Toxic epidermal necrolysis is the most severe form of the Stevens-Johnson spectrum, with more than 30 percent of the body surface losing its top skin layer. It is usually caused by a medicine and carries a high risk of death from fluid loss and infection.
Key symptoms
- Fever and flu-like illness, then painful red skin
- Large areas of blistering and peeling skin
- Painful sores in the mouth, eyes and genitals
- New medicine started in the past 1 to 8 weeks
What you find on exam
- Widespread dusky red skin with sheets of detached epidermis
- Positive Nikolsky sign: skin shears off with light pressure
- Mucosal erosions, crusted lips and red eyes
- Body surface area of detachment over 30 percent
- Vital signs: fever, fast heart rate, low blood pressure
Tests
- Skin biopsy to confirm full-thickness epidermal necrosis
- Blood count, electrolytes, kidney function, glucose and bicarbonate
- Blood and skin cultures if infection is suspected
- SCORTEN score on day 1 and day 3
Treatment basics
- Stop the culprit drug immediately
- Transfer to a burn unit for wound care, IV fluids and warming
- Daily eye care with ophthalmology to prevent scarring
- Pain control, nutrition and close watch for infection; no prophylactic antibiotics
- Cyclosporine or etanercept may be used with specialist input
Red flags
- Low blood pressure, fever or confusion (sepsis)
- Breathing difficulty or airway involvement
- Low urine output or rising creatinine
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.