Boosting effect of cyclosporine on corticosteroids in the acute management of toxic epidermal necrolysis

Authors

  • Nageswaramma Sidhabathuni Department of Dermatology and Venereology, Guntur Government Hospital, Guntur, Andhra Pradesh, India
  • Sahitya Tadi Department of Dermatology and Venereology, Guntur Government Hospital, Guntur, Andhra Pradesh, India
  • Rakesh Darla Department of Dermatology and Venereology, Guntur Government Hospital, Guntur, Andhra Pradesh, India
  • Premsagar Gomukonda Department of Dermatology and Venereology, Guntur Government Hospital, Guntur, Andhra Pradesh, India

DOI:

https://doi.org/10.18203/issn.2455-4529.IntJResDermatol20202663

Keywords:

Corticosteroid, Cyclosporin, TEN

Abstract

Toxic epidermal necrolysis (TEN) is a life-threatening dermatological emergencies. It is a rare, acute mucocutaneous disorder that usually occur secondarily as an idiosyncratic reaction to certain drugs. Prompt identification and discontinuation of the causative drug is mandatory along with adequate supportive care like proper hydration, minimize the number of skin manipulation, prevention of secondary infections. Many immunosuppressive modalities have been tried with variable results. In this manuscript, we reported 12 consecutive cases of TEN presented to our hospital over a period of 2 years from 2017 to 2019. All the cases presented with varying percentage of skin blistering and mucosal involvement secondary to an offending drug. The incriminated drug was discontinued, supportive care was initiated along with combination therapy of cyclosporine and corticosteroids as immunosuppressants. The clinical presentation, etiological drugs and treatment protocol followed and its efficacy will be described in details.

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References

Roujeau JC, Stern RS. Severe adverse cutaneous reactions to drugs. N Engl J Med. 1994;331:1272-85.

Abood GJ, Nickoloff BJ, Gamelli RL. Treatment strategies in toxic epidermal necrolysis syndrome: Where are we at? J Burn Care Res. 2008;29:269-76.

Mockenhaupt M, Viboud C, Dunant A, Naldi L, Halevy S, Bouwes Bavinck JN, et al. Stevens-Johnson syndrome and toxic epidermal necrolysis: Assessment of medication risks with emphasis on recently marketed drugs. The EuroSCAR-study. J Invest Dermatol. 2008;128:35-44.

Revuz J, Penso D, Roujeau JC, Guillaume JC, Payne CR, Wechsler J, et al. Toxic epidermal necrolysis. Clinical findings and prognosis factors in 87 patients. Arch Dermatol. 1987;123:1160-5.

Schöpf E, Stühmer A, Rzany B, Victor N, Zentgraf R, Kapp JF. Toxic epidermal necrolysis and Stevens-Johnson syndrome. An epidemiologic study from West Germany. Arch Dermatol. 1991;127:839-42.

Auquier-Dunant A, Mockenhaupt M, Naldi L, Correia O, Schröder W, Roujeau JC, et al. Correlations between clinical patterns and causes of erythema multiforme majus, Stevens-Johnson syndrome, and toxic epidermal necrolysis: Results of an international prospective study. Arch Dermatol. 2002;138:1019-24.

Pereira FA, Mudgil AV, Rosmarin DM. Toxic epidermal necrolysis. J Am Acad Dermatol. 2007;56:181-200.

Wehrli P, Viard I, Bullani R, Tschopp J, French LE. Death receptors in cutaneous biology and disease. J Invest Dermatol. 2000;115:141-8.

Guégan S, Bastuji-Garin S, Poszepczynska-Guigné E, Roujeau JC, Revuz J. Performance of the SCORTEN during the first five days of hospitalization to predict the prognosis of epidermal necrolysis. J Invest Dermatol. 2006;126:272-6.

Bastuji-Garin S, Fouchard N, Bertocchi M, Roujeau JC, Revuz J, Wolkenstein P. SCORTEN: A severity-of-illness score for toxic epidermal necrolysis. J Invest Dermatol. 2000;115:149-53.

Valeyrie-Allanore L, Wolkenstein P, Brochard L, Ortonne N, Maître B, Revuz J, et al. Open trial of ciclosporin treatment for Stevens-Johnson syndrome and toxic epidermal necrolysis. Br J Dermatol. 2010;163:847-53.

Patterson R, Miller M, Kaplan M, Doan T, Brown J, Detjen P, et al. Effectiveness of early therapy with corticosteroids in Stevens-Johnson syndrome: Experience with 41 cases and a hypothesis regarding pathogenesis. Ann Allerg. 1994;73:27-34.

Chaidemenos GC, Chrysomallis F, Sombolos K, Mourellou O, Ioannides D, Papakonstantinou M. Plasmapheresis in toxic epidermal necrolysis. Int J Dermatol. 1997;36:218-21.

Egan CA, Grant WJ, Morris SE, Saffle JR, Zone JJ. Plasmapheresis as an adjunct treatment in toxic epidermal necrolysis. J Am Acad Dermatol. 1999;40:458-61.

Heng MC, Allen SG. Efficacy of cyclophosphamide in toxic epidermal necrolysis. Clinical and pathophysiologic aspects. J Am Acad Dermatol. 1991;25:778-86.

Wolkenstein P, Latarjet J, Roujeau JC, Duguet C, Boudeau S, Vaillant L, et al. Randomised comparison of thalidomide versus placebo in toxic epidermal necrolysis. Lancet. 1998;352:1586-9.

Fernando SL. The management of toxic epidermal necrolysis. Australas J Dermatol. 2012;53:165-71.

Yang Y, Xu J, Li F, Zhu X. Combination therapy of intravenous immunoglobulin and corticosteroid in the treatment of toxic epidermal necrolysis and Stevens-Johnson syndrome: A retrospective comparative study in China. Int J Dermatol. 2009;48:1122-8.

Stella M, Clemente A, Bollero D, Risso D, Dalmasso P. Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS): Experience with high-dose intravenous immunoglobulins and topical conservative approach. A retrospective analysis. Burns. 2007;33:452-9.

Tristani-Firouzi P, Petersen MJ, Saffle JR, Morris SE, Zone JJ. Treatment of toxic epidermal necrolysis with intravenous immunoglobulin in children. J Am Acad Dermatol. 2002;47:548-52.

Campione E, Marulli GC, Carrozzo AM, Chimenti MS, Costanzo A, Bianchi L. High-dose intravenous immunoglobulin for severe drug reactions: Efficacy in toxic epidermal necrolysis. Acta Derm Venereol. 2003;83:430-2.

Metry DW, Jung P, Levy ML. Use of intravenous immunoglobulin in children with Stevens-Johnson syndrome and toxic epidermal necrolysis: Seven cases and review of the literature. Pediatrics. 2003;112:1430-6.

Prins C, Kerdel FA, Padilla RS, Hunziker T, Chimenti S, Viard I, et al. Treatment of toxic epidermal necrolysis with high-dose intravenous immunoglobulins: Multicenter retrospective analysis of 48 consecutive cases. Arch Dermatol. 2003;139:26-32.

Al-Mutairi N, Arun J, Osama NE, Amr Z, Mazen AS, Ibtesam EA, et al. Prospective, noncomparative open study from Kuwait of the role of intravenous immunoglobulin in the treatment of toxic epidermal necrolysis. Int J Dermatol. 2004;43:847-51.

Tan AW, Thong BY, Yip LW, Chng HH, Ng SK. High-dose intravenous immunoglobulins in the treatment of toxic epidermal necrolysis: An Asian series. J Dermatol. 2005;32:1-6.

Mangla K, Rastogi S, Goyal P, Solanki RB, Rawal RC. Efficacy of low dose intravenous immunoglobulins in children with toxic epidermal necrolysis: An open uncontrolled study. Indian J Dermatol Venereol Leprol. 2005;71:398-400.

Bachot N, Revuz J, Roujeau JC. Intravenous immunoglobulin treatment for Stevens-Johnson syndrome and toxic epidermal necrolysis: A prospective noncomparative study showing no benefit on mortality or progression. Arch Dermatol. 2003;139:33-6.

Zaki I, Patel S, Reed R, Dalziel KL. Toxic epidermal necrolysis associated with severe hypocalcaemia, and treated with cyclosporin. Br J Dermatol. 1995;133:337-8.

Sullivan JR, Watson A. Lamotrigine-induced toxic epidermal necrolysis treated with intravenous cyclosporin: A discussion of pathogenesis and immunosuppressive management. Australas J Dermatol. 1996;37:208-12.

Jarrett P, Rademaker M, Havill J, Pullon H. Toxic epidermal necrolysis treated with cyclosporin and granulocyte colony stimulating factor. Clin Exp Dermatol. 1997;22:146-7.

Arévalo JM, Lorente JA, González-Herrada C, Jiménez-Reyes J. Treatment of toxic epidermal necrolysis with cyclosporin A. J Trauma. 2000;48:473-8.

Robak E, Robak T, Góra-Tybor J, Chojnowski K, Strzelecka B, Waszczykowska E, et al. Toxic epidermal necrolysis in a patient with severe aplastic anemia treated with cyclosporin A and G-CSF. J Med. 2001;32:31-9.

Hashim N, Bandara D, Tan E, Ilchyshyn A. Early cyclosporine treatment of incipient toxic epidermal necrolysis induced by concomitant use of lamotrigine and sodium valproate. Acta Derm Venereol. 2004;84:90-1.

Rai R, Srinivas CR. Suprapharmacologic doses of intravenous dexamethasone followed by cyclosporine in the treatment of toxic epidermal necrolysis. Indian J Dermatol Venereol Leprol. 2008;74:263-5.

Majumdar S, Mockenhaupt M, Roujeau J, Townshend A. Interventions for toxic epidermal necrolysis. Cochrane Database Syst Rev. 2002;CD001435.

Kakourou T, Klontza D, Soteropoulou F, Kattamis C. Corticosteroid treatment of erythema multiforme major n(Stevens-Johnson syndrome) in children. Eur J Pediatr. 1997;156:90-3.

Tripathi A, Ditto AM, Grammer LC, Greenberger PA, McGrath KG, Zeiss CR, et al. Corticosteroid therapy in an additional 13 cases of Stevens-Johnson syndrome: A total series of 67 cases. Allerg Asthma Proc. 2000;21:101-5.

Chave TA, Mortimer NJ, Sladden MJ, Hall AP, Hutchinson PE. Toxic epidermal necrolysis: Current evidence, practical management and future directions. Br J Dermatol. 2005;153:241-53.

Gerdts B, Vloemans AF, Kreis RW. Toxic epidermal necrolysis: 15 years’ experience in a Dutch burns centre. J Eur Acad Dermatol Venereol. 2007;21:781-8.

Schneck J, Fagot JP, Sekula P, Sassolas B, Roujeau JC, Mockenhaupt M. Effects of treatments on the mortality of Stevens-Johnson syndrome and toxic epidermal necrolysis: A retrospective study on patients included in the prospective EuroSCAR Study. J Am Acad Dermatol. 2008;58:33-40.

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Published

2020-06-23

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