βοΈ FREE MSRA PODCAST β Toxic Epidermal Necrolysis
π§ A clear, high-yield breakdown of this life-threatening blistering skin emergency β perfect for exam prep and rapid clinical recognition.
π§ Key Learning Points
π Definition
β’ Toxic Epidermal Necrolysis (TEN) is a rare, severe mucocutaneous reaction, typically to medications, characterised by widespread epidermal necrosis and detachment affecting >30% of the body surface area.
β’ Itβs the most extreme form of the SJS/TEN spectrum.
π Causes & Risk Factors
β’ Drugs are the most common trigger (90%+):
β Antibiotics (esp. sulphonamides)
β Anticonvulsants (e.g. carbamazepine, lamotrigine)
β NSAIDs (oxicam class)
β Allopurinol
β’ Other triggers:
β Mycoplasma pneumoniae, HSV
β HLA-B*1502 allele (esp. in East Asian populations)
β HIV, SLE, malignancy
β Recent vaccination or transplant
π Pathophysiology
β’ A delayed hypersensitivity reaction (Type IV)
β’ Immune activation β cytotoxic T cells release granulysin and perforin, destroying keratinocytes
β’ Results in full-thickness epidermal necrosis
π Symptoms
β’ Prodrome: flu-like illness (fever, sore throat, conjunctivitis)
β’ Mucosal involvement early (eyes, mouth, genitals)
β’ Rapidly spreading erythematous macules, then blisters and sloughing
β’ Positive Nikolskyβs sign β skin peels with lateral pressure
π‘ Mnemonic: "Fever + Fragile skin + Facial mucosa"
π Differential Diagnosis
β’ Stevens-Johnson syndrome (SJS) β less skin involved
β’ Staphylococcal scalded skin syndrome (SSSS)
β’ Bullous pemphigoid / pemphigus vulgaris
β’ Burns
β’ Erythroderma, Toxic shock syndrome, Erythema multiforme
π Diagnosis
β’ Clinical diagnosis based on history and skin signs
β’ Skin biopsy: shows full-thickness epidermal necrosis
β’ Bloods: FBC, U&Es, LFTs, CRP β assess severity
β’ Cultures: screen for secondary infection
β’ Rule out SSSS and autoimmune blistering with biopsy + DIF
π§ No specific blood test confirms TEN
π Management
β’ Stop causative drug immediately
β’ Admit to burns/ICU unit
β’ Supportive care:
β Fluid/electrolyte replacement
β Nutritional support (often NG feeds)
β Temperature regulation
β Skin care: non-adhesive dressings, barrier nursing
β Pain relief
β’ Controversial pharmacological therapies:
β IVIG, cyclosporin, TNF-Ξ± inhibitors (limited evidence)
β Steroids: debated
β’ Multidisciplinary care: dermatology, critical care, ophthalmology
π Complications
β’ Sepsis, pneumonia, renal failure, DIC
β’ Ocular complications (dry eye, scarring, blindness)
β’ Esophageal strictures, urogenital stenosis, joint contractures
β’ Psychological trauma, chronic pain
π Prognosis
β’ High mortality (up to 30β50%)
β’ SCORTEN score predicts mortality:
β Score β₯5 β ~90% mortality
β’ Prognosis depends on:
β BSA involvement
β Age, comorbidities
β Speed of recognition and referral
β’ Lifelong avoidance of causative drug is essential
π More MSRA Resources for Toxic Epidermal Necrolysis
π Revision Notes:
https://www.passthemsra.com/topic/toxic-epidermal-necrolysis-revision-notes/
π§ Flashcards:
https://www.passthemsra.com/topic/toxic-epidermal-necrolysis-flashcards/
π¬ Accordion Q&A Notes:
https://www.passthemsra.com/topic/toxic-epidermal-necrolysis-accordion-qa-notes/
π Rapid Quiz:
https://www.passthemsra.com/topic/toxic-epidermal-necrolysis-rapid-quiz/
π§ͺ Topic Quiz:
https://www.passthemsra.com/quizzes/toxic-epidermal-necrolysis/
π Full Course:
https://www.passthemsra.com/courses/dermatology-for-the-msra/
π This episode is part of the Dermatology for the MSRA course
Explore full revision guides, flashcards, quizzes, and more at:
π https://www.passthemsra.com
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