Toxic epidermal necrolysis (TEN) is a life-threatening disease, the pathogenesis of which remains largely unknown. We describe a 23-year-old woman under treatment with clobazam who developed lesions of TEN In light-exposed areas. Patch and photopatch tests with clobazam were negative. The cellular phenotype and cytokines were studied in blister fluid. The cellular infiltrate was composed mainly of T lymphocytes with a predominant cyloloxic phenotype. Tbere was an increase in the level of tumour necrosis factor (TNI')-rv in blister fluid compared with the control (a patient with bullous pemphigoid).'iOxic epidermal necrolysis (TEN) or I.yell's syndrome is a rare but serious disease caused by necrosis of the epidermis, which gradually acqtiires a scalded appearance. The incidence of TEN is low. there being some 10 cases per million people eacb year and. although its origin is sometimes unknown, in most patients it is ihought to be a reaction triggered by drugs, mainly sulphonamides. anticonvulsants and non-steroidal anti-inllammatorics.' The pathogenesis of TEN is unknown, although it is well accepted that the mechanism hy which these lesions are produced is through a cell-mediated reaction. Occasionally, circulating immune complexes have been ibtind. We present a case of TEN in photo-exposed areas in a patient who was being treated with clobazam. Case reportA 2 5-year-i)ld woman had no relevant personal or iamiiy history except for a patch of alopecia areata on the scalp, for which she had been treated with 20mg/ day clohazani over the previous 14 days. She presented at ibc emergency unil with a pruriginous and erythematous eruption, located mainly in the facial region, on the thorax, back and limbs, which had appeared some 2 days previously. 3(ih after sun exposure on the beach. Examination revealed extensive erythematous areas with flaccid bullae and erosions, which were confltient in the aibrementioned areas, and which were absent in the areas covered by the swimsuit (Fig. 1). Nikolsky's Correspondence: Dr P.Redondo, Department of Dermatology. Hiiiversily Clinic ofNavarra, PO tiox 192. 3il)Sl}. Pamplona, Spain. sign was positive. She had involvement of the oral and genital mucosae. and had bilateral coniunelival injection. As there was clinical suspicion of Slevens-Jt)hnson syndrome or TEN. a skin biopsy was performed. This confirmed Ibe diagnosis of TEN. Clobazam therapy was stopped. Pentoxifylline (9()()mg/day)^ and a prophylactic systemic antimicrobial were administered, and supportive measures were started. The erythema progressed, with denudation over the face. neck, upper third of the torso and limbs, without affecting the non-exposed areas of the breasts, abdomen, pubis and buttocks.Within 36 b. Ihe progression had stopped, and the erythema gradually abated. Epithelialization of the denuded areas was largely completed 10 days after therapy with pentoxifylline was started. The patient was discharged from hospital 20 days after admission. The morphological appearance, the extent of involvement ( 3()-40'/{i...
In comparison with other studies, we have found a very low incidence of posttreatment erythema and edema. On the other hand, the incidence of second-degree burns is somewhat higher. This might be due to the fact that in other studies higher energy settings have been used but without overlapping pulses. Monopolar radiofrequency is a safe method of treating the skin of the face and neck, and it should be done at moderated energy settings with no immediate overlapping in order to avoid overheating and undesirable side effects.
CD24 or Nectadrin is a cell surface glycoprotein expressed in pre-B lymphocytes, T lymphocytes, neurons, muscle cells and carcinoma cells. Its function is not completely known, but it has been suggested that it is involved in cell adhesion and signalling. CD24 has recently been identified as the human molecule homologous to the murine heat-stable antigen (HSA). HSA is expressed by murine keratinocytes and delivers costimulatory signals in T-cell activation. Long-term cultures of normal human keratinocytes (HKC) were obtained from skin of human female breast sections and either left untreated or were treated with phorbol-12-myristate-13-acetate (PMA) at 10-100 ng/ml, calcium 0.5-2 mM or IFN-gamma 100-1000 U/ml, for 24-48 h. Using RT-PCR and flow cytometry we showed that HKC express low levels of CD24 even under basal conditions, and the treatment with calcium, PMA or IFN-gamma increased levels of CD24 mRNA and protein. To the best of our knowledge, this is the first report to measure CD24 expression and production by cultured HKC in basal conditions and after stimulation. Further studies are needed to determine biological and therapeutical relevance of these findings.
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