Integument Emergency: A Case Study for Toxic Epidermal Necrolysis

Toxic Epidermal Necrolysis (TEN) is an exfoliative disorder typically caused by a drug reaction. Clinically significant to Stevens Johnson Syndrome (SJS) is dermoepidermal detachment. Mortality rate with these patients is upwards to 80%.

A 77 year old female was admitted to the critical care unit for sepsis, right foot cellulitis, urinary tract infection and TEN. Comorbidities included hypertension, chronic kidney disease, right heel unstageable and left heel stage II pressure ulcers. Cutaneous manifestations included full degloving of the hands and feet, large areas of epidermal dermal detachment, as well as mucous membrane involvement.  Local wound therapy recommendations stressed immediate topical antimicrobials with a silver foam transfer dressing to reduce and prevent infection. Total Body Surface Area (TBSA) affected was estimated to be 90%. The patient had the classic positive Nikolosky’s sign in which the external layer of skin rubs off with slight friction or pressure.

The WOC Team was consulted for evaluation and recommendation for local wound care. Treatment methodology included use of a silicone foam dressing containing silver sulfate in combination with a superabsorbent dressing. In the selected therapy, the silver foam had a thirty minute activating rate with a sustained release of fourteen days. The base layer of the dressing is a soft silicone which provided atraumatic application and removal. Furthermore, the silicone transfer silver dressing and the superabsorbent dressing effectively managed wound exudate while protecting from dermal exposure.

Application of the described therapy allowed for epithelialization, moisture management, and pain management. Not only did the therapy facilitate accelerated epithelialization but also the patient received less dressing changes and better pain control with gentle healing. Lastly, implementing this local wound treatment plan, resulted in 90% epithelialization on the dorsal and anterior aspects of both hands and feet. Despite multiple organ failure, integument healing occurred within eleven days.