Toxic Epidermal Necrolysis

Toxic Epidermal Necrolysis is a topic covered in the 5-Minute Emergency Consult.

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  • One of the most fulminant and potentially fatal of all dermatologic disorders
  • Skin sloughing at the dermal–epidermal interface results in the equivalent of a 2nd-degree burn
  • Can affect up to 100% of total body surface area (BSA)
  • May extend to involve:
    • GI mucosa
    • Respiratory mucosa
    • Genitourinary/renal epithelium
  • Mechanism unclear, research indicates immunologic, cytotoxic, and delayed hypersensitivity may be involved as well as genetic susceptibility
  • Current classification system proposes 3 categories within the spectrum of Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), distinct from erythema multiforme major and based on percentage of total BSA:
    • SJS: <10% of BSA
    • SJS–TEN overlap syndrome: 10–30% of BSA
    • TEN: >30% of BSA, can affect up to 100% BSA
  • More common in older patients and immunocompromised patients
  • Mortality rate is about 30%, usually due to secondary sepsis from Staphylococcus aureus and Pseudomonas aeruginosa
  • Synonym(s):
    • Lyell syndrome
    • Fixed drug necrolysis
    • Epidermolysis necroticans combustiformis
    • Epidermolysis bullosa


  • Dose-independent drug reactions are the usual cause of TEN:
    • Drugs introduced within previous 1–3 wk are most likely candidates
    • Frequently implicated drugs include:
      • Sulfonamide and PCN antibiotics
      • Anticonvulsants (carbamazepine, phenytoin, phenobarbital, lamotrigine)
      • NSAIDs (oxicams, pyrazoles, sulindac),
      • Allopurinol
      • Corticosteroids
      • Antiretroviral drugs
  • Other rare causes: Infections, graft-versus-host disease, vaccinations, idiopathic cases (combined <4%)

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