The efficacy of intravenous immunoglobulin for the treatment of toxic epidermal necrolysis: a systematic review and meta-analysis

Background Quantitative analysis of intravenous immunoglobulin (IVIg) treatment against toxic epidermal necrolysis (TEN) is lacking. Objectives To provide a meta-analysis evidence-based examination of IVIg efficacy against TEN. Methods A systematic review and meta-analysis of literature published before 31 July 2011 was conducted. In observational controlled studies with at least eight patients with TEN receiving IVIg treatment, a pooled estimate of mortality risk was determined, comparing IVIg and supportive care. Statistical analyses were performed on raw data to compare the clinical differences between (i) high-dose and low-dose IVIg treatment in adult patients and (ii) paediatric and adult patients treated with IVIg. Results Seventeen studies met inclusion criteria. Overall mortality rate of patients with TEN treated with IVIg was 19.9%. The pooled odds ratio (OR) for mortality from six observational controlled studies comparing IVIg and supportive care was 1.00 [95% confidence interval (CI) 0.58-1.75; P = 0.99]. The pooled OR for mortality in patients treated with high-dose IVIg vs. supportive care was 0.63 (95% CI 0.27-1.44; P = 0.27). Adults treated with high-dose IVIg exhibited significantly lower mortality than those treated with low-dose IVIg (18.9% vs. 50%, respectively; P = 0.022); however, multivariate logistic regression model adjustment indicated that IVIg dose does not correlate with mortality (high vs. low dose: OR 0.494; 95% CI 0.106-2.300; P = 0.369). Paediatric patients treated with IVIg had significantly lower mortality than adults (0% vs. 21.6%; P = 0.001). Conclusions Although high-dose IVIg exhibited a trend towards improved mortality and children treated with IVIg had a good prognosis, the evidence does not support a clinical benefit of IVIg. Randomized controlled trials are necessary.