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Lau CH, Rouhani MJ, Maughan EF, Orr JC, Kolluri KK, Pearce DR, Haughey EK, Sutton L, Flatau S, Balboa PL, Bageta ML, O'Callaghan C, Smith CM, Janes SM, Hewitt R, Petrof G, Martinez AE, McGrath JA, Butler CR, Hynds RE. Lentiviral expression of wild-type LAMA3A restores cell adhesion in airway basal cells from children with epidermolysis bullosa. Mol Ther 2024; 32:1497-1509. [PMID: 38429928 PMCID: PMC11081864 DOI: 10.1016/j.ymthe.2024.02.032] [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: 08/21/2023] [Revised: 01/26/2024] [Accepted: 02/27/2024] [Indexed: 03/03/2024] Open
Abstract
The hallmark of epidermolysis bullosa (EB) is fragile attachment of epithelia due to genetic variants in cell adhesion genes. We describe 16 EB patients treated in the ear, nose, and throat department of a tertiary pediatric hospital linked to the United Kingdom's national EB unit between 1992 and 2023. Patients suffered a high degree of morbidity and mortality from laryngotracheal stenosis. Variants in laminin subunit alpha-3 (LAMA3) were found in 10/15 patients where genotype was available. LAMA3 encodes a subunit of the laminin-332 heterotrimeric extracellular matrix protein complex and is expressed by airway epithelial basal stem cells. We investigated the benefit of restoring wild-type LAMA3 expression in primary EB patient-derived basal cell cultures. EB basal cells demonstrated weak adhesion to cell culture substrates, but could otherwise be expanded similarly to non-EB basal cells. In vitro lentiviral overexpression of LAMA3A in EB basal cells enabled them to differentiate in air-liquid interface cultures, producing cilia with normal ciliary beat frequency. Moreover, transduction restored cell adhesion to levels comparable to a non-EB donor culture. These data provide proof of concept for a combined cell and gene therapy approach to treat airway disease in LAMA3-affected EB.
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Affiliation(s)
- Chun Hang Lau
- Epithelial Cell Biology in ENT Research (EpiCENTR) Group, UCL Great Ormond Street Institute of Child Health, University College London, 20c Guilford Street, London WC1N 1DZ, UK
| | - Maral J Rouhani
- Lungs for Living Research Centre, UCL Respiratory, Division of Medicine, University College London, 5 University Street, London WC1E 6JF, UK; Ear, Nose, and Throat Department, Great Ormond Street Hospital NHS Foundation Trust, London WC1N 3JH, UK
| | - Elizabeth F Maughan
- Epithelial Cell Biology in ENT Research (EpiCENTR) Group, UCL Great Ormond Street Institute of Child Health, University College London, 20c Guilford Street, London WC1N 1DZ, UK; Ear, Nose, and Throat Department, Great Ormond Street Hospital NHS Foundation Trust, London WC1N 3JH, UK
| | - Jessica C Orr
- Epithelial Cell Biology in ENT Research (EpiCENTR) Group, UCL Great Ormond Street Institute of Child Health, University College London, 20c Guilford Street, London WC1N 1DZ, UK; Lungs for Living Research Centre, UCL Respiratory, Division of Medicine, University College London, 5 University Street, London WC1E 6JF, UK
| | - Krishna K Kolluri
- Lungs for Living Research Centre, UCL Respiratory, Division of Medicine, University College London, 5 University Street, London WC1E 6JF, UK
| | - David R Pearce
- UCL Cancer Institute, University College London, 72 Huntley Street, London WC1E 6DD, UK
| | - Elizabeth K Haughey
- Infection, Immunity, and Inflammation Department, UCL Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London WC1N 1EH, UK
| | - Liam Sutton
- Ear, Nose, and Throat Department, Great Ormond Street Hospital NHS Foundation Trust, London WC1N 3JH, UK
| | - Sam Flatau
- Ear, Nose, and Throat Department, Great Ormond Street Hospital NHS Foundation Trust, London WC1N 3JH, UK
| | - Pablo Lopez Balboa
- Department of Dermatology, Great Ormond Street Hospital NHS Foundation Trust, London WC1N 3JH, UK
| | - Maria Laura Bageta
- Department of Dermatology, Great Ormond Street Hospital NHS Foundation Trust, London WC1N 3JH, UK
| | - Christopher O'Callaghan
- Infection, Immunity, and Inflammation Department, UCL Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London WC1N 1EH, UK
| | - Claire M Smith
- Infection, Immunity, and Inflammation Department, UCL Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London WC1N 1EH, UK
| | - Sam M Janes
- Lungs for Living Research Centre, UCL Respiratory, Division of Medicine, University College London, 5 University Street, London WC1E 6JF, UK
| | - Richard Hewitt
- Ear, Nose, and Throat Department, Great Ormond Street Hospital NHS Foundation Trust, London WC1N 3JH, UK
| | - Gabriela Petrof
- Department of Dermatology, Great Ormond Street Hospital NHS Foundation Trust, London WC1N 3JH, UK
| | - Anna E Martinez
- Department of Dermatology, Great Ormond Street Hospital NHS Foundation Trust, London WC1N 3JH, UK
| | - John A McGrath
- St John's Institute of Dermatology, School of Basic and Medical Biosciences, King's College London, Guy's Hospital, St Thomas Street, London SE1 9RT, UK
| | - Colin R Butler
- Epithelial Cell Biology in ENT Research (EpiCENTR) Group, UCL Great Ormond Street Institute of Child Health, University College London, 20c Guilford Street, London WC1N 1DZ, UK; Ear, Nose, and Throat Department, Great Ormond Street Hospital NHS Foundation Trust, London WC1N 3JH, UK.
| | - Robert E Hynds
- Epithelial Cell Biology in ENT Research (EpiCENTR) Group, UCL Great Ormond Street Institute of Child Health, University College London, 20c Guilford Street, London WC1N 1DZ, UK; UCL Cancer Institute, University College London, 72 Huntley Street, London WC1E 6DD, UK.
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Alotaibi SM, Zahlan A, AlAteeq M, AlMutawa H, Alobaida NW, Aljomah DS, Binnasser A. Supraglottic laryngeal manifestation of epidermolysis bullosa in a pediatric population: A literature review with four case reports. OTOLARYNGOLOGY CASE REPORTS 2023. [DOI: 10.1016/j.xocr.2023.100516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Milani A, Pace A, Iannella G, Corsi A, Cocuzza S, Maniaci A, Greco A, Magliulo G. Recessive Dystrophic Epidermolysis Bullosa: Rare Bilateral External Auditory Canal Stenosis and Surgical Treatment. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2022; 15:11795476221131196. [PMID: 36544566 PMCID: PMC9761233 DOI: 10.1177/11795476221131196] [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: 10/26/2021] [Accepted: 09/20/2022] [Indexed: 12/23/2022]
Abstract
Epidermolysis bullosa (EB) is a family of rare genetic disorders affecting the skin and mucous membranes, causing blisters and lesions. Its treatment is based on the prevention of traumatic events that could favor the onset of blisters as well as careful wound care. New therapies, including gene therapy, are under investigation. In the case described here, a rare localization of EB at the level of the ear canal is described. To our knowledge, no surgical option for treatment has previously been described in the literature. The clinical features observed and the therapeutic modalities adopted are presented and discussed. A 56-year-old female patient came to our attention for bilateral progressive hearing loss. The patient was suffering from Dystrophic EB. Surgical correction of the stenosis through a retroauricular approach was planned, with the simultaneous reconstruction of the right external auditory canal using the canaloplasty technique combined with Thiersch skin grafting. The case we report here is, to our knowledge, the second describing the surgical treatment of ear canal stenosis secondary to EB. As a result of surgical correction of the stenosis, the ear regained its physiological function and there was an improvement in hearing. In the subsequent post-operative controls, there was no recurrence of the disease, from which the patient is still free 36 months after surgery. Although conservative treatment is a solid choice, our experience seems to indicate that the surgical option allows better management of the Dystrophic EB in the external auditory canal.
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Affiliation(s)
- Alessandro Milani
- Organi di Senso Department, Sapienza
University of Rome, Rome, Italy
| | - Annalisa Pace
- Organi di Senso Department, Sapienza
University of Rome, Rome, Italy,Scienze Chirurgiche Department,
Sapienza University of Rome, Rome, Italy
| | - Giannicola Iannella
- Organi di Senso Department, Sapienza
University of Rome, Rome, Italy,Scienze Chirurgiche Department,
Sapienza University of Rome, Rome, Italy,Department of Head-Neck Surgery,
Otolaryngology, Head-Neck, and Oral Surgery Unit, Morgagni Pierantoni Hospital,
Forlì, Italy
| | - Alessandro Corsi
- Department of Molecular Medicine,
Sapienza University of Rome, Rome, Italy
| | - Salvatore Cocuzza
- Otorinolaringoiatria Department,
University of Catania, Catania, Italy
| | - Antonino Maniaci
- Otorinolaringoiatria Department,
University of Catania, Catania, Italy
| | - Antonio Greco
- Organi di Senso Department, Sapienza
University of Rome, Rome, Italy
| | - Giuseppe Magliulo
- Organi di Senso Department, Sapienza
University of Rome, Rome, Italy,Giuseppe Magliulo, Organi di Senso
Department, Sapienza University of Rome, Via Gregorio VII n.80, Rome 00165,
Italy.
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Care of the Patient with Epidermolysis Bullosa. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00484-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Robertson SJ, Prodinger C, Liu L, Skilbeck C, Petrof G, Martinez AE, Mellerio JE, Greenblatt DT. Otological complications in inversa type recessive dystrophic epidermolysis bullosa. Clin Exp Dermatol 2021; 47:717-723. [PMID: 34826142 DOI: 10.1111/ced.15029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/16/2021] [Accepted: 11/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The rare inversa subtype of recessive dystrophic epidermolysis bullosa (RDEB-I) is characterized by predominant intertriginous skin blistering and marked mucosal involvement. Specific recessive missense mutations in the collagen VII triple helix are implicated. To date, otological complications have infrequently been reported in this patient group. METHODS We conducted an observational, retrospective, double institution case record review of RDEB-I patients who presented with otological complications between January 2000 and June 2020. Diagnosis was established on the basis of clinical features, family history and mutation analysis of COL7A1. RESULTS Forty-four percent (11/25) of RDEB-I patients in our database (2 paediatric, 9 adult; mean age 40.9 years, range 8-72 years) experienced otological complications. Ten of 11 individuals (90.9%) had recurrent otitis externa, 7/11 (63.6%) had meatal stenosis and 7/11 (63.6%) had recurrent blistering of external auditory canals. All 11 patients reported hearing difficulties, with conductive hearing loss confirmed by audiology testing in 6/11 (54.5%). Three of 11 (27.3%) patients had implantable hearing aids fitted with favourable outcome; 2 bone-anchored hearing aids (BAHA) and 1 middle ear implant (MEI). One paediatric patient presented with a cholesteatoma that was surgically managed. DISCUSSION We observed a higher prevalence of otological morbidity in RDEB-I than previously reported and present the first case of cholesteatoma in EB. Our data indicate that BAHA and MEI are safe and effective treatment options for hearing loss in EB. Clinicians should be vigilant in screening for ear symptoms in RDEB-I and consider early referral to an ENT specialist.
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Affiliation(s)
- S J Robertson
- St. John's Institute of Dermatology, King's College London, Guy's Hospital, London, United Kingdom
| | - C Prodinger
- St. John's Institute of Dermatology, King's College London, Guy's Hospital, London, United Kingdom
| | - L Liu
- Viapath, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - C Skilbeck
- Department of Otorhinolaryngology-Head and Neck Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - G Petrof
- Department of Dermatology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
| | - A E Martinez
- Department of Dermatology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
| | - J E Mellerio
- St. John's Institute of Dermatology, King's College London, Guy's Hospital, London, United Kingdom
| | - D T Greenblatt
- St. John's Institute of Dermatology, King's College London, Guy's Hospital, London, United Kingdom
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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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Prodinger C, Chottianchaiwat S, Mellerio JE, McGrath JA, Ozoemena L, Liu L, Moore W, Laimer M, Petrof G, Martinez AE. The natural history of laryngo-onycho-cutaneous syndrome: A case series of six pediatric patients and literature review. Pediatr Dermatol 2021; 38:1094-1101. [PMID: 34514630 DOI: 10.1111/pde.14790] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND/OBJECTIVES Laryngo-onycho-cutaneous syndrome (LOC) is a rare subtype of junctional epidermolysis bullosa (JEB), featuring aberrant granulation tissue formation in the skin, larynx, and eyes. So far, three mutations including the specific (founder) mutation in exon 39 of LAMA3 (c.151dup) have been identified, but sparse data exists regarding the natural history, the genotype-phenotype correlation, and its differentiation from other JEB types. METHODS We reviewed our pediatric EB database to identify English children with clinical and genetically diagnosed LOC within the last 15 years. Their demographic, clinical, and laboratory data were examined. We searched three databases for case reports of LOC between January 1986 and November 2020 and extracted clinical and molecular details. RESULTS We identified 6 LOC patients, all female (mean age 5.4 years). Periungual hypergranulation and skin fragility were the earliest presenting signs (0-3 months), followed by laryngeal stenosis, symblepharon (mean onset 10.7 and 11.8 months, respectively), and dental abnormalities. Five children developed anemia at an average of 19.2 months. We identified 22 published studies in English with 31 cases. CONCLUSIONS This study delineates the disease course of LOC and highlights the overlap with some forms of JEB. Classical signs/symptoms including anemia appear early in life. Genetic analysis revealed three new LOC-associated variants and underscores the finding that interpretation of skin immunolabeling and molecular diagnostics can be challenging. We provide recommendations on management of this complex syndrome.
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Affiliation(s)
- Christine Prodinger
- Department of Dermatology and Allergology, University Hospital of the Paracelsus Medical University, Salzburg, Austria
| | | | - Jemima E Mellerio
- St. John's Institute of Dermatology, King's College London, Guy's Hospital, London, UK
| | - John A McGrath
- St. John's Institute of Dermatology, King's College London, Guy's Hospital, London, UK
| | - Linda Ozoemena
- Viapath, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Lu Liu
- Viapath, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - William Moore
- Department of Ophthalmology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Martin Laimer
- Department of Dermatology and Allergology, University Hospital of the Paracelsus Medical University, Salzburg, Austria
| | - Gabriela Petrof
- Department of Dermatology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Anna E Martinez
- Department of Dermatology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
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Abstract
Epidermolysis bullosa (EB) is a group of rare, inherited diseases characterized by skin fragility and multiorgan system involvement that presents many anesthetic challenges. Although the literature regarding anesthetic management focuses primarily on the pediatric population, as life expectancy improves, adult patients with EB are more frequently undergoing anesthesia in nonpediatric hospital settings. Safe anesthetic management of adult patients with EB requires familiarity with the complex and heterogeneous nature of this disease, especially with regard to complications that may worsen during adulthood. General, neuraxial, and regional anesthetics have all been used safely in patients with EB. A thorough preoperative evaluation is essential. Preoperative testing should be guided by EB subtype, clinical manifestations, and extracutaneous complications. Advanced planning and multidisciplinary coordination are necessary with regard to timing and operative plan. Meticulous preparation of the operating room and education of all perioperative staff members is critical. Intraoperatively, utmost care must be taken to avoid all adhesives, shear forces, and friction to the skin and mucosa. Special precautions must be taken with patient positioning, and standard anesthesia monitors must be modified. Airway management is often difficult, and progressive airway deterioration can occur in adults with EB over time. A smooth induction, emergence, and postoperative course are necessary to minimize blister formation from excess patient movement. With careful planning, preparation, and precautions, adult patients with EB can safely undergo anesthesia.
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Catano J, Uzunhan Y, Paule R, Dion J, Régent A, Legendre P, Gonin F, Martinod E, Cohen P, Puéchal X, Le Guern V, Mouthon L, Coste A, Lorut C, Lacroix C, Périé S, Terrier B. Presentation, Diagnosis, and Management of Subglottic and Tracheal Stenosis During Systemic Inflammatory Diseases. Chest 2021; 161:257-265. [PMID: 34324839 DOI: 10.1016/j.chest.2021.07.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Subglottic stenosis (SGS) and tracheal stenosis (TS) are characterized by a narrowing of the airways. The goal of this study was to describe the characteristics and prognosis of nontraumatic and nontumoral SGS or TS. RESEARCH QUESTION What are the inflammatory etiologies of SGS and TS, and what are their characteristics and prognosis? STUDY DESIGN AND METHODS This multicenter, observational retrospective study was performed in patients with SGS or TS that was neither traumatic nor tumoral. RESULTS Eighty-one patients were included, 33 (41%) with granulomatosis with polyangiitis (GPA) and 21 (26%) with relapsing polychondritis (RP). GPA-related stenoses exhibited circumferential subglottic narrowing in 85% of cases, without calcifications. In contrast, RP-related stenoses displayed anterior involvement in 76%, in a longer distance from vocal cords (4 cm), with calcifications in 62%, and extension to bronchi in 86%. Other diagnoses included bullous dermatoses (n = 3), amyloidosis (n = 3), sarcoidosis (n = 2), and Crohn's disease (n = 2); the remaining stenoses (n = 15) were idiopathic. SGS/TS was the initial manifestation of the disease in 66% of cases, with a median interval from stenosis to disease diagnosis of 12 months (interquartile range, 0-48 months). Despite the use of glucocorticoids in 80%, combined with methotrexate in 49%, endoscopic procedures were required in 68% of patients. Relapses of stenoses occurred in 76% without any difference between causes (82% in GPA, 67% in RP, and 75% in idiopathic SGS/TS). Three patients died due to the stenosis, two of RP and one of GPA. INTERPRETATION These data show that GPA and RP are the two main inflammatory diseases presenting with SGS/TS. GPA-related stenoses are mostly subglottic and circumferential, whereas RP-related stenoses are mostly tracheal, anterior, and calcified with a frequent extension to bronchi. Relapses of stenoses are common, and relapse rates do not differ between causes. Diagnosis and management of SGS/TS require a multidisciplinary approach.
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Affiliation(s)
- Jennifer Catano
- Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP)-Centre Université Paris (CUP), Paris, France
| | - Yurdagul Uzunhan
- Department of Pneumology, Reference Center for Rare Pulmonary Diseases, Hôpital Avicenne, AP-HP, INSERM U1272, Université Paris Nord, Bobigny, France
| | - Romain Paule
- Department of Internal Medicine, Hôpital Foch, Suresnes, France
| | - Jérémie Dion
- Department of Clinical Immunology, Oncopôle, Toulouse, France
| | - Alexis Régent
- Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP)-Centre Université Paris (CUP), Paris, France
| | - Paul Legendre
- Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP)-Centre Université Paris (CUP), Paris, France
| | - François Gonin
- Department of Thoracic Surgery, Hôpital Foch, Suresnes, France
| | - Emmanuel Martinod
- Department of Thoracic Surgery, Hôpital Avicenne, AP-HP, Bobigny, France
| | - Pascal Cohen
- Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP)-Centre Université Paris (CUP), Paris, France
| | - Xavier Puéchal
- Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP)-Centre Université Paris (CUP), Paris, France
| | - Véronique Le Guern
- Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP)-Centre Université Paris (CUP), Paris, France
| | - Luc Mouthon
- Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP)-Centre Université Paris (CUP), Paris, France
| | - André Coste
- Department of Otolaryngology, Hôpital Intercommunal, Créteil, France
| | | | | | - Sophie Périé
- Department of Otolaryngology (S. Périé), Clinique Hartmann, Neuilly-Sur-Seine, France
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP)-Centre Université Paris (CUP), Paris, France.
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Tang JY, Marinkovich MP, Lucas E, Gorell E, Chiou A, Lu Y, Gillon J, Patel D, Rudin D. A systematic literature review of the disease burden in patients with recessive dystrophic epidermolysis bullosa. Orphanet J Rare Dis 2021; 16:175. [PMID: 33849616 PMCID: PMC8045359 DOI: 10.1186/s13023-021-01811-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 03/31/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND/OBJECTIVE Recessive dystrophic epidermolysis bullosa (RDEB) is a genetic collagen disorder characterized by skin fragility leading to blistering, wounds, and scarring. There are currently no approved curative therapies. The objective of this manuscript is to provide a comprehensive literature review of the disease burden caused by RDEB. METHODS A systematic literature review was conducted in MEDLINE and Embase in accordance with PRISMA guidelines. Observational and interventional studies on the economic, clinical, or humanistic burden of RDEB were included. RESULTS Sixty-five studies were included in the review. Patients had considerable wound burden, with 60% reporting wounds covering more than 30% of their body. Increases in pain and itch were seen with larger wound size. Chronic wounds were larger and more painful than recurrent wounds. Commonly reported symptoms and complications included lesions and blistering, anemia, nail dystrophy and loss, milia, infections, musculoskeletal contractures, strictures or stenoses, constipation, malnutrition/nutritional problems, pseudosyndactyly, ocular manifestations, and dental caries. Many patients underwent esophageal dilation (29-74%; median dilations, 2-6) and gastrostomy tube placement (8-58%). In the severely affected population, risk of squamous cell carcinoma (SCC) was 76% and mortality from SCC reached 84% by age 40. Patients with RDEB experienced worsened quality of life (QOL), decreased functioning and social activities, and increased pain and itch when compared to other EB subtypes, other skin diseases, and the general population. Families of patients reported experiencing high rates of burden including financial burden (50-54%) and negative impact on private life (79%). Direct medical costs were high, though reported in few studies; annual payer-borne total medical costs in Ireland were $84,534 and annual patient-borne medical costs in Korea were $7392. Estimated annual US costs for wound dressings ranged from $4000 to $245,000. Patients spent considerable time changing dressings: often daily (13-54% of patients) with up to three hours per change (15-40%). CONCLUSION Patients with RDEB and their families/caregivers experience significant economic, humanistic, and clinical burden. Further research is needed to better understand the costs of disease, how the burden of disease changes over the patient lifetime and to better characterize QOL impact, and how RDEB compares with other chronic, debilitating disorders.
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Affiliation(s)
- Jean Yuh Tang
- Department of Dermatology, Stanford Universixsty School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - M Peter Marinkovich
- Department of Dermatology, Stanford Universixsty School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Eleanor Lucas
- Pharmerit - An OPEN Health Company, 4350 East West Highway, Suite 1100, Bethesda, MD, 20814, USA
| | - Emily Gorell
- Department of Dermatology, Stanford Universixsty School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Albert Chiou
- Department of Dermatology, Stanford Universixsty School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Ying Lu
- Department of Dermatology, Stanford Universixsty School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Jodie Gillon
- Abeona Therapeutics Inc, 1330 Avenue of the Americas, New York, NY, 10019, USA
| | - Dipen Patel
- Pharmerit - An OPEN Health Company, 4350 East West Highway, Suite 1100, Bethesda, MD, 20814, USA
| | - Dan Rudin
- Abeona Therapeutics Inc, 1330 Avenue of the Americas, New York, NY, 10019, USA.
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Abstract
Epidermolysis bullosa (EB) is an inherited, heterogeneous group of rare genetic dermatoses characterized by mucocutaneous fragility and blister formation, inducible by often minimal trauma. A broad phenotypic spectrum has been described, with potentially severe extracutaneous manifestations, morbidity and mortality. Over 30 subtypes are recognized, grouped into four major categories, based predominantly on the plane of cleavage within the skin and reflecting the underlying molecular abnormality: EB simplex, junctional EB, dystrophic EB and Kindler EB. The study of EB has led to seminal advances in our understanding of cutaneous biology. To date, pathogenetic mutations in 16 distinct genes have been implicated in EB, encoding proteins influencing cellular integrity and adhesion. Precise diagnosis is reliant on correlating clinical, electron microscopic and immunohistological features with mutational analyses. In the absence of curative treatment, multidisciplinary care is targeted towards minimizing the risk of blister formation, wound care, symptom relief and specific complications, the most feared of which - and also the leading cause of mortality - is squamous cell carcinoma. Preclinical advances in cell-based, protein replacement and gene therapies are paving the way for clinical successes with gene correction, raising hopes amongst patients and clinicians worldwide.
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12
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Emergency management in epidermolysis bullosa: consensus clinical recommendations from the European reference network for rare skin diseases. Orphanet J Rare Dis 2020; 15:142. [PMID: 32505191 PMCID: PMC7276067 DOI: 10.1186/s13023-020-01403-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 05/07/2020] [Indexed: 11/10/2022] Open
Abstract
Epidermolysis bullosa (EB) comprises a group of genetic disorders with the hallmark of fragility of the skin and mucosal surfaces. The severity of different types of EB varies markedly as does the occurrence of extra-cutaneous involvement and complications. A number of emergency situations may occur in the context of EB including obstruction to oral intake from oral or esophageal blisters or scarring, acute airway obstruction, acute urinary retention, sepsis and corneal erosions. Whilst general management principles apply in each of these settings, specific considerations are essential in managing EB to avoid undue trauma or damage to delicate tissues. These recommendations have been developed from a literature review and consensus from experts of the European Network for Rare Skin Disorders (ERN-Skin) to aid decision-making and optimize clinical care by non-EB expert health professionals encountering emergency situations in babies, children and adults with EB.
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Devergne C, Demirtas S, Gauvin Y, Bellon N, Chiaverini C, Misery L, Abasq-Thomas C. Laryngeal stenosis associated with epidermolysis bullosa simplex. JAAD Case Rep 2020; 6:465-467. [PMID: 32395601 PMCID: PMC7203509 DOI: 10.1016/j.jdcr.2020.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Cécile Devergne
- Dermatology, Centre Hospitalier Régional Universitaire Brest, Brest, France
- Correspondence to: Cécile Devergne, MD, 22 rue amiral linois, 29200 Brest, France.
| | - Sirin Demirtas
- Dermatology, Centre Hospitalier Régional Universitaire Brest, Brest, France
| | - Yves Gauvin
- Otorhinolaryngology, Centre Hospitalier Régional Universitaire Brest, Brest, France
| | | | | | - Laurent Misery
- Dermatology, Centre Hospitalier Régional Universitaire Brest, Brest, France
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Bourhis T, Buche S, Fraitag S, Fayoux P. Laryngeal lesion associated with epidermolysis bullosa secondary to congenital plectin deficiency. Eur Ann Otorhinolaryngol Head Neck Dis 2019; 136:203-205. [PMID: 30880037 DOI: 10.1016/j.anorl.2019.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Epidermolysis bullosa (EB) is a congenital disease characterized by fragility of epithelial structures. The skin is the organ primarily affected, resulting in the formation of skin blisters. Some forms of EB may also present mucosal lesions. CASE REPORT We report the case of a girl with epidermolysis bullosa simplex (EBS) associated with muscular dystrophy secondary to congenital plectin deficiency. She presented severe respiratory tract lesions extending from the oral cavity to the larynx. In particular, we describe our medical and surgical management of the laryngeal lesions, responsible for several episodes of respiratory distress and feeding difficulties. DISCUSSION Epidermolysis bullosa simplex associated with muscular dystrophy is a rare hereditary form of EB, as fewer than 50 cases have been reported in the literature. This form is characterized by mucosal lesions involving the upper aerodigestive tract, with consequences for feeding, phonation and breathing. Special care must be taken when performing diagnostic and therapeutic procedures to avoid worsening the lesions of this very fragile mucosa. Tracheotomy is a harmful procedure in these patients and should only be considered as a last resort.
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Affiliation(s)
- T Bourhis
- ORL et chirurgie cervicofaciale pédiatrique, hôpital Jeanne-de-Flandre, CHRU Lille, avenue Eugène-Avinée, 59037 Lille cedex, France
| | - S Buche
- Service de dermatologie, hôpital Claude-Huriez, CHRU Lille, 59037 Lille, France
| | - S Fraitag
- Service d'anatomie et cytologie pathologiques, hôpital Necker-Enfants malades, AP-HP, 75015 Paris, France
| | - P Fayoux
- ORL et chirurgie cervicofaciale pédiatrique, hôpital Jeanne-de-Flandre, CHRU Lille, avenue Eugène-Avinée, 59037 Lille cedex, France.
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Chong SC, Hon KL, Yuen LYP, Choi PCL, Ng WGG, Chiu TW. Neonatal epidermolysis bullosa: lessons to learn about genetic counseling. J DERMATOL TREAT 2018; 32:29-32. [PMID: 30280950 DOI: 10.1080/09546634.2018.1527999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Epidermolysis Bullosa (EB) is a heterogeneous group of congenital blistering diseases that usually presents in the neonatal period. EB is classified into three major categories, each with many subtypes based on the precise location at which separation or blistering occurs, namely epidermolysis bullosa simplex (EBS), junctional epidermolysis bullosa (JEB) and dystrophic epidermolysis bullosa (DEB). METHODS We describe genetics of neonatal EB in Hong Kong. RESULTS Two neonates of consanguineous Pakistani parents had the EB-Pyloric Atresia (EB-PA) variant. One had a 4 kb homozygous deletion of exon 19-25 of the ITGB4 gene, and the other with only a histopathological diagnosis. Both died of sepsis in infancy. Aberrant COL7A1 mutations in the dominant and recessive EB were described. Genetic analysis, together with histopathological classification is important to aid prognosis and counseling. JEB and EB-PA are associated with consanguinity and mortality during infancy. Morbidity and prognosis of the autosomal dominant DEB are optimistic. The autosomal recessive DEB is more severe, with neonatal onset and recurrent blistering. It is also associated with chronicity and malignant changes when the child reaches adulthood. CONCLUSION Exact genetic diagnosis aids in counseling of the family concerning the prognosis in the affected child and the risk of affected children in future pregnancies.
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Affiliation(s)
- Shuk Ching Chong
- Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong kong.,The Chinese University of Hong Kong - Baylor College of Medicine Joint Center for Medical Genetics, Shatin, Hong Kong
| | - Kam Lun Hon
- Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong kong
| | - Liz Y P Yuen
- Department of Chemical Pathology, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Paul Cheung Lung Choi
- Department of Anatomical and Cellular Pathology, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - W G Gigi Ng
- Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong kong
| | - Tor W Chiu
- The Chinese University of Hong Kong - Baylor College of Medicine Joint Center for Medical Genetics, Shatin, Hong Kong.,Division of Plastic Reconstructive and Aesthetic Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
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Wall A, Gelbard A, Vinh D, Simmons J, Donovan D, Grogan E, Ongkasuwan J. Management of laryngotracheal complications of inherited epidermolysis bullosa in the adult: A case series. OTOLARYNGOLOGY CASE REPORTS 2018. [DOI: 10.1016/j.xocr.2017.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
Mucosal lesions occur with different prevalence and severity in all subtypes of hereditary epidermolysis bullosa (EB), a group of rare genodermatoses. They are associated with increased morbidity and mortality, especially in severe junctional and dystrophic subtypes. Despite progress in clinical approaches to curative therapy, the management of these patients is still primarily symptom-oriented. Current recommendations mainly rely on expert opinion and experience from health care professionals of specialized centers, since the rarity of this disease largely limits the availability and feasibility of randomized controlled trials. Accurate preventive and supportive care measures, however, can significantly lessen symptoms, avoid/ameliorate complications, and enhance the quality of life of these patients.
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Palinko D, Matievics V, Szegesdi I, Sztano B, Rovo L. Minimally invasive endoscopic treatment for pediatric combined high grade stenosis as a laryngeal manifestation of epidermolysis bullosa. Int J Pediatr Otorhinolaryngol 2017; 92:126-129. [PMID: 28012513 DOI: 10.1016/j.ijporl.2016.11.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 11/16/2016] [Accepted: 11/19/2016] [Indexed: 10/20/2022]
Abstract
Epidermolysis bullosa refers to a clinically and genetically heterogeneous group of inherited mucocutaneous diseases. Laryngotracheal lesions are momentous regarding the risk of sudden airway obstruction. The traditional treatment is tracheostomy. This case report highlights the advantages of minimally invasive interventions. A successful combined endoscopic management of a life-threatening respiratory crisis is presented in a 4-year-old child. Combined commissure stenosis with supraglottic spread was treated by CO2 laser dissection and bilateral endoscopic arytenoid abduction lateropexy, supplemented with mitomycin C application. Due to expectable less scarring, the combination of these modern methods may be an efficient solution in these vulnerable respiratory tracts.
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Affiliation(s)
- Dora Palinko
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Szeged, Hungary.
| | - Vera Matievics
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Szeged, Hungary
| | - Ilona Szegesdi
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Hungary
| | - Balazs Sztano
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Szeged, Hungary
| | - Laszlo Rovo
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Szeged, Hungary
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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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Images in Anesthesiology: Child with Junctional Epidermolysis Bullosa, Hoarseness, and Nasal Obstruction Demonstrating Severe Laryngeal Stenosis. Anesthesiology 2016; 125:1044. [PMID: 27755034 DOI: 10.1097/aln.0000000000001201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Ptbp1 and Exosc9 knockdowns trigger skin stability defects through different pathways. Dev Biol 2015; 409:489-501. [PMID: 26546114 DOI: 10.1016/j.ydbio.2015.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 09/14/2015] [Accepted: 11/02/2015] [Indexed: 10/22/2022]
Abstract
In humans, genetic diseases affecting skin integrity (genodermatoses) are generally caused by mutations in a small number of genes that encode structural components of the dermal-epidermal junctions. In this article, we first show that inactivation of both exosc9, which encodes a component of the RNA exosome, and ptbp1, which encodes an RNA-binding protein abundant in Xenopus embryonic skin, impairs embryonic Xenopus skin development, with the appearance of dorsal blisters along the anterior part of the fin. However, histological and electron microscopy analyses revealed that the two phenotypes are distinct. Exosc9 morphants are characterized by an increase in the apical surface of the goblet cells, loss of adhesion between the sensorial and peridermal layers, and a decrease in the number of ciliated cells within the blisters. Ptbp1 morphants are characterized by an altered goblet cell morphology. Gene expression profiling by deep RNA sequencing showed that the expression of epidermal and genodermatosis-related genes is also differentially affected in the two morphants, indicating that alterations in post-transcriptional regulations can lead to skin developmental defects through different routes. Therefore, the developing larval epidermis of Xenopus will prove to be a useful model for dissecting the post-transcriptional regulatory network involved in skin development and stability with significant implications for human diseases.
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Kubanov AA, Albanova VI, Karamova AE, Chikin VV, Melekhina LYE, Bogdanova YEV. Prevalence of hereditary epidermolysis bullosa in the Russian Federation. VESTNIK DERMATOLOGII I VENEROLOGII 2015. [DOI: 10.25208/0042-4609-2015-91-3-21-30] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Goal. To study the prevalence of hereditary epidermolysis bullosa (HEB) in the Russian Federation. Materials and methods. The data on the number of HEB patients by subjects of the Russian Federation as well as their age and disease type were obtained based on questionnaires. The questionnaires were sent to dermatovenerology healthcare institutions from 85 subjects of the Russian Federation. The HEB prevalence rates in the subjects of the Russian Federation were calculated as the ratio of the number of HEB patients in the subject of the Russian Federation to the population size in the subject per million residents. Results. Information about 438 HEB patients (210 female and 228 male) aged 0-66 was collected in 70 subjects of the Russian Federation as of January 1, 2015. The disease type was specified for 139 patients (86 patients with common HEB, 50 patients with dystrophic HEB and 3 patients with the borderline form of HEB). No details about the disease type were provided for 299 patients (68.26%). The HEB prevalence rate in the subjects of the Russian Federation varies from 0 to 19.73 cases per million residents. Conclusion. These data on the HEB prevalence rate in 70 subjects of the Russian Federation are comparable to the data specified in literature sources providing information on the HEB prevalence rate in some foreign states. The data represent the first step to the development of clinical recommendations concerning HEB management and establishment of a register of in the Russian Federation.
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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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Yang CS, Kroshinksy D, Cummings BM. Neonatal junctional epidermolysis bullosa: treatment conundrums and ethical decision making. Am J Clin Dermatol 2014; 15:445-50. [PMID: 25117154 DOI: 10.1007/s40257-014-0091-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Junctional epidermolysis bullosa (JEB), generalized severe (previously called JEB, Herlitz-type) has an extremely poor prognosis, with a mean age of death at 5 months old and most dead before age 3 years. We describe a typical case of a neonate with JEB who developed failure to thrive before his death from fungal septicemia at 4 months of age. This case highlights the ethical considerations of invasive treatments such as gastrostomy tube placements, intubations, and central line placements in neonates with JEB. We review the literature as well as discuss the ethical conundrums in the care of patients with JEB and other severe forms of epidermolysis bullosa.
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Abstract
PURPOSE OF REVIEW Children with epidermolysis bullosa can present with disease(s) of the ears, nose, and throat, often related directly to the pathophysiology of their epidermolysis bullosa. Otolaryngologic diseases in children with epidermolysis bullosa have to be managed having a proper understanding of the diagnosis and pathophysiology of epidermolysis bullosa. The purpose of this review is to describe the current nomenclature and diagnostic algorithms for epidermolysis bullosa, and methods for the management of cutaneous and mucosal lesions. RECENT FINDINGS Characterization of the gene defects leading to epidermolysis bullosa has allowed the utilization of immunofluorescent techniques as the primary method for epidermolysis bullosa diagnosis. Recognizing the difficulty in managing patients with epidermolysis bullosa, several multidisciplinary groups have developed guidelines using meta-analysis of the published literature, or expert panels. Though there are currently no effective treatment modalities for epidermolysis bullosa, techniques for gene and protein replacement show promising results for future use. SUMMARY Currently, the management of cutaneous and mucosal disease in epidermolysis bullosa is based on the principles of prevention and wound care. Understanding the cause of epidermolysis bullosa types and subtypes, characteristics of skin and mucosal involvement, and prognosis will guide in the development of individualized treatment plans.
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Hon KLE, Li JJ, Cheng BL, Luk DC, Murrell DF, Choi PCL, Leung AKC. Age and etiology of childhood epidermolysis bullosa mortality. J DERMATOL TREAT 2014; 26:178-82. [DOI: 10.3109/09546634.2014.915002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Epidermolysis bullosa (EB) is a heterogeneous group of inherited skin diseases characterized by increased skin fragility and variable degrees of extracutaneous involvement. The clinical spectrum ranges from localized skin disease to a life-threatening and disabling disease with extensive extracutaneous involvement. All four major types of EB, namely EB simplex, Junctional EB, Dystrophic EB and Kindler syndrome, can present with blistering and erosions at birth and cannot be distinguished clinically in the newborn period. The extensive differential diagnosis of blistering and erosions in the neonate must be considered and common etiologies ruled out. The diagnosis of EB can be confirmed via a skin biopsy for immunoflourescence mapping. This review discusses the four major subtypes of EB and their associated extracutaneous features. The evaluation of a newborn suspected of having EB, including diagnosis and management, is also reviewed.
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Affiliation(s)
- Mercedes E Gonzalez
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY 10016, USA.
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Abstract
Laminin 332 is an essential component of the dermal-epidermal junction, a highly specialized basement membrane zone that attaches the epidermis to the dermis and thereby provides skin integrity and resistance to external mechanical forces. Mutations in the LAMA3, LAMB3 and LAMC2 genes that encode the three constituent polypeptide chains, α3, β3 and γ2, abrogate or perturb the functions of laminin 332. The phenotypic consequences are diminished dermal-epidermal adhesion and, as clinical symptoms, skin fragility and mechanically induced blistering. The disorder is designated as junctional epidermolysis bullosa (JEB). This article delineates the signs and symptoms of the different forms of JEB, the mutational spectrum, genotype-phenotype correlations as well as perspectives for future molecular therapies.
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Affiliation(s)
- Dimitra Kiritsi
- Department of Dermatology; University Freiburg Medical Center; Freiburg, Germany
| | - Cristina Has
- Department of Dermatology; University Freiburg Medical Center; Freiburg, Germany
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Upper airway complications of junctional epidermolysis bullosa. J Pediatr 2012; 160:657-661.e1. [PMID: 22050875 DOI: 10.1016/j.jpeds.2011.09.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 08/09/2011] [Accepted: 09/19/2011] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To assess the incidence of upper airway pathology in patients with junctional epidermolysis bullosa (JEB). STUDY DESIGN We conducted a retrospective chart review of all patients with JEB who came to an interdisciplinary epidermolysis bullosa center at a tertiary care institution between 2004 and 2010. RESULTS Twenty-five patients with JEB were identified, and 12 patients were seen in the otolaryngology clinic (age range, 2 months-15 years; 8 male, 4 female). Of the 12 patients, 8 underwent rigid laryngoscopy and bronchoscopy for upper respiratory tract symptoms; 7 of these patients displayed laryngeal pathology, and 5 of them underwent surgical intervention with successful resolution of symptoms. Furthermore, none of these patients had any short- or long-term complications from their surgery. A strict protocol and a precise problem-focused cold surgical technique were used in these cases to protect skin and mucus membranes. CONCLUSION With appropriate precautions, endoscopic laryngeal surgery can be safe and effective in patients with JEB and larygnotracheal disease. Endoscopic laryngeal surgery is feasible when indicated for these patients.
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Oliveira ZNPD, Périgo AM, Fukumori LMI, Aoki V. Immunological mapping in hereditary epidermolysis bullosa. An Bras Dermatol 2011; 85:856-61. [PMID: 21308310 DOI: 10.1590/s0365-05962010000600012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Indexed: 11/22/2022] Open
Abstract
Immunological mapping, an immunofluorescence technique, is currently the method most used to diagnose and differentiate the principal types of hereditary epidermolysis bullosa, since this technique is capable of determining the level of cleavage of this mechanobullous disease.
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Pagliarello C, Tabolli S. Factors affecting quality of life in epidermolysis bullosa. Expert Rev Pharmacoecon Outcomes Res 2010; 10:329-38. [PMID: 20545597 DOI: 10.1586/erp.10.28] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Epidermolysis bullosa is a rare group of inherited disorders that manifests as blistering or erosion of the skin in response to little or no apparent trauma. Patients suffer from long-term physical, social and economic consequences. Despite the fact that quality of life assessment has rapidly become a significant outcome variable in dermatology research, only a few studies regarding epidermolysis bullosa patients are available. This paper reviews studies evaluating the effect of epidermolysis bullosa on quality of life in patients and caregivers in order to assess which factors can best describe their health-related quality of life. Currently, considerable deficits prevail in both the diagnosis and treatment of rare skin diseases. Moreover, the psychological and social morbidities very easily evade the eyes of clinicians. Comparison of the impact of epidermolysis bullosa with that of other conditions is clearly valuable for making public policy decisions. This review indicates the need for more rigorous exploration of the impact of such diseases to further guide treatment and to monitor quality of care.
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Affiliation(s)
- Calogero Pagliarello
- Health Service Research Unit, IDI IRCCS, Via Monti di Creta 104, 00167 Rome, Italy
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Abstract
PURPOSE OF REVIEW This review highlights key findings, both clinical and basic, that have been published in the field of inherited epidermolysis bullosa within the past few years. RECENT FINDINGS New epidermolysis bullosa phenotypes, genotypes and modes of transmission have been identified, resulting in a revised classification system. Detailed evidence-based data are now available on the risk of extracutaneous complications in each of the major epidermolysis bullosa subtypes. Studies are now underway to try to better explain the biological aggressiveness of squamous cell carcinomas arising in epidermolysis bullosa skin. Cell and animal models have been refined and used to ascertain the feasibility of gene replacement therapy, stem cell transplantation, and treatment with injected allogeneic fibroblasts or recombinant type VII collagen. As a result, clinical trials are now being pursued to test each of these in humans. SUMMARY Epidermolysis bullosa is caused by mutations in at least 14 genes, leading to a broad spectrum of entities, each of which has its own relative risk for the development of specific extracutaneous complications and/or premature death. Intensive research, both basic and clinical, is bringing us closer to more effective treatments and possibly even a cure.
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Hernández-Martín A, Torrelo A. Epidermólisis ampollosas hereditarias: del diagnóstico a la realidad. ACTAS DERMO-SIFILIOGRAFICAS 2010. [DOI: 10.1016/j.ad.2010.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Abstract
Inherited epidermolysis bullosa (EB) encompasses a number of disorders characterized by recurrent blister formation as the result of structural fragility within the skin and selected other tissues. All types and subtypes of EB are rare; the overall incidence and prevalence of the disease within the United States is approximately 19 per one million live births and 8 per one million population, respectively. Clinical manifestations range widely, from localized blistering of the hands and feet to generalized blistering of the skin and oral cavity, and injury to many internal organs. Each EB subtype is known to arise from mutations within the genes encoding for several different proteins, each of which is intimately involved in the maintenance of keratinocyte structural stability or adhesion of the keratinocyte to the underlying dermis. EB is best diagnosed and subclassified by the collective findings obtained via detailed personal and family history, in concert with the results of immunofluorescence antigenic mapping, transmission electron microscopy, and in some cases, by DNA analysis. Optimal patient management requires a multidisciplinary approach, and revolves around the protection of susceptible tissues against trauma, use of sophisticated wound care dressings, aggressive nutritional support, and early medical or surgical interventions to correct whenever possible the extracutaneous complications. Prognosis varies considerably and is based on both EB subtype and the overall health of the patient.
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Affiliation(s)
- Jo-David Fine
- Department of Medicine (Dermatology, Vanderbilt University School of Medicine, Head, National Epidermolysis Bullosa Registry Nashville, TN, USA.
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Abstract
Epidermolysis bullosa (EB) is a class of intractable, rare, genetic disorders characterized by fragile skin and blister formation as a result of dermal-epidermal mechanical instability. EB presents with considerable clinical and molecular heterogeneity. Viable animal models of junctional EB (JEB), that both mimic the human disease and survive beyond the neonatal period, are needed. We identified a spontaneous, autosomal recessive mutation (Lamc2(jeb)) due to a murine leukemia virus long terminal repeat insertion in Lamc2 (laminin gamma2 gene) that results in a hypomorphic allele with reduced levels of LAMC2 protein. These mutant mice develop a progressive blistering disease validated at the gross and microscopic levels to closely resemble generalized non-Herlitz JEB. The Lamc2(jeb) mice display additional extracutaneous features such as loss of bone mineralization and abnormal teeth, as well as a respiratory phenotype that is recognized but not as well characterized in humans. This model faithfully recapitulates human JEB and provides an important preclinical tool to test therapeutic approaches.
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Babić I, Karaman-Ilić M, Pustisek N, Susić S, Skarić I, Kljenak A, Cikojević D. Respiratory tract involvement in a child with epidermolysis bullosa simplex with plectin deficiency: a case report. Int J Pediatr Otorhinolaryngol 2010; 74:302-5. [PMID: 20044146 DOI: 10.1016/j.ijporl.2009.10.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Accepted: 10/01/2009] [Indexed: 11/28/2022]
Abstract
We report a rare case of a child with epidermolysis bullosa simplex (EBS) with plectin deficiency but without muscular dystrophy, with severe lesions of the oral cavity, oropharyngeal, hypopharyngeal, laryngeal, tracheal and bronchial mucosa. Case report and a review of the world literature are used. The literature review revealed only five similar patients with EBS without muscular dystrophy complicated by respiratory involvement. This paper highlights the potentially serious complications of the EB in the form of breathing, swallowing and speech difficulties and describes the specific problems encountered in the treatment of this patient. Epidermolysis bullosa (EB) is a group of severe hereditary diseases, primarily of the skin, but which can also involve the respiratory and gastrointestinal tract mucosa. Respiratory tract involvement is usually only found in certain types of EB. The oral cavity and oropharynx are involved more frequently than the hypopharynx, larynx and trachea. Involvement of laryngeal and tracheal mucosa is generally associated with an increased morbidity and mortality, numerous complications and therapeutic difficulties, and is more common in junctional EB and dystrophic EB than in EBS. We present a rare case of a child with EBS and plectin deficiency with pronounced lesions of respiratory tract mucosa from the oral cavity to the bronchi and even extending into the trachea. Deciding on tracheotomy requires thorough consideration and should not be taken lightly.
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Affiliation(s)
- Irena Babić
- ENT Division, Department of Pediatric Surgery, Zagreb University Children's Hospital, Klaićeva 16, Zagreb, Croatia.
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Severe cutaneous adverse reactions: emergency approach to non-burn epidermolytic syndromes. Intensive Care Med 2009; 36:22-32. [PMID: 19787334 DOI: 10.1007/s00134-009-1659-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Accepted: 07/29/2009] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Although severe cutaneous adverse reactions (SCARs), such as Stevens-Johnson syndrome and toxic epidermal necrolysis, are rare, they are associated with considerable morbidity and mortality. METHODS The current knowledge regarding background, differential diagnoses, critical care and implications for inter-hospital emergency medical service (EMS) transport of these patients is discussed. CONCLUSION SCAR patients will substantially benefit from early interdisciplinary care and thorough consideration of complications during EMS transport and intensive care treatment.
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Fine JD, Mellerio JE. Extracutaneous manifestations and complications of inherited epidermolysis bullosa: part I. Epithelial associated tissues. J Am Acad Dermatol 2009; 61:367-84; quiz 385-6. [PMID: 19700010 DOI: 10.1016/j.jaad.2009.03.052] [Citation(s) in RCA: 161] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Revised: 02/22/2009] [Accepted: 03/03/2009] [Indexed: 01/05/2023]
Abstract
Based upon case reports and small case series, it has been known for many years that some types and subtypes of inherited epidermolysis bullosa (EB) may be at risk for developing one or more extracutaneous complications. Many of these are associated with considerable morbidity; some may result in death. Only over the past few years have there been data generated from large, well characterized cohorts. However, these data, to date, have been published almost exclusively in the nondermatologic literature. Our objective is to provide dermatologists with a comprehensive review of each major extracutaneous complication with a summary of the pertinent literature and recommendations for evaluation and optimal management. Part I highlights epithelial associated tissues, and part II addresses other organs. Based on these reviews, the readership should gain a greater understanding of the types of complications that may occur, when they are most likely to develop, and the range of medical and surgical interventions that are currently available. It should also be possible for the reader to develop surveillance strategies based on an understanding of the published evidence-based data. The breadth and range of severity of complications that arise in some EB types and subtypes within the external eye, ear, nose, upper airway, and gastrointestinal and genitourinary tracts suggest that optimal management must be multidisciplinary. Given the unique knowledge that dermatologists have of this disease, we believe that the care of the EB patient should be under the direction of his or her dermatologist, who can best assist in timely referrals to those specialists who are most experienced in the care of specific extracutaneous problems.
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Affiliation(s)
- Jo-David Fine
- The National Epidermolysis Bullosa Registry, and Department of Medicine (Dermatology), Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
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Nasr AA, Almathami A, Alhathal N, Fadin A, Zakaria H. Combined spinal and epidural anesthesia in a child with epidermolysis bullosa. Paediatr Anaesth 2008; 18:1278-9. [PMID: 19076610 DOI: 10.1111/j.1460-9592.2008.02811.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Fine JD, Eady RA, Bauer EA, Bauer JW, Bruckner-Tuderman L, Heagerty A, Hintner H, Hovnanian A, Jonkman MF, Leigh I, McGrath JA, Mellerio JE, Murrell DF, Shimizu H, Uitto J, Vahlquist A, Woodley D, Zambruno G. The classification of inherited epidermolysis bullosa (EB): Report of the Third International Consensus Meeting on Diagnosis and Classification of EB. J Am Acad Dermatol 2008; 58:931-50. [DOI: 10.1016/j.jaad.2008.02.004] [Citation(s) in RCA: 513] [Impact Index Per Article: 32.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2007] [Revised: 01/29/2008] [Accepted: 02/10/2008] [Indexed: 01/26/2023]
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Epidermolysis bullosa hereditaria. Monatsschr Kinderheilkd 2008. [DOI: 10.1007/s00112-007-1663-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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