Drug-Induced Toxic Epidermal Necrolysis: A Case Report

Toxic epidermal necrolysis (TEN) is a rare, life-threatening mucocutaneous condition, most commonly triggered by drugs, with particularly high mortality in elderly populations. The medications most frequently associated with TEN include antibiotics such as sulfamethoxazole-trimethoprim (sulfonamides), penicillins, cephalosporins, and quinolones (e.g., ciprofloxacin); anticonvulsants such as phenytoin, carbamazepine, and lamotrigine; nonsteroidal anti-inflammatory drugs (NSAIDs), especially oxicam derivatives (e.g., piroxicam), and, less commonly, ibuprofen; allopurinol; nevirapine; and other agents such as paracetamol, celecoxib, tyrosine kinase inhibitors, and immunobiological therapies like infliximab. We describe a 71-year-old, functionally dependent male who developed fever and progressive skin detachment after self-medicating with paracetamol and ibuprofen. Examination revealed widespread bullae and skin sloughing involving approximately 70% of his total body surface area (TBSA). Despite supportive measures, the patient rapidly deteriorated and died on the second day of hospitalization. TEN was assumed as the primary cause of death. The prognosis in TEN is strongly influenced by age, comorbidities, and the extent of skin involvement. Genetic predispositions, such as HLA-B15:02 (associated with carbamazepine-induced TEN, particularly in Southeast Asian populations), HLA-A31:01 (carbamazepine hypersensitivity in European, Japanese, and Latin American populations), and HLA-B*58:01 (allopurinol-induced TEN in Asian populations), are important risk factors that guide genetic screening recommendations before prescribing certain high-risk drugs. Supportive care remains the mainstay of treatment for TEN, focusing on meticulous wound care, fluid and electrolyte management, infection prevention, and pain control. However, the use of immunomodulatory therapies, such as corticosteroids, cyclosporine, and biologics, remains a subject of ongoing debate, with inconsistent evidence regarding their efficacy. Timely recognition of TEN and immediate cessation of the offending drug are paramount to improving patient outcomes and reducing mortality. This case highlights the potential role of ibuprofen, a commonly used over-the-counter NSAID, as a trigger for TEN, particularly in frail elderly individuals. Although ibuprofen is generally considered a low-risk medication, its capacity to induce severe cutaneous adverse reactions should not be underestimated. The prognosis in TEN is heavily influenced by factors such as advanced age, existing comorbidities, and the extent of skin involvement. Given the high fatality rates associated with TEN, especially in older adults, clinicians should maintain a high index of suspicion in patients presenting with acute mucocutaneous symptoms following recent drug exposure, including over-the-counter medications like ibuprofen, and emphasize the importance of public education on the dangers of unsupervised self-medication.