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Skin toxicity grade 2-4 (sequel)

Assessment and Investigations

  • Perform skin biopsy after discussion with dermatologist if diagnosis is unclear or if bullae are suspected

Low Risk

• Alopecia < grade 2
• Bullous dermatitis grade 2 (affecting 10-30% BSA) without oral or genital lesions
• Dry skin > grade 2
• Erythema multiforme grade 2 (affecting 10-30% BSA)
• Erythroderma grade 2 (covering >90% BSA)
• Pruritus > grade 2 with moderate with skin changes from scratching limiting instrumental ADL
• Rash grade 2 covering 10-30% BSA with/without symptoms, limiting instrumental ADL
• Skin atrophy > grade 2 (covering > 10% BSA)
• Skin induration > grade 2

Management escalation pathway

  • Treat ambulatory
  • Apply topical steroids twice daily
  • Apply symptomatic treatment to associated symptoms such as itching, dry skin and consider second-generation anti-histamines
  • If symptoms persist > 6 days and patient is therapy compliant: initiate oral methylprednisolone at a dose of 0.5-1mg/kg per day after discussion with dermatologist

Symptoms resolved to grade 0 to 1
Yes = A
No = B

Medium Risk

• Bullous dematitis grade 2 (affecting > 30% BSA or oral or genital involvement)
• Erythema multiforme grade 3 (>30% BSA with oral and genital erosions)
• Erythroderma grade 3 (>90% BSA)
• Rash grade > 3 (covering >30% BSA) associated with superinfection requiring antibiotics

Management escalation pathway

  • Treat ambulatory or hospitalize
  • Apply topical steroids twice daily
  • Apply symptomatic treatment to associated symptoms such as itching, dry skin and consider second-generation anti-histamines
  • consider oral/iv methylprednisolone at a dose of 1mg/kg after discussion with dermatologist
  • Treat with antibiotics as indicated after taking swaps

Symptoms resolved to grade 0 or 1 after 4 weeks of treatment
Yes = C
No = D

High Risk

• Steven Johnson syndrome
• Toxic epidermal necrolysis
• Bullous dermatis grade 4 (affecting > 30% BSA, blistering with electrolyte/fluid abnormalities)
• Erythema multiforme grade 4 (>30% BSA electrolyte/fluid abnormalities)
• Erythroderma grade 4 (>90% BSA electrolyte/fluid abnormalities)

Management escalation pathway

  • Hospitalize on ICU/burn unit
  • Apply electrolyte and fluid control
  • Apply nutritional control initiated antibiotic therapy as indicated
  • Apply general burn unit measures (e.g. sterile handling, antiseptic solution, repeated cultures, pain management …)

Continue as in C

A

  • Stop topical therapy
  • Taper steroids if given systematically

B

  • Stop topical therapy
  • Taper steroids if given systematically

C

  • Taper steroids over >1 month
  • For bullous dermatitis, a long corticosteroid taper is indicated followed by a period of low dose corticoids
  • corticosteroids (3-4 months with 4-8 mg/d)

D

  • Consider increasing the dose of steroids to 2 mg/kg
  • Consider the use of intravenous immune globulins (>3g/kg  for 1- 3 days)
  • Consider to use cyclosporine (3-5mg/d) after assessing the balance risk benefit
  • if bulleus dermatitis is confirmed (positive immunofluorescence) and not responsive to corticoids: discuss addition of nicotinamide and tetralysal with dermatologist.
Abbreviations

Abbrevations

BSA: Body Surface Area
ADL: Activities of Daily Living
ICU: Intensive Care Unit