Advertisement

Toxic Epidermal Necrolysis (TEN) and Stevens-Johnson Syndrome (SJS)

  • Grace Obeid
  • Laurence Valeyrie-Allanore
  • Pierre WolkensteinEmail author

Abstract

Toxic epidermal necrolysis (TEN) is a rare, life-threatening, usually drug-induced, mucocutaneous disease characterized by extensive necrosis of the epidermis and widespread sloughing of the skin and mucosal surfaces. TEN and Stevens-Johnson syndrome (SJS) are considered to be two variants of the same pathological process differing only by the degree of skin involvement with an involved body surface area (BSA) of <10 % in SJS and >30 % in TEN. The incidence of TEN is evaluated to 0.4–1.2 cases per million person-years. TEN occurs in all age groups but is more frequent in women, the elderly, and HIV-infected patients. According to the published data, the mortality rate in TEN varies from 25 to 30 %. A prognosis score entitled SCORTEN (see Table 98.1) was proposed in 2000 for SJS/TEN and was found to be an efficient tool to predict mortality rate in this group of patients. SCORTEN is a 7-point score with each point corresponding to a variable and a mortality rate varying from 3.2 % for a score of 0–1 point to 90 % for a score ≥5 points. SCORTEN should be performed on day 1 and repeated on day 3 post-admission. Surviving patients maintain an increased risk of morbidity with a 5-year survival rate of 65 %.

Keywords

Toxic epidermal necrolysis Stevens-Johnsons syndrome Treatment Severe cutaneous adverse drug reactions Dermatological emergency 

Abbreviations

BSA

Body surface area

EMM

Erythema multiforme major

GVHD

Graft-versus-host disease

IVIg

Intravenous immunoglobulin

SJS

Stevens-Johnson syndrome

SSSS

Staphylococcal scalded skin syndrome

TEN

Toxic epidermal necrolysis

VAS

Visual analog scale

References

  1. Bachot N, Revuz J, Roujeau JC. Intravenous immunoglobulin treatment for Stevens-Johnson syndrome and toxic epidermal necrolysis: a prospective noncomparative study showing no benefit on mortality or progression. Arch Dermatol. 2003;139:33–6.PubMedGoogle Scholar
  2. Bastuji-Garin S, Fouchard N, Bertocchi M, Roujeau JC, Revuz J, Wolkenstein P. SCORTEN: a severity-of-illness score for toxic epidermal necrolysis. J Invest Dermatol. 2000;115(2):149–53.PubMedGoogle Scholar
  3. Boorboor P, Vogt PM, Bechara FG, Alkandari Q, Aust M, Gohritz A, et al. Toxic epidermal necrolysis: use of Biobrane or skin coverage reduces pain, improves mobilisation and decreases infection in elderly patients. Burns. 2008;34(4):487–92.PubMedGoogle Scholar
  4. Castrejon JL, Berry N, El-Ghaiesh S, Gerber B, Pichler WJ, Park BK, et al. Stimulation of human T cells with sulfonamides and sulfonamide metabolites. J Allergy Clin Immunol. 2010;125(2):411–8.PubMedGoogle Scholar
  5. Chang CC, Too CL, Murad S, Hussein SH. Association of HLA-B*1502 allele with carbamazepine-induced toxic epidermal necrolysis and Stevens-Johnson syndrome in the multi-ethnic Malaysian population. Int J Dermatol. 2011;50(2):221–4.PubMedGoogle Scholar
  6. Chessman D, Kostenko L, Lethborg T, Purcell AW, Williamson NA, Chen Z, et al. Human leukocyte antigen class I-restricted activation of CD8+ T cells provides the immunogenetic basis of a systemic drug hypersensitivity. Immunity. 2008;28(6):822–32.PubMedGoogle Scholar
  7. Chung WH, Hung SI, Yang JY, Su SC, Huang SP, Wei CY, et al. Granulysin is a key mediator for disseminated keratinocyte death in Stevens-Johnson syndrome and toxic epidermal necrolysis. Nat Med. 2008;14(12):1343–50.PubMedGoogle Scholar
  8. Harr T, French LE. Toxic epidermal necrolysis and Stevens-Johnson syndrome. Orphanet J Rare Dis. 2010;5:39.PubMedPubMedCentralGoogle Scholar
  9. Huang YC, Li YC, Chen TJ. The efficacy of intravenous immunoglobulin for the treatment of toxic epidermal necrolysis: a systematic review and meta-analysis. Br J Dermatol. 2012;167(2):424–32.PubMedGoogle Scholar
  10. Kardaun SH, Jonkman MF. Dexamethasone pulse therapy for Stevens-Johnson syndrome/toxic epidermal necrolysis. Acta Derm Venereol. 2007;87(2):144–8.PubMedGoogle Scholar
  11. Kreft B, Wohlrab J, Bramsiepe I, Eismann R, Winkler M, Marsch WC. Etoricoxib-induced toxic epidermal necrolysis: successful treatment with infliximab. J Dermatol. 2010;37(10):904–6.PubMedGoogle Scholar
  12. Locharernkul C, Loplumlert J, Limotai C, Korkij W, Desudchit T, Tongkobpetch S, et al. Carbamazepine and phenytoin induced Stevens-Johnson syndrome is associated with HLA-B*1502 allele in Thai population. Epilepsia. 2008;49(12):2087–91.PubMedGoogle Scholar
  13. Lonjou C, Thomas L, Borot N, Ledger N, de Toma C, LeLouet H, et al. A marker for Stevens-Johnson syndrome …: ethnicity matters. Pharmacogenomics J. 2006;6(4):265–8.PubMedGoogle Scholar
  14. Lonjou C, Borot N, Sekula P, Ledger N, Thomas L, Halevy S, et al. A European study of HLA-B in Stevens-Johnson syndrome and toxic epidermal necrolysis related to five high-risk drugs. Pharmacogenet Genomics. 2008;18(2):99–107.PubMedGoogle Scholar
  15. Mallal S, Nolan D, Witt C, Masel G, Martin AM, Moore C, et al. Association between presence of HLA-B*5701, HLA-DR7, and HLA-DQ3 and hypersensitivity to HIV-1 reverse-transcriptase inhibitor abacavir. Lancet. 2002;359(9308):727–32.PubMedGoogle Scholar
  16. Man CB, Kwan P, Baum L, Yu E, Lau KM, Cheng AS, et al. Association between HLA-B*1502 allele and antiepileptic drug-induced cutaneous reactions in Han Chinese. Epilepsia. 2007;48(5):1015–8.PubMedGoogle Scholar
  17. McCormack M, Alfirevic A, Bourgeois S, Farrell JJ, Kasperavičiūtė D, Carrington M, et al. HLA-A*3101 and carbamazepine-induced hypersensitivity reactions in Europeans. N Engl J Med. 2011;364(12):1134–43.PubMedPubMedCentralGoogle Scholar
  18. Mockenhaupt M, Viboud C, Dunant A, Naldi L, Halevy S, Bouwes Bavinck JN, et al. Stevens-Johnson syndrome and toxic epidermal necrolysis: assessment of medication risks with emphasis on recently marketed drugs. The EuroSCAR-study. J Invest Dermatol. 2008;128(1):35–44.PubMedGoogle Scholar
  19. Morici MV, Galen WK, Shetty AK, Lebouef RP, Gouri TP, Cowan GS, et al. Intravenous immunoglobulin therapy for children with Stevens-Johnson syndrome. J Rheumatol. 2000;27(10):2494–7.PubMedGoogle Scholar
  20. Pichler WJ, Naisbitt DJ, Park BK. Immune pathomechanism of drug hypersensitivity reactions. J Allergy Clin Immunol. 2011;127(3 Suppl):S74–81.PubMedGoogle Scholar
  21. Sassolas B, Haddad C, Mockenhaupt M, Dunant A, Liss Y, Bork K, et al. ALDEN, an algorithm for assessment of drug causality in Stevens-Johnson syndrome and toxic epidermal necrolysis: comparison with case-control analysis. Clin Pharmacol Ther. 2010;88(1):60–8.PubMedGoogle Scholar
  22. Schlapbach C, Zawodniak A, Irla N, Adam J, Hunger RE, Yerly D, et al. NKp46+ cells express granulysin in multiple cutaneous adverse drug reactions. Allergy. 2011;66(11):1469–76.PubMedGoogle Scholar
  23. Valeyrie-Allanore L, Wolkenstein P, Brochard L, Ortonne N, Maître B, Revuz J, et al. Open trial of ciclosporin treatment for Stevens-Johnson syndrome and toxic epidermal necrolysis. Br J Dermatol. 2010;163(4):847–53.PubMedGoogle Scholar
  24. Valeyrie-Allanore L, Bastuji-Garin S, Guégan S, Ortonne N, Bagot M, Roujeau JC, et al. Prognostic value of histologic features of toxic epidermal necrolysis. J Am Acad Dermatol. 2013;68(2):e29–35.PubMedGoogle Scholar

Further Reading

  1. Assier H, Bastuji-Garin S, Revuz J, Roujeau JC. Erythema multiforme with mucous membrane involvement and Stevens-Johnson syndrome are clinically different disorders with distinct causes. Arch Dermatol. 1995;131(5):539–43.PubMedGoogle Scholar
  2. Auquier-Dunant A, et al. Correlation between clinical patterns and causes of erythema multiforme major, Stevens Johnson and toxic epidermal necrolysis. Arch Dermatol. 2002;138(8):1019–24.PubMedGoogle Scholar
  3. Baldwin BT, Lien MH, Khan H, Siddique M. Case of fatal toxic epidermal necrolysis due to cardiac catheterization dye. J Drugs Dermatol. 2010;9(7):837–40.PubMedGoogle Scholar
  4. Bastuji-Garin S, Zahedi M, Guillaume JC, Roujeau JC. Toxic epidermal necrolysis (Lyell syndrome) in 77 elderly patients. Age Ageing. 1993;22(6):450–6.PubMedGoogle Scholar
  5. Brown KM, Silver GM, Halerz M, Walaszek P, Sandroni A, Gamelli RLKM. Toxic epidermal necrolysis: does immunoglobulin make a difference? J Burn Care Rehabil. 2004;25(1):81–8.PubMedGoogle Scholar
  6. Caproni M, Torchia D, Schincaglia E, Volpi W, Frezzolini A, Schena D, et al. The CD40/CD40 ligand system is expressed in the cutaneous lesions of erythema multiforme and Stevens-Johnson syndrome/toxic epidermal necrolysis spectrum. Br J Dermatol. 2006;154(2):319–24.PubMedGoogle Scholar
  7. Cartotto R, Mayich M, Nickerson D, Gomez M. SCORTEN accurately predicts mortality among toxic epidermal necrolysis patients treated in a burn center. J Burn Care Res. 2008;29(1):141–6.PubMedGoogle Scholar
  8. Chavan R, el-Azhary R. Cutaneous graft-versus-host disease: rationales and treatment options. Dermatol Ther. 2011;24(2):219–28.PubMedGoogle Scholar
  9. Chung WH, Shih SR, Chang CF, Lin TY, Huang YC, Chang SC, et al. Clinicopathologic analysis of coxsackievirus a6 new variant induced widespread mucocutaneous bullous reactions mimicking severe cutaneous adverse reactions. J Infect Dis. 2013;208(12):1968–78.PubMedGoogle Scholar
  10. Dobrosavlijevic D, Milinkoic MV, Nikolic MM. Toxic epidermal necrolysis following morbilli-parotitis-rubella vaccination. J Eur Acad Dermatol Venereol. 1999;13(1):59–61.Google Scholar
  11. Egan CA, Grant WJ, Morris SE, Saffle JR, Zone JJ. Plasmapheresis as an adjunct treatment in toxic epidermal necrolysis. J Am Acad Dermatol. 1999;40(3):458–61.PubMedGoogle Scholar
  12. Fischer M, Fiedler E, Marsch WC, Wohlrab J. Antitumour necrosis factor-alpha antibodies (infliximab) in the treatment of a patient with toxic epidermal necrolysis. Br J Dermatol. 2002;146(4):707–9.PubMedGoogle Scholar
  13. Fournier S, Bastuji-Garin S, Mentec H, Revuz J, Roujeau JC. Toxic epidermal necrolysis associated with mycoplasma pneumonia infection. Eur J Clin Microbiol Infect Dis. 1995;14(6):558–9.PubMedGoogle Scholar
  14. Fritsch PO, Sidoroff A. Drug-induced Stevens-Johnson syndrome/toxic epidermal necrolysis. Am J Clin Dermatol. 2000;1(6):349–60.PubMedGoogle Scholar
  15. Garcia-Doval I, LeCleach L, Bocquet H, Otero XL, Roujeau JC. Toxic epidermal necrolysis and Stevens-Johnson syndrome: does early withdrawal of causative drugs decrease the risk of death? Arch Dermatol. 2000;136(3):323–7.PubMedGoogle Scholar
  16. Garza A, Waldman AJ, Mamel J. A case of toxic epidermal necrolysis with involvement of the GI tract after systemic contrast agent application at cardiac catheterization. Gastrointest Endosc. 2005;62(4):638–42.PubMedGoogle Scholar
  17. Gentilhomme E, Faure M, Piemont Y, Binder P, Thivolet J. Action of staphylococcal exfoliative toxins on epidermal cell cultures and organotypic skin. J Dermatol. 1990;17(9):526–32.PubMedGoogle Scholar
  18. Goerz G, Tsambaos D. Eruptive nevocytic nevi after Lyell’s syndrome. Arch Dermatol. 1978;114(9):1400–1.PubMedGoogle Scholar
  19. Grando SA, Grando AA, Glukhenky BT, Doguzov V, Nguyen VT, Holubar K. History and clinical significance of mechanical symptoms in blistering dermatoses: a reappraisal. J Am Acad Dermatol. 2003;48(1):86–92.PubMedGoogle Scholar
  20. Gregory DG. Treatment of acute Stevens-Johnson syndrome and toxic epidermal necrolysis using amniotic membrane: a review of 10 consecutive cases. Ophthalmology. 2011;118(5):908–14.PubMedGoogle Scholar
  21. Gubinelli E, Canzona F, Tonanzi T, Raskovic D, Didona B. Toxic epidermal necrolysis successfully treated with etanercept. J Dermatol. 2009;36(3):150–3.PubMedGoogle Scholar
  22. Guégan S, Bastuji-Garin S, Poszepczynska-Guigné E, Roujeau JC, Revuz J. Performance of the SCORTEN during the first five days of hospitalization to predict the prognosis of epidermal necrolysis. J Invest Dermatol. 2006;126(2):272–6.PubMedGoogle Scholar
  23. Halebian PH, Corder VJ, Madden MR, Finklestein JL, Shires GT. Improved burn center survival of patients with toxic epidermal necrolysis managed without corticosteroids. Ann Surg. 1986;204(5):503–12.PubMedPubMedCentralGoogle Scholar
  24. Haute Autorité de la Santé. Sevices des bonnes pratiques professionnelles. Guide PNDS (Protocoles Nationaux de Diagnostic et de Soins) Syndromes de Stevens-Johnson et de Lyell. 2010. French.Google Scholar
  25. Hazin R, Ibrahimi OA, Hazin MI, Kimyai-Asadi A. Stevens-Johnson syndrome: pathogenesis, diagnosis, and management. Ann Med. 2008;40(2):129–38.PubMedGoogle Scholar
  26. Hung SI, Chung WH, Liou LB, Chu CC, Lin M, Huang HP, et al. HLA-B*5801 allele as a genetic marker for severe cutaneous adverse reactions caused by allopurinol. Proc Natl Acad Sci U S A. 2005;102(11):4134–9.PubMedPubMedCentralGoogle Scholar
  27. Hung SI, Chung WH, Liu ZS, Chen CH, Hsih MS, Hui RC, et al. Common risk allele in aromatic antiepileptic-drug induced Stevens-Johnson syndrome and toxic epidermal necrolysis in Han Chinese. Pharmacogenomics. 2010;11(3):349–56.PubMedGoogle Scholar
  28. Kaniwa N, Saito Y, Aihara M, Matsunaga K, Tohkin M, Kurose K, et al. HLA-B locus in Japanese patients with anti-epileptics and allopurinol-related Stevens-Johnson syndrome and toxic epidermal necrolysis. Pharmacogenomics. 2008;9(11):1617–22.PubMedGoogle Scholar
  29. Kashiwagi M, Aihara M, Takahashi Y, Yamazaki E, Yamane Y, Song Y, et al. Human leukocyte antigen genotypes in carbamazepine-induced severe cutaneous adverse drug response in Japanese patients. J Dermatol. 2008;35(10):683–5.PubMedGoogle Scholar
  30. Khalaf D, Toema B, Dabbour N, Jehani F. Toxic epidermal necrolysis associated with severe cytomegalovirus infection in a patient on regular hemodialysis. Mediterr J Hematol Infect Dis. 2011;3(1):e2011004.PubMedPubMedCentralGoogle Scholar
  31. Kim KJ, Lee DP, Suh HS, Lee MW, Choi JH, Moon KC, et al. Toxic epidermal necrolysis: analysis of clinical course and SCORTEN-based comparison of mortality rate and treatment modalities in Korean patients. Acta Derm Venereol. 2005;85(6):497–502.PubMedGoogle Scholar
  32. Kim SH, Lee KW, Song WJ, Kim SH, Jee YK, Lee SM, et al. Carbamazepine-induced severe cutaneous adverse reactions and HLA genotypes in Koreans. Epilepsy Res. 2011;97(1–2):190–7.PubMedGoogle Scholar
  33. Lehloenya RJ, Esmail F, Christians SJ, Motsepe D, Todd G. Toxic epidermal necrolysis with failure of re-epithelialization. Could umbilical cord mesenchymal stem cell transplantation have a role? J Eur Acad Dermatol Venereol. 2013a;27(7):923–5.Google Scholar
  34. Li X, Wang D, Lu Z, Chen J, Zhang H, Sun L. Answer to ‘Toxic epidermal necrolysis with failure of re-epithelialization. Could umbilical cord mesenchymal stem cell transplantation have a role?’. J Eur Acad Dermatol Venereol. 2013b;27(7):925.Google Scholar
  35. Li X, Wang D, Lu Z, Chen J, Zhang H, Sun L. Umbilical cord mesenchymal stem cell transplantation in drug-induced Stevens-Johnson syndrome. J Eur Acad Dermatol Venereol. 2013;27(5):659–61.PubMedGoogle Scholar
  36. Magina S, Lisboa C, Leal V, Palmares J, Mesquita-Guimarães J. Dermatological and ophthalmological sequels in toxic epidermal necrolysis. Dermatology. 2003;207(1):33–6.PubMedGoogle Scholar
  37. Mehta TY, Prajapati LM, Mittal B, Joshi CG, Sheth JJ, Patel DB, et al. Association of HLA-B*1502 allele and carbamazepine-induced Stevens-Johnson syndrome among Indians. Indian J Dermatol Venereol Leprol. 2009;75(6):579–82.PubMedGoogle Scholar
  38. Meneux E, Wolkenstein P, Haddad B, Roujeau JC, Revuz J, Paniel BJ. Vulvovaginal involvement in toxic epidermal necrolysis: a retrospective study of 40 cases. Obstet Gynecol. 1998;91(2):283–7.PubMedGoogle Scholar
  39. Miyauchi H, Hosokawa H, Akaeda T, Iba H, Asada Y. T-cell subsets in drug-induced toxic epidermal necrolysis. Possible pathogenic mechanism induced by CD8-positive T cells. Arch Dermatol. 1991;127(6):851–5.PubMedGoogle Scholar
  40. Narita YM, Hirahara K, Mizukawa Y, Kano Y, Shiohara T. Efficacy of plasmapheresis for the treatment of severe toxic epidermal necrolysis: is cytokine expression analysis useful in predicting its therapeutic efficacy? J Dermatol. 2011;38(3):236–45.PubMedGoogle Scholar
  41. Nassif A, Bensussan A, Dorothée G, Mami-Chouaib F, Bachot N, Bagot M, et al. Drug specific cytotoxic T-cells in the skin lesions of a patient with toxic epidermal necrolysis. J Invest Dermatol. 2002;118(4):728–33.PubMedGoogle Scholar
  42. Nassif A, Bensussan A, Boumsell L, Deniaud A, Moslehi H, Wolkenstein P, et al. Toxic epidermal necrolysis: effector cells are drug-specific cytotoxic T cells. J Allergy Clin Immunol. 2004;114(5):1209–15.PubMedGoogle Scholar
  43. 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. 2006;27(1):26–33.PubMedGoogle Scholar
  44. Paquet P, Piérard GE, Quatresooz P. Novel treatments for drug-induced toxic epidermal necrolysis (Lyell’s syndrome). Int Arch Allergy Immunol. 2005;136(3):205–16.PubMedGoogle Scholar
  45. Paul C, Wolkenstein P, Adle H, Wechsler J, Garchon HJ, Revuz J, et al. Apoptosis as a mechanism of keratinocyte death in toxic epidermal necrolysis. Br J Dermatol. 1996;134(4):710–4.PubMedGoogle Scholar
  46. Pereira FA, Mudgil AV, Rosmarin DM. Toxic epidermal necrolysis. J Am Acad Dermatol. 2007;56(2):181–200.PubMedGoogle Scholar
  47. Rajaratnam R, Mann C, Balasubramaniam P, Marsden JR, Taibjee SM, Shah F, et al. Toxic epidermal necrolysis: retrospective analysis of 21 consecutive cases managed at a tertiary centre. Clin Exp Dermatol. 2010;35(8):853–62.PubMedGoogle Scholar
  48. Revuz J, Penso D, Roujeau JC, Guillaume JC, Payne CR, Wechsler J, et al. Toxic epidermal necrolysis. Clinical findings and prognosis factors in 87 patients. Arch Dermatol. 1987;123(9):1160–5.PubMedGoogle Scholar
  49. Roujeau JC, Stern RS. Severe adverse cutaneous reactions to drugs. N Engl J Med. 1994;331(19):1272–85.PubMedGoogle Scholar
  50. Roujeau JC, Kelly JP, Naldi L, Rzany B, Stern RS, Anderson T, et al. Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. N Engl J Med. 1995;333(24):1600–7.PubMedGoogle Scholar
  51. Saiag P, Caumes E, Chosidow O, Revuz J, Roujeau JC. Drug-induced toxic epidermal necrolysis (Lyell syndrome) in patients infected with the human immunodeficiency virus. J Am Acad Dermatol. 1992;26(4):567–74.PubMedGoogle Scholar
  52. Shortt R, Gomez M, Mittman N, Cartotto R. Intravenous immunoglobulin does not improve outcome in toxic epidermal necrolysis. J Burn Care Rehabil. 2004;25(3):246–55.PubMedGoogle Scholar
  53. Tassaneeyakul W, Tiamkao S, Jantararoungtong T, Chen P, Lin SY, Chen WH, et al. Association between HLA-B*1502 and carbamazepine-induced severe cutaneous adverse drug reactions in a Thai population. Epilepsia. 2010;51(5):926–30.PubMedGoogle Scholar
  54. Tougeron-Brousseau B, Delcampe A, Gueudry J, Vera L, Doan S, Hoang-Xuan T, et al. Vision-related function after scleral lens fitting in ocular complications of Stevens-Johnson syndrome and toxic epidermal necrolysis. Am J Ophthalmol. 2009;148(6):852–9.PubMedGoogle Scholar
  55. Trent JT, Kirsner RS, Romanelli P, Kerdel FA. Use of the SCORTEN to accurately predict mortality in patients with toxic epidermal necrolysis in the United States. Arch Dermatol. 2004;140(7):890–2.PubMedGoogle Scholar
  56. Valeyrie-Allanore L, Ingen-Housz-Oro S, Colin A, Thuillot D, Sigal ML, Binhas M. Pain management in Stevens-Johnson syndrome, toxic epidermal necrolysis and other blistering diseases. Ann Dermatol Venereol. 2011;138(10):694–7 [Article in French].PubMedGoogle Scholar
  57. Viard I, Wehrli P, Bullani R, Schneider P, Holler N, Salomon D, et al. Inhibition of toxic epidermal necrolysis by blockade of CD95 with human intravenous immunoglobulin. Science. 1998;282(5388):490–3.PubMedGoogle Scholar
  58. Wilkins J, Morrison L, White Jr CR. Oculocutaneous manifestations of the erythema multiforme/Stevens-Johnson syndrome/toxic epidermal necrolysis spectrum. Dermatol Clin. 1992;10(3):571–82.PubMedGoogle Scholar
  59. Wolkenstein P, Latarjet J, Roujeau JC, Duguet C, Boudeau S, Vaillant L, et al. Randomised comparison of thalidomide versus placebo in toxic epidermal necrolysis. Lancet. 1998;352(9140):1586–9.PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Grace Obeid
    • 1
  • Laurence Valeyrie-Allanore
    • 1
  • Pierre Wolkenstein
    • 1
    Email author
  1. 1.Department of DermatologyHenri Mondor Hospital, UPECCréteil CedexFrance

Personalised recommendations