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Lee SG, Kim SE, Jeong IH, Lee SE. Mechanism underlying pruritus in recessive dystrophic epidermolysis bullosa: Role of interleukin-31 from mast cells and macrophages. J Eur Acad Dermatol Venereol 2024; 38:895-903. [PMID: 38084871 DOI: 10.1111/jdv.19738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/26/2023] [Indexed: 04/26/2024]
Abstract
BACKGROUND Pruritus is a highly burdensome symptom in patients with epidermolysis bullosa, especially recessive dystrophic epidermolysis bullosa (RDEB); however, only a few studies have assessed the molecular pathogenesis of RDEB-associated pruritus. Interleukin (IL)-31 is a key cytokine implicated in pruritus associated with dermatologic diseases such as atopic dermatitis and prurigo nodularis. OBJECTIVE To investigate the role and cellular source of IL-31 in RDEB-associated pruritus. METHODS Serum and skin samples were obtained from 11 RDEB patients and 11 healthy controls. Pruritus visual analogue scale scores were determined. Serum levels of IL-31 and thymic stromal lymphopoietin (TSLP) were examined by enzyme-linked immunosorbent assay (ELISA). The expression of IL-31 and other pruritus mediators in the skin were examined through immunofluorescence staining, and their correlation with pruritus severity was analysed. RESULTS Serum IL-31 and TSLP were elevated in RDEB patients. IL-31 expression was increased in RDEB skin and positively correlated with pruritus severity. Most of the IL-31-expressing cells were mast cells, and some were CD206(+) M2-like macrophages. The number of substance P(+) cells was also increased in the patients' skin, and most of them were mast cells. The number of substance P(+) mast cells was correlated with the number of IL-31(+) dermal infiltrates. The number of IL-4Rα- and IL-13-expressing cells and expression of TSLP and periostin increased in RDEB skin, but without a correlation to pruritus score. CONCLUSION The increased production of skin IL-31 from mast cells and M2-like macrophages may be the mechanism underlying pruritus in RDEB.
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Affiliation(s)
- Sang Gyun Lee
- Department of Dermatology, Gangnam Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Song-Ee Kim
- Department of Dermatology, Gangnam Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - In-Hye Jeong
- Department of Dermatology, Gangnam Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Eun Lee
- Department of Dermatology, Gangnam Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Kwon IJ, Kim SE, Kim SC, Lee SE. Efficacy of oral JAK1 or JAK1/2 inhibitor for treating refractory pruritus in dystrophic epidermolysis bullosa: A retrospective case series. J Dermatol 2024; 51:441-447. [PMID: 38115742 DOI: 10.1111/1346-8138.17079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 11/22/2023] [Accepted: 12/02/2023] [Indexed: 12/21/2023]
Abstract
Refractory pruritus is the most distressing, disease-related symptom in patients with dystrophic epidermolysis bullosa (DEB), inducing an itch-scratch-blister cycle. Chronic inflammation is a hallmark of DEB, thus upregulation of inflammatory cytokines and Janus kinase (JAK) signaling may play a role in DEB-related pruritus. We retrospectively reviewed the medical records of DEB patients with refractory pruritus who were treated with either baricitinib, a JAK1/2 inhibitor, or upadacitinib, a selective JAK1 inhibitor. Patients received baricitinib (4 mg) or upadacitinib (15 mg) once a day for 2-32 weeks. A total of 12 DEB patients (six recessive DEB and six dominant DEB) were included in this study. The mean±SD baseline pruritus visual analog scale (VAS) score was 7.5 ± 1.7. Upadacitinib or baricitinib treatment resulted in a rapid and sustained decrease in itch. Four out of 12 patients (33.3%) and seven out of 10 patients (70%) showed a decrease of at least 3 points in the pruritus VAS score from baseline at weeks 2 and 4, respectively. The mean percentage changes from baseline in pruritus VAS scores at weeks 2 and 4 were -42.9% and -52.7%, respectively. Subgroup analysis showed greater reductions in the pruritus VAS score in the baricitinib group (n = 5) compared to the upadacitinib group (n = 7), and in patients with epidermolysis bullosa pruriginosa (n = 3) compared to other subtypes of DEB (n = 9); however, these differences did not reach statistical significance. Three out of 10 (33.3%) patients showed at least a 2-point reduction in pain intensity from baseline at week 4. Eight out of 12 patients (66.7%) also showed a reduction in the number of new blisters, which correlated with a reduction in the pruritus score. No patient discontinued treatment because of serious adverse events. Our results suggest that JAK1 or JAK1/2 inhibitors could be a promising treatment option for DEB-related pruritus. Long-term safety should be assessed in future studies.
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Affiliation(s)
- Il Joo Kwon
- Department of Dermatology, Gangnam Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Song-Ee Kim
- Department of Dermatology, Gangnam Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Soo-Chan Kim
- Department of Dermatology, Yongin Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, Yongin, Korea
| | - Sang Eun Lee
- Department of Dermatology, Gangnam Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Alheggi A, Alnutaifi R, Alkhonezan M, Almudawi N, Alsuhaibani R, Moons P, Aljuhani T. Measuring the impact of pruritus in patients with epidermolysis bullosa: evaluation with an itch-specific instrument. Dermatol Reports 2023; 15:9700. [PMID: 38327591 PMCID: PMC10848646 DOI: 10.4081/dr.2023.9700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 04/03/2023] [Indexed: 02/09/2024] Open
Abstract
Pruritus is one of the most debilitating symptoms for patients with epidermolysis bullosa (EB). This study aimed to assess the burden of itch and to address its dimensions across patients with EB. Forty-six patients with EB were recruited from the Saudi EB registry to participate. All participants completed the Leuven Itch Scale. The sample included 5 patients with EB simplex (EBS), 3 with junctional EB (JEB), 34 with dystrophic EB (DEB), and 4 patients had unknown type. Overall, 97.8% patients reported itch. In patients with itch, 73.3% reported that it was often or always present, longer than 2h Itch episodes was reported by JEB (66.7%) and recessive DEB (3.2%). Itch, in all its dimensions, was worst in patients with JEB and DEB than EBS. Itch occurred mostly in a hot environment (80%), when sweating (71.1%), in healing wounds (40%), and during dressing change (35.6%) whereas cold environment resulted in itch in only (2.2%). The burden of pruritus increased with increasing age. This study highlights a challenging area in EB care with a need for specific treatments.
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Affiliation(s)
- Ashjan Alheggi
- Department of Dermatology, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Raneem Alnutaifi
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Manal Alkhonezan
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Norah Almudawi
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Renad Alsuhaibani
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Philip Moons
- KU Leuven Department of Public Health and Primary Care, KU Leuven, Belgium; Institute of Health and Care Sciences, University of Gothenburg, Sweden
| | - Turki Aljuhani
- Department of Dermatology, King Fahad University Hospital, Khober, Saudi Arabia
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4
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Rangu S, Collins J, García-Romero MT, Augsburger BD, Bruckner AL, Diaz LZ, Eichenfield LF, Faig W, Gorell ES, Lefferdink R, Lucky AW, Morel KD, Paller AS, Park H, Pastrana-Arellano E, Peoples K, Wiss K, Perman MJ, Castelo-Soccio L. Assessing pain catastrophizing and functional disability in pediatric epidermolysis bullosa patients. Pediatr Dermatol 2023; 40:422-427. [PMID: 36579717 PMCID: PMC11089464 DOI: 10.1111/pde.15220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/24/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND/OBJECTIVES The primary objective was to assess pain catastrophizing and functional disability in pediatric patients with epidermolysis bullosa (EB) and their parents/guardians. Secondary objectives included examining relationships between pain catastrophizing, functional disability, and correlations with other factors (e.g., age, disease severity, and percent of body surface area (BSA) involved). METHODS Patients with EB ages 8-16 and their parents/guardians who were English or Spanish speaking completed a one-time online survey. Parent measures included: demographics questionnaire, Pain Catastrophizing Scale-Parent (PCS), and Parent Functional Disability Inventory (FDI). Child measures included: PCS child and child FDI. Higher scores on both scales indicate higher levels of catastrophizing and functional disability. RESULTS Of 31 children, the mean age was 11.47 years and the majority (70.97%) had dystrophic EB. Mean scores were: 35.84 = PCS parent; 34.58 = PCS child; 30.87 = parent FDI; 29.77 = child FDI. Total scores for PCS parent, parent FDI, and child FDI increased significantly with disease severity and percentage of involved BSA (p < .01 for all). Total scores for PCS child increased significantly with percent of EB skin involvement (p = .04) but not disease severity. Older children reported more functional disability than their parents and younger children (p = .02). CONCLUSIONS Our results demonstrate significant positive correlations between negative thoughts related to pain and the experience of functional difficulties in patients with EB and their caregivers. Psychological, psychiatric, and/or behavioral interventions to help managing chronic pain may be effective for patients with EB.
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Affiliation(s)
- Sneha Rangu
- Section of Dermatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jessica Collins
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Bret D. Augsburger
- Department of Dermatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Anna L. Bruckner
- Department of Dermatology, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Lucia Z. Diaz
- Division of Dermatology and Dermatologic Surgery, Department of Internal Medicine, Dell Medical School at the University of Texas at Austin, Austin, Texas, USA
| | - Lawrence F. Eichenfield
- Department of Dermatology, University of California San Diego, San Diego, California, USA
- Department Pediatrics, University of California San Diego, San Diego, California, USA
- Pediatric and Adolescent Dermatology, Rady Children’s Hospital San Diego, San Diego, California, USA
| | - Walter Faig
- Children’s Hospital of Philadelphia, Research Institute, Philadelphia, Pennsylvania, USA
| | - Emily S. Gorell
- Department of Dermatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California, USA
| | - Rachel Lefferdink
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Anne W. Lucky
- Department of Dermatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kimberly D. Morel
- Department of Dermatology, Vagelos College of Physicians & Surgeons, Columbia University Medical Center, New York, New York, USA
- Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University Medical Center, New York, New York, USA
| | - Amy S. Paller
- Children’s Hospital of Philadelphia, Research Institute, Philadelphia, Pennsylvania, USA
| | - Helen Park
- Department Pediatrics, University of California San Diego, San Diego, California, USA
| | | | - Kathleen Peoples
- Department of Dermatology, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Karen Wiss
- Department of Dermatology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Marissa J. Perman
- Section of Dermatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Leslie Castelo-Soccio
- Section of Dermatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- National Institutes of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Saki N, Vahedi S, Parvizi MM, Shafie'ei M, Hosseini SA, Ahramiyanpour N. Topical gabapentin 10% in the treatment of epidermolysis bullosa pruritus: A pilot, double‐blind, split‐site, randomized controlled trial. Dermatol Ther 2022; 35:e15767. [DOI: 10.1111/dth.15767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/03/2022] [Accepted: 08/10/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Nasrin Saki
- Molecular Dermatology Research Center Shiraz University of Medical Sciences Shiraz Iran
- Dermatology Department, School of Medicine Shiraz University of Medical Sciences Shiraz Iran
| | - Samira Vahedi
- Dermatology Department, School of Medicine Shiraz University of Medical Sciences Shiraz Iran
| | - Mohammad Mahdi Parvizi
- Molecular Dermatology Research Center Shiraz University of Medical Sciences Shiraz Iran
- Dermatology Department, School of Medicine Shiraz University of Medical Sciences Shiraz Iran
| | | | - Seyed Ali Hosseini
- Molecular Dermatology Research Center Shiraz University of Medical Sciences Shiraz Iran
| | - Najmeh Ahramiyanpour
- Assistant Professor of Dermatology, Department of Dermatology, Afzalipour Hospital, Afzalipour Faculty of Medicine Kerman University of Medical Sciences Kerman Iran
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Kubanov AA, Chikin VV, Karamova AE, Monchakovskaya ES. Topical treatment of inherited epidermolysis bullosa. VESTNIK DERMATOLOGII I VENEROLOGII 2021. [DOI: 10.25208/vdv1290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Inherited epidermolysis bullosa is a group of genetic skin disorders characterized by skin erosions, ulceration, skin and mucosal blistering requiring topical treatment. This review demonstrates major clinical manifestations of epidermolysis bullosa and its mechanisms of development. According to these features the main principles of topical treatment and drug therapy were developed, including physical protection from trauma, moisturizing, improvement of wound healing, prevention and management of infection, itch and pain management. Drug therapy is outlined with dosage forms, drug routes of administration, age restrictions indicated in the instruction for medical use for the medications that could be used in epidermolysis bullosa patients. The authors provide indications for clinical use of antiseptics, disinfectants, antibiotics, antimicrobial agents, emollient cream and drugs reducing itch and pain.
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7
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Lucky AW, Pope E. Pregnancy in epidermolysis bullosa: long-awaited guidelines of care. Br J Dermatol 2021; 186:602-603. [PMID: 34841510 DOI: 10.1111/bjd.20897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 10/24/2021] [Indexed: 11/26/2022]
Affiliation(s)
- A W Lucky
- Cincinnati Children's Epidermolysis Bullosa Center, Cincinnati Children's Hospital and, The University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - E Pope
- Division of Paediatric Dermatology, The Hospital for Sick Children and Professor of Pediatrics, University of Toronto, Toronto, ON, Canada
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8
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Brooks Peterson M, Strupp KM, Brockel MA, Wilder MS, Zieg J, Bruckner AL, Kaizer AM, Szolnoki JM. Anesthetic Management and Outcomes of Patients With Epidermolysis Bullosa: Experience at a Tertiary Referral Center. Anesth Analg 2021; 134:810-821. [PMID: 34591805 DOI: 10.1213/ane.0000000000005749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Epidermolysis bullosa (EB) is a group of rare epithelial disorders caused by abnormal or absent structural proteins at the epidermal-dermal junction. As a result, patients experience blisters and wounds from mild shearing forces. Some forms of EB are complicated by resultant scarring and contractures. The perioperative anesthetic management of patients with EB is complex and requires a systems-based approach to limit harm. We reviewed our experience with providing general anesthesia to patients at our tertiary EB referral center, including adverse events related to anesthetic care, outcomes in the immediate perioperative period, and details of anesthetic management. METHODS We retrospectively reviewed the charts of all patients with EB anesthetized at the Children's Hospital Colorado between January 2011 and December 2016. A subset of pediatric anesthesiologists cared for all patients using a standardized clinical care pathway. Patient demographics, detailed anesthetic methods, immediate perioperative outcomes, and adverse events were characterized. RESULTS Over a 6-year period, 37 patients underwent 202 general anesthetics. Most patients (75.7%) had dystrophic EB (DEB). Female patients comprised 48.6%. The majority (56.7%) traveled >50 miles to receive care, and many (35.1%) traveled >150 miles for their care. Common adaptations to care included avoidance of electrocardiogram leads (88.6%) and temperature probes (91.6%). Nasal fiberoptic intubation (n = 160) was performed, or natural airway/mask (n = 27) was maintained for most patients. Supraglottic devices were not used for airway management during any of the anesthetics. Anesthesia preparation time was longer (average 25.8 minutes [standard deviation {SD} = 12.7]) than our average institutional time (14 minutes). Succinylcholine was never used, and nondepolarizing muscle relaxants were used in only 1.5% of patient encounters. Blood was transfused in 16.3% of cases and iron infused in 24.8%. Average length of stay in the postanesthesia care unit was comparable to our institutional average (average 40.1 [SD = 28.6] vs 39 minutes). New skin or mucosal injury occurred in 8 encounters (4%), and desaturation occurred in 43 cases (21.3%). There were no major adverse events. CONCLUSIONS By using a specialized team and a standardized clinical care pathway, our institution was able to minimize adverse events caused by the anesthetic and surgical care of patients with EB. We recommend natural airway or nasal fiberoptic airway management, meticulous avoidance of shear stress on the skin, and a multidisciplinary approach to care. Supportive therapy such as perioperative blood transfusions and iron infusions are feasible for the treatment of chronic anemia in this population.
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Affiliation(s)
- Melissa Brooks Peterson
- From the Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Kim M Strupp
- From the Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Megan A Brockel
- From the Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Matthew S Wilder
- Department of Dermatology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Jennifer Zieg
- From the Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado.,Department of Anesthesiology and Critical Care, Rady Children's Hospital, San Diego, California.,Department of Dermatology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado.,Department of Biostatistics and Informatics, University of Colorado-Anschutz Medical Campus, Aurora, Colorado.,Department of Anesthesiology, Nemours Children's Hospital, University of Central Florida, Orlando, Florida
| | - Anna L Bruckner
- Department of Dermatology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Alexander M Kaizer
- Department of Biostatistics and Informatics, University of Colorado-Anschutz Medical Campus, Aurora, Colorado
| | - Judit M Szolnoki
- Department of Anesthesiology, Nemours Children's Hospital, University of Central Florida, Orlando, Florida
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9
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Lee SE, Lee SJ, Kim SE, Kim K, Cho B, Roh K, Kim SC. Intravenous allogeneic umbilical cord blood-derived mesenchymal stem cell therapy in recessive dystrophic epidermolysis bullosa patients. JCI Insight 2021; 6:143606. [PMID: 33491668 PMCID: PMC7934866 DOI: 10.1172/jci.insight.143606] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 12/09/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Recessive dystrophic epidermolysis bullosa (RDEB) is an incurable disease that causes severe mucocutaneous fragility due to mutations in COL7A1 (encoding type VII collagen [C7]). In this phase I/IIa trial, we evaluated the safety and possible clinical efficacy of intravenous infusion of allogeneic human umbilical cord blood–derived mesenchymal stem cells (hUCB-MSCs) in patients with RDEB. METHODS Four adult and two pediatric patients with RDEB were treated with 3 intravenous injections of hUCB-MSCs (1 × 106 to 3 × 106 cells/kg) every 2 weeks and followed up for 8–24 months after treatment. The primary endpoint was safety. Secondary endpoints related to efficacy included clinical parameters, such as disease severity score, wound assessment, itch and pain score, and quality of life. C7 expression levels and inflammatory infiltrates in the skin, as well as serum levels of inflammatory markers and neuropeptides, were also assessed. RESULTS Intravenous hUCB-MSC infusions were well tolerated, without serious adverse events. Improvements in the Birmingham Epidermolysis Bullosa Severity Score, body surface area involvement, blister counts, pain, pruritus, and quality of life were observed with maximal effects at 56–112 days after treatment. hUCB-MSC administration induced M2 macrophage polarization and reduced mast cell infiltration in RDEB skin. Serum levels of substance P were decreased after therapy. Increased C7 expression was observed at the dermoepidermal junction in 1 of 6 patients at day 56. CONCLUSION To the best of our knowledge, this is the first clinical trial of systemic administration of allogeneic hUCB-MSCs in patients with RDEB, demonstrating safety and transient clinical benefits. TRIAL REGISTRATION ClinicalTrials.gov NCT04520022. FUNDING This work was supported by Daewoong Pharmaceutical Co. Ltd. and Kangstem Biotech Co. Ltd.
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Affiliation(s)
- Sang Eun Lee
- Department of Dermatology and Cutaneous Biology Research Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung-Ju Lee
- Department of Dermatology and Cutaneous Biology Research Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Song-Ee Kim
- Department of Dermatology and Cutaneous Biology Research Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Kinam Kim
- Cellular Therapeutics Team, Daewoong Pharmaceutical Co. Ltd., Seoul, South Korea
| | - Boyoung Cho
- Cellular Therapeutics Team, Daewoong Pharmaceutical Co. Ltd., Seoul, South Korea
| | - Kyounghwan Roh
- Department of Clinical Development, Kangstem Biotech Co. Ltd., Seoul, South Korea
| | - Soo-Chan Kim
- Department of Dermatology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, South Korea
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10
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Papanikolaou M, Onoufriadis A, Mellerio JE, Nattkemper LA, Yosipovitch G, Steinhoff M, McGrath JA. Prevalence, pathophysiology and management of itch in epidermolysis bullosa. Br J Dermatol 2020; 184:816-825. [PMID: 32810291 DOI: 10.1111/bjd.19496] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2020] [Indexed: 12/18/2022]
Abstract
Epidermolysis bullosa (EB) is a highly diverse group of inherited skin disorders, resulting from mutations in genes encoding proteins of the dermoepidermal junction. Itch (pruritus) is one of the most common symptoms across all EB subtypes. It occurs in blistered or wounded sites, or manifests as a generalized phenomenon, thereby affecting both intact skin and healing wounds. The mechanism of pruritus in EB is unclear. It is likely that skin inflammation secondary to barrier disruption, wound healing cascades and dysregulated activation of epidermal sensory nerve endings are all involved in its pathophysiology on the molecular and cellular level. Understanding these mechanisms in depth is crucial in developing optimized treatments for people with EB and improving quality of life. This review summarizes current evidence on the prevalence, mechanisms and management of itch in EB.
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Affiliation(s)
- M Papanikolaou
- St John's Institute of Dermatology, School of Basic and Medical Biosciences, King's College London, London, UK
| | - A Onoufriadis
- St John's Institute of Dermatology, School of Basic and Medical Biosciences, King's College London, London, UK
| | - J E Mellerio
- St John's Institute of Dermatology, School of Basic and Medical Biosciences, King's College London, London, UK
| | - L A Nattkemper
- Dr Phillip Frost Department of Dermatology & Cutaneous Surgery and Miami Itch Centre, University of Miami Miller School of Medicine, Miami, FL, USA
| | - G Yosipovitch
- Dr Phillip Frost Department of Dermatology & Cutaneous Surgery and Miami Itch Centre, University of Miami Miller School of Medicine, Miami, FL, USA
| | - M Steinhoff
- Department of Dermatology, Hamad Medical Corporation, Weill Cornell Medicine-Qatar, Doha, Qatar.,Translational Research Institute, Hamad Medical Corporation, Weill Cornell Medicine-Qatar, Doha, Qatar.,Weill Cornell Medicine, New York, NY, USA
| | - J A McGrath
- St John's Institute of Dermatology, School of Basic and Medical Biosciences, King's College London, London, UK
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11
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Chiou AS, Choi S, Barriga M, Dutt-Singkh Y, Solis DC, Nazaroff J, Bailey-Healy I, Li S, Shu K, Joing M, Kwon P, Tang JY. Phase 2 trial of a neurokinin-1 receptor antagonist for the treatment of chronic itch in patients with epidermolysis bullosa: A randomized clinical trial. J Am Acad Dermatol 2019; 82:1415-1421. [PMID: 31541747 DOI: 10.1016/j.jaad.2019.09.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 08/19/2019] [Accepted: 09/09/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Chronic pruritus causes major morbidity in epidermolysis bullosa (EB). The substance P-neurokinin 1 receptor (SP-NK1) pathway is a promising target for treating EB-related pruritus. OBJECTIVE To evaluate the safety and efficacy of the oral NK1 receptor antagonist serlopitant in treating moderate-severe pruritus in EB. METHODS The study randomized 14 patients to serlopitant or placebo for 8 weeks, followed by a 4-week washout and optional open-label extension. The primary end point was change in itch as measured by the Numeric Rating Scale. Secondary end points were change in itch during dressing changes and wound size. RESULTS We observed greater itch reduction with serlopitant, equivalent to a 0.64-point comparative reduction on the 11-point Numeric Rating Scale by week 8, although this failed to meet statistical significance (P = .11). More serlopitant patients achieved ≥3-point reduction compared with placebo (43% vs 14%, P = .35). In post hoc analysis excluding 1 patient with a concurrent seborrheic dermatitis flare, serlopitant achieved significantly greater median itch reduction from baseline by week 4 (-2 points vs 0, P = .01). We observed no statistically significant differences in secondary end points. Serlopitant was well-tolerated. LIMITATIONS Small sample size due to disease rarity. CONCLUSION The potential itch reduction with serlopitant observed in this trial will be pursued by a larger powered trial (NCT03836001).
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Affiliation(s)
- Albert S Chiou
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California.
| | - Sara Choi
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
| | - Melissa Barriga
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
| | - Yana Dutt-Singkh
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
| | - Daniel C Solis
- Department of Internal Medicine, University of California, Riverside, California
| | - Jaron Nazaroff
- University of California, Irvine School of Medicine, Irvine, California
| | - Irene Bailey-Healy
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
| | - Shufeng Li
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
| | - Kim Shu
- Menlo Therapeutics Inc (formerly Tigercat Pharma, Inc), Redwood City, California
| | - Mark Joing
- Menlo Therapeutics Inc (formerly Tigercat Pharma, Inc), Redwood City, California
| | - Paul Kwon
- Menlo Therapeutics Inc (formerly Tigercat Pharma, Inc), Redwood City, California
| | - Jean Y Tang
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
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12
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Abstract
Epidermolysis bullosa (EB) refers to a heterogeneous group of genetic disorders characterized by epithelial fragility. We provide guidelines for management of pediatric patients with EB in the emergency department based on a review of literature, as well as insights from our own experiences caring for patients with EB. The purpose of the guidelines proposed is prevention of avoidable iatrogenic trauma to the skin and mucosa of patients with EB who are presenting to the emergency department for a variety of reasons.
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13
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Martin K, Geuens S, Asche JK, Bodan R, Browne F, Downe A, García García N, Jaega G, Kennedy B, Mauritz PJ, Pérez F, Soon K, Zmazek V, Mayre-Chilton KM. Psychosocial recommendations for the care of children and adults with epidermolysis bullosa and their family: evidence based guidelines. Orphanet J Rare Dis 2019; 14:133. [PMID: 31186066 PMCID: PMC6560722 DOI: 10.1186/s13023-019-1086-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 05/01/2019] [Indexed: 12/13/2022] Open
Abstract
Epidermolysis Bullosa (EB) is a group of rare genetic disorders resulting in skin fragility and other symptoms. Commissioned by DEBRA International and funded by DEBRA Norway, this evidence-bases guideline provides recommendations to optimise psychosocial wellbeing in EB.An international multidisciplinary panel of social and health care professionals (HCP) and people living with EB was formed. A systematic international literature review was conducted by the panel following the Scottish Intercollegiate Guidelines Network (SIGN) methodology. The resulting papers underwent systematic selection and critique processes. Included papers were allocated to 6 different outcome groups to allow data synthesis and exploration: quality of life, coping, family, wellbeing, access to HCP and pain. Based on the evidence in those papers, recommendations were made for individuals living with EB, family and caregivers and HCP working in the field.Few studies have investigated interventions and which factors lead to better outcomes, but general recommendations can be made. EB is a complex disease impacting enormously on every aspect of psychosocial life. People and families living with EB need access to multidisciplinary support, including psychological guidance, in order to improve quality of life and psychosocial wellbeing. Interventions should stimulate social participation to prevent isolation. People with EB and their families should be able to access a supportive network. HCP should be well supported and educated about the complexity of EB. They should work collaboratively with those around the individual with EB (e.g. schools, employers etc.) to provide psychosocial opportunity and care.Attention should be paid to the psychosocial impact of EB as well as physical needs. Directions for research are indicated.
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Affiliation(s)
- K. Martin
- University Hospitals Birmingham NHS Trust, Solihull Hospital, Solihull, B91 2JL, UK
| | - S. Geuens
- Universital Hospitals Leuven, Leuven, Belgium
| | - J. K. Asche
- DEBRA Norge and person living with JEB, Stavanger, Norway
| | - R. Bodan
- California State University, Fullerton, CA USA
| | - F. Browne
- Our Lady’s Children’s Hospital Crumlin, Dublin, Ireland
| | - A. Downe
- Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | | | - G. Jaega
- Psychology graduate and person living with EBS, Liverpool, UK
| | - B. Kennedy
- Our Lady’s Children’s Hospital Crumlin, Dublin, Ireland
| | - P. J. Mauritz
- The University Medical Center Groningen, Groningen, the Netherlands
| | | | - K. Soon
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | | | - K. M. Mayre-Chilton
- Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, UK
- DEBRA International, Vienna, Austria
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14
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Hafi NAB, Uvais NA. Palliative dermatology – An area of care yet to be explored. PROGRESS IN PALLIATIVE CARE 2018. [DOI: 10.1080/09699260.2018.1492685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- N. A. Bishurul Hafi
- Department of Dermatology, Regional Institute of Medical Sciences, Imphal, India
| | - N. A. Uvais
- Department of Psychiatry, Iqraa International Hospital and Research Centre, Kozhikode, India
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15
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16
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Fortuna G, Aria M, Cepeda-Valdes R, Moreno Trevino MG, Salas-Alanís JC. Pain in Patients with Dystrophic Epidermolysis Bullosa: Association with Anxiety and Depression. Psychiatry Investig 2017; 14:746-753. [PMID: 29209377 PMCID: PMC5714715 DOI: 10.4306/pi.2017.14.6.746] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 12/06/2016] [Accepted: 12/31/2016] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE We investigate the presence and the quality of pain in patients with dystrophic epidermolysis bullosa (DEB), and its correlation with the level of anxiety and depression. METHODS We collected data from 27 DEB patients and 26 healthy individuals. DEB patients and controls completed 1 scale for the quality of pain, and 1 scale for anxiety and depression. Pain was assessed with the short form of the McGill Pain Questionnaire, whereas anxiety and depression were assessed with the Hamilton rating scale for anxiety and depression. RESULTS DEB patients and healthy control individuals were homogeneous for age and gender (p>0.05). A statistically significant difference in the two groups was seen for sensory pain rating scale (p<0.001), affective pain rating scale (p=0.029), total pain rating scale (p<0.001), visual analogue scale (p=0.012) and present pain intensity (p=0.001), but not for anxiety (p=0.169) and depression (p=0.530). The characteristics of pain that showed a significant difference between DEB patients and healthy controls were shooting, splitting, tender and throbbing (p<0.05). In DEB patients pain was not correlated with anxiety or depression (p>0.05), whereas a slight correlation between pain and anxiety was found in healthy controls (p<0.05). No difference was found between quality of pain and anxiety-depression in DEB patients (p>0.05), but was between the DEB dominant and the recessive form of DEB (p=0.025). CONCLUSION The perception of pain in DEB patients appears greater than in healthy individuals, with splitting and tender characteristics being the most significant ones, but was not associated with anxious and/or depressive symptoms.
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Affiliation(s)
- Giulio Fortuna
- Department of Diagnostic Science, Louisiana State University School of Dentistry, LA, USA
- Dystrophic Epidermolysis Bullosa Research Association Mexico Foundation, Nuevo Leon, Mexico
- Federico Navarro Institute-School of Orgonomy “Piero Borrelli”, Naples, Italy
| | - Massimo Aria
- Department of Economics and Statistics, Federico II University of Naples, Naples, Italy
| | - Rodrigo Cepeda-Valdes
- Dystrophic Epidermolysis Bullosa Research Association Mexico Foundation, Nuevo Leon, Mexico
| | | | - Julio Cesar Salas-Alanís
- Dystrophic Epidermolysis Bullosa Research Association Mexico Foundation, Nuevo Leon, Mexico
- Department of Basic Science, Universidad de Monterrey, Nuevo Leon, México
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17
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Li AW, Prindaville B, Bateman ST, Gibson TE, Wiss K. Inpatient management of children with recessive dystrophic epidermolysis bullosa: A review. Pediatr Dermatol 2017; 34:647-655. [PMID: 28944966 DOI: 10.1111/pde.13276] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Recessive dystrophic epidermolysis bullosa is a disorder marked by skin and mucosal blistering after minimal trauma. Even the most routine procedures in the hospital, if done incorrectly, can precipitate extensive skin loss, pain, and scarring. Most providers have little experience working with patients with this degree of skin fragility. When a person with recessive dystrophic epidermolysis bullosa is admitted to the hospital, there are multiple considerations to keep in mind while strategizing an effective care plan: avoidance of new blisters with a "hands-off" approach; careful consideration of all indwelling devices; symptomatic management of pain, itch, and anxiety; coordination of dressing changes; aggressive treatment of skin infections; environmental and staffing considerations; and awareness of other chronic complications that affect care, such as anemia, malnutrition, and chronic pain. To minimize discomfort for patients with recessive dystrophic epidermolysis bullosa during the hospital stay, inpatient care teams should understand these considerations and modify the care plan accordingly. Prior preparation by the hospital facility and inpatient care team will facilitate the delivery of safe and effective care and greatly improve the overall patient experience.
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Affiliation(s)
- Alvin W Li
- School of Medicine, Yale University, New Haven, CT, USA
| | - Brea Prindaville
- Department of Dermatology, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Scot T Bateman
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Timothy E Gibson
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Karen Wiss
- Department of Dermatology, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA
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18
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von Bischhoffshausen S, Ivulic D, Alvarez P, Schuffeneger VC, Idiaquez J, Fuentes C, Morande P, Fuentes I, Palisson F, Bennett DLH, Calvo M. Recessive dystrophic epidermolysis bullosa results in painful small fibre neuropathy. Brain 2017; 140:1238-1251. [PMID: 28369282 PMCID: PMC5405236 DOI: 10.1093/brain/awx069] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 01/20/2017] [Indexed: 11/30/2022] Open
Abstract
Small fibres in the skin are vulnerable to damage in metabolic or toxic conditions such as diabetes mellitus or chemotherapy resulting in small fibre neuropathy and associated neuropathic pain. Whether injury to the most distal portion of sensory small fibres due to a primary dermatological disorder can cause neuropathic pain is still unclear. Recessive dystrophic epidermolysis bullosa (RDEB) is a rare condition in which mutations of proteins of the dermo-epidermal junction lead to cycles of blistering followed by regeneration of the skin. Damage is exclusive to the skin and mucous membranes, with no known direct compromise of the nervous system. It is increasingly recognized that most RDEB patients experience daily pain, the aetiology of which is unclear but may include inflammation (in the wounds), musculoskeletal (due to atrophy and retraction scars limiting movement) or neuropathic pain. In this study we investigated the incidence of neuropathic pain and examined the presence of nerve dysfunction in RDEB patients. Around three quarters of patients presented with pain of neuropathic characteristics, which had a length-dependent distribution. Quantitative sensory testing of the foot revealed striking impairments in thermal detection thresholds combined with an increased mechanical pain sensitivity and wind up ratio (temporal summation of noxious mechanical stimuli). Nerve conduction studies showed normal large fibre sensory and motor nerve conduction; however, skin biopsy showed a significant decrease in intraepidermal nerve fibre density. Autonomic nervous system testing revealed no abnormalities in heart rate and blood pressure variability however the sympathetic skin response of the foot was impaired and sweat gland innervation was reduced. We conclude that chronic cutaneous injury can lead to injury and dysfunction of the most distal part of small sensory fibres in a length-dependent distribution resulting in disabling neuropathic pain. These findings also support the use of neuropathic pain screening tools in these patients and treatment algorithms designed to target neuropathic pain.
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Affiliation(s)
| | - Dinka Ivulic
- Departamento de Fisiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Chile
| | - Paola Alvarez
- Departamento de Neurología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Victor C Schuffeneger
- Departamento de Neurología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | | | - Constanza Fuentes
- Fundación DEBRA, Chile.,Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Chile
| | | | - Ignacia Fuentes
- Fundación DEBRA, Chile.,Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Chile
| | - Francis Palisson
- Fundación DEBRA, Chile.,Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Chile.,Centro de Genética y Genómica, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Chile
| | - David L H Bennett
- Nuffield Department of clinical neurosciences, University of Oxford, UK
| | - Margarita Calvo
- Departamento de Fisiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Chile.,Departamento de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
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19
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Chiaverini C, Bourrat E, Mazereeuw-Hautier J, Hadj-Rabia S, Bodemer C, Lacour JP. [Hereditary epidermolysis bullosa: French national guidelines (PNDS) for diagnosis and treatment]. Ann Dermatol Venereol 2016; 144:6-35. [PMID: 27931749 DOI: 10.1016/j.annder.2016.07.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 07/27/2016] [Indexed: 12/22/2022]
Abstract
Hereditary epidermolysis bullosa (EB) is a heterogeneous group of rare genetic diseases characterized by fragile skin and/or mucous membrane, and it may be either local or generalized. It is caused by mutations in genes encoding different proteins involved mainly in the structure and function of the dermal-epidermal junction. Nineteen genes have so far been identified. They are classified by level of skin cleavage (from top to bottom) into four groups: EB simplex, junctional EB, dystrophic EB and Kindler syndrome. Clinically suspected diagnosis is confirmed by immunohistochemical examination of a skin biopsy at specialized centres in order to determine the level of cleavage and the deficient protein. This first step may be followed by genetic analysis. The severity of the disease is highly variable, ranging from localized forms with little effect on quality of life to rapidly lethal forms. In generalized severe forms, the extent and chronicity of lesions, as well as mucosal involvement, can lead to systemic complications: malnutrition, pain, joint contractures, chronic inflammation, amyloidosis, cutaneous squamous cell carcinoma. Some specific forms are associated with other cutaneous signs (nail involvement, alopecia, hyperpigmentation, palmoplantar keratoderma) or extracutaneous involvement (muscular dystrophy or pyloric atresia). No curative treatment of EB is available today. EB requires multidisciplinary medical care, nursing, psychological and social management. This is best provided by a specialized network, involving reference centres, centres of expertise and daily caregivers. The goal of treatment is the prevention and treatment of lesions with specific non-adherent dressings and the prevention, detection and treatment of complications. It is essential not to traumatize the skin (bandaging, friction, etc.). Protein, gene or cell replacement therapy, and allogeneic bone marrow, cord blood or pluripotent stem-cell transplantation are currently being assessed. The aim of these French recommendations (national diagnostic and treatment protocol [PNDS]) is to provide healthcare professionals with guidance on the course of EB and on optimal patient management.
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Affiliation(s)
- C Chiaverini
- Service de dermatologie, centre de référence des épidermolyses bulleuses héréditaires, hôpital l'Archet 2, CHU de Nice, 151, route Saint-Antoine-de-Ginestière, CS 23079, 06202 Nice cedex 3, France
| | - E Bourrat
- Service de dermatologie, centre de référence des maladies génétiques cutanées (MAGEC), hôpital Saint-Louis, CHU Paris - groupe hospitalier Saint-Louis - Lariboisière F.-Widal, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - J Mazereeuw-Hautier
- Service de dermatologie, centre de référence des maladies dermatologiques rares, hôpital Larrey, 24, chemin de Pouvourville, TSA 30030, 31059 Toulouse cedex 9, France
| | - S Hadj-Rabia
- Service de dermatologie, filière maladies rares de la peau (FIMARAD), centre de référence des maladies génétiques cutanées (MAGEC), hôpital Necker-Enfants-Malades, AP-HP, 149, rue de Sèvres, 75743 Paris cedex 15, France
| | - C Bodemer
- Service de dermatologie, filière maladies rares de la peau (FIMARAD), centre de référence des maladies génétiques cutanées (MAGEC), hôpital Necker-Enfants-Malades, AP-HP, 149, rue de Sèvres, 75743 Paris cedex 15, France
| | - J-P Lacour
- Service de dermatologie, centre de référence des épidermolyses bulleuses héréditaires, hôpital l'Archet 2, CHU de Nice, 151, route Saint-Antoine-de-Ginestière, CS 23079, 06202 Nice cedex 3, France.
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20
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van den Heuvel I, Gottschalk A, Langer M, Hahnenkamp K, Ellger B. Feasibility, efficacy, and safety of ultrasound-guided axillary plexus blockade in pediatric patients with epidermolysis bullosa dystrophica. Paediatr Anaesth 2016; 26:405-8. [PMID: 26857539 DOI: 10.1111/pan.12860] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND In patients suffering from epidermolysis bullosa dystrophica (DEB), the most severe form of epidermolysis bullosa, trauma or friction cause separation of the skin from underlying tissue with consecutive painful blisters, scarifications, contractures, and pseudosyndactyly. To retain functionality of the hands surgical procedures are necessary. Anesthesia is challenging as difficult airways make general anesthesia risky. Regional anesthesia is considered controversial in patients with EB as accidental subcutaneous injections can cause severe blisters. As ultrasound-guided procedures became standard of care this might have changed however. AIM In this case series, we describe feasibility, efficacy, and safety of ultrasound-guided plexus axillaris block in DEB patients undergoing hand surgery. METHOD We performed a retrospective analysis of the charts of all children with DEB undergoing hand surgery under plexus axillaris block and sedation between 2009 and 2013 in our institution. RESULTS Nineteen procedures in nine children were performed. Induction of anesthesia (securing monitoring, sedation, plexus block) took a mean time of 34 min. Perioperative analgesia was adequate in all procedures. No complications such as airway incidents, conversion to general anesthesia, movement during surgery, incomplete block, or formation of new blisters were seen. CONCLUSION Ultrasound-guided plexus axillaris block in DEB patients undergoing hand surgery in our institution has been feasible, effective, and safe.
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Affiliation(s)
- Ingeborg van den Heuvel
- Department of General Pediatrics, University Children's Hospital Muenster, Muenster, Germany
| | - Antje Gottschalk
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Martin Langer
- Department of Trauma-, Hand- and Reconstructive Surgery, Westfaelische Wilhelms-University Muenster, Muenster, Germany
| | - Klaus Hahnenkamp
- Department of Anesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Björn Ellger
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
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21
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Abstract
Genetic skin diseases, or genodermatoses, often have extracutaneous manifestations. Ocular manifestations in particular can have significant clinical implications, like blindness. Other manifestations, such as the corneal opacities that occur in X-linked ichthyosis, are asymptomatic but characteristic of a particular genodermatosis. Ophthalmologic examination can aid in diagnosis when characteristic findings are seen. The genodermatoses with ocular manifestations will be reviewed, but neurocutaneous, syndromes, genetic pigmentary disorders, and genetic metabolic diseases are not included because they are covered elsewhere in this issue.
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Affiliation(s)
- Melinda Jen
- Section of Pediatric Dermatology, Children's Hospital of Philadelphia; Departments of Pediatrics and Dermatology, Perelman School of Medicine at the University of Pennsylvania, 3550 Market St, Second floor, Philadelphia, PA, 19104.
| | - Sudha Nallasamy
- The Vision Center, Children's Hospital Los Angeles; Department of Ophthalmology, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, MS #88, Los Angeles, CA, 90027
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22
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Mellerio JE, Robertson SJ, Bernardis C, Diem A, Fine JD, George R, Goldberg D, Halmos GB, Harries M, Jonkman MF, Lucky A, Martinez AE, Maubec E, Morris S, Murrell DF, Palisson F, Pillay EI, Robson A, Salas-Alanis JC, McGrath JA. Management of cutaneous squamous cell carcinoma in patients with epidermolysis bullosa: best clinical practice guidelines. Br J Dermatol 2015; 174:56-67. [PMID: 26302137 DOI: 10.1111/bjd.14104] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2015] [Indexed: 12/24/2022]
Abstract
This article summarizes recommendations reached following a systematic literature review and expert consensus on the diagnosis and management of cutaneous squamous cell carcinomas in people with epidermolysis bullosa. The guidelines are intended to help inform decision making by clinicians dealing with this complex complication of a devastating disease.
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Affiliation(s)
- J E Mellerio
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, U.K.,Department of Dermatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, U.K
| | - S J Robertson
- Department of Dermatology, The Royal Melbourne Hospital, The Royal Children's Hospital and Monash Medical Centre, Melbourne, Australia
| | - C Bernardis
- Department of Plastic Surgery, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, U.K
| | - A Diem
- Department of Dermatology, Paracelsus Medical University, Salzburg, Austria
| | - J D Fine
- Division of Dermatology, Vanderbilt University School of Medicine, Nashville, TN, U.S.A
| | - R George
- Department of Palliative Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, U.K
| | - D Goldberg
- Division of Dermatology, University of Massachusetts, Worcester, MA, U.S.A
| | - G B Halmos
- Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - M Harries
- Department of Oncology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, U.K
| | - M F Jonkman
- Department of Dermatology, University Medical Centre Groningen, Groningen, the Netherlands
| | - A Lucky
- Department of Dermatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, U.S.A
| | - A E Martinez
- Department of Dermatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, U.K
| | - E Maubec
- Department of Dermatology, APHP, Avicenne Hospital, Bobigny, France
| | - S Morris
- Department of Oncology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, U.K
| | - D F Murrell
- Department of Dermatology, St George Hospital, University of New South Wales, Sydney, Australia
| | - F Palisson
- Facultad de Medicina, Clínica Alemana, Santiago, Chile
| | - E I Pillay
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, U.K
| | - A Robson
- Department of Dermatopathology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, U.K
| | - J C Salas-Alanis
- Basic Sciences Department, Universidad de Monterrey, Monterrey, Mexico
| | - J A McGrath
- St John's Institute of Dermatology, King's College London (Guy's Campus), London, U.K
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23
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Danial C, Adeduntan R, Gorell ES, Lucky AW, Paller AS, Bruckner AL, Pope E, Morel KD, Levy ML, Li S, Gilmore ES, Lane AT. Evaluation of Treatments for Pruritus in Epidermolysis Bullosa. Pediatr Dermatol 2015; 32:628-34. [PMID: 25557557 PMCID: PMC5079440 DOI: 10.1111/pde.12486] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pruritus is a common complication in patients with epidermolysis bullosa (EB). There is limited published data about the treatments that individuals with EB use for pruritus. The objective of the current study was to determine quantitatively which treatments individuals with EB have used for pruritus and to evaluate the perceived effectiveness of these treatments in pruritus relief. A questionnaire was developed to evaluate the treatments and therapies used for pruritus in patients of all ages and for all types of EB. Questions about bathing products, moisturizers, topical products, oral medications, dressings, and alternative therapies were included. A 5-point Likert scale (-2 = relieves itch a lot, -1 = relieves itch a little, 0 = no change, 1 = increases itch a little, 2 = increases itch a lot) was used to evaluate perceived effectiveness. Patients from seven North American EB centers were invited to participate. Greasy ointments (53.4%), lotions (45.2%), creams (40.4%), and oral hydroxyzine (39.0%) were the most frequently used treatments for pruritus. Treatments that were used frequently and perceived to be the most effective included creams (mean = -1.1), topical prescription corticosteroids (mean = -1.0), oils (mean = -0.9), oral hydroxyzine (mean = -0.9), topical diphenhydramine (mean = -0.9), and vaporizing rub (menthol, camphor, eucalyptus) (mean = -0.9). Systemic opioids (mean = 0.3), adherent bandages (mean = 0.3), and bleach baths (mean = 0.2) slightly increased pruritus. Randomized controlled trials of therapies will be necessary to develop evidence-based recommendations for control of pruritus in individuals with EB.
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Affiliation(s)
- Christina Danial
- Department of Dermatology, School of Medicine, Stanford University, Palo Alto, California
| | - Rasidat Adeduntan
- Department of Dermatology, School of Medicine, Stanford University, Palo Alto, California
| | - Emily S Gorell
- Department of Dermatology, School of Medicine, Stanford University, Palo Alto, California
| | - Anne W Lucky
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Amy S Paller
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Anna L Bruckner
- Department of Dermatology, University of Colorado School of Medicine, Aurora, Colorado.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Elena Pope
- Department of Dermatology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kimberly D Morel
- Department of Dermatology, Columbia University Medical Center, New York, New York.,Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Moise L Levy
- Department of Dermatology, Dell Children's Medical Center of Central Texas, Austin, Texas
| | - Shufeng Li
- Department of Dermatology, School of Medicine, Stanford University, Palo Alto, California
| | - Elaine S Gilmore
- Department of Dermatology, University of Rochester Medical Center, Rochester, New York
| | - Alfred T Lane
- Department of Dermatology, School of Medicine, Stanford University, Palo Alto, California
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24
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Danial C, Adeduntan R, Gorell ES, Lucky AW, Paller AS, Bruckner A, Pope E, Morel KD, Levy ML, Li S, Gilmore ES, Lane AT. Prevalence and characterization of pruritus in epidermolysis bullosa. Pediatr Dermatol 2015; 32:53-9. [PMID: 25236506 PMCID: PMC4315706 DOI: 10.1111/pde.12391] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Qualitative data suggest that pruritus is a burdensome symptom in patients with epidermolysis bullosa (EB), but the prevalence of pruritus in children and adults with EB and factors that contribute to pruritus are unknown. The objective of the current study was to quantitatively identify and to characterize pruritus that EB patients experience using a comprehensive online questionnaire. A questionnaire was developed to evaluate pruritus in all ages and all types of EB. Questions that characterize pruritus were included and factors that aggravate symptoms were investigated. Patients from seven North American EB centers were invited to participate. One hundred forty-six of 216 questionnaires were completed (response rate 68%; 73 male, 73 female; median age 20.0 years). Using a 5-point Likert scale (1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = always), itchiness was the most bothersome EB complication (mean 3.3). The average daily frequency of pruritus increased with self-reported EB severity. Pruritus was most frequent at bedtime (mean 3.8) and interfered with sleep. Factors that aggravated pruritus included healing wounds, dry skin, infected wounds, stress, heat, dryness, and humidity. Pruritus is common in individuals with EB and can be bothersome. Future studies will need to investigate the most effective treatments given to individuals with EB for pruritus.
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Affiliation(s)
- Christina Danial
- Department of Dermatology, School of Medicine, Stanford University, Stanford, California
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Mack MR, Wendelschafer-Crabb G, McAdams BD, Hordinsky MK, Kennedy WR, Tolar J. Peripheral neuro-immune pathology in recessive dystrophic epidermolysis bullosa. J Invest Dermatol 2014; 135:1193-1197. [PMID: 25431850 PMCID: PMC4366323 DOI: 10.1038/jid.2014.500] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Madison R Mack
- Department of Pediatrics, Blood and Marrow Transplant, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Brian D McAdams
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Maria K Hordinsky
- Department of Dermatology, University of Minnesota, Minneapolis, Minnesota, USA
| | - William R Kennedy
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jakub Tolar
- Department of Pediatrics, Blood and Marrow Transplant, University of Minnesota, Minneapolis, Minnesota, USA; Stem Cell Institute, University of Minnesota, Minneapolis, Minnesota, USA.
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Goldschneider KR, Good J, Harrop E, Liossi C, Lynch-Jordan A, Martinez AE, Maxwell LG, Stanko-Lopp D. Pain care for patients with epidermolysis bullosa: best care practice guidelines. BMC Med 2014; 12:178. [PMID: 25603875 PMCID: PMC4190576 DOI: 10.1186/s12916-014-0178-2] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 09/09/2014] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Inherited epidermolysis bullosa (EB) comprises a group of rare disorders that have multi-system effects and patients present with a number of both acute and chronic pain care needs. Effects on quality of life are substantial. Pain and itching are burdensome daily problems. Experience with, and knowledge of, the best pain and itch care for these patients is minimal. Evidence-based best care practice guidelines are needed to establish a base of knowledge and practice for practitioners of many disciplines to improve the quality of life for both adult and pediatric patients with EB. METHODS The process was begun at the request of Dystrophic Epidermolysis Bullosa Research Association International (DEBRA International), an organization dedicated to improvement of care, research and dissemination of knowledge for EB patients worldwide. An international panel of experts in pain and palliative care who have extensive experience caring for patients with EB was assembled. Literature was reviewed and systematically evaluated. For areas of care without direct evidence, clinically relevant literature was assessed, and rounds of consensus building were conducted. The process involved a face-to-face consensus meeting that involved a family representative and methodologist, as well as the panel of clinical experts. During development, EB family input was obtained and the document was reviewed by a wide variety of experts representing several disciplines related to the care of patients with EB. RESULTS The first evidence-based care guidelines for the care of pain in EB were produced. The guidelines are clinically relevant for care of patients of all subtypes and ages, and apply to practitioners of all disciplines involved in the care of patients with EB. When the evidence suggests that the diagnosis or treatment of painful conditions differs between adults and children, it will be so noted. CONCLUSIONS Evidence-based care guidelines are a means of standardizing optimal care for EB patients, whose disease is often times horrific in its effects on quality of life, and whose care is resource-intensive and difficult. The guideline development process also highlighted areas for research in order to improve further the evidence base for future care.
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Affiliation(s)
- Kenneth R Goldschneider
- Pain Management Center, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
| | - Julie Good
- Lucille Packard Children's Hospital, Department of Anesthesia (by courtesy, Pediatrics), Stanford University, Stanford, California, USA.
| | - Emily Harrop
- Helen and Douglas Hospices, Oxford and John Radcliffe Hospital, Oxford, USA.
| | - Christina Liossi
- University of Southampton, Southampton, UK.
- Great Ormond Street Hospital for Children NHS Trust, London, UK.
| | - Anne Lynch-Jordan
- Pain Management Center and Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
| | - Anna E Martinez
- National Paediatric Epidermolysis Bullosa Centre, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
| | - Lynne G Maxwell
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
| | - Danette Stanko-Lopp
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
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Multicentre consensus recommendations for skin care in inherited epidermolysis bullosa. Orphanet J Rare Dis 2014; 9:76. [PMID: 24884811 PMCID: PMC4110526 DOI: 10.1186/1750-1172-9-76] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 04/16/2014] [Indexed: 12/22/2022] Open
Abstract
Background Inherited epidermolysis bullosa (EB) comprises a highly heterogeneous group of rare diseases characterized by fragility and blistering of skin and mucous membranes. Clinical features combined with immunofluorescence antigen mapping and/or electron microscopy examination of a skin biopsy allow to define the EB type and subtype. Molecular diagnosis is nowadays feasible in all EB subtypes and required for prenatal diagnosis. The extent of skin and mucosal lesions varies greatly depending on EB subtype and patient age. In the more severe EB subtypes lifelong generalized blistering, chronic ulcerations and scarring sequelae lead to multiorgan involvement, major morbidity and life-threatening complications. In the absence of a cure, patient management remains based on preventive measures, together with symptomatic treatment of cutaneous and extracutaneous manifestations and complications. The rarity and complexity of EB challenge its appropriate care. Thus, the aim of the present study has been to generate multicentre, multidisciplinary recommendations on global skin care addressed to physicians, nurses and other health professionals dealing with EB, both in centres of expertise and primary care setting. Methods Almost no controlled trials for EB treatment have been performed to date. For this reason, recommendations were prepared by a multidisciplinary team of experts from different European EB centres based on available literature and expert opinion. They have been subsequently revised by a panel of external experts, using an online-modified Delphi method to generate consensus. Results Recommendations are reported according to the age of the patients. The major topics treated comprise the multidisciplinary approach to EB patients, global skin care including wound care, management of itching and pain, and early diagnosis of squamous cell carcinoma. Aspects of therapeutic patient education, care of disease burden and continuity of care are also developed. Conclusion The recommendations are expected to be useful for daily global care of EB patients, in particular in the community setting. An optimal management of patients is also a prerequisite to allow them to benefit from the specific molecular and cell-based treatments currently under development.
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Galán Gutiérrez JC, Martínez Suárez M, Tobera Noval B, Avello Taboada R. Epidermólisis bullosa de Herlitz en el paciente pediátrico: implicaciones anestésicas. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1016/j.rca.2014.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Galán Gutiérrez J, Martínez Suárez M, Tobera Noval B, Avello Taboada R. Herlitz epidermolysis bullosa in the paediatric patient: Anaesthetic implications. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1016/j.rcae.2014.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Herlitz epidermolysis bullosa in the paediatric patient: Anaesthetic implications☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1097/01819236-201442020-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Kirkorian AY, Weitz NA, Tlougan B, Morel KD. Evaluation of wound care options in patients with recessive dystrophic epidermolysis bullosa: a costly necessity. Pediatr Dermatol 2014; 31:33-7. [PMID: 24224977 DOI: 10.1111/pde.12243] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Recessive dystrophic epidermolysis bullosa (RDEB) is a genetic disorder in which mutations in collagen VII, the main component of the anchoring fibril, lead to skin fragility and to the development of acute and chronic wounds. Wound care and dressing changes are an important part of the daily lives of individuals with RDEB. Ideal wound care should improve wound healing, minimize pain, and improve quality of life. The objective of the current study was to review wound care options that might be used in a patient with RDEB and calculate the cost of these various options based on publicly available pricing of wound care products. There is a wide range of costs for wound care options in patients with RDEB. For example, a 1-day supply of dressing for a neonate boy with RDEB ranges from $10.64 for the least expensive option to $127.54 for the most expensive option. Wound care in patients with severe, generalized RDEB has not only a significant economic effect, but also directly affects quality of life in this patient population. Although randomized controlled trials evaluating different wound care products in patients with RDEB are lacking, small studies and expert opinion support the use of specialized nonadherent dressings that minimize skin trauma and promote wound healing. Until there is a cure, prospective studies are needed to assess pain, quality of life, and wound healing associated with the use of specialized wound care products for this life-altering condition.
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Affiliation(s)
- Anna Yasmine Kirkorian
- Department of Dermatology, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson, Somerset, New Jersey
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Davila-Seijo P, Hernández-Martín A, Morcillo-Makow E, de Lucas R, Domínguez E, Romero N, Monrós E, Feito M, Carretero L, Aranegui B, García-Doval I. Prioritization of therapy uncertainties in Dystrophic Epidermolysis Bullosa: where should research direct to? an example of priority setting partnership in very rare disorders. Orphanet J Rare Dis 2013; 8:61. [PMID: 23607806 PMCID: PMC3637279 DOI: 10.1186/1750-1172-8-61] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 04/11/2013] [Indexed: 12/01/2022] Open
Abstract
Background Dystrophic Epidermolysis Bullosa (DEB) is a rare genodermatosis (7 cases per million) that causes blisters and erosions with minor trauma in skin and mucosa, and other systemic complications. A recently updated systematic review showed that the research evidence about DEB therapies is poor. As new trials in DEB are difficult and expensive, it is important to prioritizise research that patients and clinicians consider more relevant. Objectives To describe and prioritize the most important uncertainties about DEB treatment shared by patients, carers and health care professionals (HCPs) in order to promote research in those areas. Methods A DEB Priority Setting Partnership (PSP) was established, including patients, carers and HCPs. DBE uncertainties were gathered from patients and clinicians, and prioritized in a transparent process, using the methodology advocated by the James Lind Alliance. Results In the consultation stage, 323 uncertainties were submitted by 58 participants. Once the duplicated and non-treatment uncertainties were removed, the remainder were reduced to a list of 24 most voted questions. These 24 uncertainties were prioritized in a final workshop where a balanced number of patients, carers and HCPs selected the top 10 therapy uncertainties. The final list includes interventions in wound care, itch and pain management, treatment and prevention of syndactyly, cancer prevention and future promising therapies. Conclusions The final list of the top 10 treatment uncertainties on the management of DEB provides guidance for researchers and funding bodies, to ensure that future research answers questions that are important to both clinicians and patients. The method proposed by the James Lind Alliance is feasible for very rare disorders.
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Affiliation(s)
- Paula Davila-Seijo
- Department of Dermatology, Complexo Hospitalario de Pontevedra (CHOP), Doutor Loureiro Crespo 2, Pontevedra 36001, Spain.
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Primo BT, da Costa DJ, Stringhini DJ, Rebellato NLB, de Moraes RS, Müller PR, Carneiro VL. Sialolithiasis in the duct of submandibular gland: a case report in patient with epidermolysis bullosa. J Contemp Dent Pract 2013; 14:339-44. [PMID: 23811670 DOI: 10.5005/jp-journals-10024-1324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIM To describe the options of treatment to remove a sialolith associated with the submandibular gland duct in a patient with epidermolysis bullosa (EB). BACKGROUND Treatment of patients with EB is very complex and involves a multidisciplinary team. This condition is characterized by a spectrum of blistering and mechanical fragility of the skin. One main feature of this disease is the esophageal constriction and possible constriction to the submandibular duct. This alteration may induce the formation of calculi in this duct, which is called sialolith. Once the sialolith obliterates the trajectory of the duct this will lead to a sialolithiasis. The calculi have to be removed. CASE REPORT Seventeen years old female patient with dystrophic EB developed a sialolith at the submandibular duct. She has a limited mouth opening and her tongue was collapsed with mouth floor. The first choice of treatment was the lithotripsy, once this procedure is less invasive and a surgical remove could worse the collapsed tongue. She was with acute pain and with a great augmentation in the submandibular area. Once the patient was debilitated and has difficult to swallow she invariably needed to be hospitalized in order to receive intravenous medication. During the hospitalization the sialolith could be seen through the opening of the duct and the calculi was removed with local anesthesia. CONCLUSION The treatment of sialolithiasis usually does not present major challenges, nevertheless if the sialolithiasis is associated with EB, the treatment became an extremely challenge. In this particular case the option of treatment was the less invasive. CLINICAL RELEVANCE This case report has an enormous clinical relevance once there is no protocol to treat patients with EB and buccal diseases.
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Affiliation(s)
- Bruno Tochetto Primo
- Department of Oral and Maxillofacial Surgery, Universidade Federal do Paraná, Curitiba, Paraná, Brazil.
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A consensus approach to wound care in epidermolysis bullosa. J Am Acad Dermatol 2012; 67:904-17. [PMID: 22387035 DOI: 10.1016/j.jaad.2012.01.016] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Revised: 01/12/2012] [Accepted: 01/16/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND Wound care is the cornerstone of treatment for patients with epidermolysis bullosa (EB); however, there are currently no guidelines to help practitioners care for these patients. OBJECTIVES The objective of this study was to generate a list of recommendations that will enable practitioners to better care for patients with EB. METHODS An expert panel generated a list of recommendations based on the best evidence available. The recommendations were translated into a survey, and sent to other EB experts to generate consensus using an online-based modified Delphi method. The list was refined and grouped into themes and specific recommendations. RESULTS There were 15 respondents (45% response rate), with significant experience in the EB field (>10 years [67%]). Respondents included physicians (67%), nurses (17%), and allied health professionals (7%). There was more than 85% agreement for all the proposed items. These were further refined and grouped into 5 main themes (assessment and management of factors that impair healing, patient-centered concerns, local wound care, development of an individualized care plan, and organizational support) and 17 specific recommendations. LIMITATIONS There is a paucity of scientific evidence with most recommendations based on expert opinion. CONCLUSIONS These recommendations will provide practitioners with a framework for caring for these patients. Additional scientific research including effectiveness studies for everyday practice and expert consensus, may further refine these recommendations.
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Goldschneider K, Lucky AW, Mellerio JE, Palisson F, del Carmen Viñuela Miranda M, Azizkhan RG. Perioperative care of patients with epidermolysis bullosa: proceedings of the 5th international symposium on epidermolysis bullosa, Santiago Chile, December 4-6, 2008. Paediatr Anaesth 2010; 20:797-804. [PMID: 20716071 DOI: 10.1111/j.1460-9592.2010.03359.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Epidermolysis bullosa (EB) has become recognized as a multisystem disorder that poses a number of pre-, intra-, and postoperative challenges. While anesthesiologists have long appreciated the potential difficult intubation in patients with EB, other systems can be affected by this disorder. Hematologic, cardiac, skeletal, gastrointestinal, nutritional, and metabolic deficiencies are foci of preoperative medical care, in addition to the airway concerns. Therefore, multidisciplinary planning for operative care is imperative. A multinational, interdisciplinary panel of experts assembled in Santiagio, Chile to review the best practices for perioperative care of patients with EB. This paper presents guidelines that represent a synthesis of evidence-based approaches and the expert consensus of this panel and are intended to aid physicians new to caring for patients with EB when operative management is indicated. With proper medical optimization and attention to detail in the operating room, patients with EB can have an uneventful perioperative course.
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Affiliation(s)
- Kenneth Goldschneider
- Division of Pain Management, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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