J AM ACAD DERMATOL VOLUME 71, NUMBER 1
3. Ng YY, Chang T, Chen TW, Liu HN, Yang AH, Yang WC. Concomitant lupus nephritis and bullous eruption in systemic lupus erythematosus. Nephrol Dial Transplant 1999;14:1739-43. 4. Terra JB, Jonkman MF, Diercks GF, Pas HH. Low sensitivity of type VII collagen enzyme-linked immunosorbent assay in epidermolysis bullosa acquisita: serration pattern analysis on skin biopsy is required for diagnosis. Br J Dermatol 2013;169:164-7. http://dx.doi.org/10.1016/j.jaad.2013.11.052
Letter to the editor To the Editor: I was delighted to read the successful experience of Fitzmaurice and colleagues with the time honored Goeckerman regimen for psoriatic patients refractory to biologic therapy.1 Although our study was not mentioned in their letter to the editor, our results are worth reviewing for those who are eager to use this effective mode of phototherapy and are unfamiliar with our findings.2 We compared the various components of the Goeckerman regimen. We showed that crude coal tar was superior to cleaner tar preparations and other tar derivatives. Because outpatient use of crude tar is messy, we demonstrated that overnight therapy was not necessary for effective results. Only a 2-hour application was necessary before broadband UVB exposure. A greasy petrolatum base was also not superior to hydrophilic ointment [a much better base cosmetically]. In addition, a 1% concentration was equivalent to higher concentrations of tar. In summary, 1% crude coal tar in hydrophilic ointment applied for 2 hours before UVL exposure was tolerated favorably by our patients and achieved excellent results. This modification will make outpatient Goeckerman far easier to administer. John W. Petrozzi, MD Retired, Department of Dermatology, University of Pennsylvania School of Medicine, Philadelphia Funding sources: None. Conflicts of interest: None declared. Correspondence to: John W. Petrozzi, MD, 150 Gill Rd, Haddonfield, NJ 08033 E-mail: [email protected] REFERENCES 1. Fitzmaurice S, Bhutani T, Koo J. Goeckerman regimen for management of psoriasis refractory to biologic therapy: the University of California San Francisco experience. J. Am Acad Dermatol 2013;69:648-9. 2. Petrozzi J, Barton JO, Kaidbey KK, Kligman AM. Updating the Goeckerman regimen for psoriasis. Br J Dermatol 1978;98: 437-44. http://dx.doi.org/10.1016/j.jaad.2013.10.069
Letters 195
Toxic epidermal necrolysis and early transfer to a regional burn unit: Is it time to reevaluate what we teach? To the Editor: We read with interest the August CME article on toxic epidermal necrolysis (TEN).1 We commend the authors for their efforts in collating a vast amount of data on a severe and understudied disease. However, we think it is important to explore the justification of the widely held belief encompassed in their statement, ‘‘the mortality rate may be reduced with early transfer to a burn unit.’’ We evaluated the list of references supporting this claim with their corresponding level of evidence (LOE) (Table I). Two studies analyzed small samples from a single burn center in Baltimore.2,3 Of these, the first did not perform multivariate regression to remove the risk of confounding and found an association between mortality and late transfer to a burn unit.2 The second study did include multivariate regression and found the initial correlation between mortality and late transfer to be negated in the slightly larger sample.3 The high prevalence of bacteremia in patients who were transferred late2 likely influenced the data in both papers.3 A multicenter retrospective study of 199 patients found that patients transferred late to a burn unit had decreased enteral therapy, less documented wound care, and increased use of prophylactic antibiotics and corticosteroids.4 Even so, there was no significance in mortality associated with early versus late transfer.4 This study as well as 1 of the previous studies recommended that, based solely on clinical experience, patients should be transferred to a burn unit.3,4 Post-discharge mortality has also been analyzed and 1 study has shown an increased mortality in patients who were transferred late to a burn unit.5 From this study, it was unclear whether such patients were transferred from home, possibly indicating lack of access to medical care, or whether they were transferred from outlying hospitals.5 These 4 studies have provided the bulk of evidence for transfer to a burn unit but suffer from serious flaws, including referral bias and confirmation bias. A recent prospective cohort study controlled for patients being in the hospital less than 7 days sought to determine whether patients transferred to specialty European centers have better survival than patients in a low-volume center. Once again, no difference in mortality was seen on multivariate regression.6 In conclusion, it is important to understand that the decision to transfer patients to a regional burn center is based on small, noncontrolled studies.
J AM ACAD DERMATOL
196 Letters
JULY 2014
Table I. Publications involving transfer to burn or specialty unit with level of evidence Design
Level of evidence
36
Retrospective, single center
III
2002
56
Retrospective, single center
III
Palmieri4
2002
199
Retrospective chart review, multicenter
III
Oplatek5
2006
46
Retrospective, single center
III
Sekula6
2013
442
RegiSCAR e multicenter, multinational, prospective cohort
IIB
Publication
Year
McGee2
1998
Ducic3
# Patients
The optimal treatment is uncertain at this time, but it is clear that TEN can easily be confused with autoimmune blistering diseases, erythema multiforme, acute generalized exanthematous pustulosis, staphylococcal scalded skin syndrome, and graft-versus-host disease to the untrained eye. Patient populations at high risk for development of severe drug reactions, such as patients with HIV/AIDS or lupus, or who have undergone blood or marrow transplantation, are complicated medically, and when they develop a life-threatening drug reaction, they may benefit from continued care by physicians familiar with their underlying disease. While burn centers are highly skilled in wound care, fluid management, and sepsis, they may not be as familiar with management of the complex medical comorbidities in these groups of patients. Dermatology hospitalists may become the optimal bridge to provide the differential diagnosis and wound care needed for these patients. This dedication may allow homogeneous care for patients and the ability to prospectively study treatments in one of the few potentially fatal dermatologic illnesses. Benjamin H. Kaffenberger, MD,a and Misha Rosenbach, MDb Dermatology, Ohio State University College of Medicine,a Columbus, and Dermatology, University of Pennsylvania Hospital,b Philadelphia
Comments
Late referrals significantly higher mortality; 6/12 late referrals were referred with bacteremia, all of whom died, in contrast to 1/24 bacteremic in the early referral group. Nonsignificant multivariate analysis of early to late transfer. Conclusion: ‘‘clinical experience suggests wound oriented intensive care management increases survival.’’ Mortality 32% overall, 51% in late transfers. Differs in enteral nutrition, prophylactic antibiotics, corticosteroids, and wound management. Late transfer nonsignificant on mortality in multivariate regression. Analyzed post-discharge mortality; it was higher in late admission to the burn unit. Did not analyze those who died during hospitalization No analysis of where patients came from or if directly admitted. High volume specialized centers vs others, controlled for time to center. No difference in survival between management.
Funding sources: None. Conflicts of interest: None declared. Correspondence to: Misha Rosenbach, MD, Perelman Center for Advanced Medicine, South Pavilion, 1st Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104 E-mail: [email protected] REFERENCES 1. Schwartz RA, McDonough PH, Lee BW. Toxic epidermal necrolysis: Part II. Prognosis, sequelae, diagnosis, differential diagnosis, prevention, and treatment. J Am Acad Dermatol 2013;69:187.e1-16. 2. McGee T, Munster A. Toxic epidermal necrolysis syndrome: mortality rate reduced with early referral to regional burn center. Plast Reconstr Surg 1998;102:1018-22. 3. Ducic I, Shalom A, Rising W, Nagamoto K, Munster AM. Outcome of patients with toxic epidermal necrolysis syndrome revisited. Plast Reconstr Surg 2002;110:768-73. 4. Palmieri TL, Greenhalgh DG, Saffle JR, Spence RJ, Peck MD, Jeng JC, et al. A multicenter review of toxic epidermal necrolysis treated in U.S. burn centers at the end of the twentieth century. J Burn Care Rehabil 2002;23(2):87-96. 5. Oplatek A, Brown K, Sen S, Halerz M, Supple K, Gamelli RL. Long-term follow-up of patients treated for toxic epidermal necrolysis. J Burn Care Res 2002;27:26-33. 6. Sekula P, Dunant A, Mockenhaupt M, Naldi L, Bouwes Bavinck JN, Halevy S, et al. Comprehensive survival analysis of a cohort of patients with Stevens-Johnson syndrome and toxic epidermal necrolysis. J Invest Dermatol 2013;133:1197-204. http://dx.doi.org/10.1016/j.jaad.2013.12.048
3. Ng YY, Chang T, Chen TW, Liu HN, Yang AH, Yang WC. Concomitant lupus nephritis and bullous eruption in systemic lupus erythematosus. Nephrol Dial Transplant 1999;14:1739-43. 4. Terra JB, Jonkman MF, Diercks GF, Pas HH. Low sensitivity of type VII collagen enzyme-linked immunosorbent assay in epidermolysis bullosa acquisita: serration pattern analysis on skin biopsy is required for diagnosis. Br J Dermatol 2013;169:164-7. http://dx.doi.org/10.1016/j.jaad.2013.11.052
Letter to the editor To the Editor: I was delighted to read the successful experience of Fitzmaurice and colleagues with the time honored Goeckerman regimen for psoriatic patients refractory to biologic therapy.1 Although our study was not mentioned in their letter to the editor, our results are worth reviewing for those who are eager to use this effective mode of phototherapy and are unfamiliar with our findings.2 We compared the various components of the Goeckerman regimen. We showed that crude coal tar was superior to cleaner tar preparations and other tar derivatives. Because outpatient use of crude tar is messy, we demonstrated that overnight therapy was not necessary for effective results. Only a 2-hour application was necessary before broadband UVB exposure. A greasy petrolatum base was also not superior to hydrophilic ointment [a much better base cosmetically]. In addition, a 1% concentration was equivalent to higher concentrations of tar. In summary, 1% crude coal tar in hydrophilic ointment applied for 2 hours before UVL exposure was tolerated favorably by our patients and achieved excellent results. This modification will make outpatient Goeckerman far easier to administer. John W. Petrozzi, MD Retired, Department of Dermatology, University of Pennsylvania School of Medicine, Philadelphia Funding sources: None. Conflicts of interest: None declared. Correspondence to: John W. Petrozzi, MD, 150 Gill Rd, Haddonfield, NJ 08033 E-mail: [email protected] REFERENCES 1. Fitzmaurice S, Bhutani T, Koo J. Goeckerman regimen for management of psoriasis refractory to biologic therapy: the University of California San Francisco experience. J. Am Acad Dermatol 2013;69:648-9. 2. Petrozzi J, Barton JO, Kaidbey KK, Kligman AM. Updating the Goeckerman regimen for psoriasis. Br J Dermatol 1978;98: 437-44. http://dx.doi.org/10.1016/j.jaad.2013.10.069
Letters 195
Toxic epidermal necrolysis and early transfer to a regional burn unit: Is it time to reevaluate what we teach? To the Editor: We read with interest the August CME article on toxic epidermal necrolysis (TEN).1 We commend the authors for their efforts in collating a vast amount of data on a severe and understudied disease. However, we think it is important to explore the justification of the widely held belief encompassed in their statement, ‘‘the mortality rate may be reduced with early transfer to a burn unit.’’ We evaluated the list of references supporting this claim with their corresponding level of evidence (LOE) (Table I). Two studies analyzed small samples from a single burn center in Baltimore.2,3 Of these, the first did not perform multivariate regression to remove the risk of confounding and found an association between mortality and late transfer to a burn unit.2 The second study did include multivariate regression and found the initial correlation between mortality and late transfer to be negated in the slightly larger sample.3 The high prevalence of bacteremia in patients who were transferred late2 likely influenced the data in both papers.3 A multicenter retrospective study of 199 patients found that patients transferred late to a burn unit had decreased enteral therapy, less documented wound care, and increased use of prophylactic antibiotics and corticosteroids.4 Even so, there was no significance in mortality associated with early versus late transfer.4 This study as well as 1 of the previous studies recommended that, based solely on clinical experience, patients should be transferred to a burn unit.3,4 Post-discharge mortality has also been analyzed and 1 study has shown an increased mortality in patients who were transferred late to a burn unit.5 From this study, it was unclear whether such patients were transferred from home, possibly indicating lack of access to medical care, or whether they were transferred from outlying hospitals.5 These 4 studies have provided the bulk of evidence for transfer to a burn unit but suffer from serious flaws, including referral bias and confirmation bias. A recent prospective cohort study controlled for patients being in the hospital less than 7 days sought to determine whether patients transferred to specialty European centers have better survival than patients in a low-volume center. Once again, no difference in mortality was seen on multivariate regression.6 In conclusion, it is important to understand that the decision to transfer patients to a regional burn center is based on small, noncontrolled studies.
J AM ACAD DERMATOL
196 Letters
JULY 2014
Table I. Publications involving transfer to burn or specialty unit with level of evidence Design
Level of evidence
36
Retrospective, single center
III
2002
56
Retrospective, single center
III
Palmieri4
2002
199
Retrospective chart review, multicenter
III
Oplatek5
2006
46
Retrospective, single center
III
Sekula6
2013
442
RegiSCAR e multicenter, multinational, prospective cohort
IIB
Publication
Year
McGee2
1998
Ducic3
# Patients
The optimal treatment is uncertain at this time, but it is clear that TEN can easily be confused with autoimmune blistering diseases, erythema multiforme, acute generalized exanthematous pustulosis, staphylococcal scalded skin syndrome, and graft-versus-host disease to the untrained eye. Patient populations at high risk for development of severe drug reactions, such as patients with HIV/AIDS or lupus, or who have undergone blood or marrow transplantation, are complicated medically, and when they develop a life-threatening drug reaction, they may benefit from continued care by physicians familiar with their underlying disease. While burn centers are highly skilled in wound care, fluid management, and sepsis, they may not be as familiar with management of the complex medical comorbidities in these groups of patients. Dermatology hospitalists may become the optimal bridge to provide the differential diagnosis and wound care needed for these patients. This dedication may allow homogeneous care for patients and the ability to prospectively study treatments in one of the few potentially fatal dermatologic illnesses. Benjamin H. Kaffenberger, MD,a and Misha Rosenbach, MDb Dermatology, Ohio State University College of Medicine,a Columbus, and Dermatology, University of Pennsylvania Hospital,b Philadelphia
Comments
Late referrals significantly higher mortality; 6/12 late referrals were referred with bacteremia, all of whom died, in contrast to 1/24 bacteremic in the early referral group. Nonsignificant multivariate analysis of early to late transfer. Conclusion: ‘‘clinical experience suggests wound oriented intensive care management increases survival.’’ Mortality 32% overall, 51% in late transfers. Differs in enteral nutrition, prophylactic antibiotics, corticosteroids, and wound management. Late transfer nonsignificant on mortality in multivariate regression. Analyzed post-discharge mortality; it was higher in late admission to the burn unit. Did not analyze those who died during hospitalization No analysis of where patients came from or if directly admitted. High volume specialized centers vs others, controlled for time to center. No difference in survival between management.
Funding sources: None. Conflicts of interest: None declared. Correspondence to: Misha Rosenbach, MD, Perelman Center for Advanced Medicine, South Pavilion, 1st Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104 E-mail: [email protected] REFERENCES 1. Schwartz RA, McDonough PH, Lee BW. Toxic epidermal necrolysis: Part II. Prognosis, sequelae, diagnosis, differential diagnosis, prevention, and treatment. J Am Acad Dermatol 2013;69:187.e1-16. 2. McGee T, Munster A. Toxic epidermal necrolysis syndrome: mortality rate reduced with early referral to regional burn center. Plast Reconstr Surg 1998;102:1018-22. 3. Ducic I, Shalom A, Rising W, Nagamoto K, Munster AM. Outcome of patients with toxic epidermal necrolysis syndrome revisited. Plast Reconstr Surg 2002;110:768-73. 4. Palmieri TL, Greenhalgh DG, Saffle JR, Spence RJ, Peck MD, Jeng JC, et al. A multicenter review of toxic epidermal necrolysis treated in U.S. burn centers at the end of the twentieth century. J Burn Care Rehabil 2002;23(2):87-96. 5. Oplatek A, Brown K, Sen S, Halerz M, Supple K, Gamelli RL. Long-term follow-up of patients treated for toxic epidermal necrolysis. J Burn Care Res 2002;27:26-33. 6. Sekula P, Dunant A, Mockenhaupt M, Naldi L, Bouwes Bavinck JN, Halevy S, et al. Comprehensive survival analysis of a cohort of patients with Stevens-Johnson syndrome and toxic epidermal necrolysis. J Invest Dermatol 2013;133:1197-204. http://dx.doi.org/10.1016/j.jaad.2013.12.048
