Toxic Epidermal Necrolysis

Toxic Epidermal Necrolysis

Toxic epidermal necrolysis (NET) is a hypersensitivity reaction on the skin that is generally triggered by drug use. Toxic epidermal necrolysis may be characterized by blistering and flaking of the skin , resembling a burn.

Toxic epidermal necrolysis is a rare condition and can cause serious complications, such as severe infections, pneumonia and sepsis. Therefore, toxic epidermal necrolysis needs to be treated immediately.

Toxic epidermal necrolysis is the same as Stevens-Johnson syndrome (SJS), which is a hypersensitivity reaction on the skin in the form of blisters. However, toxic epidermal necrolysis is a more severe version.

The most obvious difference between SJS and TEN is the extent of the injury. In SJS, the wound area is not more than 10 percent of the body surface. Whereas in toxic epidermal necrolysis, the blisters are spread more widely, which is more than 30 percent of the body surface.

Causes of Toxic Epidermal Necrolysis

The main cause of toxic epidermal necrolysis is not known with certainty. However, it is known that TEN is a type of hypersensitivity reaction . A hypersensitivity reaction is a condition when the body's immune system (immune system) mistakenly or overreacts, causing unwanted effects.

Hypersensitivity reactions to toxic epidermal necrolysis are generally triggered by drug use, such as:

  • Sulfonamides , such as co-trimoxazole
  • Beta lactam antibiotics, such as cephalosporins
  • Anticonvulsants, such as carbamazepine and phenytoin
  • Paracetamol
  • Allopurinol
  • Nevirapine
  • Non-steroidal anti-inflammatory drugs (NSAIDs) , especially the oxicam group, such as meloxicam or piroxicam

Apart from drug use, toxic epidermal necrolysis can also be triggered by several types of infection, such as:

  • Cytomegalovirus
  • Mycoplasma pneumoniae
  • Herpes simplex
  • Hepatitis A

Although rare, immunizations and organ transplants, such as bone marrow transplants, can also trigger toxic epidermal necrolysis.

Risk factors for toxic epidermal necrolysis

Toxic epidermal necrolysis can happen to anyone. However, someone with the following conditions tends to be more at risk of experiencing it:

  • 40–60 years old
  • Have had Stevens-Johnson syndrome or toxic epidermal necrolysis before
  • Have a weak immune system, for example as a result of suffering from HIV/AIDS , an autoimmune disease, or due to undergoing a series of therapies that weaken the body's immune system
  • Suffering from cancer, especially blood cancer
  • Have a family history of toxic epidermal necrolysis

Symptoms of Toxic Epidermal Necrolysis

Symptoms of toxic epidermal necrolysis usually begin with symptoms that mimic an upper respiratory infection or the flu. These symptoms can last from 1 day to 3 weeks. Some of these symptoms are:

  • Fever over 38 degrees Celsius
  • Fatigue
  • Sore throat
  • Cold and cough
  • Muscle and joint pain
  • Red and sore eyes (conjunctivitis)
  • Decreased appetite
  • Nausea and vomiting

After that, a reaction on the membranes lining the inside of the body (mucous membranes) will occur. Generally, symptoms of the mucosa cause pain and heat. However, there may also be other additional symptoms, depending on the location of the affected mucosa, such as:

  • Eyes, in the form of red eyes or sensitive to light
  • Mouth or lips, in the form of reddish, crusty lips, or canker sores
  • Throat and esophagus, in the form of difficulty swallowing
  • Urinary and genital tract, in the form of sores on the genitals and difficulty urinating
  • Respiratory tract, in the form of coughing and shortness of breath
  • Gastrointestinal tract, in the form of diarrhea

Usually, skin symptoms will occur about 1–3 days after the mucosal symptoms appear. Symptoms of a skin rash can appear suddenly on the chest, stomach or back. This rash then spreads very quickly to the face, arms and legs. Generally, skin rashes can cover the whole body within 4 days.

The rash that occurs can be in the form of reddened skin, red bumps, circular red spots, water-filled blisters that can burst, or a combination of these. All of these rashes cause pain.

Typical skin symptoms of TEN are skin blisters that can enlarge and coalesce. This causes the outermost layer of skin to peel off, leaving the red and wet middle layer of skin or dermis exposed to the outside air.

NET causes severe symptoms. In this condition, sufferers experience pain that is severe enough to cause anxiety. In addition, other organs such as the liver, kidneys, lungs, bone marrow and joints can also be affected.

When to see a doctor

Toxic epidermal necrolysis needs to be diagnosed carefully and treated in intensive care. Immediately consult a doctor if you experience a skin rash accompanied by pain and spreading quickly.

If you have experienced NET or SJS before, check with your doctor when you experience initial symptoms, such as fever, cough and runny nose, and sore throat, especially if the symptoms appear after taking drugs that can trigger NET.

Diagnosis of Toxic Epidermal Necrolysis

The doctor will ask questions and answers about the symptoms and complaints experienced by the patient, medical history of the patient and his family, and medicines consumed by the patient. After that, the doctor will physically examine the patient, especially the condition of his skin, including the severity and extent of the wound.

Generally, toxic epidermal necrolysis can already be diagnosed only by debriefing and physical examination. However, the doctor can also carry out the following supporting examinations to confirm the diagnosis:

  • Skin biopsy , to confirm the diagnosis of toxic epidermal necrolysis by taking a skin sample which will then be further examined in the laboratory
  • Blood and urine tests, to detect whether there are complications or nutritional deficiencies, and also to estimate the patient's potential for recovery

Treatment of Toxic Epidermal Necrolysis

Treatment of toxic epidermal necrolysis aims to overcome trigger factors and relieve symptoms and complaints. Treatment is also carried out based on several factors, such as age, medical history, severity, and the area of ​​the body that was injured.

Patients with toxic epidermal necrolysis need to be treated in the hospital. There are several methods that can be used to treat toxic epidermal necrolysis, namely:

Medical treatment

As a first step, the doctor will perform the following treatments:

  • Stop taking drugs that are suspected of triggering hypersensitivity reactions
  • Provide fluids through an IV, to maintain a balance of body fluid levels, because sufferers of TEN are very prone to dehydration
  • Provide ointments and bandages, to prevent further skin damage and prevent infection of the peeled skin
  • Placing the patient in an isolation room, to reduce the risk of infection
  • Insert the catheter for the patient's urine output

To relieve symptoms and complaints, patients can also be given drugs, such as:

  • Antibiotic drugs , to treat or prevent infection
  • Pain relievers, to reduce the feeling of soreness in the skin
  • Mouthwash with antiseptic content, to reduce discomfort in the mouth
  • Immunosuppressant drugs , to control excessive immune system reactions
  • Eye drops, to treat inflammation, infection, or possible damage to the eye


If drug administration cannot cure the patient's skin condition, the doctor can perform surgery. These operations can take the form of:

  • Debridement , which is a small operation to clean and remove dead tissue in the wound
  • Skin grafting, which is an operation to place healthy skin from another area of ​​the body or from a donor, into an area that has been heavily damaged

Self care

After treatment at the hospital is finished and allowed to go home, patients are encouraged to do the following self-care to reduce pain and speed healing:

  • Treat wounds according to doctor's recommendations, for example by changing bandages regularly, to speed healing and reduce the risk of infection
  • Taking care of oral health, for example using mouthwash and using a soft toothbrush if there are sores in the mouth
  • Drink enough water to prevent dehydration
  • Undergo physical therapy or physiotherapy to increase muscle strength, ability to move, and to relieve pain

Generally, the healing process takes 3–6 weeks, depending on the patient's overall condition.

Toxic Epidermal Necrolysis Complications

If not treated properly, toxic epidermal necrolysis can cause the following serious complications:

  • Changes or uneven skin color
  • Hair loss
  • Disorders of the sense of taste
  • Malnutrition
  • Infection of the skin or other organs, such as the lungs
  • Sepsis
  • Acute respiratory distress syndrome
  • Ulcers in the stomach or other parts of the digestive tract
  • Vaginal adhesions due to extensive injuries to the vagina
  • Coagulopathy or blood clots that are scattered throughout the bloodstream
  • Disorders of the eye, such as corneal ulcers , which can cause blindness

Prevention of Toxic Epidermal Necrolysis

Toxic epidermal necrolysis cannot be completely prevented. However, the risk of getting NET can be reduced by being more careful and always consulting a doctor first before taking drugs that can trigger this condition, especially if you are at risk of experiencing NET.

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