Case Report
Hyperpigmentated Scars of the Face Following a Toxic Epidermal Necrolysis (TEN): A Case Report
Stefania Tenna*, Gabriella Cassotta, Beniamino Brunetti and Paolo Persichetti
Department of Dermatology and Plastic Surgery, “Campus Bio-Medico” University, Italya
*Corresponding author: Stefania Tenna, Department of Dermatology and Plastic Surgery, “Campus Bio-Medico” University, via Alvaro del Portillo 200, 00128 Rome, Italy
Published: 09 Nov, 2016
Cite this article as:Tenna S, Cassotta G, Brunetti B, Persichetti P. Hyperpigmentated Scars of the Face Following a Toxic Epidermal Necrolysis (TEN): A Case Report. J Dermatol Plast Surg. 2016; 1(2): 1007.
Abstract
Toxic Epidermal Necrolysis (TEN) is a rare and often fatal muco-cutaneous disease usually related
to severe adverse drug reaction. The standard treatment of TEN remains controversial and to our
knowledge, all reports in literature are mostly concentrated on systemic therapy. On the contrary,
no report deals with deep skin scars that may occur. We therefore present an original case of a severe
scarring of the face following TEN, treated by fractional CO2
laser resurfacing.
Keywords: Hyperpigmentated scars; Toxic epidermal necrolysis; Fractional laser
Introduction
Toxic epidermal necrolysis (TEN), also known as Lyell’s syndrome, is an acute T-cell mediated immune disorder, caused by idiosyncratic adverse drug reaction to sulfonamides, anticonvulsivants, antiretroviral drugs, allopurinol, and non-steroidal anti-inflammatories (NSAIDs) [1]. An extensive cleavage of the epidermis from the dermis occurs due to keratinocyte apoptosis, resulting in large exposed areas, from 10 % up to more than 30% of skin detachment. General conditions are severe, and the mortality rate ranges from 5% to 35%. Primary treatment aims at the survival of the patient, rarely considering the aesthetic appearance of cutaneous sequaela [2]. The healing process of the skin is similar to a partial thickness burn injury, with secondary wound infection or self-induced picking trauma that may alter the recovery, resulting in atrophic deep scars. The management consists of different approaches: physical approach (laser, pulsed light, and cryotherapy), surgical approach (dermabrasion, punch excision etc.), fillers and chemical peels. Shallow lesions can improve with chemical peels, while non-ablative radiofrequency, subcision techniques, or subcutaneous infiltration give better results in case of deep scars. To our knowledge, few reports deal with treatments of facial scars following a TEN.
Case Presentation
A 35 years-old woman presented 3 years ago with facial scarring due to a severe TEN, following
nonsteroidal anti-inflammatory drug assumption. The patient referred no response to medical or
chemical treatment. The partial thickness damage of the dermis caused on both cheeks depressed,
rolling and boxcar scars with hyperpigmentation that enhanced the unsightly appearance of the
patient’s face (Figure 1).
To improve skin texture and lighten hyperpigmentation three fractional CO2
resurfacings were planned. The treatment was performed with a fractional CO2
Laser (SmartXide2, DEKA M.E.L.A, Calenzano, Italy) using these parameters: 500 micron spacing, 1000 Hz frequency and 45 mJ/cm2
of energy. Time interval between treatments was three months. No post-operative pain or bleeding
was registered. Face oedema and erythema resolved completely within 10 days after each treatment.
A satisfactory cosmetic appearance of the skin, with almost complete resolution of the
hyperpigmentation, was achieved (Figure 2). Follow up at 18 months showed just a mild recurrence
of skin irregularities but no hyperpigmentation and substantially confirmed a good stability of the
result (Figure 3). Patient’s satisfaction assessed by a visual analog scale (VAS) evaluation (score: 1 to
5) confirmed a high satisfaction rate (score 4) at the end of the treatment and still a good rate (score
3.5) after 18 months.
Discussion
EN often begins as a morbilliform rash that quickly converges in bigger spots with purpura
aspects, which rapidly turn into flaccid bulla, Nikolsky-positive. Large cutaneous areas are often
involved as well as mucous membrane that are interested in the 90% of the patients, with implication
of conjunctiva as a poor prognostic sign. In positive prognosis cases, a
complete healing is possible in 10-20 days [3].
Treatment usually implies intensive care unit or big burns
center, and early symptomatic therapy with huge quantity of water,
electrolytes, macrolides, and antibiotics to prevent infection [4-7].
Scarring is initially underestimated whereas aesthetic and
psychological effects may be significant, especially if the face is
involved. Obviously effective procedures for scars are well known
and numerous, all aiming to disrupt or remove scar tissue and to
allow its replacement with functional, healthy tissue. However, sub
typing scars is of paramount importance to define the correct clinical
presentation in order to choose the appropriate treatment. In our
case, the clinical presentation was more similar to a severe post acne
inflammatory reaction than to a burn, and the hyperpigmentation,
following the damage enhanced the visibility of the scars.
The laser resurfacing approach was preferred to renew the
superficial layers, removing darkened and damaged cells and to
improve deep levels, inducing formation of new collagen. Traditional
resurfacing is associated with potential side effects, such as long lasting
erythema, scarring, infection, and hyperpigmentation especially
following inflammatory reactions; whereas fractional laser is claimed
to be capable of producing only minor improvements.
Our experience confirmed that the fractional Smart Xide CO2
laser, thanks to a bipolar radiofrequency source, generates perfectly
controlled pulses (DOTs) by managing the “energy per pulse”
parameter, the “DOT spacing” between two microscopic wounds,
and the pulse duration (known as “dwell time”). Many articles already
reported its effectiveness to improve skin texture in acne scars also
combining the emission of a bipolar radiofrequency to increase the
release of heat deeper down in the dermis [8-10]. As a matter of facts,
this report supports its application also in case of refractory scars and
for the treatment of hyperpigmentation. Combined procedures with
chemical peels as well as Intense Pulsed Light can be eventually added.
Figure 1
Figure 1
Figure 1
Conclusion
Toxic Epidermal Necrolysis (TEN) is a severe and threatening disease in which the first goal is patient survival, however, scarring, following this syndrome, could be highly disfiguring. Fractional CO2 laser resurfacing proved to be a good option to improve both skin texture and hyperpigmentation, and it should be considered in these cases.
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