Toxic epidermal necrolysis (TEN) is a rare but life-threatening disease of the skin and mucous membranes. We report our experience in the treatment of pediatric TEN patients with early debridement of necrotic skin and coverage with human allograft skin.
From 1984 to 2000, 15 children (6 girls, 9 boys, 7.2 ± 1.5 years) with a histologic diagnosis of TEN and involvement of >30% total body surface area were treated at the Shriners Hospitals for Children in Galveston. All were treated in a specialized pediatric burn intensive care unit after our standard treatment protocol, including operative debridement of sloughing skin and allografting within 24 hours of admission. Outcome parameters were mortality, length of hospital stay, wound healing, clinical complications, causative drugs, corticosteroid use, and delay in referral to a burn center.
Taking a new medication (antibiotics, anticonvulsive drugs) was associated with all cases of TEN. Patients who were treated with early debridement and coverage with allograft skin showed no wound infection, and overall mortality was 7%. Total length of hospital stay was 26 ± 3 days. Long-term sequelae were changes in skin pigmentation (100%), ophthalmologic problems (40%), and diffuse itching early after wound healing (53%).
Although a rare disease in children, TEN was managed successfully in a burn center environment, using early debridement and wound coverage with allograft skin as a biological dressing. The use of corticosteroids and referral patterns seems unchanged during the past 2 decades, indicating an additional need for information and education about the disease.
Dear Teresa,
in fact, this is good point. I apologize for not explicitly stating our pain managment protocol. This definitely should have been included in the manuscript.
In addition to benadryl (diphenhydramine) infusion at 1 mg/kg/h to stop the itching occuring with the skin sloughing in the early phase, we follow our standard pain protocol for burns. This consists of acetaminophen at 15 mg/kg/dose po q4h. If this should not be sufficient, it will be augmented by morphine iv at 0.33 mg/kg/dose iv q4h or morphine po at 0.1-0.3 mg/kg/dose q4h. However, in our clinical experience coverage of the large wound surfaces and protection of the raw dermis appears to be the most important factor to reduce pain. Continuing itching also appears to be of concern for the patient during the wound healing phase and shortly afterwards. This can be addressed by benadryl medication (po at 1.25 mg/kg/dose q6h).
I hope this clarifies your concerns and sufficiently answers your questions.
Marcus Spies MD Burn Fellow Shriners Hospital for Children - Galveston Burn Unit 815 Market St Galveston, TX 77550 maspies@utmb.edu
I read with interest this description of treatment of TEN. Despite the fact that the majority of children had extensive debridement of affected skin and that numerous pharmacological and medical interventions were detailed, there was no mention of pain control or sedation agents that may have been used to assist in the recuperative period. are these not essential interventions for severely burned patients that deserve mention, or did the patients not receive these interventions?