Toxic Epidermal Necrolysis Spectrum Management at Sunnybrook Health Sciences Centre: Our Multidisciplinary Approach After Review of the Current Evidence

Abstract

Toxic epidermal necrolysis spectrum (TENS) is a rare yet severe adverse drug reaction associated with a high mortality rate. Beyond supportive care, there is still no established therapy for TENS, although recent meta-analyses and UK guideline recommendations have attempted to offer a review of relevant literature on this difficult topic. As most directed treatments lack clear consensual evidence, care centres often resort to establishing their own strategies. As Canada's largest adult burn centre and the provincial reference centre for most burn patients in Ontario, our team at the Ross Tilley Burn Centre, in collaboration with the Department of Dermatology at Sunnybrook Health Sciences Centre, Toronto, Canada, has managed over 60 confirmed cases of TENS over the past 2 decades. We would like to share our management, experience, and present our treatment protocol that we recently established by a collaborative multidisciplinary team approach to help guide treatment of these complex patients not only in Canada but worldwide.

Lab-Based Culprit Drug Identification Methods for Cutaneous Drug Eruptions: A Scoping Review

“…There were nine lab-based culprit drug investigations published across 11 observational studies 9,10,17 -25 and 14 reviews 8,26 -38 between the years of 1994 and 2020 (online supplemental file 2). They were mainly based on the measurement of immune cells or inflammatory cytokine/chemokines.…”

Toxic epidermal necrolysis in adult patients: Experience from the West Australian Collaboration

“…British guidelines published in 2016 (based on level 4 evidence) reported systemic corticosteroids, cyclosporine and IVIG did not have enough evidence establishing benefit or harm relative to conservative management 3 . A more recent protocol from Canada in 2018 suggested administration of etanercept, 50 mg, subcutaneously on admission (with consideration following 4 days of a second dose), together with cyclosporine, 5 mg/kg/day in two divided doses, intravenously, for at least 10 days 1 . Corticosteroids are an option in certain cases 1 …”

“…Toxic epidermal necrolysis (TEN) is a rare and life‐threatening disease most often triggered by a reaction to a drug typically 4–28 days after commencement 1 . It is a Type IVc cytotoxic T‐cell mediated Gell and Coombs hypersensitivity reaction 2 .…”

Sunnybrook Protocol for Treatment of Toxic Epidermal Necrolysis

“…In our recently published article on the Sunnybrook Burn Unit protocol for the treatment of toxic epidermal necrolysis (TEN), we recommended the use of etanercept, 1 among other therapies. Coincident with the publication of our article, a very important series of laboratory and clinical studies was published online ahead of print from investigators in Taiwan.…”

“…In summary, corticosteroids had potential benefits, but on balance of both efficacy and safety, etanercept appears superior. When etanercept is used, it is part of a broader therapeutic protocol, 1 so we stand by our original recommendations. This recent study adds new insights and evidence to support the use of anti–TNF-α biologicals as part of TEN protocols.…”