Accepted Manuscript. Wound Management Strategies in Stevens-Johnson syndrome/toxic Epidermal Necrolysis: An unmet need

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1 Accepted Manuscript Wound Management Strategies in Stevens-Johnson syndrome/toxic Epidermal Necrolysis: An unmet need Lee Haur Yueh, MBBS, MRCP, MMed, FAMS PII: S (18) DOI: /j.jaad Reference: YMJD To appear in: Journal of the American Academy of Dermatology Received Date: 8 May 2018 Accepted Date: 9 May 2018 Please cite this article as: Yueh LH, Wound Management Strategies in Stevens-Johnson syndrome/ Toxic Epidermal Necrolysis: An unmet need, Journal of the American Academy of Dermatology (2018), doi: /j.jaad This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

2 1 TITLE PAGE MANUSCRIPT TITLE: Wound Management Strategies in Stevens-Johnson syndrome/toxic Epidermal Necrolysis: An unmet need H Y Lee AUTHOR: 1. Lee Haur Yueh MBBS (Singapore), MRCP (UK), MMed (Internal Medicine), FAMS (Dermatology) Singapore General Hospital, Singapore CORRESPONDING AUTHOR Lee Haur Yueh Department of Dermatology Singapore General Hospital Outram Road Singapore address: lee.haur.yueh@singhealth.com.sg Telephone: Fax WORD COUNT: 333 Words REFERENCE COUNT: 6 FIGURE COUNT: 2

3 27 28 FUNDING: NONE DECLARATION OF CONFLICT OF INTEREST: NONE 29 30

4 31 32 To the editor, I would like to commend the authors for their systematic review on wound care in Stevens-Johnson syndrome (SJS) and toxic epidermal necroysis (TEN) 1. Nonetheless, any discourse on wound care would be incomplete without taking into consideration the use of conservative versus surgical wound approaches. In the conservative approach, the detached epidermis is left in situ to act as a biological dressing and additional non-adhesive dressings and bandages may be applied. In the surgical approach, operative debridement and/or manual scrubbing of the devitalized epidermis is performed. Such procedures are deemed necessary to promote adherence of the biological membranes such as allografts, xenografts or Biobrane to the underlying dermis 2.No improvement in healing time has been reported with the use of modern dressings such as Biobrane although benefits of a reduction in dressing changes is present. These benefits would need to be balanced with potential operative risks as well as risks of anaesthesia and sedation. Another consideration is the different pathogenic mechanism between toxic epidermal necrolysis and burns injury. The epidermal involvement in SJS/TEN is a dynamic process as opposed to burns. The duration from the onset of disease to maximum detachment is about 7 to 9 days, following which spontaneous re-epithelization occurs 3. At the outset/on admission, it is difficult to predict the final extent of epidermal detachment - not all affected areas will undergo full detachment. Biological dressings necessitate early debridement and application in order to reduce infective risks. Early debridement in SJS/TEN may result in removal of more epidermis than what is required. Lastly, long-term complications of post-inflammatory hyperpigmentation affect almost all patients with SJS/TEN 4. It has been our experience (Figure 1a & b) as well as others 5 that when an anti-shear approach is undertaken and the detached skin is left in situ, the severity of post inflammatory hyperpigmentation appears less severe.

5 55 56 Whilst there has been considerable effort in evaluating systemic immunomodulatory agents, comparative studies of various wound care strategies are lacking and remains an unmet need in the care of patients with SJS/TEN.

6 59 REFERENCES Castillo B, Vera N, Ortega-Loayza AG, Seminario-Vidal L. Wound care for Stevens-Johnson syndrome and toxic epidermal necrolysis: A systematic review. J Am Acad Dermatol /j.jaad Nizamogly M, Ward JA, Frew Q et al. Improving mortality outcomes of Stevens Johnson syndrome/toxic epidermal necrolysis: A regional burns centre experience. Burns 2018;44: Lim VA, Do A, Berger T et al. A decade of burn unit experience with Stevens-Johnson syndrome/toxic epidermal Necrolysis: Clinical pathological diagnosis and risk factor awareness. Burns 2016; HY Lee, SA Walsh, D Creamer. Long term complications OF Stevens-Johnson syndrome / toxic Long-term complications of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN): the spectrum of chronic problems in patients who survive an episode of SJS/TEN necessitates multidisciplinary follow up. Br J Dermatol 2017;177: Heng YK, Lee HY, Roujeau JC. Epidermal necrolysis: 60 years of errors and advances. Br J Dermatol 2015;173: Long-term complications of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN): the spectrum of chronic problems in patients who survive an episode of SJS/TEN necessitates multidisciplinary follow up. Br J Dermatol 2017;177: Dorafshar AH, Dickie SR, Cohn AB, Aycock JK, O Connor A, Tung A. Antishear therapy for toxic epidermal necr9olysis: An alternative treatment approach. Plastic Reconstr Surg 2008;122;

7 82 Legend Figure 1a: Sheet like detachment, blisters and raw erosions on the back Figure 1b: Post inflammatory hyperpigmentation accentuated in areas where detached epidermis was not left in-situ.

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