Burn Center Care of Patients with Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

2017 ◽  
Vol 44 (3) ◽  
pp. 583-595 ◽  
Author(s):  
Robert Cartotto
Keyword(s):  
Toxic Epidermal Necrolysis ◽  
Stevens Johnson Syndrome ◽  
Burn Center ◽  
Johnson Syndrome ◽  
Center Care

Differences in Treatment of Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis at Burn Centers and Nonburn Centers

2020 ◽  
Vol 41 (5) ◽  
pp. 945-950
Author(s):  
Rachel M Nygaard ◽  
Frederick W Endorf
Keyword(s):  
Toxic Epidermal Necrolysis ◽  
Severe Disease ◽  
Definitive Treatment ◽  
Stevens Johnson Syndrome ◽  
Skin Disorders ◽  
National Inpatient Sample ◽  
Term Care ◽  
Burn Centers ◽  
Burn Center ◽  
Johnson Syndrome

Abstract Stevens–Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and Stevens–Johnson/TEN overlap syndrome (SJS/TEN) are severe exfoliative skin disorders resulting primarily from allergic drug reactions and sometimes from viral causes. Because of the significant epidermal loss in many of these patients, many of them end up receiving treatment at a burn center for expertise in the care of large wounds. Previous work on the treatment of this disease focused only on the differences in care of the same patients treated at nonburn centers and then transferred to burn centers. We wanted to explore whether patients had any differences in care or outcomes when they received definitive treatment at burn centers and nonburn centers. We queried the National Inpatient Sample database from 2016 for patients with SJS, SJS/TEN, and TEN diagnoses. We considered burn centers as those with greater than 10 burn transfers to their center and fewer than 5 burn transfers out of their center in a year. Multivariable logistic regression assessed factors associated with treatment at a burn center and mortality. Using the National Inpatient Sample, a total of 1164 patients were identified. These were divided into two groups, nonburn centers vs burn centers, and those groups were compared for demographic characteristics as well as variables in their hospital course and outcome. Patients treated at nonburn centers were more likely to have SJS and patients treated at burn centers were more likely to have both SJS/TEN and TEN. Demographics were similar between treatment locations, though African-Americans were more likely to be treated at a burn center. Burn centers had higher rates of patients with extreme severity and mortality risks and a longer length of stay. However, burn centers had similar actual mortality compared to nonburn centers. Patients treated at burn centers had higher charges and were more likely to be transferred to long-term care after their hospital stay. The majority of patients with exfoliative skin disorders are still treated at nonburn centers. Patients with SJS/TEN and TEN were more likely to be treated at a burn center. Patients treated at burn centers appear to have more severe disease but similar mortality to those treated at nonburn centers. Further study is needed to determine whether patients with these disorders do indeed benefit from transfer to a burn center.

760 Patients with Pre-existing Mental Illness Who Developed Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: Lessons Learned at a Large Tertiary Burn Center and the Importance of Accurately Diagnosing Psychiatric Disorders

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S213-S214
Author(s):  
Sarah L Laughon ◽  
Michael Duplisea ◽  
Carolyn Ziemer ◽  
Lori Chrisco ◽  
Felicia N Williams ◽  
...  
Keyword(s):  
Bipolar Disorder ◽  
Psychiatric Disorder ◽  
Toxic Epidermal Necrolysis ◽  
Psychiatric Disorders ◽  
Skin Diseases ◽  
Case Series ◽  
Lessons Learned ◽  
Stevens Johnson Syndrome ◽  
Burn Center ◽  
Johnson Syndrome

Abstract Introduction In recent years, burn centers are managing more patients with exfoliative skin disorders including Stevens-Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN), and SJS/TEN overlap. While it is well known that burn patients have higher rates of co-morbid psychiatric disorders than the general population, the incidence of pre-existing psychiatric disorders among patients who develop SJS, SJS/TEN overlap, and TEN is unknown. This study aimed to characterize a cohort of patients with pre-existing psychiatric disorders admitted to a tertiary burn center for treatment of SJS, SJS/TEN overlap, and TEN with specific focus on those who received the offending agent for a psychiatric indication. Methods A retrospective descriptive case series using an institutional burn center registry was performed. All patients admitted to a single verified burn center between January 1, 2009 and December 31, 2018 with biopsy-proven SJS, SJS/TEN overlap, or TEN and the presence of a co-morbid psychiatric disorder were identified. Demographic, hospital, and clinical information were extracted from the burn registry and verified through review of the electronic medical record. Results Among 168 patients with biopsy-proven SJS, SJS/TEN overlap, or TEN, 18% (30/168) had a pre-existing psychiatric disorder, with the offending agent being prescribed for a psychiatric indication in 30% (10/30) of patients. Lamotrigine was the offending agent in 80% of cases and prescribed 100% of the time for a psychiatric indication. Of those who received lamotrigine, patients were 100% female, 63% black, and had an average age of 38 years. The mean length of stay was 24 days and 88% received a psychiatric consultation. While 75% of patients were started on lamotrigine for a diagnosis of bipolar disorder, none of these patients met criteria for bipolar disorder. Conclusions Pre-existing psychiatric comorbidity is less common among patients that develop SJS, SJS/TEN overlap, and TEN than in burn-injured patients. For patients with pre-existing psychiatric disorders who develop these potentially fatal skin diseases from an offending agent that was prescribed for a psychiatric indication, early involvement of psychiatry colleagues is recommended to ensure proper psychiatric diagnosis and management moving forward. Applicability of Research to Practice This study highlights the importance of accurate assessment for and diagnosis of bipolar disorder prior to determining treatment approach. For the burn surgeon treating these patients, early involvement of psychiatric consultants is recommended and extremely important.

501 Burn Center Referral of Patients with Suspected Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN)

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S87-S87
Author(s):  
Julie A Rizzo ◽  
David S Lidwell ◽  
Leopoldo C Cancio
Keyword(s):  
Skin Biopsy ◽  
Toxic Epidermal Necrolysis ◽  
Disease Process ◽  
Stevens Johnson Syndrome ◽  
Burn Center ◽  
Johnson Syndrome ◽  
Number Of Patients ◽  
Wide Range ◽  
Burn Unit ◽  
Life Threatening

Abstract Introduction Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are rare but potentially life-threatening, as such referral of these patients to a burn center is appropriate. However, patients with suspected SJS/TEN are often referred to the Burn Center and are found to not actually be suffering from the disease process in question. This inefficient referral process warrants further examination to identify pre-arrival those patients who are appropriate for transfer. Methods As an approved PI project we examined the records of all patients referred to our Burn Center for suspicion of SJS/TEN for the time period 2016–2018. We analyzed the corresponding data to in an attempt to more effectively identify patients with SJS/TEN and prevent unnecessary Burn Center transfers. Results Of 84 patients referred for suspected SJS/TEN 32 received confirmatory diagnosis with skin biopsy after transfer (38%). The average length of stay was 8 ICU days and 14 hospital days versus 3.6 and 9.6 days, respectively, for patients with a negative diagnosis. The mortality rate of SJS/TEN patients was 12.5% (4/32). In addition to SJS/TEN, a wide range of skin conditions were identified among referred patients, many of whom also required hospitalization, including BICU care. The various diagnoses included: Drug eruptions (14%), psoriasis (6%), dermatitis (6%), erythema multiforme (2%), lupus erythematosus (2%) and generalized exanthematous pustulosis (2%). The remainder of patients had miscellaneous or nonspecific conditions (28%). Conclusions SJS/TEN is a potentially life threatening disease often requiring hospitalization in a Burn Intensive Care Unit (BICU). However, many other disease processes have similar presentations and may also be appropriate for Burn Unit care. Without a confirmatory skin biopsy prior to referral a large number of patients are transferred to the BICU unnecessarily. Applicability of Research to Practice In the absence of skin biopsy capabilities at the referring facility an algorithm using common characteristics of actual SJS/TEN patients may improve the accuracy of pre-referral diagnosis. Additionally, this data underscores the importance of dermatology support to the Burn Unit in diagnosing and treating desquamating skin disorders.

549 Differences in Treatment of Stevens-johnson Syndrome and Toxic Epidermal Necrolysis at Burn Centers and Non-burn Centers

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S114-S115
Author(s):  
Rachel Nygaard ◽  
Frederick W Endorf
Keyword(s):  
Toxic Epidermal Necrolysis ◽  
Severe Disease ◽  
Definitive Treatment ◽  
Stevens Johnson Syndrome ◽  
Skin Disorders ◽  
Term Care ◽  
Burn Centers ◽  
Burn Center ◽  
Johnson Syndrome

Abstract Introduction Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS/TEN overlap syndrome (SJS/TEN) are severe exfoliative skin disorders resulting primarily from allergic drug reactions and sometimes from viral causes. Because of the significant epidermal loss in many of these patients, many of them end up receiving treatment at a burn center for expertise in the care of large wounds. Previous work on the treatment of this disease focused only on the differences in care of the same patients treated at non-burn centers and then transferred to burn centers. We wanted to explore whether patients had any differences in care or outcomes when they received definitive treatment at burn centers and non-burn centers. Methods We queried the National Inpatient Sample (NIS) database from 2016 for patients with SJS, SJS/TEN, and TEN diagnosis. We considered burn centers as those with greater than 10 burn transfers to their center and fewer than 5 burn transfers out of their center in a year. Multivariable logistic regression assessed factors associated with treatment at a burn center and mortality. Results Using the NIS, a total of 1164 patients were identified. These were divided into two groups, non-burn centers vs. burn centers, and those groups were compared for demographic characteristics as well as variables in their hospital course and outcome. Patients treated at non-burn centers were more likely to have SJS and patients treated at burn centers were more likely to have both SJS/TEN and TEN. Demographics were similar between treatment locations, though African-Americans were more likely to be treated at a burn center. Burn centers had higher rates of patients with extreme severity and mortality risks, and a longer length of stay. However, burn centers had similar actual mortality compared to non-burn centers. Patients treated at burn centers had higher charges and were more likely to be transferred to long-term care after their hospital stay. Conclusions The majority of patients with exfoliative skin disorders are still treated at non-burn centers. Patients with SJS/TEN and TEN were more likely to be treated at a burn center. Patients treated at burn centers appear to have more severe disease but similar mortality to those treated at non-burn centers. Our data suggest that more patients with these disorders could benefit from transfer to a burn center. Applicability of Research to Practice These data may aid in outreach efforts to improve appropriate transfers of patients with severe exfoliative skin disorders to burn centers for definitive care.

741 Trends in Offending Medications in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis in a Large Academic Burn Center

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S202-S203
Author(s):  
Michael Duplisea ◽  
Lori Chrisco ◽  
Felicia N Williams ◽  
Rabia Nizamani ◽  
Sarah L Laughon ◽  
...  
Keyword(s):  
Toxic Epidermal Necrolysis ◽  
Severity Of Illness ◽  
Stevens Johnson Syndrome ◽  
Burn Center ◽  
Emerging Trends ◽  
Johnson Syndrome ◽  
Culprit Drug ◽  
Specialized Care ◽  
Burn Units ◽  
Causative Agents

Abstract Introduction Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) is a rare, severe mucocutaneous eruption caused by medications and resulting in diffuse epidermal detachment. Patients are often referred to burn units for specialized care. This study assesses trends in precipitating medications over 10 years at our Burn Center. Methods We performed a single-site, retrospective review at our burn center using the institutional burn registry and patient charts. Patients admitted from January 1, 2009 to December 31, 2018 identified as having SJS/TEN were eligible for inclusion. Demographics, comorbidities, diagnosis, treatment, inciting agents, and severity-of-illness score for TEN (SCORTEN) were evaluated. Statistical analysis was performed using the Mann Whitney U test using SAS version 9.4 (SAS Inc., Cary, NC). Results Biopsy-proven SJS, SJS/TEN overlap, or TEN was confirmed in 168 patients. Of these, 103 had a single identified offending drug. Of these patients, 36% had been exposed to sulfamethoxazole-trimethoprim (SMX-TMP), 11% to allopurinol, and 10% to lamotrigine. Trends in culprit drug by year are shown in Figure 1. The majority of SMX-TMP and penicillin cases occurred early in the period of study; lamotrigine and pembrolizumab cases occurred more recently. Patients exposed to allopurinol presented with higher SCORTENs than patients exposed to SMX-TMP, 2.9 vs 1.9, respectively (p< 0.035). Conclusions SMX-TMP once accounted for a large portion of SJS and TEN cases at our center. In recent years, lamotrigine has become a more common offending drug, prescribed in our cohort for psychiatric indications. Also notable, in the past year we have treated three patients with TEN due to immunotherapy (pembrolizumab) for metastatic or unresectable cancer. Paralleling the increasing use of immunotherapy has been a rise of immune-related adverse events, including severe skin toxicities. Further study is warranted to determine what can be done to prevent SJS/TEN from occurring in patients treated with these drugs. Applicability of Research to Practice Understanding emerging trends in causative agents of SJS/TEN will allow the burn community to focus education efforts for providers who prescribe these medications frequently. The psychiatric and oncology communities may benefit from increased awareness of the risk of SJS/TEN in patients receiving lamotrigine and immunotherapy, respectively.

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