Toxic epidermal necrolysis (TEN) is associated with a 30% death rate. Tumour necrosis factor a (TNF-α) has been implicated in the pathogenesis of TEN. Thalidomide is a potent inhibitor of TNF-α action. We did a double-blind, randomised, placebo-controlled study of thalidomide in TEN.

The patients received a 5-day course of thalidomide 400 mg daily or placebo. The main endpoint was the progression of skin detachment after day 7. Secondary endpoints were the severity of the disease, evaluated with the simplified acute physiology score (SAPS), and the mortality. TNF-α and interleukin 6 were measured.

The study was stopped because there was excess mortality in the thalidomide group—ten of 12 patients died compared with three of ten in the placebo group (Fisher's exact test with Katz's approximation, relative risk=2·78, p=0·03). After adjustment for SAPS, mortality remained significantly higher in the thalidomide group than in the placebo group (exact logistic regression mid-p=0·007; 95% CI for odds ratio 2·7 to infinity). Plasma TNF-α concentration was higher in the thalidomide group than the placebo group on day 2, though the difference was not significant (Wilcoxon rank-sum test p=0·07).

Even though few patients were included, our data suggest that thalidomide is detrimental in TEN, possibly because of a paradoxical enhancement of TNF-α production.