Toxic epidermal necrolysis due to administration of celecoxib (Celebrex). (Letters to the Editor).

To the Editor: I read with interest the article by Friedman et alt describing a serious and potentially fatal skin reaction in a patient treated with celecoxib, a cyclooxygenase-2 inhibitor. As the potential for therapeutic applications of the cyclooxygenase inhibitors continues to increase, vigilance for adverse reactions and interactions of this class of drugs must also increase. I would like to make two points about this drug and its potential for skin reactions in regards to the case report by Friedman et al. (1) Erythema multiforme (EM) and a Stevens-Johnson syndrome (SJS)type reaction with celecoxib have been described. (2,3) The most recent of these reports was interesting in that cross-reactivity with glyburide, a sulfonamide derivative, was also postulated. (3) These cases support Freidman et al's observation that the drug was probably responsible for the skin reaction in their patient and adds weight to the importance of their case report. Second, the terminology and classification of these skin re actions requires some attention. As correctly stated by Friedman et al, the skin reaction noted in their patient "has been variously identified" so that the terms erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis have all been used to describe similar cases. Bastuji-Garin et al (4) proposed a clinical classification system for toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme based on the pattern of skin lesions and the extent of epidermal detachment. The following categories were recognized:

* Bullous erythema multiforme

* Detachment below 10% of the body surface area plus localized typical targets or raised atypical targets

* Detachment below 10% of the body surface area plus widespread erythematous or purpuric macules or flat atypical targets

* Detachment between 10% and 30% of the body surface area plus widespread purpuric macules or flat atypical targets

* Toxic epidermal necrolysis with spots

* Detachment above 30% of the body surface area plus widespread purpuric macules or flat atypical targets and toxic epidermal necrolysis with spots and with detachment above 10% of the body surface area with large epidermal sheets and without any purpuric macule or target

This clinical classification may simplify reporting of skin drug reactions of this nature and also allow for better clarity in the terminology relating to these cases.

Pierre Giglio, MD

M.D. Anderson Cancer Center

Houston, TX

References

(1.) Friedman B, Orlet HK, Still JM, Law E. Toxic epidermal necrolysis due to administration of celecoxib (Celebrex). South Med J 2002;95:1213-1214.

(2.) Gill S, Hermolin RH. Case report of a Stevens-Johnson type reaction to celecoxib. Can J Hasp Pharm 2001;54(2):146 (abstr).

(3.) Ernst EJ, Egge JA. Celecoxib-induced erythema multiforme with glyburide cross-reactivity. Pharmacotherapy 2002;22:637-640.

(4.) Bastuji-Garin S, Rzany B, Stem RS, Shear NH, Naldi L, Roujcau JC. Clinical classification of cases of toxic epidermal necrolysis, Stevens-Johnson syndrome, and etythema multiforme. Arch Dermatol 1993;129:92-96.