Inflammatory Markers Aid in Improving Mortality Prognostication of Epidermal Necrolysis

Haur Yeuh Lee, MBBS

A new investigation from Singapore concluded that novel inflammatory markers such as red cell distribution width to hemoglobin ratio (RDW/Hb) were useful in improving the mortality prognostication of epidermal necrolysis.

These markers were particularly useful when paired with the Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN).

Regarding the condition, epidermal necrolysis is a severe cutaneous adverse reaction that involves severe systemic inflammation results in extensive epithelial keratinocyte necrosis.

Haur Yeuh Lee, MBBS, Department of Dermatology, Singapore General Hospital, and fellow investigators noted that SCORTEN is the most commonly used prognostic score in epidermal necrolysis.

Additionally, they hypothesized that the identification of independent prognostic markers could aid in stratifying the risk of the condition more thoroughly.

The Methods

For their study, Lee and colleagues evaluated the association between novel inflammatory markers and in-hospital mortality in patients with epidermal necrolysis over a 17-year period from 2003 to 2019.

A total of 192 patients were enrolled in study, all of whom were selected from the national referral center for epidermal necrolysis in Singapore General Hospital.

A total of 114 patients (59.4%) were women, with the median age of this cohort being 56 years. Patients were divided into 4 risk groups, with the inflammatory marker RDW/Hb having been applied to all 4 groups.

Lee and colleagues considered in-hospital mortality rates to been the main outcome assessed in the study, while discrimination and calibration of risk scores were assessed using the area under the receiver operating characteristic curve (AUC) and calibration plot, respectively.

Finally, the evaluation f the incremental prognostic value of these markers was done with a comparison of the AUC between the old and new risk scores, as well as the use of net reclassification improvement (NRI) and integrated discrimination improvement (IDI).

The Findings

Investigators noted that among the total 192 patients included in the study, 43 (22.4%) did not survive the discharge.

Of the novel inflammatory markers, only red cell distribution width to hemoglobin ratio was significant in the prediction of in-hospital mortality after adjusting for SCORTEN (odds ratio [OR] 3.55; 95% CI, 1.76-7.16; P < .001).

When applied in the 4 risk groups, RDW/Hb showed similar discrimination to SCORTEN (AUC [95% CI]: RDW/Hb in 4 groups, 0.76 [0.69-0.84], vs SCORTEN, 0.78 [0.70-0.85], P = .89).

Additionally, when RDW/Hb was added to SCORTEN, the composite score Re-SCORTEN showed significantly better discrimination than SCORTEN alone (AUC [95% CI]: Re-SCORTEN, 0.83 [0.77-0.89], vs SCORTEN, 0.78 [0.70-0.85], P = .02).

The overall NRI was 0.94 (95% CI, 0.68-1.20), P < .001, while the IDI was 0.06 (95% CI 0.03-0.08), P < .001.

Finally, Lee and investigators noted that re-SCORTEN showed good calibration based on the calibration plot.

“In this cohort of patients, RDW/Hb, an inexpensive and readily available marker, showed similar predictive accuracy with SCORTEN,” the team wrote. “Furthermore, when used in combination with SCORTEN, it also helped augment prognostic ability.”

The study, “Improvement of Mortality Prognostication in Patients With Epidermal NecrolysisThe Role of Novel Inflammatory Markers and Proposed Revision of SCORTEN (Re-SCORTEN),” was published online in JAMA Dermatology.