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Cutaneous drug reactions (Steven johnson syndrome & Toxic epidermal…

- - - - Extensive necrosis and detachment of subepidermis
      - Apoptotic keratinocytes in subepidermis
      - Mononuclear cell (mostly CD8+) infiltrates
    - - Oral
        
        Painful hemorrhagic erosins coated by white pseudomembranes
      - Occular
        
        Photophobia, purulent conjunctivitis
      - Genital
        
        Painful micturition (ปัสสาวะแสบ) and synechiae (ท่อปัสสาวะตีบ)
    - - Erythematous, blister, confluence, symmetrically face, upper trunk and limbs extend to whole of body within 1 wk
      - Nikolsky sign : positive
  - - - HIV medication
        
        Nevirapine
      - Anticonvulsants
        
        Carbamazepine
        
        Phenytoin
      - Anti-microbial sulfonamides
        
        Bactrim
      - Gout medication
        
        Allopurinol
    - - Mycoplasma pneumoniae
        
        มักพบในเด็ก
  - - - HLA
        
        HLA-B*15:02
        
        Carbamazepine, Phenytoin
        
        HLA*58:01
        
        Allopurinol
      - Cytochrome P450
    - - 3 concept
        
        Hapten concept
        
        Drugs
        
        Beta-lactam : penicillin
        
        Drug-peptide complex (hepten) interacts with TCRs and HLA
        
        p-i concept
        
        Drugs interact directly without forming hapten
        
        Altered peptide
        
        Drug-binding to pocket
        
        Drugs
        
        Carbamazepine
        
        Abacavir
      - Cell-mediated
        
        Againsts keratinocytes
        
        Granzyme B
        
        Induce ROS increas in mitochondria
        
        Caspase
        
        Perforin (pore)
        
        Granulysin
        
        Early diagnosis
        
        APCs and leukocyte recruitment
        
        Pro-inflammatory molecule
        
        Cytokines
        
        IFN-gamma
        
        Ag presentation and upregulation HLA
        
        TNF-alpha
        
        Fas/soluble FasL
        
        Keratinocyte apoptosis
      - Hypersensitivity type 4
  - - - Corticosteroids
      - Cyclosporine A
      - IVIG :warning: severe มากๆเท่านั้น
    - - Fluid electrolytes transfusion
      - Prophylactic antibiotics :warning: สำหรับ infection เท่านั้น
      - Wound dressing
      - Eye and mouth care
- - - - Red central disk
      - Pale ring
      - Red halo
    - - Satellite cell necrosis
        
        Apoptotic keratinocytes accompanied by lymphocytes
      - Extravasated RBC
  - - - Herpes simplex virus (HSV)
        
        Related young adults acute infection 90%
    - - คล้ายกับ SJS/TEN
  - - - Without mucous involvement
    - - With mucous involvement
  - - - Acyclovir
    - - EM skin lesion
        
        Topical
      - EM major
        
        Systemic
- - - - Symmetrical erythematous, painful nodules at anterior surface of lower extremities
      - Self-resolve within 2-8 wks without scar
    - - Septal panniculitis without vasculitis
        
        Inflammation of subcutaneous tissue
        
        Early phase
        
        Neutrophils inflitrate
        
        Late phase
        
        Multinucleated giant cells (foam cell), lymphocytes
  - - - Oral contraceptive pill
    - - TB
      - Streptococci : เจอในเด็ก
    - - Hodgkin’s lymphoma
  - - - NSAIDs
      - Immunomodulator
        
        Dapsone
    - - TB, malignancy