Download sis with Thermal Water spray and non-stick Dressings

Letter to the editor
Acta Dermatovenerol Croat
2012;20(3):197-214
Concurrent Management of Toxic Epidermal Necrolysis with Thermal Water Spray and Non-Stick Dressings
Dear Editor,
We describe two patients with toxic epidermal
necrolysis (TEN) who were successfully managed with
Avene thermal spring water spray (ATSW), non-stick
dressings and intravenous immunoglobulin (IVIg),
without transfer to a burns unit.
A 28-year-old Malaysian male with TEN secondary
to carbamazepine was treated with i.v. hydrocortisone, IVIg and patient-controlled analgesia. Transfer
to a burns unit was considered until learning that debridement, stick-on dressings with mandatory sedation/intubation due to pain was the approach to skin
management. To manage his skin whilst conscious
and able to sit/stand in the high dependency unit
(HDU), we conducted regular fluid release from fresh
bullae using sterile needles, leaving the epidermis intact as its own dressing. To cleanse easily we used a
Figure 1. Case 1. Erosions, blisters and mucosal involvement
210
spray-on bacteriologically pure thermal spring water
spray (ATSW, Avene, France) and non-stick silicone
dressings to areas where the skin had sloughed off.
The patient was able to self-administer the spray to his
skin, mouth and genital areas for comfort, as were his
relatives and it was very time-efficient for the nurses
compared with opening sterile saline packs. The skin
healed without infection or scarring (Figs. 1-4).
A 40-year-old Caucasian female with TEN secondary to lamotrigine was commenced on IVIg. Bullae
were regularly popped with a sterile needle, denuded
areas dressed with non-stick dressings and ATSW to
clean her skin. Her skin healed well without scarring
and without transfer to a burns unit.
Despite the similar clinical presentations of burns
and TEN, major differences exist between these two
entities (1). TEN affects the superficial layers, originating from the inside and progressing over many days,
compared with a thermal burn which is due to a oneoff external trauma, potentially resulting in deeper
cutaneous involvement. Immunosuppressive agents
can be used in TEN as it is an immune mediated disease, unlike burns. In our experience, burns centers,
on the advice of plastic surgeons, treat the skin in TEN
patients in the same way as burns patients, with intubation, sedation, debridement of the skin and use
of silver coated adhesive dressings. Although silver
is typically thought to be safe in burns wounds, its
use in TEN is discouraged (2,3). Aggressive treatment
such as intubation in patients with mucosal fragility
can potentially cause short term and long term complications. In addition, substantial psychosocial support to family members is mandatory if transfer to an
intensive care or burns unit ensues (4). Instead, using
topical treatments including dressings and sterile
water in addition to the dehiscence of blisters can be
effective with minimal long term scarring. Thermal
spring water, a natural, bacteriologically pure water
with low mineral content (5) has been used previously in the management of TEN in conjunction with
dressings (6). ATSW is well tolerated and easily applied to mucocutaneous surfaces by nurses, relatives
and the patient themselves. It is used as an alternative to showering and bathing and prevents against
further sloughing of the skin. Being sterile, non-abra-
ACTA DERMATOVENEROLOGICA CROATICA
Letter to the editor
Acta Dermatovenerol Croat
2012;20(3):197-214
Figure 2. Popping the blisters
Figure 3. Case 1. 1 month follow up-chest
sive with soothing properties, ATSW can be applied
multiple times a day (6) and oral consumption is safe.
Based on the treatment of epidermolysis bullosa, our
protocol was to pop the blisters with a sterile needle
before they were greater than 1 cm in diameter. The
blisters were not deroofed as the epidermis acts as
its own dressing. Any erosion should be covered with
non-stick dressings. Both patients were managed in a
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high dependency setting without transfer to a burns
unit and have made good recoveries with no complications. A more conservative approach to managing
patients with TEN can result in significant cost savings
for hospitals, with less use of interventional and intensive care equipment, and without compromising
on patient care. This form of skin care not only saves
the cost of ICU/burns units but allowed the patients
211
Letter to the editor
Acta Dermatovenerol Croat
2012;20(3):197-214
Figure 4. Case 1. 1 month follow up-back
to remain conscious and was easy for the nursing
staff to administer.
References
1. Wolf R, Davidovici B. Severe cutaneous adverse
drug reactions: who should treat, where and
how?: Facts and controversies. Clin Dermatol
2010;28:344-8.
2. Frenia ML, Schauben P. Use of silver sulfadiazine in
Stevens-Johnson syndrome. Ann Pharmacother
1994;28:736-7.
3. Fuller FW. The side effects of silver sulfadiazine. J
Burn Care Res 2009;30:464-70.
4. Makowski SK. Who is at risk for psychological distress? A patient-centered process to identify risk
for posttraumatic stress disorder and depression
in families of ICU patients. Chest 2011;139:743-4.
5. Merial-Kieny C, Castex-Rizzi N, Selas B, Mery S, Guerrero D. Avene Thermal Spring Water: an active
component with specific properties. J Eur Acad
Dermatol Venereol 2011;25 Suppl 1:2-5.
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6. Petkov T, Pehlivanov G, Grozdev I, Kavaklieva S,
Tsankov N. Toxic epidermal necrolysis as a dermatological manifestation of drug hypersensitivity
syndrome. Eur J Dermatol 2007;17:422-7.
Benjamin S. Daniel1,4, George Skowronski2,4,
John Myburgh2,4, Mark Hersch3,4, Dedee F.
Murrell1,4
Department of Dermatology, St George Hospital, 2Intensive Care Unit, 3Department of
Neurology, St George Hospital; 4University of
New South Wales, Sydney, NSW, Australia
1
Corresponding author:
Professor Dedee F. Murrell
Head of Dermatology
St George Hospital
University of New South Wales
School of Medicine Sydney NSW 2217 Australia
[email protected]
Received: December 27, 2011
Accepted, May 25, 2012
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