Many past paper SAQs have asked the candidates to identify some rash, pupuric blotching, gangrenous embolic phenomena or some other visually impressive manifestation of disease. Irritatingly, the college examiners tend to remove these images from their published papers, presumably because they plan to reuse them. Previous questions of this sort have included Question 25.1 from the first paper of 2011 (erythema multiforme), Question 20.2 from the second paper of 2008 (Stevens-Johnson syndrome) and Question 10 from the first paper of 2005 (Toxic Epidermal Necrolysis). Question 15.1 from the second paper of 2012 was more about the non-specific approach to the evaluation of a gross whole-body rash. This approach is discussed below.
Vascular causes:
Infectious causes:
Neoplastic causes:
Drug-related causes
Autimmune cause
Traumatic causes
This was the subject of Question 25.1 from the first paper of 2011.
Characteristic pattern:
Infectious causes:
Drugs which cause erythema multiforme:
Stevens-Johnson Syndrome and TEN are considered diseases of the same spectrum. SJS is the less severe classification of the same disease: only ~ 10% of the skin surface is sloughed. TEN, on the other hand, is a condition of over 30% slough. In the 10-30% patients, the two conditions overlap.
Thus, the diagnostic features:
Drugs which are known to cause TEN:
Non-drug causes of TEN:
Management of TEN:
The best literature for the management of TEN is unfortunately paywalled (Fromowitz et al, 2007). That particular article shines brightest because they incorporate a long (28-point) list of management recommendations from the University of Florida protocol. Fortunately, Schneider & Cohen have an even better article, which is more recent (2017). Additionally, the 2016 UK guidelines are available as a free PDF (Creamer et al, 2016). These and other resources have been remixed and recut into the summary below.
I found this originally on the LITFL facebook page. It immediately struck me as a work of genius.
Ely, John W., and Mary Seabury Stone. "The generalized rash: Part I. Differential diagnosis." Am Fam Physician 81.6 (2010): 726-734.
Bachot, Nicolas, and Jean-Claude Roujeau. "Differential diagnosis of severe cutaneous drug eruptions." American journal of clinical dermatology 4.8 (2003): 561-572.
Clark Huff, J., William L. Weston, and Marciih G. Tonnesen. "Erythema multiforme: a critical review of characteristics, diagnostic criteria, and causes."Journal of the American Academy of Dermatology 8.6 (1983): 763-775.
Leaute-Labreze, C., et al. "Diagnosis, classification, and management of erythema multiforme and Stevens–Johnson syndrome." Archives of disease in childhood 83.4 (2000): 347-352.
Gerull, Roland, Mathias Nelle, and Thomas Schaible. "Toxic epidermal necrolysis and Stevens-Johnson syndrome: A review*." Critical care medicine39.6 (2011): 1521-1532.
Wiler, Jennifer L. "Diagnosis: Toxic Epidermal Necrolysis." Emergency Medicine News 29.9 (2007): 20-21.
Roujeau, Jean-Claude, et al. "Toxic epidermal necrolysis (Lyell syndrome)."Journal of the American Academy of Dermatology 23.6 (1990): 1039-1058.
Shiga, Sarah, and Rob Cartotto. "What are the fluid requirements in toxic epidermal necrolysis?." Journal of Burn Care & Research 31.1 (2010): 100-104.
Fromowitz, Jeffrey S., Francisco A. Ramos‐Caro, and Franklin P. Flowers. "Practical guidelines for the management of toxic epidermal necrolysis and Stevens–Johnson syndrome." International journal of dermatology 46.10 (2007): 1092-1094.
Arévalo, José M., et al. "Treatment of toxic epidermal necrolysis with cyclosporin A." Journal of Trauma and Acute Care Surgery 48.3 (2000): 473-478.
Schneider, Jeremy A., and Philip R. Cohen. "Stevens-Johnson syndrome and toxic epidermal necrolysis: a concise review with a comprehensive summary of therapeutic interventions emphasizing supportive measures." Advances in Therapy34.6 (2017): 1235-1244.
Han, Feng, et al. "Successful treatment of toxic epidermal necrolysis using plasmapheresis: A prospective observational study." Journal of critical care 42 (2017): 65-68.
Paquet, Philippe, et al. "Effect of N-acetylcysteine combined with infliximab on toxic epidermal necrolysis. A proof-of-concept study." Burns 40.8 (2014): 1707-1712.
Hunger, Robert E., et al. "Rapid resolution of toxic epidermal necrolysis with anti-TNF-α treatment." Journal of allergy and clinical immunology 116.4 (2005): 923-924.
Wolkenstein, Pierre, et al. "Randomised comparison of thalidomide versus placebo in toxic epidermal necrolysis." The Lancet 352.9140 (1998): 1586-1589.
Creamer, D., et al. "UK guidelines for the management of Stevens–Johnson syndrome/toxic epidermal necrolysis in adults 2016." British Journal of Dermatology 174.6 (2016): 1194-1227.