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Box R, Bernardis C, Pleshkov A, Jessop N, Miller C, Skye J, O’Brien V, Veerkamp M, da Rocha ACF, Cornwall R. Hand surgery and hand therapy clinical practice guideline for epidermolysis bullosa. Orphanet J Rare Dis 2022; 17:406. [DOI: 10.1186/s13023-022-02282-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 03/07/2022] [Indexed: 11/09/2022] Open
Abstract
Abstract
What is already known about this topic?
Epidermolysis bullosa (EB) causes blistering and scarring of the hands resulting in contractures fused web spaces and altered function. Surgery is needed to release contractures and web spaces and hand therapy is essential to maintain results, approaches for both differ.
What does this study add?
These guidelines aim to provide information on the surgical and conservative therapeutic hand management of children and adults diagnosed with EB. They are based on available evidence and expert consensus to assist hand surgeons and therapists in decision making, planning and treatment. They highlight the importance of a holistic multidisciplinary team (MDT) approach, where patient priorities are paramount.
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Graham T, Sooriah S, Box R, Gage H, Williams P, Clemett V, Grocott P. Participatory co-design of patient-reported outcome indicators and N-of-1 evaluation of a dressing glove for Epidermolysis bullosa. J Wound Care 2020; 29:751-762. [PMID: 33320744 DOI: 10.12968/jowc.2020.29.12.751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE In autosomal recessive dystrophic Epidermolysis bullosa, repeat blistering results in finger webbing and severe contractures of the hands. The aim of this study was to codesign patient-reported outcome indicators for hand therapy with patients, carers and clinicians, and use these to proof-of-concept test a novel dressing glove for recessive dystrophic Epidermolysis bullosa, with cost analysis. METHOD Qualitative interviews and focus groups with patients and carers generated content for the indicators. Validity and reliability were established through expert review, piloting and consensus between patients, carers and clinicians. The indicators were self-reported by patients before and while wearing the dressing glove in an N-of-1 study. Time for dressing changes and use of conventional products were also self-reported. RESULTS A total of 11 indicators were initially generated from the thematic analysis. Expert review, piloting and consensus involved six patients, five carers and eight clinicians (total n=19). Participants agreed 14 indicators, covering hand skin condition (n=4), webbing between the digits (n=4), experiences of wearing and changing dressings (n=2), hand function (n=2), wrist function (n=1) and hand pain (n=1). In Phase 3, 12 patients scored indicators before wearing the gloves and four patients completed scoring while wearing the gloves. Statistically significant improvements between pre-glove and with-glove periods were found for most participants' experience scores. Skin appearance also improved for most participants. CONCLUSIONS The indicators generated useful data, differentiation between scores and participants demonstrating proof-of-concept for patients with recessive dystrophic Epidermolysis bullosa who could wear the dressing gloves. The indicators are being used in routine practice, supporting clinical follow up, commercialisation and regulatory governance of the dressing glove.
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Affiliation(s)
- Tanya Graham
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, UK
| | - Sangeeta Sooriah
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, UK
| | - Rachel Box
- Hand Therapy Department, Guy's and St Thomas's NHS Foundation Trust, UK
| | - Heather Gage
- Faculty of Health and Medical Sciences, University of Surrey, UK
| | | | - Victoria Clemett
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, UK
| | - Patricia Grocott
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, UK
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Graham T, Sooriah S, Giampieri S, Box R, Grocott P. Iterative codesign and testing of a novel dressing glove for epidermolysis bullosa. J Wound Care 2019; 28:5-14. [PMID: 30625043 DOI: 10.12968/jowc.2019.28.1.5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Recessive dystrophic epidermolysis bullosa (RDEB) is a rare genetic skin disorder which requires intensive hand therapy to delay fusion of the digits. Existing dressings do not conform to the complex structure of the hand and are applied in patches held with additional bandages, leading to an occlusive environment. The aim was to co-design with patients a dressing glove based on their user experiences and needs. METHOD Qualitative interviews and focus groups with children and adults with RDEB, and their carers, were conducted. Iterative feedback of design cues, bench and surrogate testing of materials and prototype refinement were achieved through collaborative codesign with patients, carers, clinicians and manufacturers. RESULTS Thematic analysis generated eight user needs and corresponding design cues, addressing issues of absorbency, adherence, comfort, adaptability, ease of application and removal, breathability, protection, and hand hygiene. A prototype was selected for proof of concept testing. CONCLUSION This novel dressing glove design met the patient's requirements for a dressing, which conformed to the hand structure and sat in the web spaces to keep fingers separated. Proof of concept testing has since been undertaken with patients to determine performance, value for money and whether further developments are required.
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Affiliation(s)
- Tanya Graham
- Research Fellow, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London
| | - Sangeeta Sooriah
- Research Assistant, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London
| | - Silvia Giampieri
- Research Associate, Faculty of Life Sciences and Medicine, King's College London
| | - Rachel Box
- Clinical Specialist Occupational Therapist, Hand Therapy, Hand Therapy Department, Guy's and St Thomas's NHS Foundation Trust
| | - Patricia Grocott
- Professor of Nursing Innovation and Technology, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London
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Chan JM, Weisman A, King A, Maksomski S, Shotwell C, Bailie C, Weaver H, Bodan R, Guerrero E, Zmazek M, Khuu P. Occupational therapy for epidermolysis bullosa: clinical practice guidelines. Orphanet J Rare Dis 2019; 14:129. [PMID: 31174559 PMCID: PMC6556021 DOI: 10.1186/s13023-019-1059-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 04/08/2019] [Indexed: 12/20/2022] Open
Abstract
The purpose of this article is to summarize the Dystrophic Epidermolysis Bullosa Research Association (DEBRA) International evidence-based Clinical Practice Guidelines (CPGs) for the provision of occupational therapy (OT) for children and adults living with inherited epidermolysis bullosa (EB). This is a rare genetic disorder characterized by skin fragility leading to blister formation occurring spontaneously or following minor trauma. Current OT practice for persons with EB is based on anecdotal care, clinical expertise and trial and error with collaboration between caregiver and patient. Intervention based on research is needed to establish a foundation of knowledge to guide international practitioners to create and improve standards of care and to be able to work effectively with those living with the rare diagnosis of this condition. This CPG was created by an international panel with expertise working with persons with EB. The panel was made up of 11 members including OT’s, a physiotherapist, a medical doctor, social worker, person with EB and a carer of a person with EB. It describes the development of recommendations for 5 outcomes determined by survey of persons with EB, caregivers, and experienced healthcare professionals. The outcomes include independence in activities of daily living (ADL), independence in instrumental ADL, maximization of hand function (non-surgical), fine motor development and retention, and oral feeding skills. The recommendations are supplemented with additional files that include photos and specific examples to further guide occupational therapists or, in situations where an OT is not available, other members of the healthcare team. As the disorder of EB is rare, evidence-based CPGs are needed to provide a base of knowledge and practice for OTs throughout the world with the goal of providing quality care to patients, while improving their functional independence and quality of life. In addition, this information is valuable as a basis for further research.
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Affiliation(s)
- Jennifer M Chan
- Department of Rehabilitation, Lucile Packard Children's Hospital Stanford, 321 Middlefield Road, Menlo Park, CA, 94025, USA.
| | - Amy Weisman
- Department of Rehabilitation, Lucile Packard Children's Hospital Stanford, 321 Middlefield Road, Menlo Park, CA, 94025, USA
| | - Alex King
- Phoenix Children's Hospital, Phoenix, USA
| | | | | | | | | | - Rebecca Bodan
- School of Nursing, California State University Fullerton, Fullerton, USA
| | | | | | - Phuong Khuu
- Department of Rehabilitation, Lucile Packard Children's Hospital Stanford, 321 Middlefield Road, Menlo Park, CA, 94025, USA
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Tuncer S, Sezgin B, Kaya B, Ayhan S, Latifoglu O. An algorithmic approach for the management of hand deformities in dystrophic epidermolysis bullosa. J Plast Surg Hand Surg 2017; 52:80-86. [PMID: 28669251 DOI: 10.1080/2000656x.2017.1338183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Treatment of hand deformities in epidermolysis bullosa patients represents a challenging field in hand surgery practice, thus a systematic approach by a team is mandatory for a successful result. A simple and practical algorithm for the surgical treatment of hand deformities in EB was employed by the authors where the deformities of each digit in EB patients was categorized according to pseudosyndactyly and interphalangeal joint contracture severity for guidance during the surgical treatment. The current study retrospectively reviewed the medical records and photographic data of 13 EB patients followed in our department, for whom a systematic approach to the management and treatment was used. Mild cases were treated by surgical release and secondary healing with non-adhesive dressing while moderate cases were treated with autologous dermal grafts harvested with a special technique that were fixed on denuded areas on the proximal interphalageal joints after release. The remaining areas were treated similarly to the mild group. Additional K-wires were applied for two weeks in severe cases. A total of 21 procedures were performed on 13 EB patients with hand deformities according to the proposed treatment strategy. Functional recovery was satisfactory for each patient and the outcomes were dependent upon the severity of deformity. A multidisciplinary and conscious approach followed by an algorithmic surgical treatment protocol described in the study has been beneficial in providing consistent and successful long-term results for these patients.
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Affiliation(s)
- Serhan Tuncer
- a Department of Plastic, Reconstructive and Aesthetic Surgery , Gazi University School of Medicine , Ankara , Turkey
| | - Billur Sezgin
- b Department of Plastic, Reconstructive and Aesthetic Surgery , Koç University School of Medicine , Istanbul , Turkey
| | - Basar Kaya
- c Department of Plastic, Reconstructive and Aesthetic Surgery , Ufuk University School of Medicine , Ankara , Turkey
| | - Suhan Ayhan
- a Department of Plastic, Reconstructive and Aesthetic Surgery , Gazi University School of Medicine , Ankara , Turkey
| | - Osman Latifoglu
- a Department of Plastic, Reconstructive and Aesthetic Surgery , Gazi University School of Medicine , Ankara , Turkey
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Ahmad RCS, Bruckner AL. A survey of epidermolysis bullosa care in the United States and Canada. Pediatr Dermatol 2014; 31:169-75. [PMID: 24456084 DOI: 10.1111/pde.12258] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Epidermolysis bullosa (EB) is a group of rare, inherited, blistering diseases that typically present in infancy. EB is not curable, and treatment is entirely supportive. There is a paucity of standardized recommendations to guide management. To assess the current state of EB care, an original online survey was conducted targeting attending physicians experienced with the care of EB. Members of the Society for Pediatric Dermatology residing in the United States and Canada served as the source pool. Parameters assessed included clinic visits, availability of subspecialists, and performance of surveillance studies. Fifty-six completed surveys were analyzed. Most providers saw between 1 and 10 individuals with EB per year in a general dermatology clinic. For each EB type there was considerable variation in the frequency of clinic visits, availability and use of specialists, and use of laboratory and imaging studies. Some agreement was observed in the frequency of follow-up for infants with more severe EB types, as well as for the components of a history, physical, and routine laboratory studies. These findings describe variations in the current state of EB care that pediatric dermatologists provide. The development and acceptance of evidence-based guidelines and outcome measures may lead to greater uniformity in EB care.
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Sari E, Eryilmaz T, Tetik G, Ozakpinar HR, Eker E. Suprathel(®) -assisted surgical treatment of the hand in a dystrophic epidermolysis bullosa patient. Int Wound J 2014; 11:472-5. [PMID: 24517465 DOI: 10.1111/iwj.12226] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Accepted: 01/03/2014] [Indexed: 11/30/2022] Open
Abstract
Epidermolysis bullosa (EB) is a progressive familial disorder composed of dermal mucosal blisters, flexion contractures and pseudosyndactylies. Flexion contractures and pseudosyndactyly can be treated with surgery but usually require skin grafting. Because of poor wound healing, skin graft harvesting is a challenge in these patients. In order to prevent donor-site morbidities due to skin graft harvesting some alloplastic materials were introduced. In this study, we focused on Suprathel(®) as a new allograft material for covering the skin defects of a patient with dystrophic EB.
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Affiliation(s)
- Elif Sari
- Plastic, Reconstructive and Aesthetic Surgery Department, Kirikkale University Faculty of Medicine, Yahsihan-Kirikkale, Turkey
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Formsma SA, Maathuis CBG, Robinson PH, Jonkman MF. Postoperative hand treatment in children with recessive dystrophic epidermolysis bullosa. J Hand Ther 2008; 21:80-4; quiz 85. [PMID: 18215755 DOI: 10.1197/j.jht.2007.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2007] [Revised: 10/01/2007] [Accepted: 10/01/2007] [Indexed: 02/03/2023]
Abstract
The purpose of this study is to give an overview of the postoperative hand treatment options in children with recessive dystrophic epidermolysis bullosa (EB) and to introduce a treatment protocol and discuss the indications and timing. Recessive dystrophic EB is a rare hereditary blistering skin condition, which leads to severe hand deformities. The aim of surgical intervention is to temporarily increase hand function and delay the recurrence of deformation. The aim of postoperative treatment is to maintain optimal range of motion of the wrist, fingers, and thumb and to delay recurrence of deformity to enlarge the possibilities of hand function. Two postoperative treatment programs are described in the literature: a program with static splinting and a program with dynamic splinting. Both splinting programs include exercises. This postoperative treatment program for EB starts with dynamic splinting, followed by static splinting in combination with exercises.
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Affiliation(s)
- S A Formsma
- Center for Rehabilitation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Fivenson DP, Scherschun L, Cohen LV. Apligraf in the treatment of severe mitten deformity associated with recessive dystrophic epidermolysis bullosa. Plast Reconstr Surg 2003; 112:584-8. [PMID: 12900618 DOI: 10.1097/01.prs.0000070730.95956.01] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- David P Fivenson
- Department of Dermatology, Henry Ford Health System, Detroit, MI 48202, USA.
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Fivenson DP, Scherschun L, Choucair M, Kukuruga D, Young J, Shwayder T. Graftskin therapy in epidermolysis bullosa. J Am Acad Dermatol 2003; 48:886-92. [PMID: 12789180 DOI: 10.1067/mjd.2003.502] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Epidermolysis bullosa (EB) is a family of 23 genetic skin disorders for which treatments are mainly supportive. Graftskin is a bilayered living human skin construct characterized by a normal expression profile of all the genes reported as mutant in EB. OBJECTIVE The objective of this study was to evaluate the efficiency and durability of graftskin in the treatment of EB. METHODS A total of 9 children with EB were treated with graftskin. These include EB simplex: Dowling-Meara type (n = 2); Weber-Cockayne type (n = 1); junctional EB-Herlitz type (n = 1); and recessive dystrophic EB (n = 5). Lesions were debrided of epidermis and crusts followed by application of fenestrated graftskin under sterile conditions. Syndactyly hand release for "mitten deformity" was performed after removal of all epidermis under general anesthesia. All treatment sites were dressed with a nonadherent contact layer followed by absorbent foam dressing, roll gauze, and a compression wrap covering and were left intact for 1 week. Graft take was assessed clinically at weeks 1, 2, 4, 12, and 20 to 28. Graft persistence was assessed by electron microscopy and polymerase chain reaction analysis at weeks 4 and 12, and between weeks 20 and 28 on selected cases. RESULTS A total of 96 sites were treated with 90% to 100% healing observed by 5 to 7 days, and many sites appearing as normal skin by 10 to 14 days. Finger and hand lesions showed 50% to 90% improvement in range of motion over baseline. Two children learned to walk after graftskin treatment of chronic plantar lesions. Two children had improvement in their chronic anemia after graftskin treatment. All patients and/or parents reported rapid pain resolution. Immunologic and genetic studies of graft persistence revealed evidence of donor DNA up to 28 weeks after graftskin application. None of the samples from female patients demonstrated Y chromosome-specific sequence when analyzed by the method of short tandem repeat. CONCLUSION The encouraging results reported herein support the hypothesis that graftskin is more than a simple bandage or a source of growth factors to stimulate autologous closure of EB wounds. The improved quality of life and rapid achievement of growth/development milestones we have observed makes this an exciting step forward in the care of the patient with EB.
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