Stevens-Johnson syndrome and toxic epidermal necrolysis: topical treatment influencing systemic response

Abstract

Toxic epidermal necrolysis (TEN) and Steven-Johnson syndrome (SJS) are rare, but potentially life-threatening diseases, which relate to a variety of medications, and which are characterised by widespread epidermal necrosis. Although sepsis is currently accepted as the main cause of mortality, much of the morbidity and subsequent threat to life is orchestrated by an exaggerated inflammatory response with major outpouring of cytokines and destructive matrix metalloproteinases (MMPs). These mediators and proteinases cause intense destruction of the extracellular matrix, major fluid shifts, and a systemic inflammatory response (SIRS) that has life-threatening consequences. Modern therapeutic interventions, aside from resuscitative efforts, have sought to control not only the potential sepsis, but also the marked inflammatory response in relation to this pathology. Nanocrystalline silver (NCS) is one such agent. It has exceptional antimicrobial efficacy, but is also effective in lowering MMP levels, a critical part of the disease process. Twelve cases of confirmed TEN, treated with NCS, were analysed with a view to assessing efficacy and setting logical guidelines for this devastating condition. Eleven out of the 12 cases were categorised in the TEN diagnostic group, with total body-surface area involvement ranging from 22-100% (mean 64%). Two patients in the series died (16.6%), but both had a severe co-morbid disease background. Topical application of NCS (Acticoat, Smith and Nephew Hull, UK) dressings, as part of a comprehensive dressing protocol, proved successful in the management of this devastating disease. Guidelines for the management of TEN are suggested.