Treatment of Toxic Epidermal Necrolysis with the Combination of Infliximab and High-Dose Intravenous Immunoglobulin

Abstract

Background: Therapeutic evidence for toxic epidermal necrolysis (TEN) is indicative for high-dose intravenous immunoglobulin yet inconclusive for corticosteroids. Objective: To describe the combination of corticosteroids, infliximab and a high-dose intravenous immunoglobulin course for TEN. Patients and Methods: In three patients (SCORTEN survival probabilities: 41.7%, 64.2%, 41.7%) disease control was evaluated by (a) employing quantitative image analysis to measure progression of skin detachment and (b) patients’ outcome (complete re-epithelization). Published cases of TEN treatments with infliximab were retrieved from PubMed. Results: Within 48 h skin disease progression was arrested in all patients. Two patients were discharged after 3 weeks without any sequels from skin or conjunctivae. One patient passed away on the ninth day, however with noticeably improved skin (mortality rate: 33% observed vs. 50% expected). A PubMed search retrieved five TEN patients treated successfully with infliximab. Conclusion: The described combination presents a feasible therapeutic alternative for TEN that warrants further evaluation.

Combination of Infliximab and High-Dose Intravenous Immunoglobulin for Toxic Epidermal Necrolysis: Successful Treatment of an Elderly Patient

“…Extensive epidermal keratinocyte cell death via cytotoxic T-cell stimulation, activation of Fas-Fas ligand interactions, and increased TNFa levels locally in the skin and in the circulation underlie the pathogenesis of TEN. It is suggested that the present combination modality efficiently arrests the detrimental progression of this condition through targeted modification of the above pathophysiologic aberrations [4]. Pharmacologic targeting of increased TNFa levels in TEN patients seems to be a promising emerging treatment strategy [4].…”

“…It is suggested that the present combination modality efficiently arrests the detrimental progression of this condition through targeted modification of the above pathophysiologic aberrations [4]. Pharmacologic targeting of increased TNFa levels in TEN patients seems to be a promising emerging treatment strategy [4]. However, designing trials to prove the efficacy of a therapeutic approach in a rare and serious disease as is TEN is not without any pitfalls.…”

“…Immediately after the establishment of diagnosis, treatment was initiated in loco according to a recent therapeutic proposal [4]. She was not transferred to a reference center as she strongly wished to be nursed nearby her residence.…”

Chronic Ocular Complications of Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis: The Role of Systemic Immunomodulatory Therapy

“…28 There have been multiple studies examining the efficacy of IVIG in SJS/TEN patients, and the results have been inconsistent regarding survival rates and length of hospitalizations. 83,[104][105][106][107] Interestingly, the initiation of IVIG during the acute phase does not appear to diminish the severity of later ocular complications. 20 20 They determined that systemic modulation had no significant effect on final visual acuity or the incidence of chronic ocular complications.…”

Biologics in dermatology: An integrated review

“…There are many reports[169170171172173174] of successful use of Infliximab, and a few of etanercept (LOE5). It has been used alone, as well as in combination with IVIG and steroids, producing rapid response.…”