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Popp C, Miller W, Eide C, Tolar J, McGrath JA, Ebens CL. Beyond the Surface: A Narrative Review Examining the Systemic Impacts of Recessive Dystrophic Epidermolysis Bullosa. J Invest Dermatol 2024; 144:1943-1953. [PMID: 38613531 DOI: 10.1016/j.jid.2024.03.008] [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: 09/15/2023] [Revised: 02/09/2024] [Accepted: 03/02/2024] [Indexed: 04/15/2024]
Abstract
Recessive dystrophic epidermolysis bullosa (RDEB) is a rare genetic disease resulting from inadequate type VII collagen (C7). Although recurrent skin blisters and wounds are the most apparent disease features, the impact of C7 loss is not confined to the skin and mucous membranes. RDEB is a systemic disease marred by chronic inflammation, fibrotic changes, pain, itch, and anemia, significantly impacting QOL and survival. In this narrative review, we summarize these systemic features of RDEB and promising research avenues to address them.
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Affiliation(s)
- Courtney Popp
- Division of Blood and Marrow Transplant & Cellular Therapy, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, Minnesota, USA
| | - William Miller
- Division of Blood and Marrow Transplant & Cellular Therapy, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, Minnesota, USA
| | - Cindy Eide
- Division of Blood and Marrow Transplant & Cellular Therapy, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jakub Tolar
- Division of Blood and Marrow Transplant & Cellular Therapy, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, Minnesota, USA; MHealth Fairview Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - John A McGrath
- St. John's Institute of Dermatology, Guy's Hospital, School of Basic & Medical Biosciences, King's College London, London, United Kingdom
| | - Christen L Ebens
- Division of Blood and Marrow Transplant & Cellular Therapy, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, Minnesota, USA; MHealth Fairview Masonic Children's Hospital, Minneapolis, Minnesota, USA.
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Quintana-Castanedo L, Sánchez-Ramón S, Maseda R, Illera N, Pérez-Conde I, Molero-Luis M, Butta N, Arias-Salgado EG, Monzón-Manzano E, Zuluaga P, Martínez-Santamaría L, Fernández-Arquero M, Llames SG, Meana Á, de Lucas R, Del Río M, Vicente Á, Escámez MJ, Sacedón R. Unveiling the value of C-reactive protein as a severity biomarker and the IL4/IL13 pathway as a therapeutic target in recessive dystrophic epidermolysis bullosa: A multiparametric cross-sectional study. Exp Dermatol 2024; 33:e15146. [PMID: 39075828 DOI: 10.1111/exd.15146] [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: 03/05/2024] [Revised: 06/24/2024] [Accepted: 07/14/2024] [Indexed: 07/31/2024]
Abstract
Patients with recessive dystrophic epidermolysis bullosa (RDEB) experience numerous complications, which are exacerbated by inflammatory dysregulation and infection. Understanding the immunological mechanisms is crucial for selecting medications that balance inflammation control and immunocompetence. In this cross-sectional study, aiming to identify potential immunotherapeutic targets and inflammatory biomarkers, we delved into the interrelationship between clinical severity and systemic inflammatory parameters in a representative RDEB cohort. Encompassing 84 patients aged 1-67 and spanning all three Epidermolysis Bullosa Disease Activity and Scarring Index (EBDASI) severity categories, we analysed the interrelationship of infection history, standard inflammatory markers, systemic cytokines and Ig levels to elucidate their roles in RDEB pathophysiology. Our findings identify C-reactive protein as an excellent biomarker for disease severity in RDEB. A type 2 inflammatory profile prevails among moderate and severe RDEB patients, correlating with dysregulated circulating IgA and IgG. These results underscore the IL4/IL13 pathways as potential evidence-based therapeutic targets. Moreover, the complete inflammatory scenario aligns with Staphylococcus aureus virulence mechanisms. Concurrently, abnormalities in IgG, IgE and IgM levels suggest an immunodeficiency state in a substantial number of the cohort's patients. Our results provide new insights into the interplay of infection and immunological factors in the pathogenesis of RDEB.
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Affiliation(s)
- Lucía Quintana-Castanedo
- Department of Dermatology, IdiPAZ Health Research Institute, Hospital La Paz, Madrid, Spain
- Department of Dermatology, Marqués de Valdecilla University Hospital, Santander, Spain
| | - Silvia Sánchez-Ramón
- Department of Immunology, IML and IdISSC Health Research Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Rocío Maseda
- Department of Dermatology, IdiPAZ Health Research Institute, Hospital La Paz, Madrid, Spain
| | - Nuria Illera
- Departamento de Bioingeniería, Universidad Carlos III de Madrid, Madrid, Spain
- Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER)-ISCIII, Madrid, Spain
- Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD, UAM), Madrid, Spain
| | - Isabel Pérez-Conde
- Department of Dermatology, IdiPAZ Health Research Institute, Hospital La Paz, Madrid, Spain
| | | | - Nora Butta
- Department of Hematology and Hemotherapy, IdiPAZ Health Research Institute, Hospital La Paz, Madrid, Spain
| | - Elena G Arias-Salgado
- Department of Hematology and Hemotherapy, IdiPAZ Health Research Institute, Hospital La Paz, Madrid, Spain
| | - Elena Monzón-Manzano
- Department of Hematology and Hemotherapy, IdiPAZ Health Research Institute, Hospital La Paz, Madrid, Spain
| | - Pilar Zuluaga
- Department of Statistics and Operations Research, Faculty of Medicine, Madrid, Spain
| | - Lucía Martínez-Santamaría
- Departamento de Bioingeniería, Universidad Carlos III de Madrid, Madrid, Spain
- Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER)-ISCIII, Madrid, Spain
- Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD, UAM), Madrid, Spain
| | - Miguel Fernández-Arquero
- Department of Immunology, IML and IdISSC Health Research Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Sara G Llames
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER)-ISCIII, Madrid, Spain
- Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD, UAM), Madrid, Spain
- Unidad de Ingeniería Tisular, Centro Comunitario Sangre y Tejidos de Asturias (CCST), Oviedo, Spain
- Instituto Universitario Fernández-Vega, Fundación de Investigación Oftalmológica (FIO), Oviedo, Spain
| | - Álvaro Meana
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER)-ISCIII, Madrid, Spain
- Unidad de Ingeniería Tisular, Centro Comunitario Sangre y Tejidos de Asturias (CCST), Oviedo, Spain
- Instituto Universitario Fernández-Vega, Fundación de Investigación Oftalmológica (FIO), Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Raúl de Lucas
- Department of Dermatology, IdiPAZ Health Research Institute, Hospital La Paz, Madrid, Spain
| | - Marcela Del Río
- Departamento de Bioingeniería, Universidad Carlos III de Madrid, Madrid, Spain
- Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER)-ISCIII, Madrid, Spain
- Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD, UAM), Madrid, Spain
| | - Ángeles Vicente
- Department of Cell Biology, Faculty of Medicine, UCM, Health Research Institute of the Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - María José Escámez
- Departamento de Bioingeniería, Universidad Carlos III de Madrid, Madrid, Spain
- Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER)-ISCIII, Madrid, Spain
- Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD, UAM), Madrid, Spain
| | - Rosa Sacedón
- Department of Cell Biology, Faculty of Medicine, UCM, Health Research Institute of the Hospital Clínico San Carlos (IdISSC), Madrid, Spain
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Condorelli AG, Nobili R, Muglia A, Scarpelli G, Marzuolo E, De Stefanis C, Rota R, Diociaiuti A, Alaggio R, Castiglia D, Odorisio T, El Hachem M, Zambruno G. Gamma-Secretase Inhibitors Downregulate the Profibrotic NOTCH Signaling Pathway in Recessive Dystrophic Epidermolysis Bullosa. J Invest Dermatol 2024; 144:1522-1533.e10. [PMID: 38237731 DOI: 10.1016/j.jid.2023.10.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 09/29/2023] [Accepted: 10/12/2023] [Indexed: 03/03/2024]
Abstract
Recessive dystrophic epidermolysis bullosa (RDEB) is a rare skin fragility disorder caused by mutations in COL7A1. RDEB is hallmarked by trauma-induced unremitting blistering, chronic wounds with inflammation, and progressive fibrosis, leading to severe disease complications. There is currently no cure for RDEB-associated fibrosis. Our previous studies and increasing evidence highlighted the profibrotic role of NOTCH pathway in different skin disorders, including RDEB. In this study, we further investigated the role of NOTCH signaling in RDEB pathogenesis and explored the effects of its inhibition by γ-secretase inhibitors DAPT and PF-03084014 (nirogacestat). Our analyses demonstrated that JAG1 and cleaved NOTCH1 are upregulated in primary RDEB fibroblasts (ie, RDEB-derived fibroblasts) compared with controls, and their protein levels are further increased by TGF-β1 stimulation. Functional assays unveiled the involvement of JAG1/NOTCH1 axis in RDEB fibrosis and demonstrated that its blockade counteracts a variety of fibrotic traits. In particular, RDEB-derived fibroblasts treated with PF-03084014 showed (i) a significant reduction of contractility, (ii) a diminished secretion of TGF-β1 and collagens, and (iii) the downregulation of several fibrotic proteins. Although less marked than PF-03084014-treated cells, RDEB-derived fibroblasts exhibited a reduction of fibrotic traits also upon DAPT treatment. This study provides potential therapeutic strategies to antagonize RDEB fibrosis onset and progression.
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Affiliation(s)
- Angelo Giuseppe Condorelli
- Genodermatosis Unit, Translational Pediatrics and Clinical Genetics Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Rebecca Nobili
- Genodermatosis Unit, Translational Pediatrics and Clinical Genetics Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Anita Muglia
- Genodermatosis Unit, Translational Pediatrics and Clinical Genetics Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giorgia Scarpelli
- Genodermatosis Unit, Translational Pediatrics and Clinical Genetics Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Elisa Marzuolo
- Genodermatosis Unit, Translational Pediatrics and Clinical Genetics Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Rossella Rota
- Department of Hematology and Oncology, Cell and Gene Therapy Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Andrea Diociaiuti
- Genodermatosis Unit, Translational Pediatrics and Clinical Genetics Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy; Dermatology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rita Alaggio
- Pathology Unit and Predictive Molecular Pathology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy; Department of Medical-Surgical Sciences and Biotechnologies, University of Rome "La Sapienza", Rome, Italy
| | - Daniele Castiglia
- Laboratory of Molecular and Cell Biology, Istituto Dermopatico dell'Immacolata-IRCCS, Rome, Italy
| | - Teresa Odorisio
- Laboratory of Molecular and Cell Biology, Istituto Dermopatico dell'Immacolata-IRCCS, Rome, Italy
| | - May El Hachem
- Genodermatosis Unit, Translational Pediatrics and Clinical Genetics Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy; Dermatology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giovanna Zambruno
- Genodermatosis Unit, Translational Pediatrics and Clinical Genetics Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Kwon A, Hwang A, Miller CH, Reimer-Taschenbrecker A, Paller AS. Osteoporosis and bone health in pediatric patients with epidermolysis bullosa: A scoping review. Pediatr Dermatol 2024; 41:385-402. [PMID: 38205535 DOI: 10.1111/pde.15527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 12/23/2023] [Indexed: 01/12/2024]
Abstract
Nutritional compromise, low levels of vitamin D, chronic inflammation, abnormal growth, and physical inactivity affect bone metabolism and compromise long-term bone health in individuals with epidermolysis bullosa (EB). The result is a high risk for osteopenia, osteoporosis, and pathologic fractures, but this important consequence of EB has been the focus of few investigations. Our scoping review found 21 publications that assessed the current understanding and clinical practices for monitoring of osteoporosis and its treatment in EB. Recommendations summarized from 13 of these publications include early nutritional and weight assessments before 2 years of age; bloodwork every 6-12 months starting at birth; Tanner stage assessments every 6 months to detect any pubertal delay; DEXA scans starting at age 6 years with repeated scans every 1-2 years, except in mild cases; and vitamin D supplementation of 80-320 IU daily for children 0-7 years and 720 IU for patients >8 years.
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Affiliation(s)
- Andie Kwon
- Department of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Austin Hwang
- Department of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Corinne H Miller
- Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Antonia Reimer-Taschenbrecker
- Department of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Dermatology, University of Freiburg, Freiburg, Germany
| | - Amy S Paller
- Department of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Reimer-Taschenbrecker A, Hess M, Davidovic M, Hwang A, Hübner S, Hofsaess M, Gewert S, Eyerich K, Has C. IL-6 levels dominate the serum cytokine signature of severe epidermolysis bullosa: A prospective cohort study. J Eur Acad Dermatol Venereol 2024. [PMID: 38376135 DOI: 10.1111/jdv.19898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/22/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Systemic inflammation is considered a major player in the pathogenesis of epidermolysis bullosa (EB), but its pattern has only been described in small heterogeneous cohorts. There is controversy if and how systemic inflammation should be therapeutically targeted. METHODS We examined serum proinflammatory, anti-inflammatory, and itch related cytokines in a paediatric cohort of 29 patients with junctional and dystrophic EB. The cytokine that emerged as the most relevant was measured in a validation cohort of 42 patients during follow-up visits over 2 years. RESULTS IL-6 showed the most consistent and highest aberration dominating systemic inflammation. IL-6 correlated with wound body surface area (BSA) in both, finding and validation cohorts. Patients with less than 3% wound BSA had normal IL-6, while IL-6 levels significantly increased at more than 5% and 10% of wound BSA. TGF-β was only marginally elevated in patients with severe recessive dystrophic EB, while TNF-α, IFN-γ and IL-1β varied inconsistently. Patients reporting itch showed elevations in type 2 immunity (IgE, TSLP, IL4 and/or IL-31, respectively). CONCLUSIONS Our data suggest a dominant skin barrier and wound healing inflammatory pattern in junctional and dystrophic EB that depends on the wound area and not on the EB type. In EB, itch mediators may be similar to other pruritic disorders.
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Affiliation(s)
- A Reimer-Taschenbrecker
- Department of Dermatology, Medical Faculty and Medical Center, University of Freiburg, Freiburg, Germany
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - M Hess
- Institute of Medical Biometry and Statistics, Medical Faculty and Medical Center, University of Freiburg, Freiburg, Germany
| | - M Davidovic
- Department of Dermatology, Medical Faculty and Medical Center, University of Freiburg, Freiburg, Germany
| | - A Hwang
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - S Hübner
- Department of Dermatology, Medical Faculty and Medical Center, University of Freiburg, Freiburg, Germany
| | - M Hofsaess
- Department of Dermatology, Medical Faculty and Medical Center, University of Freiburg, Freiburg, Germany
| | - S Gewert
- Department of Dermatology, Medical Faculty and Medical Center, University of Freiburg, Freiburg, Germany
| | - K Eyerich
- Department of Dermatology, Medical Faculty and Medical Center, University of Freiburg, Freiburg, Germany
| | - C Has
- Department of Dermatology, Medical Faculty and Medical Center, University of Freiburg, Freiburg, Germany
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Zidório APC, Carvalho KMBD, Dutra ES. Assessment of nutrient intakes of children and adolescents with recessive dystrophic epidermolysis bllosa, severe subtype. NUTR HOSP 2023; 40:286-294. [PMID: 36719008 DOI: 10.20960/nh.04330] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Introduction Background and aims: epidermolysis bullosa (EB) is a rare disease presenting with skin fragility and formation of blisters. Constant presence of skin lesions, loss of blood, wastage of heat through the open skin, increased turnover of proteins and infections, result in increased energy, protein, and micronutrient needs. This study investigated the intake adequacy of energy, protein, zinc, iron, and dietary fiber in children with epidermolysis bullosa. Methods: this cross-sectional, analytical study was conducted with children and adolescents of up to 18 years of age with recessive dystrophic EB, severe subtype. Demographic data and clinical manifestations affecting food consumption were collected. Nutritional assessment was performed through anthropometric data. We used a formula to estimate specific energy needs for EB, and ratio of skin lesions was also evaluated to assist in estimating energy needs. A protein adequacy of 115 % to 200 % of the Recommended Dietary Allowance was considered for the adequacy of protein intake. And the Dietary Reference Intake tables according to sex and age were used as a reference for micronutrients. Intake assessment was performed using seven consecutive daily food records. Sip feed consumption was considered for intake assessment. Results: all patients showed undernutrition and presented at least three clinical symptoms that affect food consumption: pseudosyndactyly, microstomy, and blisters in the oral cavity. Sip feed constituted between 20 % and 50 % of the patients' energy intake. Intake of iron and zinc was adequate for most patients (confidence of adequacy ≥ 0.85), while fiber intake was below the reference value. Conclusions: this study underscores the importance of nutritional monitoring for EB patients, which is often interpreted as a skin disease but has enormous nutritional repercussions.
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Affiliation(s)
- Ana Paula Caio Zidório
- Clinical Nutrition Unit. Hospital Universitário de Brasília. Faculdade de Ciências de Saúde. Universidade de Brasília
| | | | - Eliane Said Dutra
- Graduate Program in Human Nutrition. Faculdade de Ciências de Saúde. Universidade de Brasília
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Liy-Wong C, Tarango C, Pope E, Coates T, Bruckner AL, Feinstein JA, Schwieger-Briel A, Hubbard LD, Jane C, Torres-Pradilla M, Zmazek M, Lara-Corrales I. Consensus guidelines for diagnosis and management of anemia in epidermolysis bullosa. Orphanet J Rare Dis 2023; 18:38. [PMID: 36823529 PMCID: PMC9948325 DOI: 10.1186/s13023-022-02448-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 07/17/2022] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Anemia is a common complication of severe forms of epidermolysis bullosa (EB). To date, there are no guidelines outlining best clinical practices to manage anemia in the EB population. The objective of this manuscript is to present the first consensus guidelines for the diagnosis and management of anemia in EB. RESULTS Due to the lack of high-quality evidence, a consensus methodology was followed. An initial survey exploring patient preferences, concerns and symptoms related to anemia was sent to EB patients and their family members. A second survey was distributed to EB experts and focused on screening, diagnosis, monitoring and management of anemia in the different types of EB. Information from these surveys was collated and used by the panel to generate 26 consensus statements. Consensus statements were sent to healthcare providers that care for EB patients through EB-Clinet. Statements that received more than 70% approval (completely agree/agree) were adopted. CONCLUSIONS The end result was a series of 6 recommendations which include 20 statements that will help guide management of anemia in EB patients. In patients with moderate to severe forms of EB, the minimum desirable level of Hb is 100 g/L. Treatment should be individualized. Dietary measures should be offered as part of management of anemia in all EB patients, oral iron supplementation should be used for mild anemia; while iron infusion is reserved for moderate to severe anemia, if Hb levels of > 80-100 g/L (8-10 g/dL) and symptomatic; and transfusion should be administered if Hb is < 80 g/L (8 g/dL) in adults and < 60 g/L (6 g/dL) in children.
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Affiliation(s)
- Carmen Liy-Wong
- Division of Dermatology and Rheumatology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada.
| | - Cristina Tarango
- grid.24827.3b0000 0001 2179 9593Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Elena Pope
- grid.17063.330000 0001 2157 2938Division of Dermatology, The Hospital for Sick Children, University of Toronto, Toronto, ON Canada
| | - Thomas Coates
- grid.42505.360000 0001 2156 6853Keck School of Medicine, Division of Hematology/Oncology, Department of Pediatrics, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA USA
| | - Anna L. Bruckner
- grid.430503.10000 0001 0703 675XEpidermolysis Bullosa Clinic, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA
| | - James A. Feinstein
- grid.430503.10000 0001 0703 675XEpidermolysis Bullosa Clinic, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA
| | - Agnes Schwieger-Briel
- grid.412341.10000 0001 0726 4330Pediatric Skin Center, Department of Dermatology, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Lynne D. Hubbard
- grid.420545.20000 0004 0489 3985Department of Nutrition and Dietetics, Rare Diseases Centre at St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Clapham Jane
- grid.420545.20000 0004 0489 3985Lead EB CNS, Rare Diseases Centre, St John’s Institute of Dermatology, St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust and DEBRA UK, London, UK
| | - Mauricio Torres-Pradilla
- grid.442070.5Fundación Universitaria de Ciencias de la Salud and Hospital de San José, Bogotá, Colombia
| | | | - Irene Lara-Corrales
- grid.17063.330000 0001 2157 2938Division of Dermatology, The Hospital for Sick Children, University of Toronto, Toronto, ON Canada
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Alheggi A, McGrath JA, Hubbard L, Greenblatt DT, Mellerio JE. Treatment of multifactorial anaemia in adults with severe epidermolysis bullosa using intravenous ferric carboxymaltose: a single institution, observational, retrospective study. Br J Dermatol 2023; 188:306-307. [PMID: 36763865 DOI: 10.1093/bjd/ljac075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 10/23/2022] [Accepted: 10/24/2022] [Indexed: 01/09/2023]
Affiliation(s)
- Ashjan Alheggi
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Dermatology, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - John A McGrath
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Lynne Hubbard
- Dietetics Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Danielle T Greenblatt
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jemima E Mellerio
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Tarango C, Quinn CT, Augsburger B, Lucky AW. Iron status and burden of anemia in children with recessive dystrophic epidermolysis bullosa. Pediatr Dermatol 2023; 40:288-293. [PMID: 36594493 DOI: 10.1111/pde.15239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 12/17/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND OBJECTIVES To describe the prevalence, severity, and management of anemia in a cohort of children with recessive dystrophic epidermolysis bullosa (RDEB) and to highlight the use of soluble transferrin receptor (sTfR) to diagnose iron deficiency in this chronic inflammatory state. METHODS We studied a cohort of 114 patients with RDEB followed at a pediatric hospital-based Epidermolysis Bullosa Center from 2010 to 2020; data were prospectively tracked in a comprehensive clinical database that captured all visits, laboratory tests, iron infusions, and transfusions. The primary outcome was occurrence of anemia, which was assessed by age and sex, with and without transfusion support. Secondary outcomes included iron status using a combination of ferritin and sTfR levels, the cumulative incidence of parenteral iron therapy and transfusions, and survival. RESULTS In RDEB, anemia begins in the first year of life and becomes more frequent and severe with age. The prevalence of iron deficiency anemia (IDA) estimated by ferritin was 33.6% (37/110), but the sTfR/log10 -ferritin ratio indicated a 1.5-fold higher true prevalence of IDA of 50.6% (41/81). 53.5% (61/114) received parenteral iron infusions, transfusions, or both. Higher ferritin was associated with earlier mortality. CONCLUSIONS Individuals with RDEB have a high burden of anemia (IDA and anemia of inflammation) that requires frequent medical interventions. The sTfR/log10 -ferritin ratio improves the detection of iron deficiency in the context of inflammation and guides therapy.
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Affiliation(s)
- Cristina Tarango
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Charles T Quinn
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Bret Augsburger
- Division of Dermatology, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Anne W Lucky
- Division of Dermatology, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Kleinman EP, Reimer-Taschenbrecker A, Haller CN, Paller AS, Levy ML, Eichenfield LF. Gastrostomy tube feeding in epidermolysis bullosa: A multi-center assessment of caregiver satisfaction. Pediatr Dermatol 2022; 40:270-275. [PMID: 36461900 DOI: 10.1111/pde.15207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/12/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND/OBJECTIVES Gastrostomy tubes (G-tubes) are a feasible intervention for nutritional support in patients with epidermolysis bullosa (EB) who suffer from gastrointestinal involvement. However, some parents may be apprehensive about this surgical intervention. The purpose of this study is to assess caregiver satisfaction and experiences after G-tube insertion in children with EB. METHODS Nine institutions sent an anonymous 89-item online questionnaire to caregivers of patients with EB and active G-tubes during an 8-week study period. The questionnaire consisted of eight sections and was formatted with multiple choice, Likert scales, dichotomous scales (yes/no), and free text. RESULTS Twenty caregiver surveys were completed. All caregivers were parents (100%). The average age of G-tube placement was 2.7 years (SD: 2.1, range 0-8) and duration of the G-tube utilization was an average of 12.0 years (SD: 7.8, range 1-25). EB subtypes were dystrophic (n = 15/20, 75%), junctional (n = 3/20, 15%), and simplex (n = 2/10, 10%). Almost all caregivers (n = 18/20, 90%) reported high levels of satisfaction with G-tube management (scores > 20 on the modified SAGA-8 scale). More than half of caregivers (n = 12/20, 60%) reported that, retrospectively, they would have desired earlier adoption of the G-tube. Caregivers rated mealtimes as more enjoyable and easier both for themselves and the individual with EB post-G-tube placement. CONCLUSION The survey demonstrates a high rate of satisfaction for G-tube use among caregivers of patients with EB across varying ages and household settings. The free-text responses provide unique insight into caregiver's individual experiences regarding G-tubes to be considered for future studies.
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Affiliation(s)
- Elana P Kleinman
- Rady Children's Hospital of San Diego, San Diego, California, USA.,University of California San Diego School of Medicine, San Diego, California, USA
| | - Antonia Reimer-Taschenbrecker
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Dermatology, Medical Center-University of Freiburg, Freiburg, Germany
| | - Courtney N Haller
- University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Amy S Paller
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Moise L Levy
- University of Texas at Austin Dell Medical School, Austin, Texas, USA.,Dell Children's Medical Center, Austin, Texas, USA
| | - Lawrence F Eichenfield
- Rady Children's Hospital of San Diego, San Diego, California, USA.,University of California San Diego School of Medicine, San Diego, California, USA
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11
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Yerlett N, Petrof G, Bageta M, Balboa PL, Martinez AE. The impact of using a multistrain probiotic supplement on gastrointestinal function in children and adolescents with severe recessive dystrophic epidermolysis bullosa. Clin Exp Dermatol 2022; 48:llac070. [PMID: 36763734 DOI: 10.1093/ced/llac070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Children and adolescents with severe recessive dystrophic epidermolysis bullosa (RDEB-S) often have severe constipation in addition to gastrointestinal dysbiosis, due to frequent antibiotic use and reduced oral diet. Constipation is treated with long-term use of high daily doses of macrogol gel (Movicol Paediatric PlainTM or LaxidoTM). Constipation is refractory to increases in fibre and fluids, and impacts severely on quality of life. AIM To study the initial impact and efficacy of using a multistrain probiotic supplement daily for 12 weeks in patients with RDEB-S. The authors sought to determine the impact of such a supplement on gastrointestinal symptoms, stool consistency and the use of macrogol gel to treat constipation, as well as understanding patient reaction, palability and ease of use. METHODS Patients were identified through the epidermolysis bullosa tertiary multidisciplinary team clinic in July 2021. Patients were included if they had a diagnosis of RDEB-S, prescribed at least one sachet of macrogol gel and provided written consent to take part. Patients were provided, proprietary liquid multistrain probiotic supplement (Symprove™) with a high bacterial count, at a dose of 1 mL kg-1 once a day. Each patient completed an anonymous, nine-question, electronic survey to document symptoms and report overall findings at the start and end of a 12-week trial period. RESULTS Four patients with RDEB-S (two boys and two girls; age range 7-14 years) who met the inclusion criteria were approached to take part. All patients had chronic constipation requiring daily macrogol gel use (range 2-5 sachets per day). Three out of four (75%) completed the 12-week course. At baseline (before supplementation commenced), all three (100%) patients reported poor oral appetite, constipation, flatulence, abdominal bloating and pain, and frequent skin infections requiring oral antibiotics, with two of the three (66%) patients also having nausea. After 12 weeks of supplementation, all three patients (100%) reported a significant improvement in abdominal pain and bloating, nausea, stool consistency, stool frequency, flatulence and increased appetite. Two of the three patients (66%) were able to reduce their macrogol gel usage and the third patient (33%) was able to stop macrogol gel usage altogether during the study period. All three patients said they would choose to continue using the supplement if it was available. CONCLUSION We have shown in this case series that giving a multistrain probiotic supplement in patients with RDEB-S has the potential to improve stool consistency and reduce or prevent the need for chronic macrogol gel use. Future larger-scale, placebo-controlled trials are needed to confirm these results.
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Affiliation(s)
| | - Gabriela Petrof
- Department of Dermatology, Great Ormond Street Hospital, London, UK
| | - Maria Bageta
- Department of Dermatology, Great Ormond Street Hospital, London, UK
| | | | - Anna E Martinez
- Department of Dermatology, Great Ormond Street Hospital, London, UK
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12
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Rodari G, Guez S, Salera S, Ulivieri FM, Tadini G, Brena M, Profka E, Giacchetti F, Arosio M, Giavoli C. A single-centre study on predictors and determinants of pubertal delay and growth impairment in Epidermolysis Bullosa. PLoS One 2022; 17:e0274072. [PMID: 36067143 PMCID: PMC9447886 DOI: 10.1371/journal.pone.0274072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/22/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Delayed puberty is a possible complication of Epidermolysis Bullosa (EB), though the actual incidence is still unknown. In chronic illnesses delayed puberty should be correctly managed since, if untreated, can have detrimental effects on adult height attainment, peak bone mass achievement and psychological health.
Aims and methods
This is a single-centre study on pubertal development, growth and bone status in EB. Auxological, densitometric (areal Bone Mineral Density-aBMD Z-score, Bone Mineral Apparent Density-BMAD Z-score, Trabecular Bone Score-TBS and Bone Strain Index-BSI at Lumbar spine) and body composition data (Total Body DXA scans) were collected. Disease severity was defined according to Birmingham Epidermolysis Bullosa Severity (BEBS) score.
Results
Twenty-one patients (12 Recessive Dystrophic EB-RDEB, 3 Dominant Dystrophic EB, 3 Junctional EB-JEB, 2 EB Simplex and one Kindler EB) aged 13 years (females) or 14 years (males) and above were enrolled (age 16.2±2.5 years, M/F 11/10). Short stature was highly prevalent (57%, mean height -2.12±2.05 SDS) with 55% patients with height <-2SD their mid-parental height. 7/21 patients (33%, 6 RDEB and 1 JEB) had delayed puberty with a median BEBS of 50 (range 29 to 63), a height SDS of -2.59 SDS (range -5.95 to -2.22) and a median lumbar BMAD Z-score of -4.0 SDS (range -5.42 to -0.63 SDS). Pubertal status was negatively associated with BEBS, skin involvement, inflammatory state and positively with height SDS and BMI SDS.
Conclusions
Pubertal delay is highly prevalent in EB, especially in patients with RDEB and JEB, high severity score and inflammatory state. Moreover, pubertal delay worsens growth impairment and bone health. A study on pubertal induction is ongoing to enlighten possible beneficial effects on adult height attainment and peak bone mass accrual.
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Affiliation(s)
- Giulia Rodari
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Endocrinology Unit, Milan, Italy
- University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy
- * E-mail: ,
| | - Sophie Guez
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Pediatric Highly Intensive Care Unit, Milano, Italy
| | - Simona Salera
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Pediatric Highly Intensive Care Unit, Milano, Italy
| | - Fabio Massimo Ulivieri
- Centre for Diagnosis and Treatment of Osteoporosis, Casa di Cura La Madonnina, Milan, Italy
| | - Gianluca Tadini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Pediatric Dermatology, Pediatric Highly Intensive Care Unit, Milano, Italy
| | - Michela Brena
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Pediatric Dermatology, Pediatric Highly Intensive Care Unit, Milano, Italy
| | - Eriselda Profka
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Endocrinology Unit, Milan, Italy
| | - Federico Giacchetti
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Endocrinology Unit, Milan, Italy
| | - Maura Arosio
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Endocrinology Unit, Milan, Italy
- University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy
| | - Claudia Giavoli
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Endocrinology Unit, Milan, Italy
- University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy
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13
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Predominance of Staphylococcus correlates with wound burden and disease activity in dystrophic epidermolysis bullosa: a prospective case-control study. J Invest Dermatol 2022; 142:2117-2127.e8. [PMID: 35149000 DOI: 10.1016/j.jid.2022.01.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 01/06/2022] [Accepted: 01/19/2022] [Indexed: 01/04/2023]
Abstract
Recessive dystrophic epidermolysis bullosa (RDEB) is characterized by skin blistering and wounds. To uncover changes in skin and mucosal microbiome related to age and disease progression, and microbiome impact on clinical and inflammatory laboratory parameters, swabs from wounded and unwounded skin, oral mucosa and stool samples of 28 children with RDEB and 28 healthy controls were subjected to 16S-rRNA gene sequencing. Skin microbiome of RDEB patients showed significantly reduced alpha diversity compared to healthy controls and early, age-dependent predominance of Staphylococcus aureus first in wounds, then in unwounded skin. These findings were more pronounced in severe disease with higher abundances of Staphylococcus aureus compared to intermediate disease. Staphylococcus aureus abundance correlated significantly with both acute and chronic wound burden. Changes in oral mucosal and gut microbiome were discrete with no significant differences in alpha diversity. Our findings show that children with RDEB experience skin microbiome changes early in life. Longitudinal studies should confirm that dysbiosis starts in wounds and later extends to unwounded skin. The predominance of Staphylococcus aureus significantly correlates with wound burden and disease activity, and to some extent with systemic inflammation.
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14
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Chen VM, Southwell K, Huynh E, Gavett S, Richey L, Esmail M. Corneal Changes and Strategies to Improve Survival of Hypomorphic Collagen VII-Deficient Mice for the Study of Ocular Dystrophic Epidermolysis Bullosa. Comp Med 2022; 72:14-21. [PMID: 35131003 DOI: 10.30802/aalas-cm-21-000063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Ophthalmic study of collagen CVII hypomorphic mice is uniquely challenging due to the strain's published survival rate to weaning of 24%. Because chronic ocular fibrosis requires time to develop, optimizing the survival rate is of critical importance.In this study, standard husbandry practices were enhanced by the addition of sterilized diet and drug delivery gels, acidified water, irradiated food pellets, cellulose fiber bedding, minimal handling, removal of siblings within 2-3 wk from birth, and a preferred housing location. Survival rates per breeding cycle, sex, weight, and cause of early euthanasia were recorded and analyzed over 43 mo. Overall, 49% of mice survived to weaning and 76% of weaned mice survived to 20 wk of age. Corneal opacities were seen in 65% of mice by 20 wk, but only 10% of eyes showed the sustained opacification that was indicative of fibrosis. Corneal opacities occurred at the same rate as in humans with epidermolysis bullosa. 66% of the mice showed weight loss at 11 wk. Males required early euthanasia 4 times more often than did females. Euthanasia was required for urinary obstruction due to penile prolapse in 88% of males. With our enhanced care protocol, hypomorphic mice in our colony survived at twice the published rate. With this revised husbandry standard, experiments planned with termination endpoints of 14 wk for males and 17 wk for females are more likely to reach completion.
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15
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Guttmann-Gruber C, Piñón Hofbauer J, Tockner B, Reichl V, Klausegger A, Hofbauer P, Wolkersdorfer M, Tham KC, Lim SS, Common JE, Diem A, Ude-Schoder K, Hitzl W, Lagler F, Reichelt J, Bauer JW, Lang R, Laimer M. Impact of low-dose calcipotriol ointment on wound healing, pruritus and pain in patients with dystrophic epidermolysis bullosa: A randomized, double-blind, placebo-controlled trial. Orphanet J Rare Dis 2021; 16:473. [PMID: 34749770 PMCID: PMC8576995 DOI: 10.1186/s13023-021-02062-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/30/2021] [Indexed: 12/25/2022] Open
Abstract
Background Wound management is a critical factor when treating patients with the inherited skin fragility disease dystrophic epidermolysis bullosa (DEB). Due to genetic defects in structural proteins, skin and mucous epithelia are prone to blistering and chronic wounding upon minor trauma. Furthermore, these wounds are commonly associated with excessive pruritus and predispose to the development of life-threatening squamous cell carcinomas, underscoring the unmet need for new therapeutic options to improve wound healing in this patient cohort. Vitamin D3 is acknowledged to play an important role in wound healing by modulating different cellular processes that impact epidermal homeostasis and immune responses. In this study, we evaluate the safety and efficacy of low-dose calcipotriol, a vitamin D3 analogue, in promoting wound healing and reducing itch and pain in patients with DEB. Methods Eligible DEB patients, aged ≥ 6 years and with a known mutation in the COL7A1 gene, were recruited to a placebo-controlled, randomized, double blind, cross-over phase II monocentric clinical trial. Patients were required to have at least two wounds with a minimum size of 6 cm2 per wound. The primary objective was to evaluate efficacy of daily topical application of a 0.05 µg/g calcipotriol ointment in reducing wound size within a 4-week treatment regimen. Secondary objectives were to assess safety, as well as the impact of treatment on pruritus, pain, and bacterial wound colonization in these patients. Results Six patients completed the clinical trial and were included into the final analysis. Topical low-dose calcipotriol treatment led to a significant reduction in wound area at day 14 compared to placebo (88.4% vs. 65.5%, P < 0.05). Patients also reported a significant reduction of pruritus with calcipotriol ointment compared to placebo over the entire course of the treatment as shown by itch scores of 3.16 vs 4.83 (P < 0.05) and 1.83 vs 5.52 (P < 0.0001) at days 14 and 28, respectively. Treatment with low-dose calcipotriol did not affect serum calcium levels and improved the species richness of the wound microbiome, albeit with no statistical significance. Conclusions Our results show that topical treatment with low-dose calcipotriol can accelerate wound closure and significantly reduces itch, and can be considered a safe and readily-available option to improve local wound care in DEB patients. TrialRegistration EudraCT: 2016–001,967-35. Registered 28 June 2016, https://www.clinicaltrialsregister.eu/ctr-search/trial/2016-001967-35/AT Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-02062-2.
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Affiliation(s)
- Christina Guttmann-Gruber
- EB House Austria, Research Program for Molecular Therapy of Genodermatoses, Department of Dermatology and Allergology, University Hospital of the Paracelsus Medical University, Salzburg, Austria
| | - Josefina Piñón Hofbauer
- EB House Austria, Research Program for Molecular Therapy of Genodermatoses, Department of Dermatology and Allergology, University Hospital of the Paracelsus Medical University, Salzburg, Austria
| | - Birgit Tockner
- EB House Austria, Research Program for Molecular Therapy of Genodermatoses, Department of Dermatology and Allergology, University Hospital of the Paracelsus Medical University, Salzburg, Austria
| | - Victoria Reichl
- EB House Austria, Research Program for Molecular Therapy of Genodermatoses, Department of Dermatology and Allergology, University Hospital of the Paracelsus Medical University, Salzburg, Austria
| | - Alfred Klausegger
- EB House Austria, Research Program for Molecular Therapy of Genodermatoses, Department of Dermatology and Allergology, University Hospital of the Paracelsus Medical University, Salzburg, Austria
| | - Peter Hofbauer
- Landesapotheke Salzburg, Department of Production, Hospital Pharmacy, Salzburg, Austria
| | - Martin Wolkersdorfer
- Landesapotheke Salzburg, Department of Production, Hospital Pharmacy, Salzburg, Austria
| | - Khek-Chian Tham
- Skin Research Institute of Singapore, A*STAR, 8A Biomedical Grove, Immunos #06-06, Singapore, Singapore
| | - Seong Soo Lim
- Skin Research Institute of Singapore, A*STAR, 8A Biomedical Grove, Immunos #06-06, Singapore, Singapore
| | - John E Common
- Skin Research Institute of Singapore, A*STAR, 8A Biomedical Grove, Immunos #06-06, Singapore, Singapore
| | - Anja Diem
- EB House Austria, Outpatient Unit, Department of Dermatology and Allergology, Paracelsus Medical University, Salzburg, Austria
| | - Katharina Ude-Schoder
- EB House Austria, Outpatient Unit, Department of Dermatology and Allergology, Paracelsus Medical University, Salzburg, Austria
| | - Wolfgang Hitzl
- Research Office Biostatistics, Paracelsus Medical University, Salzburg, Austria.,Department of Ophthalmology and Optometry, Paracelsus Medical University Salzburg, Müllner Hauptstr. 48, 5020, Salzburg, Austria.,Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, Muellner Hauptstrasse 48, 5020, Salzburg, Austria
| | - Florian Lagler
- Institute for Inborn Errors of Metabolism and Department of Pediatrics, Paracelsus Medical University, Salzburg, Austria
| | - Julia Reichelt
- EB House Austria, Research Program for Molecular Therapy of Genodermatoses, Department of Dermatology and Allergology, University Hospital of the Paracelsus Medical University, Salzburg, Austria
| | - Johann W Bauer
- EB House Austria, Research Program for Molecular Therapy of Genodermatoses, Department of Dermatology and Allergology, University Hospital of the Paracelsus Medical University, Salzburg, Austria.,Department of Dermatology and Allergology, University Hospital Salzburg, Paracelsus Medical University, Muellner-Hauptstrasse 48, 5020, Salzburg, Austria
| | - Roland Lang
- Department of Dermatology and Allergology, University Hospital Salzburg, Paracelsus Medical University, Muellner-Hauptstrasse 48, 5020, Salzburg, Austria.
| | - Martin Laimer
- EB House Austria, Research Program for Molecular Therapy of Genodermatoses, Department of Dermatology and Allergology, University Hospital of the Paracelsus Medical University, Salzburg, Austria. .,Department of Dermatology and Allergology, University Hospital Salzburg, Paracelsus Medical University, Muellner-Hauptstrasse 48, 5020, Salzburg, Austria.
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16
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Nyström A, Bruckner-Tuderman L, Kiritsi D. Dystrophic Epidermolysis Bullosa: Secondary Disease Mechanisms and Disease Modifiers. Front Genet 2021; 12:737272. [PMID: 34650598 PMCID: PMC8505774 DOI: 10.3389/fgene.2021.737272] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/25/2021] [Indexed: 12/30/2022] Open
Abstract
The phenotypic presentation of monogenetic diseases is determined not only by the nature of the causative mutations but also is influenced by manifold cellular, microenvironmental, and external factors. Here, heritable extracellular matrix diseases, including dystrophic epidermolysis bullosa (DEB), are no exceptions. Dystrophic epidermolysis bullosa is caused by mutations in the COL7A1 gene encoding collagen VII. Deficiency of collagen VII leads to skin and mucosal fragility, which progresses from skin blistering to severe fibrosis and cancer. Clinical and pre-clinical studies suggest that targeting of secondary disease mechanisms or employment of natural disease modifiers can alleviate DEB severity and progression. However, since many of these mechanisms are needed for tissue homeostasis, informed, selective targeting is essential for safe and efficacious treatment. Here, we discuss a selection of key disease modifiers and modifying processes active in DEB, summarize the still scattered knowledge of them, and reflect on ways forward toward their utilization for symptom-relief or enhancement of curative therapies.
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Affiliation(s)
- Alexander Nyström
- Department of Dermatology, Medical Faculty, Medical Center - University of Freiburg, Freiburg, Germany.,Freiburg Institute for Advanced Studies, Freiburg, Germany
| | - Leena Bruckner-Tuderman
- Department of Dermatology, Medical Faculty, Medical Center - University of Freiburg, Freiburg, Germany
| | - Dimitra Kiritsi
- Department of Dermatology, Medical Faculty, Medical Center - University of Freiburg, Freiburg, Germany
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17
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Has C, El Hachem M, Bučková H, Fischer P, Friedová M, Greco C, Nevoránková P, Salavastru C, Mellerio JE, Zambruno G, Bodemer C. Practical management of epidermolysis bullosa: consensus clinical position statement from the European Reference Network for Rare Skin Diseases. J Eur Acad Dermatol Venereol 2021; 35:2349-2360. [PMID: 34545960 DOI: 10.1111/jdv.17629] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/13/2021] [Indexed: 01/13/2023]
Abstract
Inherited epidermolysis bullosa (EB) comprises rare disorders that manifest with fragility and blistering of the skin and mucous membranes, with variable clinical severity. Management of EB is challenging due to disease rarity and complexity, the wide range of extracutaneous manifestations and a profound impact on daily life for the patient and family members. Although reference centres providing multidisciplinary care for EB exist in each European country, it is common for healthcare professionals that are not specialized in this rare disorder to treat EB patients. Here, experts of the European Reference Network for Rare and Undiagnosed Skin Diseases (ERN-Skin, https://ern-skin.eu) propose practical recommendations for the diagnosis and management of the commonest clinical issues, skin blisters and wounds, oral manifestations, pain and itch.
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Affiliation(s)
- C Has
- Department of Dermatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - M El Hachem
- Dermatology Unit and Genodermatosis Unit, Genetics and Rare Diseases Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - H Bučková
- Department of Dermatology, Children's Hospital, University Hospital Brno, Brno, Czech Republic
| | - P Fischer
- Department of Prosthetic Dentistry, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - M Friedová
- NevDent, Dental Private Clinic, Brno, Czech Republic
| | - C Greco
- Pain and Palliative Care Unit, Hôpital Necker Enfants Malades, Paris, France
| | - P Nevoránková
- NevDent, Dental Private Clinic, Brno, Czech Republic
| | - C Salavastru
- Paediatric Dermatology Department, "Carol Davila" University of Medicine and Pharmacy, Colentina Clinical Hospital, Bucharest, Romania
| | - J E Mellerio
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - G Zambruno
- Genodermatosis Unit, Genetics and Rare Diseases Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - C Bodemer
- Service de Dermatologie, Hôpital Necker Enfants Malades, Paris, France
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18
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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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19
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Abstract
Epidermolysis bullosa (EB) is a group of rare genetic disorders for which significant progress has been achieved in the development of molecular therapies in the last few decades. Such therapies require knowledge of mutant genes and specific mutations, some of them being allele specific. A relatively large number of clinical trials are ongoing and ascertaining the clinical efficacy of gene, protein or cell therapies or of repurposed drugs, mainly in recessive dystrophic EB. It is expected that some new drugs may emerge in the near future and that combinations of different approaches may result in improved treatment outcomes for individuals with EB.
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Tartaglia G, Cao Q, Padron ZM, South AP. Impaired Wound Healing, Fibrosis, and Cancer: The Paradigm of Recessive Dystrophic Epidermolysis Bullosa. Int J Mol Sci 2021; 22:5104. [PMID: 34065916 PMCID: PMC8151646 DOI: 10.3390/ijms22105104] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023] Open
Abstract
Recessive Dystrophic Epidermolysis Bullosa (RDEB) is a devastating skin blistering disease caused by mutations in the gene encoding type VII collagen (C7), leading to epidermal fragility, trauma-induced blistering, and long term, hard-to-heal wounds. Fibrosis develops rapidly in RDEB skin and contributes to both chronic wounds, which emerge after cycles of repetitive wound and scar formation, and squamous cell carcinoma-the single biggest cause of death in this patient group. The molecular pathways disrupted in a broad spectrum of fibrotic disease are also disrupted in RDEB, and squamous cell carcinomas arising in RDEB are thus far molecularly indistinct from other sub-types of aggressive squamous cell carcinoma (SCC). Collectively these data demonstrate RDEB is a model for understanding the molecular basis of both fibrosis and rapidly developing aggressive cancer. A number of studies have shown that RDEB pathogenesis is driven by a radical change in extracellular matrix (ECM) composition and increased transforming growth factor-beta (TGFβ) signaling that is a direct result of C7 loss-of-function in dermal fibroblasts. However, the exact mechanism of how C7 loss results in extensive fibrosis is unclear, particularly how TGFβ signaling is activated and then sustained through complex networks of cell-cell interaction not limited to the traditional fibrotic protagonist, the dermal fibroblast. Continued study of this rare disease will likely yield paradigms relevant to more common pathologies.
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Affiliation(s)
- Grace Tartaglia
- Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, 233 S. 10th Street, BLSB 406, Philadelphia, PA 19107, USA; (G.T.); (Q.C.); (Z.M.P.)
| | - Qingqing Cao
- Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, 233 S. 10th Street, BLSB 406, Philadelphia, PA 19107, USA; (G.T.); (Q.C.); (Z.M.P.)
| | - Zachary M. Padron
- Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, 233 S. 10th Street, BLSB 406, Philadelphia, PA 19107, USA; (G.T.); (Q.C.); (Z.M.P.)
- The Joan and Joel Rosenbloom Research Center for Fibrotic Diseases, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Andrew P. South
- Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, 233 S. 10th Street, BLSB 406, Philadelphia, PA 19107, USA; (G.T.); (Q.C.); (Z.M.P.)
- The Joan and Joel Rosenbloom Research Center for Fibrotic Diseases, Thomas Jefferson University, Philadelphia, PA 19107, USA
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA 19107, USA
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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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Maseda R, Martínez-Santamaría L, Sacedón R, Butta N, de Arriba MDC, García-Barcenilla S, García M, Illera N, Pérez-Conde I, Carretero M, Jiménez E, Melen G, Borobia AM, Jiménez-Yuste V, Vicente Á, del Río M, de Lucas R, Escámez MJ. Beneficial Effect of Systemic Allogeneic Adipose Derived Mesenchymal Cells on the Clinical, Inflammatory and Immunologic Status of a Patient With Recessive Dystrophic Epidermolysis Bullosa: A Case Report. Front Med (Lausanne) 2020; 7:576558. [PMID: 33324660 PMCID: PMC7726418 DOI: 10.3389/fmed.2020.576558] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 11/02/2020] [Indexed: 12/22/2022] Open
Abstract
Recessive dystrophic epidermolysis bullosa (RDEB) is an incurable inherited mucocutaneous fragility disorder characterized by recurrent blisters, erosions, and wounds. Continuous blistering triggers overlapping cycles of never-ending healing and scarring commonly evolving to chronic systemic inflammation and fibrosis. The systemic treatment with allogeneic mesenchymal cells (MSC) from bone marrow has previously shown benefits in RDEB. MSC from adipose tissue (ADMSC) are easier to isolate. This is the first report on the use of systemic allogeneic ADMSC, correlating the clinical, inflammatory, and immunologic outcomes in RDEB indicating long-lasting benefits. We present the case of an RDEB patient harboring heterozygous biallelic COL7A1 gene mutations and with a diminished expression of C7. The patient presented with long-lasting refractory and painful oral ulcers distressing her quality of life. Histamine receptor antagonists, opioid analgesics, proton-pump inhibitors, and low-dose tricyclic antidepressants barely improved gastric symptoms, pain, and pruritus. Concomitantly, allogeneic ADMSC were provided as three separate intravenous injections of 106 cells/kg every 21 days. ADMSC treatment was well-tolerated. Improvements in wound healing, itch, pain and quality of life were observed, maximally at 6-9 months post-treatment, with the relief of symptoms still noticeable for up to 2 years. Remarkably, significant modifications in PBL participating in both the innate and adaptive responses, alongside regulation of levels of profibrotic factors, MCP-1/CCL2 and TGF-β, correlated with the health improvement. This treatment might represent an alternative for non-responding patients to conventional management. It seems critical to elucidate the paracrine modulation of the immune system by MSC for their rational use in regenerative/immunoregulatory therapies.
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Affiliation(s)
- Rocío Maseda
- Department of Dermatology, La Paz University Hospital, Madrid, Spain
| | - Lucía Martínez-Santamaría
- Department of Bioengineering, Carlos III University (UC3M), Madrid, Spain
- Rare Diseases Networking Biomedical Research Centre (CIBERER) U714, Madrid, Spain
- Regenerative Medicine and Tissue Engineering Group, Health Research Institute Foundation of the Jiménez Díaz Foundation, Madrid, Spain
- Centre for Energy, Environment and Technology Research (CIEMAT), Madrid, Spain
| | - Rosa Sacedón
- Department of Cell Biology, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Nora Butta
- Hematology Unit, La Paz University Hospital-IdiPAZ, Madrid, Spain
| | - María del Carmen de Arriba
- Department of Bioengineering, Carlos III University (UC3M), Madrid, Spain
- Regenerative Medicine and Tissue Engineering Group, Health Research Institute Foundation of the Jiménez Díaz Foundation, Madrid, Spain
- Centre for Energy, Environment and Technology Research (CIEMAT), Madrid, Spain
| | | | - Marta García
- Department of Bioengineering, Carlos III University (UC3M), Madrid, Spain
- Rare Diseases Networking Biomedical Research Centre (CIBERER) U714, Madrid, Spain
- Regenerative Medicine and Tissue Engineering Group, Health Research Institute Foundation of the Jiménez Díaz Foundation, Madrid, Spain
- Centre for Energy, Environment and Technology Research (CIEMAT), Madrid, Spain
| | - Nuria Illera
- Rare Diseases Networking Biomedical Research Centre (CIBERER) U714, Madrid, Spain
- Regenerative Medicine and Tissue Engineering Group, Health Research Institute Foundation of the Jiménez Díaz Foundation, Madrid, Spain
- Centre for Energy, Environment and Technology Research (CIEMAT), Madrid, Spain
| | | | - Marta Carretero
- Rare Diseases Networking Biomedical Research Centre (CIBERER) U714, Madrid, Spain
- Regenerative Medicine and Tissue Engineering Group, Health Research Institute Foundation of the Jiménez Díaz Foundation, Madrid, Spain
- Centre for Energy, Environment and Technology Research (CIEMAT), Madrid, Spain
| | - Eva Jiménez
- Department of Cell Biology, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Gustavo Melen
- Cell & Gene Therapies Laboratory, Niño Jesus University Hospital, Madrid, Spain
| | - Alberto M. Borobia
- Clinical Pharmacology Department, School of Medicine, La Paz University Hospital, IdiPAZ, Autonomous University of Madrid, Madrid, Spain
| | | | - Ángeles Vicente
- Department of Cell Biology, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Marcela del Río
- Department of Bioengineering, Carlos III University (UC3M), Madrid, Spain
- Rare Diseases Networking Biomedical Research Centre (CIBERER) U714, Madrid, Spain
- Regenerative Medicine and Tissue Engineering Group, Health Research Institute Foundation of the Jiménez Díaz Foundation, Madrid, Spain
- Centre for Energy, Environment and Technology Research (CIEMAT), Madrid, Spain
| | - Raúl de Lucas
- Department of Dermatology, La Paz University Hospital, Madrid, Spain
| | - María José Escámez
- Department of Bioengineering, Carlos III University (UC3M), Madrid, Spain
- Rare Diseases Networking Biomedical Research Centre (CIBERER) U714, Madrid, Spain
- Regenerative Medicine and Tissue Engineering Group, Health Research Institute Foundation of the Jiménez Díaz Foundation, Madrid, Spain
- Centre for Energy, Environment and Technology Research (CIEMAT), Madrid, Spain
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Prodinger C, Bauer JW, Laimer M. Translational perspectives to treat Epidermolysis bullosa-Where do we stand? Exp Dermatol 2020; 29:1112-1122. [PMID: 33043517 PMCID: PMC7756480 DOI: 10.1111/exd.14194] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/26/2020] [Accepted: 09/04/2020] [Indexed: 02/06/2023]
Abstract
Epidermolysis bullosa (EB) is the prototypical example of genetic skin fragility disorders. Genotypic heterogeneity, modifier genes, epigenetic, biochemical and environmental factors alter and determine pathogenic traits and, ultimately, the wide and striking phenotypic variability in EB. Besides the primary structural-functional defect, chronic tissue damage with induction and dysregulation of inflammatory pathways is a common pathogenic mechanism in EB. In localized variants, the inflammatory aberrations may mainly affect the micromilieu of lesional skin, while a systemic inflammatory response was shown to contribute to the systemic morbidity in severe EB subtypes with extensive cutaneous involvement. Our continued understanding of the pathophysiology of EB, as well as advances in molecular technologies, has paved the way for translational therapeutic approaches. The spectrum comprises of corrective and symptom-relieving therapies that include innovative therapeutic options garnered from the bench, repurposed drugs approved for other diseases, as well as strategies for gene-, protein- and cell-based therapies. Immunological traits further define new targets of therapy, aimed at improving skin barrier restoration, microbial surveillance and infection control, wound healing and anti-neoplastic effects. Clinical availability and feasibility of these approaches for all EB patients and subtypes are currently limited, reflecting issues of efficacy, specificity, tolerability and safety. A multistep targeting approach and highly individualized, risk-stratified combinatory treatment plans will thus be essential for sustained efficacy and improved overall quality of life in EB.
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Affiliation(s)
- Christine Prodinger
- Department of Dermatology and AllergologyUniversity Hospital of the Paracelsus Medical University SalzburgSalzburgAustria
| | - Johann W Bauer
- Department of Dermatology and AllergologyUniversity Hospital of the Paracelsus Medical University SalzburgSalzburgAustria
| | - Martin Laimer
- Department of Dermatology and AllergologyUniversity Hospital of the Paracelsus Medical University SalzburgSalzburgAustria
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24
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Has C, Bauer JW, Bodemer C, Bolling MC, Bruckner-Tuderman L, Diem A, Fine JD, Heagerty A, Hovnanian A, Marinkovich MP, Martinez AE, McGrath JA, Moss C, Murrell DF, Palisson F, Schwieger-Briel A, Sprecher E, Tamai K, Uitto J, Woodley DT, Zambruno G, Mellerio JE. Consensus reclassification of inherited epidermolysis bullosa and other disorders with skin fragility. Br J Dermatol 2020; 183:614-627. [PMID: 32017015 DOI: 10.1111/bjd.18921] [Citation(s) in RCA: 387] [Impact Index Per Article: 96.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Several new genes and clinical subtypes have been identified since the publication in 2014 of the report of the last International Consensus Meeting on Epidermolysis Bullosa (EB). OBJECTIVES We sought to reclassify disorders with skin fragility, with a focus on EB, based on new clinical and molecular data. METHODS This was a consensus expert review. RESULTS In this latest consensus report, we introduce the concept of genetic disorders with skin fragility, of which classical EB represents the prototype. Other disorders with skin fragility, where blisters are a minor part of the clinical picture or are not seen because skin cleavage is very superficial, are classified as separate categories. These include peeling skin disorders, erosive disorders, hyperkeratotic disorders, and connective tissue disorders with skin fragility. Because of the common manifestation of skin fragility, these 'EB-related' disorders should be considered under the EB umbrella in terms of medical and socioeconomic provision of care. CONCLUSIONS The proposed classification scheme should be of value both to clinicians and researchers, emphasizing both clinical and genetic features of EB. What is already known about this topic? Epidermolysis bullosa (EB) is a group of genetic disorders with skin blistering. The last updated recommendations on diagnosis and classification were published in 2014. What does this study add? We introduce the concept of genetic disorders with skin fragility, of which classical EB represents the prototype. Clinical and genetic aspects, genotype-phenotype correlations, disease-modifying factors and natural history of EB are reviewed. Other disorders with skin fragility, e.g. peeling skin disorders, erosive disorders, hyperkeratotic disorders, and connective tissue disorders with skin fragility are classified as separate categories; these 'EB-related' disorders should be considered under the EB umbrella in terms of medical and socioeconomic provision of care. Linked Comment: Pope. Br J Dermatol 2020; 183:603.
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Affiliation(s)
- C Has
- Department of Dermatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - J W Bauer
- Department of Dermatology and Allergology and EB Haus Austria University Hospital of the Paracelsus Medical University Salzburg, Austria
| | - C Bodemer
- Department of Dermatology, Necker Hospital des Enfants Malades, University Paris-Centre APHP 5, Paris, France
| | - M C Bolling
- University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - L Bruckner-Tuderman
- Department of Dermatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - A Diem
- Department of Dermatology and Allergology and EB Haus Austria University Hospital of the Paracelsus Medical University Salzburg, Austria
| | - J-D Fine
- Vanderbilt University School of Medicine, Nashville, TN, USA; National Epidermolysis Bullosa Registry, Nashville, TN, USA
| | - A Heagerty
- Heart of England Foundation Trust, Birmingham, UK
| | - A Hovnanian
- INSERM UMR1163, Imagine Institute, Department of Genetics, Necker hospital for sick children, Paris University, Paris, France
| | - M P Marinkovich
- Stanford University School of Medicine, Stanford, Palo Alto Veterans Affairs Medical Center CA, USA
| | - A E Martinez
- Dermatology Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - J A McGrath
- St John's Institute of Dermatology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - C Moss
- Birmingham Children's Hospital and University of Birmingham, UK
| | - D F Murrell
- St George Hospital and University of New South Wales, Sydney, Australia
| | - F Palisson
- DEBRA Chile, Facultad de Medicina Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - A Schwieger-Briel
- Department of Pediatric Dermatology, University Children's Hospital Zürich, Zürich, Switzerland
| | - E Sprecher
- Division of Dermatology, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - K Tamai
- Dermatology Department, University of Osaka, Osaka, Japan
| | - J Uitto
- Thomas Jefferson University, Philadelphia, PA, USA
| | - D T Woodley
- University of Southern California, Los Angeles, CA, USA
| | - G Zambruno
- Dermatology Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - J E Mellerio
- St John's Institute of Dermatology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
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25
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Affiliation(s)
- M Laimer
- Department of Dermatology and Allergology, University Hospital of the Paracelsus Medical University Salzburg, Muellner Hauptstrasse 48, A-5020, Salzburg, Austria
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