Comparison of Suprathel® and allograft skin in the treatment of a severe case of toxic epidermal necrolysis.

Toxic epidermal necrolysis (TEN) is a rare potentially lifethreatening drug-induced skin disorder resulting in extensive mucocutaneous exfoliation and systemic involvement. TEN is now generally considered to result from a disregulated immune reaction against epithelial cells. TEN was first described by Alan Lyell [1] and is therefore commonly referred to as Lyell’s disease or syndrome. It is closely related to Stevens–Johnson syndrome (SJS) and both conditions are considered to be caused by the same disease process. SJS is often defined by less than 10% epidermal loss and TEN more than 30% loss with those in between classified as SJS-TEN. Clinically they present with an acute macular erythematous rash with bullae which can rapidly progress to extensive areas of epidermal separation and shedding. A positive Nikolsky’s sign (slight rubbing of the skin resulting in exfoliation of the outermost layer) is characteristic [2]. The SCORTEN severity of illness scoring system helps to predict mortality in TEN patients [3]. Due to often extensive areas of epidermal involvement with resultant water, electrolyte and protein losses it is generally agreed that these patients should be admitted early to a Burn Unit [1]. At present there are no standard management guidelines but treatment should be multidisciplinary with prompt diagnosis, withdrawal of the suspected drug, supportive care and wound management. Many specific pharmacological therapies are cited in the literature but a general consensus and evidence base is lacking. However topical wound care is an integral part of the overall management of this condition. The areas of epidermal loss can be compared to the wound of a partial-thickness burn and thus many different wound dressings are available. At present there is no general agreement as to what is the most efficacious and appropriate wound care material. Suprathel (PMI Polymedics Innovations GmbH, Germany) is a recently introduced epidermal substitute. It is composed of a synthetic co-polymer of polylactide, trimethylene carbonate, and e-caprolactone and has been used in partial-thickness burns as well as in split-thickness skin graft donor sites. It is reported to reduce pain in both burn and donor site wounds and also to reduce exudation of donor sites compared to a conventional open method [4,5]. There are two reports of the use of Suprathel in Staphylococcal scalded skin syndrome [6] and TEN in a young infant [7]. Allograft (cadaveric) skin however is well recognised for its use in TEN as well as its versatility in burn patients in general [8–10]. We report our experience in the use of Suprathel and allograft skin in a severe case of TEN.