Herlitz junctional epidermolysis bullosa: a case report and review of current diagnostic methods

[Bart syndrome associated to lethal junctional epidermolysis bullosa (Herlitz form)]

We present the case of a newborn with congenital absence of skin in the anterior part of the left leg that shortly after developed bulla and erosions in hands, feet, ears, buttocks and mouth. The cutaneous biopsy and ultrastructural and immunohistochemical studies showed a subepidermal bulla in the lamina lucida, absence of hemidesmosomes and marked decrease of laminin 5, thus establishing the diagnosis of Bart syndrome associated to the Herlitz form of lethal junctional epidermolysis bullosa. Bart syndrome consists of congenital and localized absence of skin, nail abnormalities and mucoc-cutaneous bullae. It is usually associated to dystrophic epidermolysis bullosa. The Herlitz form of junctional epidermolysis bullosa is a rare variant, usually lethal that is produced by mutations in the genes coding for the anchor protein laminin 5. To our knowledge this is the second case that reports an association between Bart syndrome and lethal junctional epidermolysis bullosa and the first in which the results of immunofluorescence mapping are published.

Treatment of two patients with Herlitz junctional epidermolysis bullosa with artificial skin bioequivalents

OBJECTIVE

To evaluate the effects of a treatment with artificial skin bioequivalents in Herlitz junctional epidermolysis bullosa (H-JEB).

METHODS

Two infants, both homozygous for the Herlitz mutation R635X in the LAMB3 gene, who had refractory anemia and hypoproteinemia as a result of a continuous loss of body fluids through multiple large erosions, were treated with artificial skin bioequivalents.

RESULTS

In the first patient, 10 of 13 acute or chronic wounds were found healed 3 to 6 weeks after the treatment, and the protein, iron, and hemoglobin levels normalized. Normal weight gain and marked improvement of the quality of life for this patient's family have been evident since. Nine treated wounds remained healed for at least 18 weeks and appeared to be more resistant to trauma. In a skin biopsy from a treated site obtained after 9 weeks, DNA of the graft was still detectable by polymerase chain reaction. In the second patient, who was treated at a late stage of the disease, only 2 of 18 chronic wounds were found healed at 3 weeks after the treatment. One site remained healed completely, and some additional islets of the grafts persisted for longer. There were no adverse events.

CONCLUSION

Early treatment with artificial skin substitutes may improve the clinical course of H-JEB. However, a true cure of the cutaneous manifestations of H-JEB would require gene therapy of autologous epidermal stem cells, which could then be transplanted by using this or a similar cultured skin bioequivalent.