Wound care for Stevens-Johnson syndrome and toxic epidermal necrolysis

To the Editor: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are acute and life-threatening drug reactions characterized by extensive mucocutaneous exfoliation. SJS and TEN occur rarely, with an annual incidence of 1.2 to 9.2 and 0.4 to 1.9 per million, respectively.1Hsu D.Y. Brieva J. Silverberg N.B. Silverberg J.I. Morbidity and mortality of Stevens-Johnson syndrome and toxic epidermal necrolysis in United States adults.J Invest Dermatol. 2016; 136: 1387-1397Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar, 2Frey N. Jossi J. Bodmer M. et al.The epidemiology of Stevens-Johnson syndrome and toxic epidermal necrolysis in the UK.J Invest Dermatol. 2017; 137: 1240-1247Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar Wound care for SJS and/or TEN mirrors local trends in burn management, as current guidelines lack strong evidence for these pathologic processes.3Creamer D. Wals S.A. Dziewulski P. et al.UK guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults 2016.J Plast Reconstr Aesthet Surg. 2016; 69: e119-e153Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 4Endorf F.W. Cancio L.C. Gibran N.S. Toxic epidermal necrolysis clinical guidelines.J Burn Care Res. 2008; 29: 706-712Crossref PubMed Scopus (60) Google Scholar, 5White K.D. Abe R. Ardern-Jones M. et al.SJS/TEN 2017: building multidisciplinary networks to drive science and translation.J Allergy Clin Immunol Pract. 2018; 6: 38-69Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar The aim of this review is to assess the effects of dressings used in the wound care in patients with SJS and/or TEN and present evidence rated according to the Strength of Recommendation Taxonomy criteria that will aid clinicians in determining the best approach to wound care for their patients with SJS and/or TEN. A review of the literature describing wound management in patients with SJS and TEN was conducted as outlined in Supplemental Fig 1 (available at http://www.jaad.org). The search terms used were (((“toxic epidermal necrolysis” [Supplementary Concept]) OR “toxic epidermal necrosis” OR “Stevens Johnson syndrome”) AND (biosynthetic OR collagen OR debridement OR dressing OR silver OR topical OR wound)). All retrospective studies, case reports, and case series describing wound management in patients with SJS and/or TEN were included. A total of 22 articles that included the primary outcome of time to re-epithelialization (average time, 14.16 ± 9.42 days) were selected. Table I6-27 summarizes the results.Table IStudies includedDressing type studiedStudy typeSORT criteriaSystemic therapyNo. of patientsAverage days to re-epithelizationAverage pain scale score (1-10)No. of dressing changes/wkLOS, dSurvival rateCost of dressingAllograft Lindford et al, Burns 2011;37:e67-e72.CRIVIG, steroids117.5NR3.528100%0.8 euros/cm2 Pianigiani et al, Dermatol Surg 2002;28:1173-1176.CRSteroids28NR0NR100%NRAntiseptic Boorboor et al, Burns 2008;34:487-492.RCSCNR8165.5716.663%NRBiosynthetic Arevalo and Lorente, J Burn Care Rehabil 1999;20:406-410.RCSCCyclosporine812.7NR027.3100%NR Bannasch et al, Arch Dermatol 2004;140:160-162.CRNR112NR035100%NR Boorboor et al, Burns 2008;34:487-492.RCSCNR612.52.9017.366%NR Bradley et al, Ann Plast Surg 1995;35:124-132.CRSteroids39NR014.3100%$88/ft2 Lindford et al, Burns 2011;37:e67-e72.CRIVIG, Steroids112NR028100%0.5 euros/cm2 Madry et al, Pol Przegl Chir 2011;83:541-548.CRNR121NR0NR100%NR Oomman and Goodwin, J Med Res Sci 2014;19:577-579.CRNR114NR0NR100%NR Pfurtscheller et al, Pediatr Derm 2008;25:541-543.CRNR18NR1100%NR Rogers et al, Burns 2017;43:1464-1472.RCSCYes, many2413NR034100%$0.23/cm2 Sowder, J Burn Care Rehabil 1990;11:237-239.CRSteroids114NR0NR100%NRFiber Imamura et al, Int J Dermatol 1996;35:834-835.CRSteroids156NR256100%NR Melandri, J Eur Acad Dermatol Venereol 2007;21:426-427.CRIVIG17NR012100%NRSilver-impregnated Asz et al, J Pediatr Surg 2006;41:e9-e12.CRNR120NR220100%NR Huang et al, Burns 2008;34:63-66.CRSteroids18NR1NR100%NR Huang et al, Burns 2010;36:121-126.RCSCNR910.452NR66%NR Huang et al, Adv Skin Wound Care 2014;27:210-215.RCSCNR89.55.752NR75%NR McCarthy and Donovan, J Wound Ostomy Continence Nurs 2016;43:650-651.CRNR112NR1NR100%NR McCullough et al, Burns 2017;43:200-205.RCSCIVIG, steroids4014NR2.517.190%NR Neema and Chatterjee, Indian J Dermatol Venereol Leprol 2017;83:121-124.CRIVIG19NR312100%NR Vern-Gross et al, Case Rep Dermatol 2012;4:72-75.CRIVIG, steroids114NR223100%NRSimple Huang et al, Adv Skin Wound Care 2014;27:210-215.RCSCNR1211.927.427NR100%NRXenograft Marvin et al, Arch Surg 1984;119:601-605.CSNR512.4NR01980%NRC, C-level recommendation is based on consensus, usual practice, opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening; CR, case report; CS, case series; IVIG, intravenous immunoglobulin; LOS, length of stay; NR, not reported; RCS, retrospective study; SORT, Strength of Recommendation Taxonomy. Open table in a new tab C, C-level recommendation is based on consensus, usual practice, opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening; CR, case report; CS, case series; IVIG, intravenous immunoglobulin; LOS, length of stay; NR, not reported; RCS, retrospective study; SORT, Strength of Recommendation Taxonomy. Simple dressings (topical creams or ointments covered with bandages) and modern dressings (fiber, biologic, and synthetic) were studied. The most commonly used dressings in the wound care of patients with SJS and/or TEN were biosynthetic dressings, followed by silver-impregnated fiber dressings. Table II describes the characteristics of the dressings reported. Although all the included articles reported survival rates, only 15 reported length of stay (which varied by hospital setting, such as critical care unit or ward floor) or total hospital stay. The number of weekly dressing changes was obtained in all studies, either directly from the articles or by calculation to the closest decimal point. Pain severity during dressing changes was reported in 5 studies. Compared with simple dressings, modern dressings offer the advantage of a reduced number of dressing changes, which results in improved patient comfort. However, there is no apparent impact of their use on healing time. Most studies did not report side effects or cost of dressings. No adverse events related to the dressings were documented.Table IIDressings used and their characteristicsDressing typeBrands usedCompositionProposed mechanism of actionAdvantagesDisadvantagesSimplen/aOpen weave cotton gauzeBreathable and absorbent; wicks away exudateVery inexpensive and readily available; versatility in that it can be used with any preferred topicalCan adhere and macerate wound beds; daily dressing changes required; pain during dressing changesSynthetic BiosyntheticBiobrane, Smith&Nephew, Ontario, CanadaSilicone membrane bonded to a nylon mesh; embedded with porcine collagen peptidesAssumes the role of epidermis by maintaining moist environment without accumulating exudateOne-time application; transparentCostly OtherSuprathel, PolyMedics Innovations, Denkendorf, GermanyThin microporous membraneStimulates angiogenesis and wound healing; acidification decreases bacterial growthOne-time application; transparentCostlyFiber Silver-impregnatedNanocrystalline silver (brand not reported)Not describedNonadherent, absorbent wound dressing that helps to maintain a moist environment at the wound surfaceSilver decreases risk of infection, modulates matrix metalloproteinases, and promotes neovascularization, which may result in faster wound healing; fewer dressing changesConflicting evidence regarding silver cytotoxicity in vitro and potential risk of systemic silver absorption in patients with involvement of large surface areas; costlyAquacel, Convatec, Bridgewater, NJHydrofiber embedded with silver ions Crystalline celluloseVeloderm, BTS srl, Ancona, ItalyCellulose microfibrilsDecreased dressing changesCostly Alginate fiberNot reportedNonwoven fibers derived from seaweedCooling effect; easy application; calcium ions can be hemostaticBecomes a gel that can be messy; works only with exudative wounds, not with dry woundsBiologic Porcine xenograftNot reportedPorcine epidermis and dermis with collagen and growth factorsServes as natural barrier for replacement of damaged skinAbundant; inexpensive; histologically similar to human skinOpaque; epidermis underneath cannot be visualized Cadaveric allograftTheraskin, Solsys Medical, Newport News, VAHuman epidermis and dermis with collagen and growth factorsProvides human-derived factors and cytokinesOpaque; epidermis underneath cannot be visualized; costly; limited availabilityn/a, Not applicable. Open table in a new tab n/a, Not applicable. A total of 13 studies used a concomitant systemic medication. Systemic steroids and intravenous immunoglobulin were the most frequently used. Whether any of these systemic medications affected time to re-epithelialization remains to be determined. No randomized clinical trials or studies with large power were found in our search. No studies met grade A or B Strength of Recommendation Taxonomy criteria (Table I). The limitations of the studies selected include small sample sizes, use of systemic medication, and variation of time to diagnosis and time to placement of dressings. There was a lack of studies comparing 2 or more wound care interventions. In conclusion, the use of modern dressings should be considered as part of standard therapy because of less frequent dressing changes and improved reported patient comfort. Further clinical studies are warranted, as their influence on healing time is yet to be determined. Wound management strategies in Stevens-Johnson syndrome/toxic epidermal necrolysis: An unmet needJournal of the American Academy of DermatologyVol. 79Issue 4PreviewTo the Editor: I would like to commend the authors for their systematic review on wound care in Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN).1 Nonetheless, any discourse on wound care would be incomplete without taking into consideration the use of conservative versus surgical wound approaches. Full-Text PDF

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