drug induced exfoliative dermatitis drug induced exfoliative dermatitis

Medicines have been linked to every type of rash, ranging from mild to life-threatening. 2010;37(10):9046. Drug induced exfoliative dermatitis: state of the art CAS Advise of potential risk to a fetus and use of effective contraception. If there is a high suspicion of infection without a documented source of infection, broad range empiric therapy should be started. To avoid the appearance of gastric stress ulcer it is recommended to start a therapy with intravenous proton pump inhibitors. . Jarrett P, et al. Staphylococcal Scalded Skin Syndrome: criteria for Differential Diagnosis from Lyells Syndrome. 2010;163(4):84753. Hence, the apparent increase in cases of exfoliative dermatitis may be related to the introduction of many new drugs. Therefore, the clinician should always consider drugs as a possible cause. Science. Chapter 23. Exfoliative Dermatitis | Fitzpatrick's Dermatology in The site is secure. 1991;97(4):697700. Archivio Istituzionale della Ricerca Unimi, Nayak S, Acharjya B. Gastrointest Endosc. Wu PA, Cowen EW. Br J Clin Pharmacol. A pseudolymphoma reaction with fever, arthralgias, lymphadenopathy, hepatosplenomegaly, anemia and erythroderma may develop as a result of hypersensitivity to dapsone or antiepileptic drugs. doi: 10.1016/j.jaad.2013.05.003. Dermatologic disorders occasionally present as exfoliative dermatitis. Clinical features; Delayed type hypersensitivity; Drug hypersensitivity; Erythema multiforme; Exfoliative dermatitis; Lyells syndrome; Pathogenesis; StevensJohnson syndrome; Therapy; Toxic epidermal necrolysis. Qilu Pharmaceutical Co., Ltd. GEFITINIB- gefitinib tablet, coated PubMed Int Arch Allergy Immunol. Paulmann M, Mockenhaupt M. Severe drug-induced skin reactions: clinical features, diagnosis, etiology, and therapy. Toxic epidermal necrolysis associated with Mycoplasma pneumoniae infection. The administration of a single dose of 5mg/kg was able to stop disease progression in 24h and to induce a complete remission in 614days. J Clin Apher. Also a vesical catheter should be placed to avoid urethral synechiae and to have a precise fluid balance. Exanthematous drug eruptions. Fernando SL. Antitumour necrosis factor-alpha antibodies (infliximab) in the treatment of a patient with toxic epidermal necrolysis. T and NK lymphocytes can produce FasL that eventually binds to target cells. Hospitalization is usually necessary for initial evaluation and treatment. Erythema multiforme StevensJohnson syndrome and toxic epidermal necrolysis. Proc Natl Acad Sci USA. Hepatobiliary: jaundice, hepatitis, including . Lymphocyte transformation test (LTT) performed as described by Pichler and Tilch [77] shows a lower sensitivity in severe DHR compared to less severe DHR [78] but, if available, should be performed within 1week after the onset of skin rash in SJS and TEN [79]. Goulden V, Goodfield MJ. Sequelae of exfoliative dermatitis are not widely reported. Pharmacogenet Genom. Unfortunately, the clinical picture does not contribute to an understanding of the underlying cause. 1995;5(4):2558. Hung S-I, et al. If it is exfoliative dermatitis that's drug induced, it's easy to treat . In EMM their efficacyis demonstrated in controlling the evolution of the disease [106]. 2007;48(5):10158. Patients with underlying skin disorders may respond much more slowly to therapy, but clearing almost always occurs eventually. 2003;21(1):195205. The authors concluded that they couldnt demonstrate corticosteroids efficacy in monotherapy, but the use of steroid alone is not linked to an increased risk of mortality due to infective complications [108, 109]. Dermatitis - Diagnosis and treatment - Mayo Clinic Sekula P, et al. Gout and its comorbidities: implications for therapy. Download Free PDF. Ayangco L, Rogers RS 3rd. Fitzpatricks dermatology in general medicine. Main discriminating factors between EMM, SJS, SJS-TEN, TEN and SSSS is summarized in Table3 [84]. Erythema multiforme and toxic epidermal necrolysis. Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involving skin and usually occurring from days to several weeks after drug exposure. Fritsch PO. Google Scholar. Careers. Analysis for circulating Szary cells may be helpful, but only if the cells are identified in unequivocally large numbers. The induction dosage in EMM is usually 1mg/kg/day that should be maintained until a complete control of the skin is obtained. Two Cases in Adult Patients. Immunol Allergy Clin North Am. A marker for StevensJohnson syndrome: ethnicity matters. 2008;4(4):22431. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): Focus on the Pathophysiological and Diagnostic Role of Viruses. Drugs that have been implicated in the causation of LPP include captopril, cinnarizine, ramipril, simvastatin, PUVA, and antituberculous medications. doi: 10.4065/mcp.2009.0379. All authors read and approved the final manuscript. Allergol Immunopathol (Madr). This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Guidelines for the management of drug-induced liver injury[J]. Gen Dent. Incidence of toxic epidermal necrolysis and StevensJohnson Syndrome in an HIV cohort: an observational, retrospective case series study. CAS Yacoub, MR., Berti, A., Campochiaro, C. et al. Utility of the lymphocyte transformation test in the diagnosis of drug sensitivity: dependence on its timing and the type of drug eruption. Immune-histopathological features allow to distinguish generalized bullous drug eruption from SJS/TEN [36]. Stevens-Johnson syndrome and toxic epidermal necrolysis due to anticonvulsants share certain clinical and laboratory features with drug-induced hypersensitivity syndrome, despite differences in cutaneous presentations. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Eur J Clin Microbiol Infect Dis. J Dermatol. Chemicals and Drugs 61. Polak ME, et al. 2009;182(12):80719. Arch Dermatol. Amphotericin B injection and potassium-depleting agents: When corticosteroids are administered concomitantly with potassium-depleting agents (ie, amphotericin B, diuretics), patients should be observed closely for development of hypokalemia.There have been cases reported in which concomitant . Article Chung WH, Hung SI. See this image and copyright information in PMC. Pichler WJ, Tilch J. Ann Intern Med. Orton PW, et al. In most severe cases the suggested dosage is iv 11.5mg/kg/day. Generalized exfoliative dermatitis, or erythroderma, is a severe inflammation of the entire skin surface. J Am Acad Dermatol. Severe Cutaneous Adverse Reactions: The Pharmacogenomics from Research to Clinical Implementation. 2000;22(5):4137. Moreover, after granulysin depletion, they observed an increase in cell viability. Journal of Pharmaceutical Research and health Care. Some anti-seizure medicines have also been known to cause exfoliative dermatitis. The EuroSCAR-study. Chung W-H, et al. 1983;8(6):76375. Gueudry J, et al. 2002;118(4):72833. Fritsch PO. Each of these physiologic disruptions is potentially life-threatening. This compressed maturation process results in an overall greater loss of epidermal material, which is manifested clinically as severe scaling and shedding. PubMed The balance of fluids and electrolytes should be closely monitored, since dehydration or hypervolemia can be problems. Pemphigus vulgaris, paraneoplastic pemphigus, bullous pemphigoid and linear IgA dermatosis have to be considered. Arch Dermatol. Mockenhaupt M, et al. Drug-induced Exfoliative Dermatitis & Eosinophils Increased: Causes 2. Its also characterized by a cell-poor infiltrate, where macrophages and dendrocytes with a strong TNF- immunoreactivity predominate [6, 50]. Roujeau JC, et al. 2013;69(4):37583. It is a reaction pattern and cutaneous manifestation of a myriad of underlying ailments, including psoriasis and eczema, or a reaction to the consumption of . In serious cases invasive ventilation can be necessary for ARDS. Google Scholar. A case of anti-BP230 antibody-positive dyshidrosiform bullous pemphigoid secondary to dipeptidyl peptidase-4 inhibitor in a 65-year-old Filipino female StevensJohnson syndrome and toxic epidermal necrolysis: assessment of medication risks with emphasis on recently marketed drugs. 2023 BioMed Central Ltd unless otherwise stated. Infliximab: chimeric IgG monoclonal anti-TNF- antibody. Systemic corticosteroids: These are the most common used drugs because of their known anti-inflammatory and immunosuppressive effect through the inhibition of activated cytotoxic T-cells and the production of cytokines. The authors concluded for a potential beneficial effect of Cys A and a possible improvement in survival compared to IVIG. Partial to full thickness epidermal necrosis, intraepidermal vesiculation or subepidermal blisters, due to spongiosis and to the cellular damage of the basal layer of the epidermis, can be present in the advanced disease [49] Occasionally, severe papillary edema is also present [20]. Fitzpatricks dermatology in general medicine. 2010;2(3):18994. Allergic rhinitis and atopic dermatitis. Medical search. Web Toxic epidermal necrolysis: Part I Introduction, history, classification, clinical features, systemic manifestations, etiology, and immunopathogenesis. Paraneoplastic pemphigus is associated with neoplasms, most commonly of lymphoid tissue, but also Waldenstrms macroglobulinemia, sarcomas, thymomas and Castlemans disease. Dupixent DUPILUMAB 200 mg/1.14mL sanofi-aventis U.S. LLC Their occurrence can be prevented by avoiding drug over-prescription and drug associations that interfere with the metabolism of the most frequent triggers [118]. In contrast with DRESS, eosinophilia and atypical lymphocytes are not described in patients with SJS or TEN. Gonzalez-Delgado P, et al. Even patients with clear histories of preexisting dermatoses tend to have biopsies that are not diagnostic when they present with erythroderma.2, Laboratory evaluation of patients with erythroderma is generally not very helpful in determining a specific diagnosis. Increased peripheral blood flow can result in high-output cardiac failure. Four cases are described, two of which were due to phenindione sensitivity. It is a clinical manifestation and usually associated with various underlying cutaneous disorders, drug induced reactions and malignancies. The lymphocyte transformation test in the diagnosis of drug hypersensitivity. 2005;94(4):41923. 1996;135(2):3056. 2013;69(2):173174. -, Schwartz RA, McDonough PH, Lee BW. Etoricoxib-induced toxic epidermal necrolysis: successful treatment with infliximab. EMM is a clinically severe, potentially life-threatening, extensive sloughing of epidermis, generally involving mucosal tissue. In EM a lymphocytic infiltrate (CD8+ and macrophages), associated with vacuolar changes and dyskeratosis of basal keratinocytes, is found along the dermo-epidermal junction, while there is a moderate lymphocytic infiltrate around the superficial vascular plexus [20]. 1991;127(6):8318. Article Terms and Conditions, Applications of Immunopharmacogenomics: Predicting, Preventing, and Understanding Immune-Mediated Adverse Drug Reactions. It is necessary to obtain as soon as possible a central venous access and to start a continuous monitoring of vital signs. A systematic review of treatment of drug-induced StevensJohnson syndrome and toxic epidermal necrolysis in children. 2012;51(8):889902. Erythema multiforme and toxic epidermal necrolysis. MRY, MGS, EN and GC designed the study, selected scientifically relevant information, wrote and revised the manuscript. journal.pds.org.ph The authors wish to thank Dr. Gary White for the picture of EM showed in Fig. Burns. -. In conclusion we suggest that therapy with cyclosporine is valuable option with a dosage of 35mg/kg oral or iv for 7days. Br J Dermatol. Google Scholar. Sokumbi O, Wetter DA. The approach to treatment should include discontinuation of any potentially causative medications and a search for any underlying malignancy. Federal government websites often end in .gov or .mil. Genotyping is recommended in specific high-risk ethnic groups (e.g. Other cases are ultimately classifiable as another dermatosis. Ann Burns Fire. In more severe cases antiviral therapies should be given together with intravenous immunoglobulins [93]. 543557. Infectious agents are the major cause of EM, in around 90% of cases, especially for EM minor and in children. Erythroderma (Exfoliative dermatitis) - Dermatology Advisor Schneck J, et al. PubMed Erythema multiforme and toxic epidermal necrolysis: a comparative study. Comprehensive survival analysis of a cohort of patients with StevensJohnson syndrome and toxic epidermal necrolysis. Am J Dermatopathol. Ethambutol Induced Exfoliative Dermatitis - academia.edu Drug induced exfoliative dermatitis: state of the art, https://doi.org/10.1186/s12948-016-0045-0, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/. Exfoliative dermatitis, including Stevens-Johnson syndrome, drug rash with eosinophilia and systemic symptoms, and toxic epidermal necrolysis, has occurred with anti-PD-1/PD-L1 treatments. Chang CC, et al. Skin conditions. Grieb G, et al. Plasmapheresis may have a role in the treatment of ED because it removes Fas-L [96], other cytokines known to be implied in the pathogenesis (IL-6, IL-8, TNF-) [97, 98]. 2014;70(3):53948. [113] retrospectively compared mortality in 64 patients with ED treated either with iv or oral Cys A (35mg/kg) or IVIG (25g/Kg). and transmitted securely. Contact Dermatitis. Heat loss is another major concern that accompanies a defective skin barrier in patients with exfoliative dermatitis. A significant number of these patients eventually progress to cutaneous T-cell lymphoma.8, Clinically, the first stage of exfoliative dermatitis is erythema, often beginning as single or multiple pruritic patches, involving especially the head, trunk and genital region. Cutaneous drug eruptions are one of the most common types of adverse reaction to medications, with an overall incidence of 23% in hospitalized patients [1]. Sassolas B, et al. They usually have fever, are dyspneic and cannot physiologically feed. Erythroderma - Wikipedia AB, CC, ET, GAR, AN, EDL, PF performed a critical revision on the current literature about the described topic, wrote and revised the manuscript. 2023 Jan 30;11(2):346. doi: 10.3390/microorganisms11020346. Albeit the lack of epidemiologic data regarding EM, its reported prevalence is less than 1% [710]. 00 Comments Please sign inor registerto post comments. Both hyperthermia and hypothermia are reported. Nat Med. Consultation with an oncologist who is well-versed in treatment of cutaneous T-cell lymphoma is advisable once the disease progresses to the tumor stage. Morel E, et al. [3] The causes and their frequencies are as follows: Idiopathic - 30% Drug allergy - 28% Seborrheic dermatitis - 2% Contact dermatitis - 3% Atopic dermatitis - 10% Lymphoma and leukemia - 14% Psoriasis - 8% Treatment [ edit] Exp Dermatol. Ko TM, et al. (in Chinese) . Antipyretic therapy. Allergol Int. Pemphigus vulgaris usually starts in the oral mucosa followed by blistering of the skin, which is often painful. Mittmann N, et al. Recurrent erythema multiforme: clinical characteristics, etiologic associations, and treatment in a series of 48 patients at Mayo Clinic, 2000 to 2007. . Drug induced exfoliative dermatitis: State of the art - ResearchGate One of the most common malignancies associated with exfoliative dermatitis is cutaneous T-cell lymphoma, which may not manifest for months or even years after the onset of the skin condition. 2011;20(5):103441. Springer Nature. Once ED has occurred, it has to be managed in the adequate setting with a multidisciplinary approach, and every effort has to be made to identify and avoid the trigger and to prevent infectious and non-infectious complications. Skin eruptions caused by CBZ occur in 24% of the patients on this therapy and include pruritic and erythematous rashes, urticaria, photosensitivity reactions, alterations in skin pigmentation, exfoliative dermatitis, and toxic epidermal necrolysis View on Wiley ncbi.nlm.nih.gov Save to Library Create Alert Cite 12 Citations Citation Type 2008;53(1):28. TNF- has a dual role: interacts with TNF-R1 activating Fas pathway and activates NF-B leading to cell survival. Cyclosporine A (Cys A): Cys A works through the inhibition of calcineurin, that is fundamental for cytotoxic T lymphocytes activation. Orphanet J Rare Dis. Gastrointestinal: pancreatitis, glossitis, dyspepsia. Clin Exp Dermatol. Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involving skin and usually occurring from days to several weeks after drug exposure. 2, and described below. EMM is characterizes by target lesions, circular lesions of 1-2cm of diameter, that are defined as typical or atypical that tends to blister. Article A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. (5.7, 8.1, 8.3) ADVERSE REACTIONS The most commonly reported adverse drug reactions (ADRs), reported in more than 20% of the patients and greater than placebo were skin reactions and diarrhea . Huang SH, et al. Although the final result of this dual interaction is still under investigation, it seems that the combination of TNF-, IFN- (also present in TEN patients) and the activation of other death receptors such as TWEAK can lead to apoptosis of keratinocytes [44]. Hypothermia can result in ventricular flutter, decreased heart rate and hypotension. c. Amyloidosis. 2002;65(9):186170. The dermis shows an inflammatory infiltrate characterized by a high-density lichenoid infiltrate rich in T cells (CD4+ more than CD8+) with macrophages, few neutrophils and occasional eosinophils; the latter especially seen in cases of DHR [5, 50]. Smith SD, et al. 1996;134(4):7104. Szary syndrome, the leukemic variant of mycosis fungoides, is also associated with exfoliative dermatitis. Four main pathways have been found to play important roles in the pathogenesis of keratinocyte death: (1) Fas-FasL interaction, (2) Perforin/granzyme B pathway, (3) Granulysin and (4) Tumor necrosis factor (TNF-) [26]. See permissionsforcopyrightquestions and/or permission requests. Palynziq PEGVALIASE 20 mg/mL BioMarin Pharmaceutical Inc. In conclusion, therapy wth IVIG should be started within the first 5days and an high-dosage regimen should be preferred (2.54g/kg for adults and 0.251.5g/kg in children divided in 35days). 1). Erythema multiforme (photo reproduced with permission of Gary White, MD): typical target lesions (white arrows) together with atypical two-zoned lesions (black arrows). Exfoliative Dermatitis: Symptoms, Causes, and Treatment - WebMD Drug induced exfoliative dermatitis - yxw_88 - | Bickle K, Roark TR, Hsu S. Autoimmune bullous dermatoses: a review. J Am Acad Dermatol. Generalized bullous fixed drug eruption is distinct from StevensJohnson syndrome/toxic epidermal necrolysis by immunohistopathological features. Corticosteroids could also reduce the amount of keratinocytes apoptosis and the activation of caspases [105]. N Engl J Med. Here we provide a systematic review on frequency, risk factors, pathogenesis, clinical features and management of patients with drug induced ED. It is also recommended to void larger vesicles with a syringe. 2012;66(3):1906. PubMed Read this article to find out all its symptoms, causes and treatments. (adult rickets), anticonvulsant-induced rickets and osteomalacia, osteoporosis, renal osteodystrophy . By using this website, you agree to our TEN is also known as Lyell syndrome, since it was first described by Alan Lyell in 1956 [2, 60]. MalaCards based summary: Exfoliative Dermatitis is related to holocarboxylase synthetase deficiency and dermatitis, and has symptoms including exanthema An important gene associated with Exfoliative Dermatitis is SPINK5 (Serine Peptidase Inhibitor Kazal Type 5). Schopf E, et al. The drug level peaks after 1- 4 h in plasma after ingestion with 95% protein binding. Please enable it to take advantage of the complete set of features! 2022 May;35(5):e15416. 2012;166(2):32230. Carbamazepine and phenytoin induced StevensJohnson syndrome is associated with HLA-B* 1502 allele in Thai population. These molecules may play a role in amplifying the immune response and in increasing the release of other toxic metabolites from inflammatory cells [48]. Exfoliative dermatitis, also known as erythroderma, is an uncommon but serious skin disorder that family physicians must be able to recognize and treat appropriately. b. Atopic dermatitis. 2010;125(3):70310. 1998;37(7):5203. In patients with SJS/TEN increased serum levels of retinoid acid have been found. Shared and restricted T-cell receptor use is crucial for carbamazepine-induced Stevens-Johnson syndrome. Systemic and potentially life-threatening complications include fluid and electrolyte imbalance, thermoregulatory disturbance, fever, tachycardia, high-output failure, hypoalbuminemia, and septicemia. Before Del Pozzo-Magana BR, et al. Insidious development of the erythroderma, progressive debilitation of the patient, absence of previous skin disease and resistance to standard therapy are features that may suggest an underlying malignancy.6,11, Erythroderma is also associated with disorders that cannot easily be classified into groups. In vitro diagnostic assays are effective during the acute phase of delayed-type drug hypersensitivity reactions. Medication use and the risk of StevensJohnson syndrome or toxic epidermal necrolysis. 2016;2:14. J Allergy Clin Immunol. Bastuji-Garin S, et al. Clinical Presentations of Severe Cutaneous Drug Reactions in HIV Pharmacogenomics J. Paradisi A, et al. asiatic) before starting therapies with possible triggers (e.g. Hospitalization and dermatologic consultation are indicated in most cases to ensure that all of the necessary cutaneous, laboratory and radiologic investigations and monitoring are performed. PTs have to be performed at least 6months after the recovery of the reaction, and show a variable sensitivity considering the implied drug, being higher for beta-lactam, glycopeptide antibiotics, carbamazepine, lamotrigine, proton pump inhibitors, tetrazepam, trimethoprimsulfametoxazole, pseudoephedrine and ramipril [7376]. 2004;59(8):80920. A correlation between increased levels of perforin/granzyme B and the severity of TEN was also described [38]. 2004;114(5):120915. Energy requirements of pediatric patients with StevensJohnson syndrome and toxic epidermal necrolysis. EDs are serious and potentially fatal conditions. 2009;29(3):51735. 2013;133(5):1197204. 5% silver nitrate compresses have antiseptic properties. The most common causes of exfoliative dermatitis are best remembered by the mnemonic device ID-SCALP. Google Scholar. oboda J, Dudzik A, Chomyszyn-Gajewska M. Ramirez GA, Ripa M, Burastero S, Benanti G, Bagnasco D, Nannipieri S, Monardo R, Ponta G, Asperti C, Cilona MB, Castagna A, Dagna L, Yacoub MR. Microorganisms. Beneficial effect of plasma exchange in the treatment of toxic epidermal necrolysis: a series of four cases. Takahashi R, et al. Delayed reactions to drugs show levels of perforin, granzyme B, and Fas-L to be related to disease severity. It recommended to used G-CSF in patients with febrile neutropenia [94, 95]. Google Scholar. J Am Acad Dermatol. New York: McGraw-Hill; 2003. p. 54357. Department of Allergy and Clinical Immunology, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy, Mona-Rita Yacoub,Maria Grazia Sabbadini&Giselda Colombo, Vita-Salute San Raffaele University, Milan, Italy, Mona-Rita Yacoub,Alvise Berti,Corrado Campochiaro,Enrico Tombetti,Giuseppe Alvise Ramirez,Maria Grazia Sabbadini&Giselda Colombo, Section of Allergy and Clinical Immunology, Dept. Fischer M, et al. Supportive and specific care includes both local and systemic measures, as represented in Fig. Clinical, etiologic, and histopathologic features of StevensJohnson syndrome during an 8-year period at Mayo Clinic. Arch Dermatol. Barbaud A, et al. Systemic derangements may occur with exfoliative. Downey A, et al. J Dermatol Sci. Abe R, et al. National Library of Medicine Erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. No uniformity of opinion exists concerning the best treatment for cutaneous T-cell lymphoma. Erythema multiforme (EM), StevensJohnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. The .gov means its official. Hydration and hemodynamic balance. These patches tend to spread until, after a matter of days or weeks, most of the skin surface is covered with an erythematous, pruritic eruption. Blood counts and bone marrow studies may reveal an underlying leukemia. Erythroderma in adults - UpToDate 2012;66(6):e22936. Ann Intern Med. Copyright 2023 American Academy of Family Physicians. A multicentre study to determine the value and safety of drug patch tests for the three main classes of severe cutaneous adverse drug reactions. New York: McGraw-Hill; 2003. p. 585600. 2015;64(3):2779. Mediterr J Hematol Infect Dis. Kaffenberger BH, Rosenbach M. Toxic epidermal necrolysis and early transfer to a regional burn unit: is it time to reevaluate what we teach? It should be used only in case of a documented positivity of cultural samples.