Toxic epidermal necrolysis: a burn-centre challenge

OBJECTIVE: To describe the clinical features and outcome of patients with toxic epidermal necrolysis. DESIGN: Case series. SETTING: Ross Tilley Burn Centre, Wellesley Hospital, Toronto. PATIENTS: Ten patients (seven women) with toxic epidermal necrolysis referred to the centre from 1984 to 1990. INTERVENTION: Biobrane (Winthrop Pharmaceuticals, New York) was applied to all raw surfaces after the epidermis had been completely separated. It was not removed until the epidermis had regenerated. MAIN RESULTS: The age of the patients varied from 27 to 90 (mean 45) years. The proportion of body surface area involved was 20% to 95% (mean 58.5%). Nine of the patients had received steroids and antibiotics prophylactically before being referred to the burn centre; the steroids were immediately tapered and the antibiotics withdrawn unless there was a specific infection. Urinary tract infection developed in seven patients, respiratory failure in six and systemic sepsis in six. All of the patients ultimately required antibiotics for treatment of systemic infections. Two patients died; both had severe illness before the onset of the toxic epidermal necrolysis. Biobrane provided a marked reduction in pain, eliminated the need for further dressings and allowed early, aggressive physiotherapy. The wounds healed completely within 14 to 21 days, with no significant scarring or need for skin grafting. CONCLUSIONS: The use of a temporary skin substitute is recommended for the treatment of toxic epidermal necrolysis. There is no indication for prophylactic steroid or antibiotic therapy; indeed, such therapy is probably contraindicated.