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Jayawardena NS, Wargon O, Tatian AH. Review: the spectrum of antimicrobial resistance in bacteria isolated from wounds of patients with epidermolysis bullosa. J DERMATOL TREAT 2024; 35:2370424. [PMID: 38936964 DOI: 10.1080/09546634.2024.2370424] [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: 05/07/2024] [Accepted: 06/14/2024] [Indexed: 06/29/2024]
Abstract
Purpose: Cutaneous infection in epidermolysis bullosa (EB) can cause significant morbidity, mortality, and dangerous sequelae. This review article aims to delve into the known epidemiology of EB, highlight the disease's primary causative agents and their antimicrobial resistance spectrum.Materials and methods: A thorough literature search was conducted using Medline, EMBASE, JBI and PubMed to gather data on the microbial landscape of EB wounds. The focus was on identifying the most common bacteria associated with EB infections and assessing their antimicrobial resistance profiles.Results: The analysis revealed that Staphylococcus aureus is the most frequently identified bacterium in EB wounds, with a notable prevalence of methicillin-resistant strains (MRSA). Specific studies on mupirocin resistance further indicated rising rates of mupirocin-resistant Staphylococcus aureus, with one study reporting rates as high as 16.07%. Additionally, high resistance to other antibiotics, such as levofloxacin and trimethoprim/sulfamethoxazole, was observed in MRSA isolates.Conclusions: The findings highlight the critical need for regular resistance surveillance and the prudent use of mupirocin to manage infections effectively in EB. The multi-drug resistant nature of pathogens in EB presents a significant challenge in treatment, highlighting the importance of antimicrobial stewardship. Ultimately, given the sparse literature and the rarity of large-scale studies, further longitudinal research on the antimicrobial resistance profile of bacteria isolated from EB wounds is essential.
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Affiliation(s)
- Nikhila S Jayawardena
- Department of Dermatology, Sydney Children's Hospital, Randwick, Australia
- Faculty of Medicine and Health, University of New South Wales, Kensington, Australia
| | - Orli Wargon
- Department of Dermatology, Sydney Children's Hospital, Randwick, Australia
- Faculty of Medicine and Health, University of New South Wales, Kensington, Australia
| | - Artiene H Tatian
- Department of Dermatology, Sydney Children's Hospital, Randwick, Australia
- Faculty of Medicine and Health, University of New South Wales, Kensington, Australia
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Fuentes I, Yubero MJ, Morandé P, Varela C, Oróstica K, Acevedo F, Rebolledo‐Jaramillo B, Arancibia E, Porte L, Palisson F. Longitudinal study of wound healing status and bacterial colonisation of Staphylococcus aureus and Corynebacterium diphtheriae in epidermolysis bullosa patients. Int Wound J 2023; 20:774-783. [PMID: 36787273 PMCID: PMC9927916 DOI: 10.1111/iwj.13922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/24/2022] [Accepted: 07/27/2022] [Indexed: 11/29/2022] Open
Abstract
Epidermolysis bullosa (EB) is an inherited disorder characterised by skin fragility and the appearance of blisters and wounds. Patient wounds are often colonised or infected with bacteria, leading to impaired healing, pain and high risk of death by sepsis. Little is known about the impact of bacterial composition and susceptibility in wound resolution, and there is a need for longitudinal studies to understand healing outcomes with different types of bacterial colonisation. A prospective longitudinal study of 70 wounds from 15 severe EB patients (Junctional and Recessive Dystrophic EB) from Chile. Wounds were selected independently of their infected status. Wound cultures, including bacterial species identification, composition and Staphylococcus aureus (SA) antibiotic susceptibility were registered. Wounds were separated into categories according to their healing capacity, recognising chronic, and healing wounds. Hundred-one of the 102 wound cultures were positive for bacterial growth. From these, 100 were SA-positive; 31 were resistant to Ciprofloxacin (31%) and only seven were methicillin-resistant SA (7%). Ciprofloxacin-resistant SA was found significantly predominant in chronic wounds (**P < .01). Interestingly, atoxigenic Corynebacterium diphtheriae (CD) was identified and found to be the second most abundant recovered bacteria (31/101), present almost always in combination with SA (30/31). CD was only found in Recessive Dystrophic EB patients and not related to wound chronicity. Other less frequent bacterial species found included Pseudomonas aeruginosa, Streptococus spp. and Proteus spp. Infection was negatively associated with the healing status of wounds.
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Affiliation(s)
- Ignacia Fuentes
- DEBRA ChileSantiagoChile
- Centro de Genética y Genómica, Facultad de Medicina Clínica AlemanaUniversidad del DesarrolloSantiagoChile
| | - María Joao Yubero
- DEBRA ChileSantiagoChile
- Pediatrics and Pediatric Infectious Diseases of Clínica Alemana, Facultad de Medicina AlemanaUniversidad del DesarrolloSantiagoChile
| | | | - Carmen Varela
- Laboratorio ClínicoClinica Alemana de SantiagoSantiagoChile
| | - Karen Oróstica
- Instituto de Investigación Interdisciplinaria, Vicerrectoría AcadémicaUniversidad de TalcaTalcaChile
| | - Francisco Acevedo
- Department of Hematology Oncology, School of MedicinePontificia Universidad Católica de ChileSantiagoChile
| | - Boris Rebolledo‐Jaramillo
- Centro de Genética y Genómica, Facultad de Medicina Clínica AlemanaUniversidad del DesarrolloSantiagoChile
| | | | - Lorena Porte
- Laboratorio Clínico, Clínica Alemana de Santiago, Facultad de Medicina Clínica AlemanaUniversidad del DesarrolloSantiagoChile
| | - Francis Palisson
- DEBRA ChileSantiagoChile
- Servicio de Dermatología, Facultad de Medicina Clínica AlemanaUniversidad del DesarrolloSantiagoChile
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Bloodstream Infection in Children With Epidermolysis Bullosa. Pediatr Infect Dis J 2023; 42:510-514. [PMID: 36795569 DOI: 10.1097/inf.0000000000003871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND Epidermolysis bullosa (EB) is frequently complicated by skin infection, which can lead to bacteremia. However, bloodstream infections (BSI) in patients with EB have not been well described. METHODS Retrospective study of BSI in children 0-18 years with EB from a national reference unit in Spain, in 2015-2020. RESULTS Among 126 children with EB, we identified 37 BSI episodes in 15 patients (14 recessive dystrophic EB, 1 junctional EB). The most frequent microorganisms were Pseudomonas aeruginosa (n = 12) and Staphylococcus aureus (n = 11). Five P. aeruginosa isolates were ceftazidime-resistant (42%), 4 of which were also resistant to meropenem and quinolones (33%). As for S. aureus, 4 (36%) were methicillin-resistant and 3 (27%) clindamycin-resistant. In 25 (68%) BSI episodes skin cultures had been performed in the previous 2 months. The most frequent isolates were also P. aeruginosa (n = 15) and S. aureus (n = 11). In 13 cases (52%), smear and blood cultures grew the same microorganism, with the same antimicrobial resistance pattern in 9 isolates. Twelve patients (10%) died during follow-up (9 RDEB and 3 JEB). BSI was the cause of death in 1 case. In patients with severe RDEB, a history of BSI was associated with higher mortality (OR 6.1, 95% CI: 1.33-27.83, P = 0.0197). CONCLUSIONS BSI is an important cause of morbidity in children with severe forms of EB. The most frequent microorganisms are P. aeruginosa and S. aureus, with high rates of antimicrobial resistance. Skin cultures can help guide treatment decisions in patients with EB and sepsis.
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Alheggi A, Alzakry L, Khunayn R, Alshareef R, Al-Khalid Y. Skin cleansing and wound care practice in patients with epidermolysis bullosa: A cross-sectional study. JOURNAL OF DERMATOLOGY & DERMATOLOGIC SURGERY 2022. [DOI: 10.4103/jdds.jdds_99_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Kubanov AA, Chikin VV, Karamova AE, Monchakovskaya ES. Topical treatment of inherited epidermolysis bullosa. VESTNIK DERMATOLOGII I VENEROLOGII 2021. [DOI: 10.25208/vdv1290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Inherited epidermolysis bullosa is a group of genetic skin disorders characterized by skin erosions, ulceration, skin and mucosal blistering requiring topical treatment. This review demonstrates major clinical manifestations of epidermolysis bullosa and its mechanisms of development. According to these features the main principles of topical treatment and drug therapy were developed, including physical protection from trauma, moisturizing, improvement of wound healing, prevention and management of infection, itch and pain management. Drug therapy is outlined with dosage forms, drug routes of administration, age restrictions indicated in the instruction for medical use for the medications that could be used in epidermolysis bullosa patients. The authors provide indications for clinical use of antiseptics, disinfectants, antibiotics, antimicrobial agents, emollient cream and drugs reducing itch and pain.
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Santin JT, Mariath LM, Rossato AM, Schuler-Faccini L, Kiszewski AE. Prevalence and antimicrobial resistance profile of Staphylococcus aureus in inherited epidermolysis bullosa: a cross-sectional multicenter study in Brazil. Int J Dermatol 2021; 60:1126-1130. [PMID: 34047367 DOI: 10.1111/ijd.15634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 04/06/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Infection is an important complication of epidermolysis bullosa (EB), and Staphylococcus aureus has been pointed out as the most common pathogen among this population. The objective of this study was to investigate the prevalence and antimicrobial resistance profile of S. aureus colonizing EB patients in Brazil. METHODS This cross-sectional multicenter study was conducted between December 2015 and December 2017. We included a total of 89 individuals with EB from medical centers across Brazil. Data were obtained through clinical and bacteriological investigation. S. aureus were identified by biochemical tests. The nuc and mecA genes were confirmed by PCR assay. Antimicrobial susceptibility was investigated by disk diffusion method. RESULTS The overall prevalence of S. aureus was 51.7% (46/89). Methicillin-resistant S. aureus (MRSA) was detected in 24.7% (19/77) of all S. aureus isolates, colonizing 15.7% (14/89) of all patients. Community-associated (CA)-MRSA strains were resistant against sulfamethoxazole/trimethoprim and levofloxacin (P < 0.05%). S. aureus colonization of the nares and belly button represented a 3.4 times higher risk of simultaneous skin lesion colonization (P < 0.05%). CONCLUSIONS The high frequency of MRSA colonizing patients with EB is alarming considering its association with life-threatening complications and poorer outcomes. EB patients are at increased risk of colonization and infection by Staphylococcus aureus and CA-MRSA. Getting to know S. aureus carriage sites and its antimicrobial susceptibility profile is key when planning new individualized and more effective prophylactic and therapeutic measures.
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Affiliation(s)
- Juliana T Santin
- Postgraduate Program in Child and Adolescent Health, Faculty of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Luiza M Mariath
- Postgraduate Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Adriana M Rossato
- Basic Health Department, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Rio Grande do Sul, Brazil
| | - Lavínia Schuler-Faccini
- Postgraduate Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Ana E Kiszewski
- Service of Dermatology, Irmandade Santa Casa de Misericórdia de Porto Alegre/Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Rio Grande do Sul, Brazil.,Section of Pediatric Dermatology, Hospital da Criança Santo Antônio, Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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Bar J, Sarig O, Lotan-Pompan M, Dassa B, Miodovnik M, Weinberger A, Sprecher E, Segal E, Samuelov L. Evidence for cutaneous dysbiosis in dystrophic epidermolysis bullosa. Clin Exp Dermatol 2021; 46:1223-1229. [PMID: 33682945 DOI: 10.1111/ced.14592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/10/2021] [Accepted: 02/01/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND The human microbiome project addresses the relationship between bacterial flora and the human host, in both healthy and diseased conditions. The skin is an ecosystem with multiple niches, each featuring unique physiological conditions and thus hosting different bacterial populations. The skin microbiome has been implicated in the pathogenesis of many dermatoses. Given the role of dysbiosis in the pathogenesis of inflammation, which is prominent in dystrophic epidermolysis bullosa (DEB), we undertook a study on the skin microbiome. AIM To characterize the skin microbiome in a series of patients with DEB. METHODS This was a case-control study of eight patients with DEB and nine control cases enrolled between June 2017 and November 2018. The skin of patients with DEB was sampled at three different sites: untreated wound, perilesional skin and normal-appearing (uninvolved) skin. Normal skin on the forearm was sampled from age-matched healthy controls (HCs). We used a dedicated DNA extraction protocol to isolate microbial DNA, which was then analysed using next-generation microbial 16S rRNA sequencing. Data were analysed using a series of advanced bioinformatics tools. RESULTS The wounds, perilesional and uninvolved skin of patients with DEB demonstrated reduced bacterial diversity compared with HCs, with the flora in DEB wounds being the least diverse. We found an increased prevalence of staphylococci species in the lesional and perilesional skin of patients with DEB, compared with their uninvolved, intact skin. Similarly, the uninvolved skin of patients with DEB displayed increased staphylococcal content and significantly different microbiome diversities (other than staphylococci) compared with HC skin. CONCLUSIONS These findings suggest the existence of a unique DEB-associated skin microbiome signature, which could be targeted by specific pathogen-directed therapies. Moreover, altering the skin microbiome with increasing colonization of bacteria associated with nonchronic wounds may potentially facilitate wound healing in patients with DEB.
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Affiliation(s)
- J Bar
- Division of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - O Sarig
- Division of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - M Lotan-Pompan
- Department of Computer Science and Applied Mathematics, Weizmann Institute of Science, Rehovot, Israel.,Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
| | - B Dassa
- Bioinformatics Unit, Life Sciences Core Facilities, Weizmann Institute of Science, Rehovot, Israel
| | - M Miodovnik
- Division of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - A Weinberger
- Department of Computer Science and Applied Mathematics, Weizmann Institute of Science, Rehovot, Israel.,Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
| | - E Sprecher
- Division of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - E Segal
- Department of Computer Science and Applied Mathematics, Weizmann Institute of Science, Rehovot, Israel.,Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
| | - L Samuelov
- Division of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Interplay between ESKAPE Pathogens and Immunity in Skin Infections: An Overview of the Major Determinants of Virulence and Antibiotic Resistance. Pathogens 2021; 10:pathogens10020148. [PMID: 33540588 PMCID: PMC7912840 DOI: 10.3390/pathogens10020148] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 12/16/2022] Open
Abstract
The skin is the largest organ in the human body, acting as a physical and immunological barrier against pathogenic microorganisms. The cutaneous lesions constitute a gateway for microbial contamination that can lead to chronic wounds and other invasive infections. Chronic wounds are considered as serious public health problems due the related social, psychological and economic consequences. The group of bacteria known as ESKAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter sp.) are among the most prevalent bacteria in cutaneous infections. These pathogens have a high level of incidence in hospital environments and several strains present phenotypes of multidrug resistance. In this review, we discuss some important aspects of skin immunology and the involvement of ESKAPE in wound infections. First, we introduce some fundamental aspects of skin physiology and immunology related to cutaneous infections. Following this, the major virulence factors involved in colonization and tissue damage are highlighted, as well as the most frequently detected antimicrobial resistance genes. ESKAPE pathogens express several virulence determinants that overcome the skin's physical and immunological barriers, enabling them to cause severe wound infections. The high ability these bacteria to acquire resistance is alarming, particularly in the hospital settings where immunocompromised individuals are exposed to these pathogens. Knowledge about the virulence and resistance markers of these species is important in order to develop new strategies to detect and treat their associated infections.
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Levin LE, Shayegan LH, Lucky AW, Hook KP, Bruckner AL, Feinstein JA, Whittier S, Lauren CT, Pope E, Lara-Corrales I, Wiss K, McCuaig CC, Powell J, Eichenfield LF, Levy ML, Diaz L, Glick SA, Paller AS, Price HN, Browning JC, Morel KD. Characterization of wound microbes in epidermolysis bullosa: Results from the epidermolysis bullosa clinical characterization and outcomes database. Pediatr Dermatol 2021; 38:119-124. [PMID: 33247481 PMCID: PMC7906915 DOI: 10.1111/pde.14444] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND/OBJECTIVES Patients with epidermolysis bullosa (EB) require care of wounds that are colonized or infected with bacteria. A subset of EB patients are at risk for squamous cell carcinoma, and bacterial-host interactions have been considered in this risk. The EB Clinical Characterization and Outcomes Database serves as a repository of information from EB patients at multiple centers in the United States and Canada. Access to this resource enabled broad-scale analysis of wound cultures. METHODS A retrospective analysis of 739 wound cultures from 158 patients from 13 centers between 2001 and 2018. RESULTS Of 152 patients with a positive culture, Staphylococcus aureus (SA) was recovered from 131 patients (86%), Pseudomonas aeruginosa (PA) from 56 (37%), and Streptococcus pyogenes (GAS) from 34 (22%). Sixty-eight percent of patients had cultures positive for methicillin-sensitive SA, and 47%, methicillin-resistant SA (18 patients had cultures that grew both methicillin-susceptible and methicillin-resistant SA at different points in time). Of 15 patients with SA-positive cultures with recorded mupirocin susceptibility testing, 11 had mupirocin-susceptible SA and 6 patients mupirocin-resistant SA (2 patients grew both mupirocin-susceptible and mupirocin-resistant SA). SCC was reported in 23 patients in the entire database, of whom 10 had documented wound cultures positive for SA, PA, and Proteus species in 90%, 50%, and 20% of cases, respectively. CONCLUSIONS SA and PA were the most commonly isolated bacteria from wounds. Methicillin resistance and mupirocin resistance were reported in 47% and 40% of patients tested, respectively, highlighting the importance of ongoing antimicrobial strategies to limit antibiotic resistance.
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Affiliation(s)
- Laura E Levin
- Department of Dermatology, Columbia University Irving Medical Center, New York, NY, USA
| | - Leila H Shayegan
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Anne W Lucky
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kristen P Hook
- Department of Dermatology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Anna L Bruckner
- Departments of Dermatology and Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - James A Feinstein
- Departments of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Susan Whittier
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Christine T Lauren
- Departments of Pediatrics and Dermatology, Columbia University Irving Medical Center, New York, NY, USA
| | - Elena Pope
- Section of Dermatology, Division of Paediatric Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Irene Lara-Corrales
- Section of Dermatology, Division of Paediatric Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Karen Wiss
- Division of Dermatology, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Catherine C McCuaig
- Departments of Pediatrics and Dermatology, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
| | - Julie Powell
- Department of Dermatology, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
| | - Lawrence F Eichenfield
- Departments of Pediatrics and Dermatology, University of California San Diego, San Diego, CA, USA
| | - Moise L Levy
- Departments of Pediatrics and Dermatology, Dell Children's Medical Center, Austin, TX, USA
| | - Lucia Diaz
- Department of Dermatology, Dell Children's Medical Center, Austin, TX, USA
| | - Sharon A Glick
- Department of Dermatology, State University of New York Downstate Medical Center, Brooklyn, NY, USA
| | - Amy S Paller
- Departments of Pediatrics and Dermatology, Northwestern University, Chicago, IL, USA
| | - Harper N Price
- Department of Dermatology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - John C Browning
- Department of Dermatology, The Children's Hospital of San Antonio, San Antonio, TX, USA
| | - Kimberly D Morel
- Departments of Pediatrics and Dermatology, Columbia University Irving Medical Center, New York, NY, 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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Perez VA, Morel KD, Garzon MC, Lauren CT, Levin LE. Review of transition of care literature: Epidermolysis bullosa-A paradigm for patients with complex dermatologic conditions. J Am Acad Dermatol 2020; 87:623-631. [PMID: 32592878 DOI: 10.1016/j.jaad.2020.06.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/08/2020] [Accepted: 06/17/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Transition from pediatric to adult care is a critical component of health care for children with long-term needs. The characteristics of epidermolysis bullosa (EB) demand higher than average levels of provider support. There is consensus among health care professionals regarding the importance of transition; however, there is a scarcity of practical information regarding models for patients with EB. OBJECTIVE To review transition of care programs in varying specialties. Highlight practical considerations to facilitate the development of programs for patients with EB and other complex dermatologic conditions. METHODS Articles were identified via MEDLINE and EMBASE health literature databases and screened for relevance to transition of care. RESULTS Various models for transition exist. A well-executed formal transition program, early introduction, interdisciplinary collaboration, and psychosocial support were themes associated with successful outcomes. LIMITATIONS Transition of care programs that have not been described in the literature are not reflected in this review. CONCLUSIONS Patients with EB have unique needs that affect transition and span expertise across traditional boundaries, such as dependency on others for daily skin care, failure to thrive, and risk of squamous cell carcinoma. Given the rarity of the disease, patients with EB will benefit from collaborative efforts to develop programs to optimize successful transition.
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Affiliation(s)
- Victoria A Perez
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York.
| | - Kimberly D Morel
- Department of Dermatology, Columbia University Irving Medical Center and New York Presbyterian Hospital, New York, New York; Department of Pediatrics, Columbia University Irving Medical Center and New York Presbyterian Hospital, New York, New York
| | - Maria C Garzon
- Department of Dermatology, Columbia University Irving Medical Center and New York Presbyterian Hospital, New York, New York; Department of Pediatrics, Columbia University Irving Medical Center and New York Presbyterian Hospital, New York, New York
| | - Christine T Lauren
- Department of Dermatology, Columbia University Irving Medical Center and New York Presbyterian Hospital, New York, New York; Department of Pediatrics, Columbia University Irving Medical Center and New York Presbyterian Hospital, New York, New York
| | - Laura E Levin
- Department of Dermatology, Columbia University Irving Medical Center and New York Presbyterian Hospital, New York, New York
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McNamara SA, Hirt PA, Weigelt MA, Nanda S, de Bedout V, Kirsner RS, Schachner LA. Traditional and advanced therapeutic modalities for wounds in the paediatric population: an evidence-based review. J Wound Care 2020; 29:321-334. [PMID: 32530778 DOI: 10.12968/jowc.2020.29.6.321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Children can have non-healing wounds due to a wide range of pathologies, including epidermolysis bullosa (EB), pilonidal disease and Stevens-Johnson syndrome, with some causes being iatrogenic, including extravasation injuries and medical device-related hospital-acquired pressure ulcers. Furthermore, paediatric wounds are vastly different from adult wounds and therefore require a different treatment approach. While there are numerous types of dressings, topical remedies, and matrices with high-tier evidence to support their use in adults, evidence is scarce in the neonatal and paediatric age groups. The purpose of this review is to discuss the basic principles in paediatric wound management, as well as to present new treatment findings published in the literature to date. The benefits and risks of using different types of debridement are discussed in this review. Various topical formulations are also described, including the need to use antibiotics judiciously. METHOD Databases were searched for relevant sources including Pubmed, Embase, Web of Science and DynaMed. Search terms used included 'wound care', 'wound management', 'paediatrics', 'children', 'skin substitutes', and 'grafts'. Additionally, each treatment and disease entity was searched for relevant sources, including, for example: 'Apligraf', 'dermagraft', 'Manuka honey', 'antibiotic', 'timolol', and 'negative pressure wound therapy' (NPWT). RESULTS Amniotic membrane living skin equivalent is a cellular matrix that has been reportedly successful in treating paediatrics wounds and is currently under investigation in randomised clinical trials. Helicoll is an acellular matrix, which shows promise in children with recessive dystrophic EB. NPWT may be used as a tool to accelerate wound closure in children; however, caution must be taken due to limited evidence to support its safety and efficacy in the paediatric patient population. Integra has been reported as a useful adjunctive treatment to NPWT as both may act synergistically. Hospitalised children and neonates frequently have pressure ulcers, which is why prevention in this type of wound is paramount. CONCLUSION Advancements in wound care are rapidly expanding. Various treatments for non-healing wounds in paediatric and neonatal patients have been reported, but high tier evidence in these populations is scarce. We hope to shed light on existing evidence regarding the different therapeutic modalities, from debridement techniques and dressing types to tissue substitutes and topical remedies. There have been promising results in many studies to date, but RCTs involving larger sample sizes are necessary, in order to determine the specific role these innovative agents play in paediatric wounds and to identify true safety and efficacy.
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Affiliation(s)
- Stephanie A McNamara
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
| | - Penelope A Hirt
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
| | - Maximillian A Weigelt
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
| | - Sonali Nanda
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
| | - Valeria de Bedout
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
| | - Robert S Kirsner
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
| | - Lawrence A Schachner
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
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13
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Malone M, Radzieta M, Jensen SO, Mahon C. Wound biofilms and their role in individuals with epidermolysis bullosa. Australas J Dermatol 2020; 61:279-280. [PMID: 32201933 DOI: 10.1111/ajd.13274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Matthew Malone
- South Western Sydney LHD, Limb Preservation and Wound Research Academic Unit, Ingham Institute of Applied Medical Research, Liverpool, Sydney, NSW, Australia.,School of Medicine, Infectious Diseases and Microbiology, Western Sydney University, Campbelltown, Sydney, NSW, Australia
| | - Michael Radzieta
- South Western Sydney LHD, Limb Preservation and Wound Research Academic Unit, Ingham Institute of Applied Medical Research, Liverpool, Sydney, NSW, Australia.,School of Medicine, Infectious Diseases and Microbiology, Western Sydney University, Campbelltown, Sydney, NSW, Australia
| | - Slade O Jensen
- South Western Sydney LHD, Limb Preservation and Wound Research Academic Unit, Ingham Institute of Applied Medical Research, Liverpool, Sydney, NSW, Australia.,School of Medicine, Infectious Diseases and Microbiology, Western Sydney University, Campbelltown, Sydney, NSW, Australia
| | - Caroline Mahon
- Department of Dermatology, Canterbury District Health Board, Christchurch Hospital, Christchurch, New Zealand
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14
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Shayegan LH, Levin LE, Galligan ER, Lucky AW, Bruckner AL, Pope E, Lara-Corrales I, Wiss K, McCuaig CC, Garzon MC, Eichenfield LF, Hook KP, Browning JC, Schachner LA, Perman MJ, Castelo-Soccio L, Levy ML, Glick SA, Morel KD. Skin cleansing and topical product use in patients with epidermolysis bullosa: Results from a multicenter database. Pediatr Dermatol 2020; 37:326-332. [PMID: 31944391 DOI: 10.1111/pde.14102] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND/OBJECTIVES Epidermolysis bullosa (EB) comprises a group of inherited skin blistering diseases. There is currently no cure, and management includes skin protection and prevention of infection. To date, there has been no systematic investigation of home skin care practices among EB patients on a multicenter scale. METHODS This cross-sectional, observational study included data collected from patients with EB enrolled in the Epidermolysis Bullosa Characterization and Clinical Outcomes Database (EBCCOD) who provided answers to a patient-directed questionnaire between January 1, 2017, and December 31, 2017. RESULTS Of 202 respondents, 130 (64.4%) had dystrophic EB, 51 (25.2%) had EB simplex, 21 (7.4%) had junctional EB, 3 (1.5%) had Kindler syndrome, and 3 (1.5%) had an unspecified subtype. Seventy-eight patients reported cleansing in plain water only (39%). Of those who used an additive in their cleansing water, 75 (57%) added salt, 71 (54%) added bleach, 36 (27%) added vinegar, and 34 (26%) endorsed the use of an "other" additive (multiple additives possible). Reported concentrations of additives ranged widely from 0.002% sodium hypochlorite and 0.002% acetic acid solutions, which are thought to have negligible effects on microbes, to 0.09% sodium hypochlorite and 0.156% acetic acid, concentrations shown to be cytotoxic. One hundred eighty-eight patients answered questions regarding topical product use (93%). Of those, 131 reported topical antimicrobial use (70%). Mupirocin and bacitracin were the most commonly reported topical antibiotics (59, 58 [31.4%, 30.9%], respectively). CONCLUSIONS These findings highlight the variety of skin care routines and frequent use of topical antimicrobials among EB patients and have potential implications for antibiotic resistance. The reported range of bleach and vinegar additives to cleansing water, including cytotoxic concentrations, emphasizes the need for clear and optimized skin cleansing recommendations.
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Affiliation(s)
- Leila H Shayegan
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Laura E Levin
- Department of Dermatology, Columbia University Irving Medical Center, New York, New York
| | - Eloise R Galligan
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Anne W Lucky
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Anna L Bruckner
- Departments of Dermatology and Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Elena Pope
- Section of Dermatology, Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Irene Lara-Corrales
- Section of Dermatology, Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Karen Wiss
- Division of Dermatology, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | | | - Maria C Garzon
- Departments of Dermatology and Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Lawrence F Eichenfield
- Departments of Pediatrics and Dermatology, University of California San Diego, San Diego, California
| | - Kristen P Hook
- Department of Dermatology, University of Minnesota Medical School, Minneapolis, Minnesota
| | - John C Browning
- Department of Pediatric Dermatology, Children's Hospital San Antonio, San Antonio, Texas
| | - Lawrence A Schachner
- Department of Dermatology, University of Miami Miller School of Medicine, Miami, Florida
| | - Marissa J Perman
- Section of Pediatric Dermatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Leslie Castelo-Soccio
- Section of Pediatric Dermatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Moise L Levy
- Departments of Pediatrics and Medicine (Dermatology), Dell Medical School, University of Texas, Austin, Texas
- Department of Pediatric Dermatology, Dell Children's Medical Center, Austin, Texas
| | - Sharon A Glick
- Department of Dermatology, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Kimberly D Morel
- Departments of Dermatology and Pediatrics, Columbia University Irving Medical Center, New York, New York
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15
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Hammersen J, Neuner A, Wild F, Schneider H. Attenuation of Severe Generalized Junctional Epidermolysis Bullosa by Systemic Treatment with Gentamicin. Dermatology 2019; 235:315-322. [PMID: 31132778 DOI: 10.1159/000499906] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 03/25/2019] [Indexed: 11/19/2022] Open
Abstract
Severe generalized junctional epidermolysis bullosa (JEB), a lethal genodermatosis, is mainly caused by premature termination codons (PTCs) in one of the three genes encoding the anchoring protein laminin-332. Only symptomatic treatment has been established; overcoming PTCs by aminoglycosides may represent an interesting alternative. This retrospective study aimed at assessing for the first time the clinical effects of systemic gentamicin application in infants with severe generalized JEB. Five patients, homozygous or compound-heterozygous for PTCs in the gene LAMB3, were treated with gentamicin which was administered intravenously or by intramuscular injection at doses of 7.5 mg/kg/d for three weeks. Skin biopsies were investigated by immunofluorescence analyses. Clinical effects of the medication were recorded with a parent questionnaire and by assessing weight-for-age charts. Gentamicin application was well tolerated, long hospitalization was not required. Low levels of laminin-332 could be detected in a skin sample obtained after treatment. Gentamicin had a positive impact on skin fragility and daily life in four patients but did not influence weight gain and failed to reverse the lethal course of the disease. Gentamicin injections should be considered regularly in cases of severe generalized JEB caused by PTCs as they may attenuate JEB symptoms without impeding quality of life.
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Affiliation(s)
- Johanna Hammersen
- Department of Pediatrics, University Hospital Erlangen, Erlangen, Germany,
| | - Andrea Neuner
- Nikolaus Fiebiger Center for Molecular Medicine, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Florian Wild
- Department of Pediatrics, Hospital St. Elisabeth, Neuburg an der Donau, Germany
| | - Holm Schneider
- Department of Pediatrics, University Hospital Erlangen, Erlangen, Germany
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