Etanercept as a Treatment for Toxic Epidermal Necrolysis

A single subcutaneous injection of a TNF inhibitor effectively treated moderate to severe TEN.

Toxic epidermal necrolysis (TEN) is a serious skin condition with a mortality rate of approximately 30%. Management includes removal of the inciting agent (withdrawal of offending drug, antimicrobial therapy for infectious agents, etc.) and supportive care. Many patients also receive systemic steroids, cyclosporine, or IVIg, aimed at improving skin and mucosal lesions. These authors report the results of treatment with the tumor necrosis factor (TNF) inhibitor etanercept.

A TEN diagnosis was given if the patient had blisters and erosions involving >30% of body surface area. In all 10 cases, a drug or phytotherapy product was the suspected cause. Several patients had mucosal, ocular, or genital involvement. Severity was quantified using the SCORe of Toxic Epidermal Necrosis (SCORTEN) scale; three patients had severe disease and none had mild disease. All patients were provided supportive therapy and received a single dose of etanercept (50 mg subcutaneously) within 6 hours of hospitalization. There were no deaths despite an expected death rate of 30%, based on the SCORTEN scores. Complete cures occurred in all 10 patients, with no adverse effects or complications attributable to etanercept. The median time to healing was 8.5 days (range 7–20 days).

Comment

Previous case reports described an association between TNF inhibitors and reduced disease severity and healing of skin lesions in toxic epidermal necrolysis. However, this is the largest published series of TEN patients treated with a TNF inhibitor. Unfortunately, a comparison group was not included. However, these findings are impressive and could form the basis for larger clinical trials of efficacy. Until such studies are conducted, it may be reasonable to consider etanercept or other TNF inhibitors as a treatment for TEN.

Reviewing Author

Craig A. Elmets, MD

Disclosures

Consultant / Advisory board Astellas Pharmaceuticals

EquityVaxin

Grant / Research support NIH; NIH/NCI; Veteran’s Administration; Ferndale Laboratories; Kyowa Hakko Kirin Pharma, Inc.

Editorial boards Cancer Prevention Research; Photodermatology, Photoimmunology, & Photomedicine; UpToDate; eMedicine; Journal of Dermatological Sciences; JAMA Dermatology

Leadership positions in professional societies American Academy of Dermatology (Vice Chair, Committee on Science and Research); Photomedicine Society (Board of Directors)