Inspired by the encouraging finding reported by his group based on pulse systemic steroid and topical betamethasone therapies, the author drafted the editorial entitled “Acute Management of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis to Minimize Ocular Sequelae” with a single purpose in mind, that is, to call consulting ophthalmologists’ attention to take an active role in ameliorating potentially blinding complications during the acute care of patients inflicted with Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN; see the first and the last paragraph of the editorial). This effort is augmented by a new literature revelation indicating that SJS/TEN can be distinguished, clinically, from an often-confusing entity termed erythema multiforme and that promising therapies have emerged to avert ophthalmic sequelae.
The clinical team associated with Sotozono and associates should be congratulated for being able to exercise clinical acumen in distinguishing SJS/TEN from erythema multiforme based on clinical course, acral distribution of characteristic skin lesions, and histopathologic features of skin biopsy specimens (described in more details in the editorial ). Even if the diagnosis of SJS/TEN is established, the concern of microbial (not limited to herpes simplex virus) infections in severe skin blistering disease is real because they are not simply a cause (as suggested in most cases of erythema multiforme), but also are a known concomitant threat and complication. It comes as no surprise that many textbooks of dermatology and acute care medicine strike a clear and cautious note about systemic administration of glucocorticoids (not limited to a high dose) for fear of inciting infections in the wake of managing patients with life-threatening diseases (literature also cited in the editorial ). Contrary to what is suggested in the correspondence by Sotozono and associates, the author actually took an opposing stance to this conventional wisdom and stated in the editorial that “weighing against the risk of likely ocular morbidity and blindness, it seems justified to contemplate the purported high-dose pulse steroid therapy as soon as the clinical diagnosis of SJS/TEN is established and if common viral and microbial infections can be excluded by skin biopsies and microbial cultures of the tissue and the blood.” It should be noted that the aforementioned clinical endeavors in promptly establishing a correct diagnosis and excluding concomitant infection have not been pursued consistently and vigorously by all subspecialties involved in the acute care of SJS/TEN patients. Further educational efforts are needed to make the entire medical community outside of ophthalmology aware of the importance of acute intervention in potentially blinding SJS/TEN.
The author did not suggest that amniotic membrane transplantation may be a better strategy for reducing immunoreactions on the ocular surface. Instead, the author questioned whether “there is a better strategy that one may deploy to abort disease progression by specifically targeting the pathogenic basis that leads to skin blisters and relentless ocular surface inflammation.” Fully recognizing the importance of an editorial to include and balance all views, the author was obliged to discuss the clinical efficacy by amniotic membrane transplantation in acute SJS/TEN because a total of 6 patients had been reported to have been treated successfully in 5 papers dating from 2002 (reviewed by Gregory and recently by Shay and associates ). Sotozono and associates are correct in stating that amniotic membrane transplantation cannot and does not address the systemic adverse effect purportedly caused by the cytokine storm in acute SJS/TEN. However, one may also argue how they can, based on their noncomparative clinical results of 5 patients, conclude that “steroid pulse therapy and topical betamethasone should be considered to prevent corneal epithelial stem cell loss in the limbal region and cicatricial changes.” The author believes that the editorial took a fair and just stand by concluding that “further clinical studies with a larger sample size are warranted to help determine the pros and cons of these new therapies ( including IVIG, etc. ) that can be delivered at the acute stage” (italics added).