INTRODUCTION

Toxic epidermal necrolysis (TEN) is an exfoliative disorder of the skin usually caused by an adverse reaction to a drug; the most common drugs associated with TEN are the sulfonamides, antifungals, and anticonvulsants.1 TEN shares some similarities to Steven-Johnson syndrome, but it provokes a systemic immune response and more severe clinical manifestations. Prodromal symptoms, including fever and malaise, are similar to Steven-Johnson syndrome. The acute phase lasts 1 to 2 days; initial clinical manifestations include sensations of burning or tenderness of the skin, followed by development of lesions with a diffuse and generalized appearance, and ultimately epidermal detachment. Target lesions are not seen in patients experiencing TEN syndrome; instead, they develop large confluent plaques that comprise 30% or greater of the total body surface area (TBSA). Mucosal membrane involvement can be formidable with at least 2 or more surfaces involved, such as but not limited to oral and ophthalmologic mucosal lesions. Pertinent histopathology includes epidermal necrosis, large areas of epidermal detachments, and dermoepidermal separation. Many complications can arise from TEN including shock, hemodynamic instability, and full-thickness necrosis. Recovery time for TEN varies from 1 to 6 weeks; mortality rates of up to 80% have been reported.1

The goal of wound care is to prevention of further mechanical trauma to the skin and management of wound infection.2 Bacterial proliferation on the wound surface can lead to an invasive infection.3 Initiation of topical antimicrobial agents should begin early for better infection control. One should manage exudate, prevent maceration, and prevent further wound trauma to the patient. Medical management includes immunosuppressive therapy using cyclosporin A. Corticosteroid therapy is not recommended.3 This clinical challenges article describes successful topical management of a patient with TEN syndrome using a silver silicone-based, perforated foam contact layer in conjunction with a superabsorbent dressing.

CASE

A 77-year-old white woman initially presented to our emergency department with fever; she was 5'3", 68.3 kg, and of medium frame. Comorbid conditions included hypertension, chronic kidney disease, bilateral heel pressure injuries, and recent gastrointestinal bleed. She was admitted to a medical-surgical unit, and initial assessment of the skin revealed painful erythroderma of her trunk. She was ultimately transferred to the intensive care unit. Four days after hospital admission, our WOC team was consulted to assist with local wound care related to TEN. Cutaneous manifestations at that time included full degloving of the hands and feet, large areas of epidermal detachment, and mucous membrane ulcerations. The TBSA affected by TEN was approximately 90%. The patient had positive Nikolosky's sign characterized by sloughing of top layers of skin slip away when lower layers were rubbed or subjected to even mild pressure.

When we were initially consulted, topical therapy included petrolatum-based contact layers combined with a triple antibiot ic ointment. Disadvantages of this approach included cumbersome application, pain to touch of the wound bed, and frequent applications because of limited absorption of wound fluid. Local wound care, comprised of application of a nonadherent emulsion layer and roll gauze. During dressing changes, the intensive care nurses reported signs of pain including moaning, crying, pulling away, and increased heart rate, despite being medicated with intravenous hydromorphone. A 24-hour delay in implementation of our recommendations for topical therapy occurred due to collaborative discussion among the wound care physician, intensivist, infectious disease specialist, and dermatologist. A cutaneous biopsy was also obtained during this period. During this period, WOC nurses also observed signs of pain during dressing changes and increased maceration and denuding of damaged skin.

We recommended use of a silicone foam transfer dressing containing silver sulfate in combination with a superabsorbent dressing (Mepilex Transfer Ag, Mextra, Molnlycke Health Care, Norcross, Georgia). We chose this option because of dressing's ability to minimize pain, absorb exudate, manage bioburden, and provide maximal wear time between dressing changes. The silver sulfate within this dressing has a 30-minute activating rate and a sustained release period of 14 days. The base layer of the dressing allowed atraumatic application and removal during dressing changes. Each digit was individually wrapped with the silicone transfer foam directly to the partial thickness injury and secured with a secondary roll gauze. Large areas of dermal exposure were treated with large sheets of silicone transfer foam dressings, a secondary superabsorbent dressing (Mextra, Molnlycke, Norcross, Georgia), and a conformable wrap. Because of its ability to absorb exudate, dressing changes were completed every 5 to 7 days, which was well within the 14-day sustained release timeframe. This approach also allowed the silver-based contact layer to remain in place while the secondary superabsorbent dressing was changed as needed. At each dressing change, we observed improvement of the wound bed with increasing amounts of epithelium along with absence of maceration and biofilm. Due to the large TBSA affected by TEN, the medical and WOC nursing team concurred that infection prevention and protection of the exposed dermis were the primary concerns.

When sufficient epithelialization occurred, the frequency of the superabsorbent outer dressing change was reduced from 2 to 3 times in a 20-hour shift, to weekly while still optimizing wound bed moisture. Although the contact layer of the dressing remained intact, members of our team inspected the dressings daily. The secondary dressing, which was fashioned like a mitt, was gently opened to observe the integrity of the perforated, silver foam contact layer, and assess the patient for maceration and/or visible epithelialization. Serial photos were obtained to monitor progress; ongoing assessment revealed that epithelialization was noted on both hands within 12 days.

Although the patient experienced signs of pain during therapy before initiation of the approach to topical therapy we recommended, these symptoms abated after initiation of topical therapy using a silicone foam transfer dressing with silver sulfate and a secondary superabsorbent dressing. As a result analgesic medications were not required for daily evaluation of dressings or weekly dressing changes.

DISCUSSION

A literature review was performed in CINHAL (EBSCOhost) searching for topical treatment options. This search revealed little research or clinical practice articles describing options for topical treatment of patients with TEN.4 One study evaluated management of ophthalmologic lesions via steroids and an amniotic membrane.5 Multiple authors recommended application of topical antibacterial preparations, such as polymyxin-bacitracin ointments or a silver-based cream, to facilitate moist wound healing.1 Dressings recommended for management of TEN included a nanocrystaline silver dressing (Acticoat, Smith and Nephew, Andover, Massachusetts) and silver hydrofiber (Aquacel Ag, Covatec, Skillman, New Jersey). 3,6 We also found a single multisite study that recommended use of a silicone silver foam dressing as an alternative to silver sulfadiazine for burn management.7 We applied a similar approach, use of a silicone silver foam dressing as an alternative to application of a topical antibiotic preparation to care for our patients with TEN. This approach also reduced frequency of dressing changes with associated trauma to affected skin and reduction of pain during dressing changes. The silicone transfer dressing allowed wound exudate to wick into a secondary dressing; as a result we were able to allow the silver layer to remain on the wound bed for multiple days with interim changes of the secondary dressing alone.

CONCLUSION

Use of a silicone foam dressing with silver sulfate for topical management of a 77-year-old woman with TEN affecting 90% of TBSA promoted epithelization, reduced trauma associated with frequent dressing changes, and reduced pain during dressing changes. Epithelialization occurred with a 12-day period following initiation of this approach to topical treatment.

REFERENCES