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Clinical Evaluation Comparing the Efficacy of Aquacel Ag with Vaseline Gauze versus 1% Silver Sulfadiazine Cream in Toxic Epidermal Necrolysis
Abstract
The purpose of this study was to determine whether using Aquacel Ag (ConvaTec, Skillman, New Jersey) with Vaseline (Unilever, London, England) gauze instead of silver sulfadiazine cream (SSD) as the wound care protocol to treat toxic epidermal necrolysis (TEN) can improve wound healing, pain control, and reduction of labor costs.
A retrospective chart review.
A burn center with 2 plastic surgeons and 11 nursing staff.
A pathologist diagnosed TEN in 35 patients admitted to the burn center from 1995 to 2009.
Parameters included the patient's profile, dressing choice, severity-of-illness score for TEN, time to 95% re-epithelialization, visual analog scale pain scores before second dressing change, and labor cost. The exclusion criterion was wound care with neither Aquacel Ag with Vaseline nor SSD exclusively.
Twenty patients were enrolled in this study. In the group using Aquacel Ag with Vaseline gauze, the visual analog scale score was significantly less than that of the SSD group (P = .02). Labor costs were significantly lower in the Aquacel Ag with Vaseline gauze group (P < .01). Commencement of specific dressing to 95% re-epithelialization (P = .09) and time spent in the second dressing change (P = .05) had no statistical significance between the 2 groups.
This study showed that Aquacel Ag with Vaseline gauze decreased pain and labor costs but did not shorten wound healing time. Thus, Aquacel Ag with Vaseline gauze can be an efficient method for treating TEN wounds.
... Nangole found that treatment with Aquacel Ag silver Hydrofiber dressings can decrease mortality in patients with Toxic epidermal necrolysis [12]. Huang et al. showed that Aquacel Ag with Vaseline gauze decreased pain and labor costs [13]. ...
Gunshot wound leads to deep soft tissue damages known as penetrating trauma. Wound healing in patient with the gunshot is a dynamic and complex process that requires a suitable approach to promote the healing process. The reason for this is that such wounds are usually deep and extensive. Modern wound dressing in perforated wounds without a fracture or neurovascular injury may be considered for wound healing of outpatients. We report on an 18-year-old girl patient with gunshot wound who was referred to the wound clinic. The symptoms of wound dehiscence in the periumbilical site were observed following to lose suture after primary surgery. Therefore, a new special dressing approach was adopted. Healing of periumbilical wound was successfully achieved at the end.
... Vaseline® has been shown to heal wounds by stopping bacteria from spreading in the skin and wounds from sticking to the gauze [22,24]. Numerous studies have combined Vaseline® and other substances in order to improve or accelerate wound healing [20,[25][26][27]. ...
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Bioactive glass (BG) has recently been proposed to be used for wound healing with Vaseline®. To accelerate the wound healing by incorporation of the Zinc (Zn) into BG, undoped and 5 wt% zinc-doped 45S5 BG (16 wt%) were prepared with Vaseline® to create the ointments for wound healing as a VBG and VBG-Zn, respectively. The results showed that desired composition, irregular form, and no porous surface have obtained for BGs. FT-IR spectrum of Zn-doped BG demonstrates increasing Network Connectivity due to Zn incorporation. Ointments exhibited pseudoplastic behaviour and viscoelastic characteristic, indicating that ointments have good topical application. Ointments did not toxic effect towards L929 cells in terms of biocompatibility for topical applications. In vitro wound healing assays revealed that VBG-Zn promotes wound healing thanks to incorporation of the Zn accelerates skin wound closure. All findings point to VBG-Zn ointment having a greater potential for wound healing applications.
... Antibiotics including topical preparations are available for treating wound [9]. Besides being expensive, these agents possess problems such as drug resistance and hypersensitivity, which can delay the wound healing process [10,11]. ...
Wounds account for severe morbidity, socioeconomic distress, and mortality around the globe. For several years, various herbal products are used to expedite and augment the innate wound healing process. In Ethiopian folkloric medicine, Verbascum sinaiticum L. (V. sinaiticum) is commonly applied as a wound-healing agent. e present study investigated the potential wound healing and antioxidant properties of hydroalcoholic leaf extract of V. sinaiticum. e 80% methanol extract, formulated as 5% (w/ w) and 10% (w/w) ointments, was evaluated in excision and incision wound models using nitrofurazone and simple ointment as positive and negative controls, respectively. Parameters such as wound contraction, period of epithelialization, and tensile strength were determined. Moreover, its in vitro antioxidant property was evaluated using a DPPH assay. In the excision model, both doses (5% and 10% w/w) of the extract showed a signi cant (p < 0.001) wound healing e cacy compared to the negative control as evidenced by enhanced wound contraction rate and shorter epithelialization time records. In the incision model, the lower dose (5% w/w) ointment formulation of the extract exhibited the maximum increment in tensile strength (85.6%) that was signi cant (p < 0.001) compared to negative and untreated controls. Animals treated with 5% w/w ointment, furthermore, showed a signi cantly (p < 0.05) higher percentage of tensile strength than nitrofurazone treated ones. Moreover, the hydroalcoholic extract of the plant showed a noticeable free radical scavenging property. e result of the present study upholds the folkloric use of V. sinaiticum in the treatment of wounds.
... Vaseline gauze (VG), which is widely used in clinics, possesses the moisture-retention ability and can reduce the pain and prevent synechia formation. 15,16 However, the disadvantage of VG is obvious by lacking the antibacterial activity, and thus limiting its clinical application. ...
Wound dressings are always needed after skin injury; however, most of the dressings still leave room for improvement. Here, we would like to develop an effective dressing with the ability to improve wound healing. A chitosan-Vaseline gauze (CVG) dressing was developed by coating the chitosan mixture and Vaseline on sterile gauze with subsequent drying. Infrared spectroscopy and electron microscopy were used to investigate the miscibility and structure of the dressing. The cytotoxicity and antibacterial nature were evaluated in vitro. The studies of water retention rate, wound healing, and tissue compatibility were carried out over a period of 14 days on full-thickness skin wounds of male Sprague-Dawley rats. It was observed that the CVG dressing demonstrated functional structure by miscibility, non-cytotoxicity, and good antibacterial effects against both Gram-positive and Gram-negative bacteria. The water retention rate incresased up to 25% after applying CVG for 3 hours. Besides, CVG treatment increased angiogenesis and improved microvascular density in wounds. The wounds treated with CVG showed size deduction with new collagen aggregations similar to those in the normal dermis. All the aforementioned results suggest that CVG dressing could be a promising candidate for wound treatment.
... Vaseline as a classic and common ointment base is often used for burns, wounds and other skin lesions. And silver sulfadiazine cream (SSD) is the most widespread topical treatment for burns, toxic epidermal necrolysis wounds, bullous disorders, and ulcers [4]. However, there are also some potential side effects simultaneously including leukopenia when applied to large burn surfaces, hypersensitivities, delays in the wound healing processes, and serious cytotoxic activity in the host cells [5][6][7]. ...
Callicarpa nudiflora has been widely used in Li nationality medicine and treated burns and scalds in China. Our objective was to preliminarily elucidate healing effect and action mechanism of Callicarpa nudiflora water extract (CNE) on the scald wounds using an experimental rat mode. The second-degree scald wounds were induced by hot water on dorsal surface of Sprague-Dawley (SD) rats, and then they were randomly divided into 5 groups as follows: control (CON), Vaseline, Silver sulfadiazine (SSD), and Vaseline supplemented with 10% and 20% CNE groups. These ointments were employed locally once daily for 21 days. The macroscopic analysis showed CNE significantly accelerated the wound healing process and lowered the wound areas on days 15, 18, and 21 especially in 20% CNE group compared to CON group. Histopathological evaluation showed the mildly hypertrophic epidermis and the intact dermis in the 20% CNE-treated group were obviously distinguished from CON group on day 21. The CNE-treated groups had no obvious effect for TNF- α and IL-10 expressions on the second day and 14th day, while TGF- β 1 expression level was decreased on the 21th day and VEGF level was increased on the 7th day in the 20% CNE group. Furthermore, the expression level of Samd3 was strongly inhibited in 20% CNE group. These findings suggested that the CNE can enhance the wound healing and skin repair in deep second-degree scald rats and thus support its traditional use.
... The application of sterile Vaseline permeated gauze maintains a moist wound surface to facilitate healing. 16,17 In this study, essential Vaseline album used for ointment only served to moisturize the surface of the skin while Adeps played its role to absorb the liquid. However, since it does not contain any active ingredient, the restoration of tissue in the wound that was only given the base of the ointment was not disrupted so that the healing phases such as inflammation, re-epithelization and connective tissue formation can be processed naturally to recover itself, as long as there is no infection of the wound. ...
Background: It has been reported by the Ministry of Health that the prevalence of wounded and worsening events is increasing in Indonesia. This situation requires more intensive attention. Eel mucus has been an alternative treatment of wounds in some parts of Indonesian society since ancient times. Aim and Objectives: To explore the effectiveness of eel mucus ointment as a natural wound healing product. Material and Methods: This experimental study used 45 mice divided into 3 groups; 15 mice in each group. All mice were aseptically wounded 1.5 cm on their anterior region of back skin using a sterile scalpel, and then treated with placebo, povidone iodine ointment, and with eel mucous ointment (Belutidine). On the third, sixth and ninth day, the mice were sacrificed. Data on wound length were taken on 9th day. Microscopic data of histologic slides collected were: number of neutrophil, mono-nuclear, neo-vascular and fibrosis cells. Data were analyzed using statistical analysis. Results: There was a significant difference in wound length between the groups (p = 0.008). The number of mono-nuclear cells on the third day was different significantly among the groups (p = 0.008). There was no significant difference of the overall observed cells on day 6 and there was a difference in mean number of neutrophils and fibrosis on day nine (p < 0.05). On day nine, the group treated with eel mucus ointment had the highest number of mean of neo-vascular and fibrosis cells. Conclusion: Eel mucous ointment is effective for wound healing.
... However, the silicone tube itself has poor plasticity, which makes it easy to produce joint space during the padding process. Therefore, the padding process requires the use of Vaseline-coated gauze, which is more difficult to work with [13]. Chitosan, a new natural macromolecule material that is non-toxic, biocompatible, and biodegradable, is used in clinical wound dressing to promote wound healing and prevent postoperative adhesions. ...
Background
This study aimed to investigate the efficacy and safety of 3 nasal packing products (silicone tube, Beschitin-F, and Aquacel1-Ag) after functional endoscopic sinus surgery (FESS) for chronic rhinosinusitis (CRS) patients in China.
Material/Methods
Sixty-six CRS patients undergoing FESS surgery were randomly divided into 3 groups (22 patients in each group): the silicone tube group, the Beschitin-F group, and the Aquacel1-Ag group. Postoperative headache, nasal pain, nasal bleeding, and swelling of the nasal mucosa were observed at 1 month after FESS surgery. Bacteriology of chronic rhinosinusitis was conducted by culturing the removed nasal packing.
Results
The VAS scores of nasal pain in the silicone tube group were lower than in the Beschitin-F and the Aquacel1-Ag groups. The volume of nasal bleeding in the Beschitin-F group was higher than in the silicone tube and Aquacel1-Ag groups. The adhesion rate of the nasal cavity in the Beschitin-F1 group (2/22, 9.1%) was also higher than in the silicone tube group (0/22, 0%) and the Aquacel1-Ag group (0/22, 0%). The results of bacterial culture from removed nasal packing showed that coagulase-negative staphylococci (CNS) was more frequent in the silicone tube group than in the Beschitin-F and Aquacel1-Ag groups, but Streptococcus pneumonia, Haemophilus influenza, and Gram-negative rods were more common in the Aquacel1-Ag group than in the silicone tube and Beschitin-F groups.
Conclusions
These results indicate that the silicone tube may be more effective and safe than Beschitin-F and Aquacel1-Ag as nasal packing after FES surgery for CRS.
Toxic epidermal necrolysis (TEN) involves extensive mucocutaneous loss, and care is supportive. The approach to wound care includes surgical debridement or using dressings while leaving the epidermis intact. Robust evidence for either approach is lacking. We compared surgical debridement to the use of dressings while leaving the epidermis in situ (referred to hereon as dressings) in adult patients with TEN. The primary outcome assessed was mortality. The secondary outcome was time to re‐epithelialisation. The impact of medications was evaluated. An individual patient data (IPD) systematic review and meta‐analysis was undertaken. A random effects meta‐analysis and survival analysis for IPD data examined mortality, re‐epithelisation time and the effect of systemic medications. The quality of evidence was rated per the Grading of Recommendations Assessment, Development and Evaluation (GRADE). PROSPERO: CRD42021266611 Fifty‐four studies involving 227 patients were included in the systematic review and meta‐analysis, with a GRADE from very low to moderate. There was no difference in survival in patients who had surgical debridement or dressings (univariate: p = 0.91, multivariate: p = 0.31). Patients who received dressings re‐epithelialised faster than patients who underwent debridement (multivariate HR: 1.96 [1.09–3.51], p = 0.023). Intravenous immunoglobulin (univariate HR: 0.21 [0.09–0.45], p < 0.001; multivariate HR: 0.22 [0.09–0.53], p < 0.001) and cyclosporin significantly reduced mortality (univariate HR: 0.09 [0.01–0.96], p = 0.046; multivariate HR: 0.06 [0.01–0.73], p = 0.028) irrespective of the wound care. This study supports the expert consensus of the dermatology hospitalists, that wound care in patients with TEN should be supportive with the epidermis left intact and supported with dressings, which leads to faster re‐epithelialisation.
Objective
The aim of this study was to evaluate the effect of vaseline gauze (VG) patching on the treatment of large traumatic perforation of tympanic membrane (TM).
Material and methods
90 patients with traumatic perforation larger than 25% of the TM were randomly allocated into the control group of observation only, VG group, and Gelfoam patch alone group. The closure rate and closure time among the 3 groups were compared at 3 months.
Results
In total, 82 large traumatic perforations were analyzed in this study. The closure rates in the control, VG, and gelfoam patch groups were 84.6%, 100.0%, and 89.3%, respectively ( P = 0.637). Post-hoc multiple comparisons showed that the difference between the control and VG groups was significant ( P = 0.047), but the difference wasn’t significant between gelfoam alone and control groups ( P = 0.699) or VG groups ( P = 0.236). The mean closure times were 5.41 ± 1.47, 2.14 ± 0.93, and 3.00 ± 0.62 weeks for the control, VG, and gelfoam patch groups, respectively ( P < 0.001). Post-hoc multiple comparisons showed that the difference was significant between the control and VG groups ( P < 0.001) or gelfoam alone group ( P < 0.001) or VG and gelfoam groups ( P < 0.05).
Conclusions
VG improved the closure rate and shortened the closure time compared with observation only, which could be an effective patch material for repairing traumatic lager perforations in the outpatient setting, which is readily available and convenient.
Objective
The objective of this study was to compare the efficacy of ofloxacin ear drops, vaseline gauze (VG) and dry gelfoam alone on the large traumatic perforations of tympanic membrane (TM).
Material and methods
A randomized prospective analysis was performed for the treatment of traumatic perforation larger than 25 % of the entire TM. The closure rate, closure time, and hearing gain between ofloxacin ear drops, VG and gelfoam alone groups were compared at 3 months.
Results
Final analysis was performed on 70 patients. The closure rates of perforation in the ofloxacin ear drops, VG, and dry gelfoam patch groups were 100.0 %, 92.0 %, and 87.5 %, respectively (P = 0.41).The mean closure times were 8.67 ± 3.1, 10.65 ± 4.2, and 14.33 ± 7.5 days for the ofloxacin ear drops, VG, and gelfoam patch alone groups, respectively. The closure times among the 3 groups were significantly different (P = 0.003). In addition, there was a significant difference between the ofloxacin ear drops and gelfoam patch alone groups with regard to closure time (P = 0.003), while there was no significant difference between the ofloxacin ear drops and VG groups (P = 0.080) or VG and gelfoam patch groups (P = 0.056).The mean hearing gain was 11.4 ± 2.3 dB for the ofloxacin ear drops group, 11.7 ± 4.1 dB for the VG group, and 12.2 ± 1.6 dB for the gelfoam patch group (P = 0.69).
Conclusions
The repairing of traumatic perforations didn't require an exogenous biological scaffold. Ofloxacin ear drops and VG were a deal material for repairing traumatic perforation in otology clinic, which not only was readily available and inexpensive but also showed faster closure compared with dry gelfoam alone.
Vaseline gauze is a common type of wound dressing that consist of absorbent gauze impregnated with white petrolatum. It has excellent anti-adhesive property which can reduce trauma during dressing changes. However, this kind of wound dressing doesn’t have bacterial killing property. Thus, a new kind of wound dressing that has anti-adhesive and bactericidal properties is needed urgently. Creating slippery liquid-impregnated porous surfaces (SLIPS) that insensitive to the structure of porous solid are generally viewed as a new anti-adhesion strategy. To expand the potential utility of SLIPS as substitute for vaseline gauze, dual-functional slippery membranes with anti-adhesion and bactericidal properties by using triclosan, vegetable oils and polylactic acid (PLA) were prepared. It’s demonstrated that the triclosan-loaded/vegetable oils-infused PLA membranes (T/V-PM) has good cytocompatibility in vitro. Notably, the T/V-PM can gradually release biocide molecule into surrounding aqueous media. Moreover, the T/V-PM can kill planktonic bacterial cells without loss of their antifouling property. The in vivo study revealed that the T/V-PM can prevent the secondary injuries during wound dressing changes. This simple and low-cost strategy can be applied to inhibit blood and bacterial adhesion, and prevent tissue adhesion at the wound site. It’s confirmed that the T/V-PM have great potential as substitute for vaseline gauze.
Background
Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are potentially fatal adverse drug reactions. The characteristics of these diseases are changing with the use of novel drugs, posing new challenges to doctors. We aimed to review recent SJS/TEN cases in order to assist general practitioners with timely diagnosis and correct management.
Methods
We conducted a retrospective chart review of SJS/TEN patients in a referral center in Taiwan from 2009 to 2019. We included 24 patients' charts and analyzed demographic data, medication histories, clinical courses, human leukocyte antigen (HLA) alleles, and long‐term complications.
Results
The average age was 63.4 years, and the average toxic epidermal necrolysis‐specific severity of illness score was 1.9. The most common culprit drug was carbamazepine (33.3%), followed by antibiotics (12.5%) and nonsteroidal anti‐inflammatory drugs (8.3%). Two cases were caused by immune checkpoint inhibitors, and one of them had a long latency of 210 days. Three out of the four patients carrying HLA‐B*15:02 had carbamazepine‐induced SJS/TEN. All patients were treated with systemic corticosteroids in the acute stage of the diseases. The length of in‐hospital stay did not correlate with the average daily dose of corticosteroids. The overall mortality rate was 4.2%, and the disease‐specific mortality rate was 0%.
Conclusions
The most common culprit drug was carbamazepine, which had strong association with HLA‐B*15:02. There was no statistically significant correlation between in‐hospital stay and the average daily dose of corticosteroids. Immune checkpoint inhibitor‐related SJS/TEN may have an extended latent period.
Introduction:
Few studies have reported the physical complications among Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) survivors.
Objective:
The aim of this study was to comprehensively characterize the physical complications among SJS/TEN survivors and to learn about patients' perspectives of surviving SJS/TEN.
Methods:
SJS/TEN survivors older than 18 years of age were assessed by different methods: a medical interview; a questionnaire assessing patients' perspectives; thorough skin, oral mucous membrane, and ophthalmic examinations; and a retrospective assessment of medical records.
Results:
Our cohort consisted of 17 patients with a mean time of 51.6 ± 74.7 months (median 9, range 1-228) following SJS/TEN. The most common physical complications identified in the medical examination were post-inflammatory skin changes (77%), cutaneous scars (46%), dry eyes (44%), symblepharon, and chronic ocular surface inflammation (33% each). Novel physical sequelae included chronic fatigue (76%) and pruritus (53%). We also found a novel association between the number of mucous membranes affected in the acute phase of SJS/TEN and hair loss during the 6 months following hospital discharge; hair loss was reported in 88% of the group of patients who had three or more mucous membranes affected versus 29% of patients who had less than three mucous membranes involved (p = 0.0406). Following hospital discharge due to SJS/TEN, 59% of patients were followed by a dermatologist, although 88% had dermatological complications; 6% were followed by an ophthalmologist, even though 67% had ophthalmological complications; and 6% of female survivors were followed by a gynecologist, even though 27% had gynecological complications.
Conclusion:
Survivors of SJS/TEN suffer from severe physical complications impacting their health and lives that are mostly under recognized and not sufficiently treated by medical professionals.
Objectives
Recent clinical reports showed excellent results when the lay open method was used for the treatment of chronic sacrococcygeal pilonidal sinus, despite keeping the wound open for a considerable time which increases the risk of infection, delayed closure, and recurrence. In this study, we aim to analyze the factors influencing the outcome of the laid open sacrococcygeal pilonidal wound regarding wound infection, complete wound closure, and recurrence.
Methods
A prospective cohort study of 472 patients with chronic sacrococcygeal pilonidal sinus who had the lay open procedure between January 2000 and December 2012 was done. 326 were male and 146 were female. Lay open was performed to all patients. Postoperative care and follow-up methods were similar in all patients. Preoperative, intraoperative, and postoperative factors affecting the outcome were analyzed.
Results
The mean age was 27.6 years. Male gender, smoking, BMI ≥ 30 kg/m², diabetes mellitus, the sinus number, wound depth of more than 3 cm, packing the wound, the cleaning material for wound irrigation, regular postoperative shaving of hair around the wound, postoperative complications mainly pus discharge from the wound, and poor postoperative body hygiene were the factors statistically found to represent a significant difference in association with longer wound healing time (P ≤ 0.01). The recurrence rate was 0% after four years of follow-up.
Conclusion
We concluded that many factors could affect the outcome of the laid open wound of the chronic sacrococcygeal pilonidal sinus. For the best outcome, careful consideration of these factors could help achieve an excellent result.
Burns are the most extensive forms of soft tissue injuries occasionally resulting in extensive and deep wounds and death. Burns can lead to severe mental and emotional distress, because of excessive scarring and skin contractures. Treatment of burns has always been a difficult medical problem and many different methods have been used to treat such injuries, locally. Biofilms are a collection of microorganisms that delay wound healing. One of the new methods of prevention and treatment of burn wound infections is application of antimicrobials, which act on biofilms and prevent the wound infection. Biofilm initiates a persistent, low-grade, inflammatory response, impairing both the epithelialisation and granulation tissue formation. Skin grafts have been shown to dramatically reduce deaths from infection. However, grafting has considerable limitations. Such injuries are long-lasting and many patients suffer from chronic pain for a long time. Tissue engineering is a new approach in reducing the limitations of conventional treatments and producing a supply of immunologically tolerant artificial tissue, leading to a permanent solution for damaged tissues; such criteria make it a cost-effective and reliable treatment modality. To overcome the present limitations of burn wound healing, knowledge about the latest findings regarding healing mechanisms is important. Here the authors discuss the most important events regarding burn wound healing and review the latest treatment strategies that have been used for burn wounds from in vitro to clinical levels. Finally, we discuss the role of tissue engineering and regenerative medicine in the future of burn wound healing, modelling and remodelling.
Aquacel Ag® (ConvaTec, Princeton, NJ, USA) is a new hydrofiber wound dressing consisting of soft non-woven sodium carboxymethylcellulose fibers integrated with ionic silver. It is a moisture-retention dressing, which forms a gel on contact with wound fluid and has antimicrobial properties of ionic silver. We present a current literature review on Aquacel Ag®, of both in vitro and in vivo efficacy and clinical applications. In vitro and in vivo studies have demonstrated the wide antimicrobial properties of Aquacel Ag®, and additionally demonstrated the cytotoxicity of ionic silver to keratinocytes and fibroblasts that cause delay in wound re-epithelialization. Clinical studies confirmed that Aquacel Ag® is an effective and safe dressing for a variety of wound types, both acute and chronic. Incorporation of ionic silver into the hydrofibers does not cause undue alteration in the performance properties of the base dressing, which continues to provide favorable wound moisture and exudate management. The addition of ionic silver reduces local pain and dressing changes, and provides significant broad-spectrum antimicrobial properties, with no delay in wound healing.
Withdrawal of the drug(s) that cause severe cutaneous adverse reactions is usually recommended without proof that it alters the course of those reactions.
To determine whether the timing of causative drug withdrawal is related to the prognosis of patients with toxic epidermal necrolysis (TEN) or Stevens-Johnson syndrome (SJS).
A 10-year observational study (January 1, 1987, through October 30, 1997) of patients admitted to a dermatological intensive care unit, using binary logistic regression analysis.
A single referral unit in a university hospital.
Consecutive sample of 203 patients with TEN or SJS. Exclusion criteria included causative drug undetermined, lack of information on disease evolution, the date of causative drug(s) withdrawal, or the date when the first definite sign of TEN or SJS appeared.
Death before hospital discharge.
One hundred thirteen patients were included; 74 had TEN and 39 had SJS; 20 died. The drug causing TEN or SJS was withdrawn early in 64 patients and late (after the first definite sign of TEN or SJS) in 49 patients. After adjustment for confounding variables (age, maximum extent of detachment, admission year, human immunodeficiency virus status), our model showed that the earlier the causative drug was withdrawn, the better the prognosis (odds ratio, 0.69 for each day; 95% confidence interval, 0.53-0.89). Patients exposed to causative drugs with long half-lives had an increased risk of dying (odds ratio, 4.9; 95% confidence interval, 1.3-18.9). The variables did not interact.
Prompt withdrawal of drug(s) that are suspected to cause SJS or TEN may decrease mortality. Prompt withdrawal of causative drugs should be a priority when blisters or erosions appear in the course of a drug eruption.
Aquacel Hydrofiber is a moisture retentive topical dressing that has been demonstrated to be safe and efficacious for the management of partial-thickness burns, showing parity for most dressing related aspects to cadaver skin for this indication. Recently, 1.2% w/w silver has been added to the Aquacel Hydrofiber, to create Aquacel Ag. This new material releases silver within the dressing for up to two weeks, and it is this duration that differentiates it from other sustained release silver delivery products indicated for burn management. The dressing was tested in a phase II noncomparative trial in superficial, mid dermal, and mixed partial-thickness burns. Percentage and speed of reepithelialization were satisfactory and appear to be similar at least to results noted with silver sulfadiazine, although, no direct comparisons were performed in this study. Pain reduction between baseline and postburn day number three and five was statistically significant. Conformability, general ease of use and other functional dressing properties were rated very positively. Overall, Aquacel Ag combines several properties known to be beneficial for the management of partial-thickness burns and is a very good choice for superficial and mid-thickness burn injuries.
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN, Lyell's syndrome) are now considered to be distinct clinical entities within a spectrum of adverse cutaneous drug reactions of increasing severity based on their surface of skin detachment. Within this spectrum, SJS which can be considered as a minor form of TEN is characterized by less than 10% body surface area of skin detachment, and an average reported mortality of 1-5%, whereas TEN is characterized by more than 30% skin detachment, and an average reported mortality 25-35%. Both SJS and TEN are characterized morphologically by the rapid onset of keratinocyte cell death by apoptosis, a process that results in the separation of the epidermis from the dermis. Recent evidence is supportive of a role for inflammatory cytokines and the death receptor Fas and its ligand FasL in the pathogenesis of keratinocyte apoptosis during TEN. This Fas-mediated keratinocyte apoptosis that is the last step culminating in epidermal detachment in TEN can be inhibited in vitro by antagonistic monoclonal antibodies to Fas, and by intravenous immunoglobulins (IVIG) which have been shown to contain natural anti-Fas antibodies. Consequently, over the last few years, numerous case reports and 9 non-controlled clinical studies containing 10 or more patients have analyzed the therapeutic effect of IVIG in TEN. Taken together, although each study has its potential biases, 7 of 9 such studies point towards a benefit of IVIG used at doses greater than 2 g/kg on the mortality associated with TEN. These studies should serve as the basis for designing an appropriate prospective trial or for conducting a metaanalysis in the near future, in order to determine the therapeutic efficacy of IVIG in TEN.
A short-cut review was carried out to establish whether silver sulphadiazine cream is better than normal dressing in promoting healing without infection. A total of 410 papers were found using the reported searches, of which 12 showed the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that although there is evidence of antibacterial effect, there is no direct evidence of improved healing or reduced infection.
Toxic Epidermal Necrolysis (TEN) is life-threatening dermatological disease characterized by extensive destruction of the epidermis is associated with a 25-60% mortality rate in adults. We presented one patient with TEN with 86% skin slough treated successfully using AQUACEL Ag exclusively. All of the wounds were healed completely 8 days after onset of TEN. AQUACEL Ag is an efficient and cost-effective adjunct in the treatment of TEN.
• Eighty-seven patients with toxic epidermal necrolysis were observed at Hôpital Henri Mondor in Créteil, France, over the last 12 years. The mean percentage of body surface area involved was 39%. Erosive mucous membrane lesions, identical to those of Stevens-Johnson syndrome, were present in all but three cases. Necrolysis was sometimes generalized within 24 hours but usually spread progressively after a Stevens-Johnson syndrome—like aspect at the onset. Mortality was 25%. Infection, mainly with Staphylococus aureus and Pseudomonas aeruginosa, was the first cause of death, clearly responsible in ten of 20 cases. Age, extension of necrolysis, idiopathic nature of toxic epidermal necrolysis, ingestion of many drugs, elevation of urea, creatinine, and glucose levels, neutropenia, lymphopenia, and thrombocytopenia were statistically linked to a bad prognosis. A multivariant analysis showed that three of these prognosis factors are of paramount importance, namely: age, area of necrolysis, and serum urea level. Pigmentary changes and sicca syndrome were frequently observed sequelae in survivors.
(Arch Dermatol 1987;123:1160-1165)
Burn depth and burn size are crucial determinants for assessing patients suffering from burns [1]. Therefore, a correct evaluation of these factors is optimal for adapting the appropriate treatment in modern burn care. Burn surface assessment is subject to considerable differences among clinicians [2]. This work investigated the accuracy among experts based on conventional surface estimation methods (e.g. "Rule of Palm", "Rule of Nines" or "Lund-Browder Chart"). The estimation results were compared to a computer-based evaluation method. Survey data was collected during one national and one international burn conference. The poll confirmed deviations of burn depth/size estimates of up to 62% in relation to the mean value of all participants. In comparison to the computer-based method, overestimation of up to 161% was found. We suggest introducing improved methods for burn depth/size assessment in clinical routine in order to efficiently allocate and distribute the available resources for practicing burn care.
Toxic epidermal necrolysis (TEN) represents the most severe drug-related skin condition that is potentially life-threatening with no well-established treatments. The application of corticosteroid therapy is controversial, whereas recently intravenous immunoglobulin (IVIG) therapy is emerging as a promising new method. A severity-of-illness score for TEN (SCORTEN) has gained acceptance in some western countries. In this study, the authors' objectives were to assess the applicability of SCORTEN in Chinese patients with TEN and to evaluate the efficacy of the combination therapy of IVIG and corticosteroid in these patients. The authors performed a retrospective review of data from 61 patients with TEN treated at their intensive care unit from 2000 to 2010 to assess the performance of SCORTEN. In particular, 55 patients between 2002 and 2010 were grouped as a series to compare the therapeutic effects of corticosteroid therapy and IVIG combined therapy contemporaneously. During this period, 16 patients were administered with corticosteroid therapy and 39 were treated with the combination therapy. An initial dose of 1.5 mg/kg/day of methylprednisolone was given to all TEN patients. The combination therapy was combined with a total dose of 2 g/kg IVIG within 5 days. Areas under receiver operating characteristic curves and Hosmer-Lemeshow statistic were analyzed to illustrate the performance of SCORTEN. The comparison of the efficacy of the two therapies was conducted on the basis of clinical outcomes, standardized mortality ratio (SMR), and survival analysis. The overall actual mortality of patients between 2000 and 2010 was 16% (10/61), statistically insignificantly lower than predicted (24%, SMR = 67.98). Excellent discriminatory power (the areas under the receiver operating characteristic curves: 88.9, 88.2, 90.6%) and good calibration (P = .637, .833, .530) were found in all the groups. In patients admitted between 2002 and 2010, IVIG combined therapy showed a trend toward reducing the mortality rate (13%, SMR = 52.35), whereas corticosteroid monotherapy suggested no such difference (31%, SMR = 123.92). Besides, the cumulative survival rates of the combination therapy were higher at almost all the levels of SCORTEN, especially at the score of 5 (P = .039). Compared with corticosteroid alone, the combination therapy arrested progression earlier (P = .013), although it did not significantly lead to a tapering of corticosteroid or a reduction of the time of hospitalization. SCORTEN was generally applicable to Chinese patients with TEN. The comparison of the effect indicated that the combination therapy might achieve a better therapeutic effect than the administration of corticosteroid alone, especially in severe TEN patients.
Toxic epidermal necrolysis (TEN) is associated with a significant mortality of 30-50% and long-term sequelae. Treatment includes early admission to a burn unit, where management with precise fluid, electrolyte, protein, and energy supplementation, moderate mechanical ventilation, and expert wound care can be provided. Specific treatment with immunosuppressive drugs or immunoglobulins did not show an improved outcome in most studies and remains controversial. We have treated the cutaneous lesions of seven patients of TEN with collagen sheet dressings and have found a significant reduction in morbidity. The sheets are a one-time dressing, easy to apply and they reduce fluid loss, prevent infection, reduce pain, avoid repeated dressings and gradually peal off as the underlying lesions heal.
Toxic epidermal necrolysis (TEN) is a severe cutaneous drug reaction with a mortality rate of approximately 30%. The hallmark of TEN is widespread epidermal sloughing due to keratinocyte apoptosis. Multiple genetic associations between TEN and specific ethnic populations have been determined. The pathophysiology of TEN has yet to be fully elucidated; however, current pathogenic models implicate Fas ligand, granulysin, and reactive oxygen species. The value of current therapies, such as intravenous immunoglobulin and corticosteroids, remains under evaluation.
An open, parallel, randomized, comparative, multicenter study was implemented to evaluate the cost-effectiveness, performance, tolerance, and safety of a silver-containing soft silicone foam dressing (Mepilex Ag) vs silver sulfadiazine cream (control) in the treatment of partial-thickness thermal burns. Individuals aged 5 years and older with partial-thickness thermal burns (2.5-20% BSA) were randomized into two groups and treated with the trial products for 21 days or until healed, whichever occurred first. Data were obtained and analyzed on cost (direct and indirect), healing rates, pain, comfort, ease of product use, and adverse events. A total of 101 subjects were recruited. There were no significant differences in burn area profiles within the groups. The cost of dressing-related analgesia was lower in the intervention group (P = .03) as was the cost of background analgesia (P = .07). The mean total cost of treatment was $309 vs $513 in the control (P < .001). The average cost-effectiveness per treatment regime was $381 lower in the intervention product, producing an incremental cost-effectiveness ratio of $1688 in favor of the soft silicone foam dressing. Mean healing rates were 71.7 vs 60.8% at final visit, and the number of dressing changes were 2.2 vs 12.4 in the treatment and control groups, respectively. Subjects reported significantly less pain at application (P = .02) and during wear (P = .048) of the Mepilex Ag dressing in the acute stages of wound healing. Clinicians reported the intervention dressing was significantly easier to use (P = .03) and flexible (P = .04). Both treatments were well tolerated; however, the total incidence of adverse events was higher in the control group. The silver-containing soft silicone foam dressing was as effective in the treatment of patients as the standard care (silver sulfadiazine). In addition, the group of patients treated with the soft silicone foam dressing demonstrated decreased pain and lower costs associated with treatment.
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe cutaneous reactions that are medication-induced in most instances. While the clinical manifestations of SJS and TEN are well-defined, the optimal treatment for these disorders is not. Case reports have shown benefit with the use of a variety of agents including tumor necrosis factor-alpha inhibitors and cyclophosphamide, whereas thalidomide was associated with an increased mortality. Plasmapheresis and cyclosporine have also demonstrated efficacy anecdotally, albeit with an even smaller number of cases in the literature. Most of the reporting has focused on the use of systemic corticosteroids and intravenous immunoglobulin (IVIG) for these severe reactions. The majority of studies analyzing the use of IVIG in the treatment of SJS/TEN show a benefit, though more recent series cast doubt upon this conclusion. The results of these studies are summarized in this present review study.
The aims of this review are to summarize the definitions, causes, and clinical course as well as the current understanding of the genetic background, mechanism of disease, and therapy of toxic epidermal necrolysis and Stevens-Johnson syndrome.
PubMed was searched using the terms toxic epidermal necrolysis, Stevens-Johnson syndrome, drug toxicity, drug interaction, and skin diseases.
Toxic epidermal necrolysis and Stevens-Johnson syndrome are acute inflammatory skin reactions. The onset is usually triggered by infections of the upper respiratory tract or by preceding medication, among which nonsteroidal anti-inflammatory agents, antibiotics, and anticonvulsants are the most common triggers. Initially the diseases present with unspecific symptoms, followed by more or less extensive blistering and shedding of the skin. Complete death of the epidermis leads to sloughing similar to that seen in large burns. Toxic epidermal necrolysis is the most severe form of drug-induced skin reaction and includes denudation of >30% of total body surface area. Stevens-Johnson syndrome affects <10%, whereas involvement of 10%-30% of body surface area is called Stevens-Johnson syndrome/toxic epidermal necrolysis overlap. Besides the skin, mucous membranes such as oral, genital, anal, nasal, and conjunctival mucosa are frequently involved in toxic epidermal necrolysis and Stevens-Johnson syndrome. Toxic epidermal necrolysis is associated with a significant mortality of 30%-50% and long-term sequelae. Treatment includes early admission to a burn unit, where treatment with precise fluid, electrolyte, protein, and energy supplementation, moderate mechanical ventilation, and expert wound care can be provided. Specific treatment with immunosuppressive drugs or immunoglobulins did not show an improved outcome in most studies and remains controversial. The mechanism of disease is not completely understood, but immunologic mechanisms, cytotoxic reactions, and delayed hypersensitivity seem to be involved.
Profound knowledge of exfoliative skin diseases is needed to improve therapy and outcome of these life-threatening illnesses.
For decades silver-containing antibiotics such as silver sulfadiazine (SSD) have been applied as standard topical therapy for patients with partial-thickness burns and venous stasis ulcers. This evidence-based review intends to answer the following research question: in ambulatory patients with partial-thickness burns or stasis dermatitis ulcers, does the use of topical SSD compared with nonantibiotic dressings improve mortality, wound healing, re-epithelialization, or infection rates?
MEDLINE, EMBASE, Cochrane Library, and other databases were searched. We considered trials that enrolled patients of any age with partial-thickness burns or venous stasis ulcers and randomized them to either topical SSD or placebo, saline-soaked gauze, paraffin gauze, sterile dry dressing, or nonantibiotic moist dressing. Outcomes included mortality, wound healing, speed of re-epithelialization, and infection rates.
For burns, our search revealed 400 potential articles. No human studies met the inclusion criteria. Only 7 animal studies (1 mouse, 4 rat, and 2 pig) were relevant to the proposed question. These animal studies provided conflicting results. Whereas some support the use of SSD for treatment of partial-thickness burns, others question its effectiveness. For stasis dermatitis ulcer, the search identified 50 articles for review, of which 20 abstracts were reviewed, and one article met the inclusion criteria. This study did not show any significant improvement in the rate of complete healing in SSD group compared with placebo either at 4 weeks (relative risk 6.2, 95% confidence interval 0.8-48) or at 1 year (relative risk 5.2, 95% confidence interval 0.6-41.6) of follow-up.
There is insufficient evidence to either support or refute the routine use of SSD for ambulatory patients with either partial-thickness burns or stasis dermatitis ulcers to decrease mortality, prevent infection, or augment wound healing in human beings.
Silver sulfadiazine has been used as a topical burn wound treatment for many years. Pain associated with dressing changes is a common problem in burn wounds. Aquacel Ag, a hydrofiber dressing coated with ionic silver has been reported to reduce burn wound infection and promote antimicrobial activity. The purpose of this study was to show the benefits of Aquacel Ag for the treatment of partial thickness burns. This prospective randomized study was conducted in 70 patients who had partial thickness burns less than 15% of total body surface area and were treated at Siriraj outpatient burn clinic during December 2006-February 2008. Patients were divided into two groups: Aquacel Ag-treated group with dressing changes every 3 days (35 patients) and 1% silver sulfadiazine-treated group, with daily dressing changes (35 patients). There was no difference in demographic data including age, gender, burn percentage between groups. Time-to-wound healing pain score during dressing change and cost of treatment were compared between both groups. Time-to-wound closure was significantly shorter in the Aquacel Ag-treated group (10 +/- 3 versus 13.7 +/- 4 days, P < 0.02) as well as pain scores at days 1, 3 and 7 (4.1 +/- 2.1, 2.1 +/- 1.8, 0.9 +/- 1.4 versus 6.1 +/- 2.3, 5.2 +/- 2.1, 3.3 +/- 1.9, respectively, P < 0.02). Total cost of treatment was 52 +/- 29 US dollars for the Aquacel Ag-treated group versus 93 +/- 36 US dollars for the silver sulfadiazine-treated group. This study showed that Aquacel Ag increased time to healing, decreased pain symptoms and increased patient convenience because of limiting the frequency of replacement of the dressing at lower total cost. This study confirms the efficacy of Aquacel Ag for the treatment of partial thickness burns at an outpatient clinic.
Aquacel Ag((R)) (ConvaTec, Princeton, NJ, USA) is a new hydrofiber wound dressing consisting of soft non-woven sodium carboxymethylcellulose fibers integrated with ionic silver. It is a moisture-retention dressing, which forms a gel on contact with wound fluid and has antimicrobial properties of ionic silver. We present a current literature review on Aquacel Ag((R)), of both in vitro and in vivo efficacy and clinical applications. In vitro and in vivo studies have demonstrated the wide antimicrobial properties of Aquacel Ag((R)), and additionally demonstrated the cytotoxicity of ionic silver to keratinocytes and fibroblasts that cause delay in wound re-epithelialization. Clinical studies confirmed that Aquacel Ag((R)) is an effective and safe dressing for a variety of wound types, both acute and chronic. Incorporation of ionic silver into the hydrofibers does not cause undue alteration in the performance properties of the base dressing, which continues to provide favorable wound moisture and exudate management. The addition of ionic silver reduces local pain and dressing changes, and provides significant broad-spectrum antimicrobial properties, with no delay in wound healing.
This study established human body surface area (BSA) database and estimation formula based on three-dimensional (3D) scanned data. For each gender, 135 subjects were drawn. The sampling was stratified in five stature heights and three body weights according to a previous survey. The 3D body surface shape was measured using an innovated 3D body scanner and a high resolution hand/foot scanner, the total body surface area (BSA) and segmental body surface area (SBSA) were computed based on the summation of every tiny triangular area of triangular meshes of the scanned surface; and the accuracy of BSA measurement is below 1%. The results of BSA and sixteen SBSAs were tabulated in fifteen strata for the Male, the Female and the Total (two genders combined). The %SBSA data was also used to revise new Lund and Browder Charts. The comparison of BSA shows that the BSA of this study is comparable with the Du Bois and Du Bois' but smaller than that of Tikuisis et al. The difference might be attributed to body size difference between the samples. The comparison of SBSA shows that the differences of SBSA between this study and the Lund and Browder Chart range between 0.00% and 2.30%. A new BSA estimation formula, BSA=71.3989 x H(.7437) x W(.4040), was obtained. An accuracy test showed that this formula has smaller estimation error than that of the Du Bois and Du Bois'; and significantly better than other BSA estimation formulae.
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe adverse drug reactions, characterized by a low incidence but high mortality, initially described as separate entities, but today considered variants of the same pathologic process and differing only for severity. The majority of cases appear to be related to idiosyncratic drug reactions. The drugs most commonly involved are: antibiotics such as sulfonamides, beta-lactam, tetracyclines and quinolones; anticonvulsants such as phenytoin, phenobarbital and carbamazapine; antiretroviral drugs; nonsteroidal anti-inflammatory drugs, allopurinol. There is common agreement to consider TEN as the manifestation of a disregulated immune reaction against epithelial cells. During the first stages of TEN, apoptosis mediates keratinocyte death and the pivotal role of Fas-FasL pathway activation during TEN is undoubted. T cell cytotoxicity, demonstrated during TEN, has been shown to be mediated by the perforin-granzyme pathway. It seems, also, clear that a peculiar cytokine pattern plays an important role in TEN pathogenesis. The cutaneous findings result in an acute macular erythematous rash with bullae. These lesions rapidly exhibit Nikolsky's sign and a separation of large sheets of epidermis from the dermis and a subsequent localised shedding develops rapidly, which can become very extensive. When feasible, admission in burn or intensive care unit, positioning the patients in air-fluidised beds, is universally considered crucial in TEN treatment. The prompt withdrawal of the suspected drug, fluid and electrolyte replacement and topical wound care are the first line of therapy. The use of corticosteroids has been abandoned and the role of immunosuppressants, despite some success, is not well defined and is not considered as a standard. A trial comparing thalidomide versus placebo in TEN patients was suspended because mortality rate increased in the treated group. Infliximab, a chimeric monoclonal antibody to TNF-alpha, has been administered to a patient, in single infusion, with a favourable outcome. Plasmapheresis is reported to lead to some success in TEN treatment, with improvement of clinical conditions and high percentage of survival. Different authors reported good results in terms of decreasing mortality and morbidity or improving clinical conditions of the use of human intravenous immunoglobulins (IVIGs). Regardless, the true utility of this treatment remains controversial. In 2005, the authors (ML and RC), dealing with a number of severe TEN cases, proposed a new protocol based on the combination of these last two techniques reporting their preliminary results in the treatment of severe TEN patients.
Toxic epidermal necrolysis (TEN) is a rare condition with potentially high mortality and involves severe exfoliative disease of the skin and mucous membranes induced by drugs. The reported fatality of TEN varies widely from 20% to 60%. The technique for TEN wound coverage described in this article involves the use of various dressings.
Nine women with histologically confirmed TEN (>30% total body surface area, TBSA) were treated at our burn intensive care unit. All patients received hydrotherapy and wounds were covered with Aquacel Ag and Vaseline gauzes onlay. Following this, elastic cotton bandage was wrapped around the dressing. The dressing was changed and the wound evaluated twice a week. Efficacy was established by the wound achieving>or=95% re-epithelialisation of the study area.
The mean age was 60.1 years (range from 7 to 88 years). The percentage of body surface area affected by epidermal slough ranged from 30% to 85% TBSA, with a mean of 51%. One patient expired due to severe sepsis on day 3. Eight patients achieved over 95% wound healing. All wounds healed well without the need for skin grafting. However, two of them expired on day 14 and day 20 because of pneumonia and retention of carbon dioxide, respectively. The average duration to achieve 95% wound healing was 10.4 days in eight cases (range from 7 to 14 days). No adverse reactions were noted.
Aquacel Ag dressing can be easily removed during hydrotherapy. The wound pain is reduced. By changing the dressing just twice a week, we were able to evaluate the wound directly, decrease the odour and increase the quality of life of the patients. In addition, lower frequency of dressing changes decreases the manpower requirements and is cost effective. Use of Aquacel Ag with Vaseline gauze is a good alternative for the management of TEN wounds.
Silver sulfadiazine cream has an enviable safety record in burn treatment. However, it side effects, exemplified by allergic reactions to its sulfadiazine moiety, silver staining of the treated burn wound, hyperosmolality, methemoglobinemia, and hemolysis due to a congential lack of glucose-6-phospate dehydrogenase, may be missed or misinterpreted. Early post burn leukopenia, once thought to be a side effect of the use of silver sulfadiazine in burn wound therapy, is no longer regarded as such since it has been found to occur with the use of other burn topical agents. Its presence is no longer an indication to discontinue silver sulfadiazine burn wound therapy. Because these side effects are uncommon, any one physician or burn facility usually has limited experience in diagnosing and treating them.
The pathogenetic mechanisms, the clinical aspects, diagnosis, complications, sequelae, prognosis and treatment are discussed.
Toxic epidermal necrolysis (TEN), is an exfoliative dermatological disorder of unknown cause. A patient with TEN loses epidermis in sheet-like fashion, leaving extensive areas of denuded dermis that must be treated like a large, superficial, partial-thickness burn wound. Methods of coverage described in the English literature over the last decade include the use of several dressings such as fresh-frozen or cryopreserved cadaver allograft, porcine xenograft, and amnionic membrane. Successful use of the biosynthetic dressing, Biobrane, has been described after burn injuries and Stevens-Johnson syndrome; however, its use in TENS has not. We present three patients with TEN treated successfully in our burn center over the past 12 months using Biobrane. The patients were men aged 20, 58, and 77 years, with 58% to 95% total body surface area slough. Diagnosis was confirmed by skin biopsy on admission, and drug ingestion was implicated in each instance. Each patient was thoroughly debrided in the operating room shortly after admission, and denuded areas were covered with Biobrane within 24 to 48 hours of admission. Biobrane demonstrated greater than 90% adherence by 48 hours, and no wound sepsis occurred. Each patient demonstrated epithelialization within 9 days. Patients were ambulatory at 72 hours. Corticosteroids and prophylactic antibiotics were avoided. Enteral nutritional support and aggressive septic surveillance was routine. Hospital stay was between 13 and 30 days without mortality. Early use of Biobrane in patients with TEN appears to provide a reasonable means of wound coverage.
36 Key opinion leaders in the field of burn care from countries all over the world participated in a survey on their preferences for ways of treating different types of burns. The article describes the results of the survey and analyses the different treatment preferences.
Toxic epidermal necrolysis (TEN) is an exfoliative skin disorder that may involve a large body surface area and mucosal surfaces. The microscopic changes that occur with this condition are similar to those that occur with superficial dermal burns, such as dermal detachment from the underlying dermis. Complications of TEN are related to the loss of the epithelial skin barrier and include pain, fluid and electrolyte loss, and an increased risk of sepsis. The treatment of a patient with TEN is best accomplished in a burn unit, where expert treatment of these complications can be provided. Medical treatment includes the administration of immunosuppressive therapy and the discontinuation of any previous corticosteroid treatment. Surgical management includes the debridement of necrotic areas. In this article, the surgical management of 8 consecutive patients with TEN who were admitted to the intensive care burn unit at the Hospital Universitario de Getafe in Madrid, Spain, from 1996 to 1998 is described. These patients were treated with extensive early debridement of necrotic skin areas followed by wound coverage with Biobrane (Dow B. Hickam, Inc, Sugarland, Tex), a temporary semisynthetic skin substitute. Skin coverage with this material decreases pain and fluid loss, and it possibly facilitates epithelization and decreases the risk of sepsis, without adverse side effects. This semisynthetic material meets some standards of an ideal skin substitute: it is easy to use, provides several beneficial physiologic effects, and improves patients' comfort. In the 8 cases of patients with TEN that were studied, the use of Biobrane skin substitute for the coverage of massive areas of detached skin was found to be an important aspect of treatment.
The accuracy and variability of burn size calculations using four Lund and Browder charts currently in clinical use and two Rule of Nine's diagrams were evaluated. The study showed that variability in estimation increased with burn size initially, plateaued in large burns and then decreased slightly in extensive burns. The Rule of Nine's technique often overestimates the burn size and is more variable, but can be performed somewhat faster than the Lund and Browder method. More burn experience leads to less variability in burn area chart drawing estimates. Irregularly shaped burns and burns on the trunk and thighs had greater variability than less irregularly shaped burns or burns on more defined anatomical parts of the body.
The mortality of toxic epidermal necrolysis is about 30%. Our purpose was to develop and validate a specific severity-of-illness score for cases of toxic epidermal necrolysis admitted to a specialized unit and to compare it with the Simplified Acute Physiology Score and a burn scoring system. A sample of 165 patients was used to develop the toxic epidermal necrolysis-specific severity-of-illness score and evaluate the other scores, a sample of 75 for validation. Model development used logistic regression equations that were translated into probability of hospital mortality; validation used measures of calibration and discrimination. We identified seven independent risk factors for death and constituted the toxic epidermal necrolysis-specific severity-of-illness score: age above 40 y, malignancy, tachycardia above 120 per min, initial percentage of epidermal detachment above 10%, serum urea above 10 mmol per liter, serum glucose above 14 mmol per liter, and bicarbonate below 20 mmol per liter. For each toxic epidermal necrolysis-specific severity-of-illness score point the odds ratio was 3.45 (confidence interval 2.26-5.25). Probability of death was: P(death) = elogit/1 + elogit with logit = -4.448 + 1.237 (toxic epidermal nec-rolysis-specific severity-of-illness score). Calibration demonstrated excellent agreement between expected (19. 6%) and actual (20%) mortality; discrimination was also excellent with a receiver operating characteristic area of 82%. The Simplified Acute Physiology Score and the burn score were also associated with mortality. The discriminatory powers were poorer (receiver operating characteristic area: 72 and 75%) and calibration of the Simplified Acute Physiology Score indicated a poor agreement between expected (9.1%) and actual (26.7%) mortality. This study demonstrates that the risk of death of toxic epidermal necrolysis patients can be accurately predicted by the toxic epidermal necrolysis-specific severity-of-illness score. The Simplified Acute Physiology Score and burn score appear to be less adequate.
The purpose of this study was to examine burn patients' pain and anxiety experiences during resting conditions and procedures. The relationship of contextual factors and interventions to pain and anxiety were also explored. Procedural pain was significantly higher than resting pain (P = .02); however, there were no significant differences in anxiety between resting conditions and procedures (P = .16). There was a significant difference between burn patients' acceptable level of pain, resting pain, and procedural pain (P = .01). Resting pain was significantly lower than patients' acceptable level of pain (P = < .01). Procedural pain was slightly lower than patients' acceptable level of pain, but these results were not statistically significant (P = .37). Percent of total body surface burned was associated with increased procedural anxiety (P = .022). Family presence correlated with decreased procedural pain (P = .011) and midazolam use (P = .047). Prior experience with the procedure was associated with increased morphine(P = .003) and midazolam use (P = .029). These findings support the multifactorial nature of burn pain and anxiety and provide guidance for practice.
Toxic epidermal necrolysis, a rare and often fatal disease, mimics second degree burns and requires the expertise of an interdisciplinary team approach as used in burn centers. This article explores the diagnosis and acute and long-term treatment approaches. Readers will learn how effective treatment can improve outcomes and maximize recovery from this devastating disease.
Toxic epidermal necrolysis (TEN) is a potentially fatal disorder that involves large areas of skin desquamation. Patients with TEN are often referred to burn centers for expert wound management and comprehensive care. The purpose of this study was to define the presenting characteristics and treatment of TEN before and after admission to regional burn centers and to evaluate the efficacy of burn center treatment for this disorder. A retrospective multicenter chart review was completed for patients admitted with TEN to 15 burn centers from 1995 to 2000. Charts were reviewed for patient characteristics, non-burn hospital and burn center treatment, and outcome. A total of 199 patients were admitted. Patients had a mean age of 47 years, mean 67.7% total body surface area skin slough, and mean Acute Physiology and Chronic Health Evaluation (APACHE II) score of 10. Sixty-four patients died, for a mortality rate of 32%. Mortality increased to 51% for patients transferred to a burn center more than one week after onset of disease. Burn centers and non-burn hospitals differed in their use of enteral nutrition (70 vs 12%, respectively, P < 0.05), prophylactic antibiotics (22 vs 37.9%, P < 0.05), corticosteroid use (22 vs 51%, P < 0.05), and wound management. Age, body surface area involvement, APACHE II score, complications, and parenteral nutrition before transfer correlated with increased mortality. The treatment of TEN differs markedly between burn centers and non-burn centers. Early transport to a burn unit is warranted to improve patient outcome.
Silver products have two key advantages: they are broad-spectrum antibiotics and are not yet associated with drug resistance. This article, the first in a two-part series, describes the main mechanism of action of this metallic element.
The aim of this study was to determine any occupationally relevant allergic contact sensitizations in hand dermatitis in a jeweler. Patch test with European Standard, vehicle, medicaments, and metal series (Finn chambers on Scanpor) was performed. Readings were taken on day 2 and day 4. Allergic positive reaction to colophonium 20% pet and silver nitrate 0.5% aq was detected. The contact sensitivities to silver and colophonium seem to be occupationally relevant in this case.
Drug-induced toxic epidermal necrolysis (TEN) is a life-threatening disease characterized by extensive destruction of the epidermis. It apparently results from the formation of specific toxic drug metabolites by the keratinocytes. The mortality rate which averages 25-30% is mainly due to secondary septicemia, and to ionic and metabolic disturbances following loss of epidermal integrity. Apoptosis is the likely mechanism leading to massive keratinocyte death in TEN. Dysregulations in the tumor necrosis factor-alpha (TNF-alpha) pathway, CD95 system (Fas ligand, CD95L; Fas receptor, CD95R) and calcium homeostasis in the epidermis are involved in this apoptotic process. An active role has also been ascribed to T lymphocytes, macrophages and factor XIIIa-positive dermal dendrocytes. Despite progress, treatment of TEN remains controversial. In the past, systemic glucocorticoids were used in order to target the inflammatory reaction in TEN. However, there was no evidence for improvement of the healing process, while corticosteroids worsened the prognosis by increasing the risk of septicemia. Only a few cases have been treated with other drugs including cyclophosphamide, pentoxyfilline, thalidomide, anti-TNF-alpha antibodies and cyclosporin A. In the recent past, some TEN patients were treated with intravenous human immunoglobulins (IVIG). The rationale for such a treatment was to block the CD95 system on keratinocytes. The early promising clinical results of IVIG treatment in TEN were subsequently challenged. This review compares the effectiveness and drawbacks of the major drugs presently used in TEN treatment. Some future prospects in TEN management are also discussed.
Toxic epidermal necrolysis (TEN) is a rare disorder characterized by extensive epidermal death. Almost all cases appear to be caused by an idiosyncratic drug reaction. Proposed pathogenic mechanisms are conflicting, and the evidence for the benefits of individual treatments is inadequate, and in some cases contradictory. The mortality rate remains high. We review the literature pertaining to the pathogenesis of TEN and drug reactions in general. The rationale for therapeutic interventions, together with reported evidence of efficacy, are considered. We present a composite model of TEN, based on previous work and suggested pathogeneses of TEN, mechanisms of drug reactions and reported cytotoxic lymphocyte (CTL) cytolytic pathways. In this system, TEN, like some other cutaneous drug eruptions, is an HLA class I-restricted, specific drug sensitivity, resulting in clonal expansion of CD8+ CTLs. Cytotoxicity is mediated by CTL granzyme and possibly death receptor (DR) ligand (DR-L), probably Fas ligand (FasL). Particular to TEN, there is then an amplification sequence involving further DR-L expression. FasL is likely to be particularly important but tumour necrosis factor (TNF) may well contribute, via the TNF receptor 1 (TNF-R1) death pathway. Alternatively, we suggest the possibility of upregulation of an antiapoptotic TNF-R1-nuclear factor kappaB pathway, which would proscribe treatments which downregulate this pathway. None of the published data on individual treatment efficacies is sufficiently strong to suggest a definitive single treatment. Currently a multifaceted regimen appears indicated, targeting various likely intermediary mechanisms, including elimination of residual drug, immunosuppression, inhibition of DR pathways, general antiapoptotic strategies, and aggressive supportive care. Particular attention has been directed at avoiding potential conflicts between different treatments and avoiding agents that theoretically might have a net proapoptotic rather than antiapoptotic effect. Nursing on a specialized unit is of paramount importance.
Conflicting recommendations and clinical applications have been given concerning best practices for the management of burn blisters associated with partial-thickness burns. Arguments for the preservation of intact blisters center on the idea of naturally occurring biologic protection whereas the débridment of blisters has been advocated because of the perceived decreases in wound infection and complications. Recurring themes in burn wound management that are considered in this debate include infection, healing, functional and aesthetic outcome, patient comfort, ease of dressing care, and cost efficiency. The management of burn blisters should be supported by evidence across these six categories, should match the expertise of the provider, and should use the available resources in the practice setting. The purpose of this review is combine the findings of a comprehensive review of the published literature with respect to the management of blisters in the partial-thickness burn into a clinical guideline for best practice based on available evidence.
This prospective, randomized study compared protocols of care using either AQUACEL Ag Hydrofiber (ConvaTec, a Bristol-Myers Squibb company, Skillman, NJ) dressing with silver (n = 42) or silver sulfadiazine (n = 42) for up to 21 days in the management of partial-thickness burns covering 5% to 40% body surface area (BSA). AQUACEL Ag dressing was associated with less pain and anxiety during dressing changes, less burning and stinging during wear, fewer dressing changes, less nursing time, and fewer procedural medications. Silver sulfadiazine was associated with greater flexibility and ease of movement. Adverse events, including infection, were comparable between treatment groups. The AQUACEL Ag dressing protocol tended to have lower total treatment costs (Dollars 1040 vs. Dollars 1180) and a greater rate of re-epithelialization (73.8% vs 60.0%), resulting in cost-effectiveness per burn healed of Dollars 1,409.06 for AQUACEL Ag dressing and Dollars 1,967.95 for silver sulfadiazine. A protocol of care with AQUACEL(R) Ag provided clinical and economic benefits compared with silver sulfadiazine in patients with partial-thickness burns.
Silver products have been used for thousands of years for their beneficial effects, often for hygiene and in more recent years as antimicrobials on wounds from burns, trauma, and diabetic ulcers. Silver sulfadiazine creams (Silvazine and Flamazine) are topical ointments that are marketed globally. In recent years, a range of wound dressings with slow-release Ag compounds have been introduced, including Acticoat, Actisorb Silver, Silverlon, and others. While these are generally accepted as useful for control of bacterial infections (and also against fungi and viruses), key issues remain, including importantly the relative efficacy of different silver products for wound and burn uses and the existence of microbes that are resistant to Ag+. These are beneficial products needing further study, although each has drawbacks. The genes (and proteins) involved in bacterial resistance to Ag have been defined and studied in recent years.
Silver compounds have been exploited for their medicinal properties for centuries. At present, silver is reemerging as a viable treatment option for infections encountered in burns, open wounds, and chronic ulcers. The gold standard in topical burn treatment is silver sulfadiazine (Ag-SD), a useful antibacterial agent for burn wound treatment. Recent findings, however, indicate that the compound delays the wound-healing process and that silver may have serious cytotoxic activity on various host cells. The present review aims at examining all available evidence about effects, often contradictory, of silver on wound infection control and on wound healing trying to determine the practical therapeutic balance between antimicrobial activity and cellular toxicity. The ultimate goal remains the choice of a product with a superior profile of infection control over host cell cytotoxicity.
To report a case of toxic epidermal necrolysis (TEN) involving 90% body surface area, successfully treated with a nanocrystalline silver dressing (Acticoat, Smith & Nephew, Largo, FL).
A review of the hospital and acute wound center patient records and the recent English medical literature regarding TEN and nanocrystalline silver dressing.
We found only 1 report of TEN treated with a nanocrystalline silver dressing. The nanocrystalline silver dressing was both effective in preventing wound infection and convenient for treating our patient with TEN.
The use of nanocrystalline silver dressing should be considered for the treatment of TEN.
Unlabelled:
Toxic epidermal necrolysis (TEN) is an unpredictable, life-threatening drug reaction associated with a 30% mortality. Massive keratinocyte apoptosis is the hallmark of TEN. Cytotoxic T lymphocytes appear to be the main effector cells and there is experimental evidence for involvement of both the Fas-Fas ligand and perforin/granzyme pathways. Optimal treatment for these patients remains to be clarified. Discontinuation of the offending drug and prompt referral to a burn unit are generally agreed upon steps. Beyond that, however, considerable controversy exists. Evidence both pro and con exists for the use of IVIG, systemic corticosteroid, and other measures. There is also evidence suggesting that combination therapies may be of value. All the clinical data, however, is anecdotal or based on observational or retrospective studies. Definitive answers are not yet available. Given the rarity of TEN and the large number of patients required for a study to be statistically meaningful, placebo controlled trials are logistically difficult to accomplish. The absence of an animal model further hampers research into this condition. This article reviews recent data concerning clinical presentation, pathogenesis and treatment of TEN.
Learning objectives:
At the conclusion of this learning activity, participants should have acquired a more comprehensive knowledge of our current understanding of the classification, clinical presentation, etiology, pathophysiology, prognosis, and treatment of TEN.
Since their first descriptions in 1922 and 1948, respectively, Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) have become recognized as manifestations--with different severity--of the same disease process along a spectrum of illness. Even today, decades after their description, there is still disagreement about when a particular bullous disease evolves from erythema multiforme to SJS/TEN. There is no disagreement, however, about the potentially life-threatening nature of the disease. Many cases are misdiagnosed, especially in their early stages. In this paper we address our current understanding of this disease spectrum and discuss both accepted and more controversial modes of therapy.
Toxic epidermal necrolysis (TEN) is an uncommon but potentially life-threatening condition that involves sloughing of the skin at the dermoepidermal junction. TEN is a well-recognized syndrome and is part of a range of severe mucocutaneous intolerance reactions, mostly elicited by drugs and/or their metabolites. Reported mortality rates vary widely from 20 to 75%. Several systemic treatment protocols for TEN have been published; however, none has been formally standardized in a randomized controlled trial. The present study documents the current management principles and trends seen in 16 patients admitted with TEN or Stevens-Johnson syndrome over a 5-year period at the Concord Repatriation General Hospital Burns Unit.
Data were collected by retrospective chart review, and parameters included in the study were patient demographics, causative agents, percentage total body surface area and/or mucosal involvement, complications, treatment and outcome. In particular, dressing choice and documented healing of skin lesions were noted.
Sixteen patients were identified, with the beta-lactam antibiotics most commonly implicated as the cause. Complications tended to relate to degree of sepsis and/or mucous membrane involvement. Nanocrsytalline silver dressings, such as Acticoat (Smith & Nephew, Mount Waverley, Victoria, Australia), were used predominantly in more recent cases.
The shift in dressing choice from traditional Vaseline-impregnated gauze coincided with a general trend towards the use of nanocrystalline silver dressings for superficial burns after 2003. The nanocrystalline silver dressings have shown considerable advantage over previously used dressings, with no adverse reactions noted and good healing of the skin lesions for all patients.
We wished to determine whether changing our centre's practice of using Acticoat instead of Silvazine as our first-line burns dressing provided a better standard of care in terms of efficacy, cost and ease of use. A retrospective cohort study was performed examining 328 Silvazine treated patients from January 2000 to June 2001 and 241 Acticoat treated patients from July 2002 to July 2003. During those periods the respective dressings were used exclusively. There was no significant difference in age, %BSA and mechanism of burn between the groups. In the Silvazine group, 25.6% of children required grafting compared to 15.4% in the Acticoat group (p=0.001). When patients requiring grafting were excluded, the time taken for re-epithelialisation in the Acticoat group (14.9 days) was significantly less than that for the Silvazine group (18.3 days), p=0.047. There were more wounds requiring long term scar management in the Silvazine group (32.6%) compared to the Acticoat group (29.5%), however this was not significant. There was only one positive blood culture in each group, indicating that both Silvazine and Acticoat are potent antimicrobial agents. The use of Acticoat as our primary burns dressing has dramatically changed our clinical practice. Inpatients are now only 18% of the total admissions, with the vast majority of patients treated on an outpatient basis. In terms of cost, Acticoat was demonstrated to be less expensive over the treatment period than Silvazine . We have concluded that Acticoat is a safe, cost-effective, efficacious dressing that reduces the time for re-epithelialisation and the requirement for grafting and long term scar management, compared to Silvazine.
Wound dressings containing silver as antimicrobial agents are available in various forms and formulations; however, little is understood concerning their comparative efficacy as antimicrobial agents. Eight commercially available silver-containing dressings, Acticoat 7, Acticoat Moisture Control, Acticoat Absorbent, Silvercel, Aquacel Ag, Contreet F, Urgotol SSD and Actisorb, were tested to determine their comparative antimicrobial effectiveness in vitro and compared against three commercially available topical antimicrobial creams, a non treatment control, and a topical silver-containing antimicrobial gel, Silvasorb. Zone of inhibition and quantitative testing was performed by standard methods using Escherichia coli, Pseudomonas aeruginosa, Streptococcus faecalis and Staphylococcus aureus. Results showed all silver dressings and topical antimicrobials displayed antimicrobial activity. Silver-containing dressings with the highest concentrations of silver exhibited the strongest bacterial inhibitive properties. Concreet F and the Acticoat dressings tended to have greater antimicrobial activity than did the others. Topical antimicrobial creams, including silver sulfadiazine, Sulfamylon and gentamicin sulfate, and the topical antimicrobial gel Silvasorb exhibited superior bacterial inhibition and bactericidal properties, essentially eliminating all bacterial growth at 24 hours. Silver-containing dressings are likely to provide a barrier to and treatment for infection; however, their bactericidal and bacteriostatic properties are inferior to commonly used topical antimicrobial agents.
Toxic epidermal necrolysis is a rare disease with high mortality due to generalised infection, sepsis or lung involvement, and requires discontinuation of all potentially triggering medications and intensive care in a specialised burn centre. Apart from wound care with antiseptics, wound coverage may be achieved with a skin substitute; treatments are compared with regard to infection, protein loss, re-epithelialisation and mortality.
Of 14 people with toxic epidermal necrolysis affecting >30% body surface area, eight received daily dressing changes using Lavasept nd six received wound coverage with Biobrane. Demographic data, SCORTEN score, mortality, visual-analog pain scale, mobilisation, time to re-epithelialisation, serum protein, albumin, C-reactive protein and leukocytes, and body temperature were evaluated in all cases.
Mean age of patients was 68.0+/-14.8 years, mean body surface area affected was 66.4%, median SCORTEN score was three and overall mortality was 36%. In the Biobrane ompared with the Lavasept control) group, mean pain was significantly reduced (2.9 versus 5.5 on the scale, p<0.05), mobilisation was significantly earlier (walking at 3 days versus 7 days, p=0.003), re-epithelialisation was complete in 12.5 days versus 16 days, and at 9 days there was reduced decrease of serum proteins and significantly lower levels of C-reactive protein and white cells (p<0.05).
Early wound coverage with synthetic skin substitute such as Biobrane s beneficial compared with conservative antiseptic wound treatment, but mortality rate is not significantly different.