Treatment And Prognosis for Stevens-Johnson Syndrome

Early diagnosis and recognition with prompt withdrawal of all suspected potential causative drugs are essential for a favorable outcome. Morbidity and mortality decrease if the culprit drug is withdrawn no later than the day when blisters or erosions first occurred. No difference was seen for drugs with long half-lives. The patient must be transferred to an intensive care unit or a burn center. Rapid referral reduces risk of infection, mortality rate and period of hospitalization. Supportive care is the mainstay of treatment. Intervention should include intravenous fluid and electrolyte replacement, environmental temperature control, careful and aseptic handling, early initiation of enteral nutrition by nasogastric tube and pain and anxiety control. Many remedies have been proposed for topical care. Silver-sulfadiazine (silverol) should be avoided because it contains sulfa which is one of the culprit drugs capable of inducing SJS-TEN.

Systemic Corticosteroids. Systemic steroid therapy has been the accepted treatment for SJS-TEN for years. It is believed to suppress the intensity and the extension of the necrolytic process in the skin as well as in internal organs.

Conversely, the use of steroids has also almost become a contraindicated mode of therapy. They were regarded as being hazardous, owing to reports of iatrogenic decrease of host resistance, increase of morbidity and complications, prolonged recovery and reduced survival, following their use.

Parallel to the change in regard to steroid treatment in SJS-TEN, the management of this severe disease was shifted to specialized burn centers and was taken over by nondermatologists, mostly surgeons, who sometimes erroneously regarded SJS-TEN and burns as similar entities. However, in terms of etiology and pathogenesis, a burn is a one-time acute event that affects the skin from the outside, whereas SJS-TEN is a more complex, probably immune (T lymphocyte)-mediated process that reaches the skin from within. The disease process continues to progress over a period of several days after first appearance.

Today, in the absence of clinical control trials, most authors believe that systemic steroids are of unproven benefit in early forms of and are clearly harmful in advanced SJS-TEN.

Intravenous Immunoglobulin. As mentioned previously, the results of IVIg treatment are not uniform in all reports. It should be avoided in patients with renal failure, as increased mortality has been observed. Thus, currently intravenous immune globulin is not considered part of the standard of care for TEN.

In conclusion, optimal treatment for the SJS-TEN spectrum remains to be clarified. To date, no specific treatment has been proven to be beneficial for SJS-TEN. The best management is early recognition, prompt withdrawal of causative drugs and supportive care.

Prognosis
In order to rank severity and predict prognosis in TEN patients, the severity-of-illness score (SCORTEN), was developed. The score is a mathematical tool consisting of the sum of seven clinical variables (age, history of malignancy, heart rate, initial epidermal detachment, admission blood urea nitrogen, glucose levels and serum bicarbonate) as prognostic factors.

The SJS-TEN spectrum is an acute illness with potentially life-threatening complications. Reported mortality rates are 5% with SJS, 10-15% with overlap forms and 30-35% with TEN. Most deaths in patients with TEN are a result of sepsis-induced organ failure.

TEN might also result in late complications, such as transitory hyper- and/or hypopigmentation, scarring primarily due to pressure or secondary infections, alopecia, anonychia and sicca-like syndrome. Phimosis and vaginal synechiae may also be present. Ocular sequelae affecting up to 40% of the survivors may cause corneal lesions, which may result in severe impairment of vision. Therefore, intensive ophthalmologic follow-up and treatment is mandatory in patients with the SJS-TEN spectrum.

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Treatment for Acna

If you haven't been able to control your acne adequately, you may want to consult a primary-care physician or dermatologist. The goal of treatment should be the prevention of scarring (not a flawless complexion) so that after the condition spontaneously resolves there is no lasting sign of the affliction. Here are some of the options available:

• Topical (externally applied) antibiotics and antibacterials: These include erythromycin (E-Mycin, Eryc, Ery-Tab, PCE, Pediazole, Ilosone),clindamycin (BenzaClin, Duac), sulfacetamide (Klaron), and azelaic acid(Azelex or Finacea).
• Retinoids: Retin-A (tretinoin) has been around for years, and preparations have become milder and gentler while still maintaining its effectiveness. Newer retinoids include adapalene (Differin) and tazarotene (Tazorac). These medications are especially helpful for unclogging pores. Side effects may include irritation and a mild increase in sensitivity to the sun. With proper sun protection, however, they can be used even during sunny periods. In December 2008, the U.S. FDA approved the combination medication known as Epiduo gel, which contains the retinoid adapalene along with the antibacterial cleanser benzoyl peroxide. This once-daily prescription treatment was approved for use in patients 12 years of age and older.
• Oral antibiotics: Doctors may start treatment with tetracycline(Sumycin) or one of the related "cyclines," such as doxycycline(Vibramycin, Oracea, Adoxa, Atridox and others) and minocycline(Dynacin, Minocin). Other oral antibiotics that are useful for treating acne are cefadroxil (Duricef), amoxicillin (Amoxil, DisperMox, Trimox), and the sulfa drugs.
• Problems with these drugs can include allergic reactions (especially sulfa), gastrointestinal upset, and increased sun sensitivity. Doxycycline, in particular, is generally safe but can sometime cause esophagitis (irritation of the esophagus, producing discomfort when swallowing) and an increased tendency to sunburn.
• Despite many people's concerns about using oral antibiotics for several months or longer, such use does not "weaken the immune system" and make them more susceptible to infections or unable to use other antibiotics when necessary.
• Recently published reports that long-term antibiotic use may increase the risk of breast cancer will require further study, but at present they are not substantiated. In general, doctors prescribe oral antibiotic therapy for acne only when necessary and for as short a time as possible.
• Oral contraceptives: Oral contraceptives, which are low in estrogen to promote safety, have little effect on acne one way or the other. Some contraceptive pills have been to shown to have modest effectiveness in treating acne. Those FDA approved for treating acne are Estrostep,Ortho Tri-Cyclen, and Yaz. Most dermatologists work together with primary physicians or gynecologists when recommending these medications.

• Spironolactone (Aldactone): This drug blocks androgen (hormone) receptors. It can cause breast tenderness, menstrual irregularities, and increased potassium levels in the bloodstream. It can help some women with resistant acne, however, and is generally well-tolerated in the young women who need it.

• Cortisone injections: To make large pimples and cysts flatten out fast, doctors inject them with a form of cortisone.

• Isotretinoin: (Accutane was the original brand name; there are now several generic versions in common use, including Sotret, Claravis, and Amnesteem.) Isotretinoin is an excellent treatment for severe, resistant acne and has been used on millions of patients since it was introduced in Europe in 1971 and in the U.S. in 1982. It should be used for people with severe acne, chiefly of the cystic variety, which has been unresponsive to conventional therapies like those listed above. The drug has many potential serious side effects and requires a number of unique controls before it is prescribed. This means that isotretinoin is not a good choice for people whose acne is not that bad but who are frustrated and want "something that will knock acne out once and for all."
• Used properly, isotretinoin is safe and produces few side effects beyond dry lips and occasional muscle aches. This drug is prescribed for five to six months. Fasting blood tests are monitored monthly to check liver function and the level of triglycerides, substances related to cholesterol, which often rise a bit during treatment, but rarely to the point where treatment has to be modified or stopped.
• Even though isotretinoin does not remain in the body after therapy is stopped, improvement is often long-lasting. It is safe to take two or three courses of the drug if unresponsive acne makes a comeback. It is, however, best to wait at least several months and to try other methods before using isotretinoin again.
• Isotretinoin has a high risk of inducing birth defects if taken by pregnant women. Women of childbearing age who take isotretinoin need two negative pregnancy tests (blood or urine) before starting the drug, monthly tests while they take it, and another after they are done. Those who are sexually active must use two forms of contraception, one of which is usually the oral contraceptive pill. Isotretinoin leaves the body completely when treatment is done; women must be sure to avoid pregnancy for one month after therapy is stopped. There is, however, no risk to childbearing after that time.
• Other concerns include inflammatory bowel disease and the risk of depression and suicide in patients taking isotretinoin. Government oversight has resulted in a highly publicized and very burdensome national registration system for those taking the drug. This has reinforced concerns in many patients and their families have that isotretinoin is dangerous. In fact, large-scale studies so far have shown no convincing evidence of increased risk for those taking isotretinoin compared with the general population. It is important for those taking this drug to report changes in mood or bowel habits (or any other symptoms) to their doctors. Even patients who are being treated for depression are not barred from taking isotretinoin, whose striking success often improves the mood and outlook of patients with severe disease.
• Laser treatments: Recent years have brought reports of success in treating acne using lasers and similar devices, alone or in conjunction with photosensitizing dyes. It appears that these treatments are safe and can be effective, but it is not clear that their success is lasting. At this point, laser treatment of acne is best thought of as an adjunct to conventional therapy, rather than as a substitute.
• Chemical peels: Whether the superficial peels (like glycolic acid) performed by aestheticians or deeper ones performed in the doctor's office, chemical peels are of modest, supportive benefit only, and in general, they do not substitute for regular therapy.
• Treatment of acne scars: For those patients whose acne has gone away but left them with permanent scarring, several options are available. These include surgical procedures to elevate deep, depressed acne scars and laser resurfacing to smooth out shallow acne scars. Newer forms of laser resurfacing ("fractional resurfacing") are less invasive and heal faster than older methods, although results are less complete and they may need to be repeated three or more times. These treatments can help, but they are never completely successful at eliminating acne scars.

What are other things you can do for acne?

• Cosmetics: Don't be afraid to hide blemishes with flesh-tinted coverups or even foundation, as long at it is water-based (which makes it noncomedogenic). There are many quality products available.
• Facials: While not absolutely essential, steaming and "deep-cleaning" pores is useful, both alone and in addition to medical treatment, especially for people with "whiteheads" or "blackheads."Having these pores unclogged by a professional also reduces the temptation to do it yourself.
• Pore strips: Pharmacies now carry, under a variety of brand names, strips which you put on your nose, forehead, chin, etc., to "pull out" oil from your pores. These are, in effect, a do-it-yourself facial. They are inexpensive, safe, and work reasonably well if used properly.
• Toothpaste? One popular home remedy is to put toothpaste on zits. There is no medical basis for this. Ditto for vinegar.

What is a good basic skin regimen?

These are all good basic skin regimens that may help with the acne battle:

1. Cleanse twice daily with a 5% benzoyl peroxide wash. An alternative for those who are allergic to benzoyl peroxide is 2% salicylic acid.
2. Apply a gel or cream containing 5% benzoyl peroxide; an alternative is sulfur or resorcinol.
3. At night, apply a spot cream containing sulfur to the affected areas.
4. Use a light skin moisturizer and water-based oil-free makeup.

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