All-trans retinoic acid exacerbates Stevens-Johnson syndrome and toxic epidermal necrolysis via TNF signaling pathways: A network toxicology, molecular docking, and experimental study

Abstract

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe hypersensitivity reactions characterized by extensive epidermal necrosis, often induced by medications. This research aims to investigate the involvement of all-trans retinoic acid (ATRA), a derivative of vitamin A known to induce dermatological toxicity resembling SJS/TEN, in the development of these conditions. Utilizing network toxicology methodologies, molecular docking technology, and experimental validation, we identified 159 common targets between ATRA and SJS, 38 with TEN, and 27 shared among all three conditions through databases such as SwissTargetPrediction and GeneCards. Protein-protein interaction (PPI) network analyses highlighted key targets like TNF, MAPK1, and IL6, associated with apoptosis, inflammation, and immune regulation. Enrichment analyses identified significant pathways, particularly TNF, MAPK, and JAK-STAT signaling pathways. Molecular docking studies confirmed strong binding interactions between ATRA and these central targets. Experimental results demonstrated that ATRA treatment reduced keratinocyte viability, increased apoptosis, raised lactate dehydrogenase (LDH) release, and upregulated pro-inflammatory cytokines such as TNF-α, IL1B, IL6, and PTGS2 in human keratinocyte cell lines (HaCaT) and primary keratinocytes (NHEK).Western blot analysis revealed ATRA-induced upregulation of cleaved caspase-3 and phosphorylated NF-κB p65, alongside increased COX-2 and TNF-α protein levels, confirming activation of apoptotic and inflammatory pathways downstream of TNF signaling. These findings suggest that ATRA may exacerbate SJS/TEN pathogenesis by influencing apoptotic pathways and inflammatory responses via TNF-related mechanisms, offering insights for exploring therapeutic targets and enhancing drug safety in clinical settings.