclosporine (11%), and anti-TNF in 11% (50% etanercept, 50% infliximab). Fourteen percent do not use any systemic treatment. Sixty-two percent of centers' directors reported usage of early debridement of nonviable tissue. The most common topical treatment reported was silver-coated/silver-impregnated dressings (73%), followed by semisynthetic/synthetic dressings (43%), topical antimicrobials (43%), and bioactive skin substitutes (38%). Sixty-two percent reported using amniotic membrane transplantation for the management of acute ocular complications (35% rarely use it, 16% frequently use it, and 11% always use it). Eighty-six percent never prescribe prophylactic antibiotics in the management of patients with TEN, 11% rarely prescribe, and 3% frequently prescribe. Unfortunately, only 16% of directors reported that their center refers patients to a support group. The results of our study demonstrate a lack of correlation in the management of TEN in North America versus the published consensus on the management of TEN established at the 8th International Congress on Cutaneous Adverse Drug Reactions (iSCAR 2013)5Dodiuk-Gad R.P. Chung W.H. Yang C.H. et al.The 8th International Congress on Cutaneous Adverse Drug Reactions, Taiwan, 2013: focus on severe cutaneous adverse reactions.Drug Saf. 2014; 37: 459-464Crossref PubMed Scopus (9) Google Scholar (Fig 1). These results demonstrate the lack of implementation of the knowledge gathered in the last decades on the management of TEN in North America. Hence, there is a crucial need to formulate up-to-date treatment guidelines for patients with TEN in North America, a need confirmed by the majority (70%) of centers' directors. 1.Which best describes your clinical environment:a.Burn Centerb.Dermatology Departmentc.Dermatology clinicd.OtherYour answer: _________2.Please indicate your workplace location in North America:a.United Statesb.Canadac.OtherYour answer: _________3.Please indicate your workplace category:a.Community hospitalb.University affiliated hospitalc.OtherYour answer: _________4.Please indicate the type of populations treated in your center/department:a.Adult populationb.Pediatric populationc.Both adults and pediatric population (a+b)d.OtherYour answer: _________5.How many patients with Toxic Epidermal Necrolysis (TEN) have you treated in your center in the last 5 years?a.0b.1-5c.6-10d.>10Your answer: _________6.Does your center/department have guidelines for the assessment of patients with Toxic Epidermal Necrolysis (TEN)? NOTE: We recognize that guidelines vary but we are interested if you have a guideline at all.a.Yes (our own center's version)b.Yes (use the ABA or other published guideline)a.Guideline used: _________c.Nod.I don't knowYour answer: _________7.Does your center/department have guidelines for the treatment of patients with Toxic Epidermal Necrolysis (TEN)? NOTE: We recognize that guidelines vary but we are interested if you have a guideline at all.a.Yes (our own center's version)b.Yes (use the ABA or other published guideline)i.Guideline used: __________c.Nod.I don't knowYour answer: __________8.Do you use the SCORTEN severity measure to assess the risk of death for patients with Toxic Epidermal Necrolysis (TEN)?a.Neverb.Rarelyc.Frequentlyd.Alwayse.I don't knowf.I am not familiar with the SCORTEN scoreYour answer: __________9.Do you use the ALDEN calculation for the assessment of drug causality in patients with Toxic Epidermal Necrolysis (TEN)?a.Neverb.Rarelyc.Frequentlyd.Alwayse.I don't knowf.I am not familiar with the ALDEN scoreYour answer: __________10.Which of the following systemic treatments have you used for the management of your patients with Toxic Epidermal Necrolysis (TEN) in the last 5 years?a.Intravenous immunoglobulin – IVIG, total dose < 3 g/kgb.Intravenous immunoglobulin – IVIG, total dose ≥ 3 g/kgc.Systemic corticosteroidsd.Cyclosporine (Ciclosporin)e.Infliximab (Remicade)f.Etanercept (Enbrel)g.N-acetylcysteine (NAC)h.Plasmapheresisi.Cyclophosphamidej.Other treatments- please specify Please indicate all treatments including combinations.Your answers: __________11.Are you using idealized body weight for the calculation of the intravenous immunoglobulin (IVIG) dosage?a.YESb.NOc.I don't knowd.Other- please specifyYour answer: __________12.Do you use amniotic membrane transplantation for the management of acute ocular complications?a.Neverb.Rarelyc.Frequentlyd.Alwayse.I don't knowf.I am not familiar with the usage of amniotic membrane implantationYour answer: __________13.Which of the following topical treatments have you used for the management of your patients with Toxic Epidermal Necrolysis (TEN) in the last 5 years?a.Early debridement of nonviable tissueb.Bioactive skin substitutes, such as human amnion or fresh/cryopreserved skin cadaver allograft (skin bank), porcine skin xenograft, or cultured keratinocyte allograftsc.Semi-synthetic and synthetic dressings, such as Biobrane, Suprathel, Calcium-sodium alginatesd.Silver-coated or silver-impregnated dressingse.Nanocrystalline silver-coated dressingsf.Topical antimicrobials, such as silver nitrate, chlorhexidine, silver sulfadiazine, iodine, mupirocing.Combinations of topical treatmentsh.Other treatments- please specifyPlease indicate all the various treatments including combinations.Your answers: __________14.Are you prescribing prophylactic antibiotic treatment in the management of your patients with Toxic Epidermal Necrolysis (TEN)?a.Neverb.Rarelyc.Frequentlyd.Alwayse.I don't knowYour answer: __________15.Which, if any, of these follow-up methods do you employ for patients who survived Toxic Epidermal Necrolysis (TEN)?a.Referral to a support groupb.Follow-up assessment in the dermatology/burn center clinicc.Follow-up assessment by the family physiciand.No follow upYour answer: __________16.Do you think there is a need to formulate international treatment guidelines for patients with Toxic Epidermal Necrolysis (TEN)?a.Yesb.Noc.I don't knowd.Other- please specifyYour answer: __________17.May you please share with us your experience, challenges and insights in the treatment of patients with Toxic Epidermal Necrolysis (TEN)?Your comments:18.Other Comments: