1
|
Box R, Bernardis C, Pleshkov A, Jessop N, Miller C, Skye J, O'Brien V, Veerkamp M, da Rocha ACF, Cornwall R. Hand surgery and hand therapy clinical practice guideline for epidermolysis bullosa. Orphanet J Rare Dis 2022; 17:406. [PMID: 36345025 PMCID: PMC9641806 DOI: 10.1186/s13023-022-02282-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 03/07/2022] [Indexed: 11/09/2022] Open
Abstract
WHAT IS ALREADY KNOWN ABOUT THIS TOPIC?: Epidermolysis bullosa (EB) causes blistering and scarring of the hands resulting in contractures fused web spaces and altered function. Surgery is needed to release contractures and web spaces and hand therapy is essential to maintain results, approaches for both differ. WHAT DOES THIS STUDY ADD?: These guidelines aim to provide information on the surgical and conservative therapeutic hand management of children and adults diagnosed with EB. They are based on available evidence and expert consensus to assist hand surgeons and therapists in decision making, planning and treatment. They highlight the importance of a holistic multidisciplinary team (MDT) approach, where patient priorities are paramount.
Collapse
Affiliation(s)
- Rachel Box
- Hand Therapy Department, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Catina Bernardis
- Hand Surgery Department, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Alexander Pleshkov
- Federal State Budgetary Institution All-Russian Centre for Emergency and Radiation Medicine, Saint Petersburg, Russia
| | - Nicky Jessop
- Clinical Specialist Congenital Hand Anomalies and Dermatology, Great Ormond Street Hospital for Children NHS Foundation Trust, Occupational Therapy, Level 5 Frontage Building, Great Ormond Street, London, WC1N 3JH, UK
| | - Catherine Miller
- Plastic Surgery/Dermatology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, WC1N 3JH, UK
| | - Jennifer Skye
- Fairview Health Services/M Health, University of Minnesota, 909 Fulton Street SE, Minneapolis, MN, 55455, USA
| | - Virginia O'Brien
- Fairview Health Services/M Health, University of Minnesota, 909 Fulton Street SE, Minneapolis, MN, 55455, USA
| | - Matthew Veerkamp
- Cincinnati Children's Hospital and Medical Centre, 3333 Burnet Ave, OH 45229H, Cincinnati, USA
| | | | - Roger Cornwall
- Orthopaedic Surgery and Developmental Biology, Cincinnati Children's Hospital, 3333 Burnet Ave, OH 45229, Cincinnati, USA
| |
Collapse
|
2
|
Graham T, Sooriah S, Box R, Gage H, Williams P, Clemett V, Grocott P. Participatory co-design of patient-reported outcome indicators and N-of-1 evaluation of a dressing glove for Epidermolysis bullosa. J Wound Care 2020; 29:751-762. [PMID: 33320744 DOI: 10.12968/jowc.2020.29.12.751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE In autosomal recessive dystrophic Epidermolysis bullosa, repeat blistering results in finger webbing and severe contractures of the hands. The aim of this study was to codesign patient-reported outcome indicators for hand therapy with patients, carers and clinicians, and use these to proof-of-concept test a novel dressing glove for recessive dystrophic Epidermolysis bullosa, with cost analysis. METHOD Qualitative interviews and focus groups with patients and carers generated content for the indicators. Validity and reliability were established through expert review, piloting and consensus between patients, carers and clinicians. The indicators were self-reported by patients before and while wearing the dressing glove in an N-of-1 study. Time for dressing changes and use of conventional products were also self-reported. RESULTS A total of 11 indicators were initially generated from the thematic analysis. Expert review, piloting and consensus involved six patients, five carers and eight clinicians (total n=19). Participants agreed 14 indicators, covering hand skin condition (n=4), webbing between the digits (n=4), experiences of wearing and changing dressings (n=2), hand function (n=2), wrist function (n=1) and hand pain (n=1). In Phase 3, 12 patients scored indicators before wearing the gloves and four patients completed scoring while wearing the gloves. Statistically significant improvements between pre-glove and with-glove periods were found for most participants' experience scores. Skin appearance also improved for most participants. CONCLUSIONS The indicators generated useful data, differentiation between scores and participants demonstrating proof-of-concept for patients with recessive dystrophic Epidermolysis bullosa who could wear the dressing gloves. The indicators are being used in routine practice, supporting clinical follow up, commercialisation and regulatory governance of the dressing glove.
Collapse
Affiliation(s)
- Tanya Graham
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, UK
| | - Sangeeta Sooriah
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, UK
| | - Rachel Box
- Hand Therapy Department, Guy's and St Thomas's NHS Foundation Trust, UK
| | - Heather Gage
- Faculty of Health and Medical Sciences, University of Surrey, UK
| | | | - Victoria Clemett
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, UK
| | - Patricia Grocott
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, UK
| |
Collapse
|
3
|
Graham T, Sooriah S, Giampieri S, Box R, Grocott P. Iterative codesign and testing of a novel dressing glove for epidermolysis bullosa. J Wound Care 2019; 28:5-14. [PMID: 30625043 DOI: 10.12968/jowc.2019.28.1.5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Recessive dystrophic epidermolysis bullosa (RDEB) is a rare genetic skin disorder which requires intensive hand therapy to delay fusion of the digits. Existing dressings do not conform to the complex structure of the hand and are applied in patches held with additional bandages, leading to an occlusive environment. The aim was to co-design with patients a dressing glove based on their user experiences and needs. METHOD Qualitative interviews and focus groups with children and adults with RDEB, and their carers, were conducted. Iterative feedback of design cues, bench and surrogate testing of materials and prototype refinement were achieved through collaborative codesign with patients, carers, clinicians and manufacturers. RESULTS Thematic analysis generated eight user needs and corresponding design cues, addressing issues of absorbency, adherence, comfort, adaptability, ease of application and removal, breathability, protection, and hand hygiene. A prototype was selected for proof of concept testing. CONCLUSION This novel dressing glove design met the patient's requirements for a dressing, which conformed to the hand structure and sat in the web spaces to keep fingers separated. Proof of concept testing has since been undertaken with patients to determine performance, value for money and whether further developments are required.
Collapse
Affiliation(s)
- Tanya Graham
- Research Fellow, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London
| | - Sangeeta Sooriah
- Research Assistant, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London
| | - Silvia Giampieri
- Research Associate, Faculty of Life Sciences and Medicine, King's College London
| | - Rachel Box
- Clinical Specialist Occupational Therapist, Hand Therapy, Hand Therapy Department, Guy's and St Thomas's NHS Foundation Trust
| | - Patricia Grocott
- Professor of Nursing Innovation and Technology, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London
| |
Collapse
|
4
|
Khandelwal V, Choudhary D, Kumar Sharma S, Doval D. Bone marrow transplant for recessive dystrophic epidermolysis bullosa. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2019. [DOI: 10.1016/j.phoj.2019.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
|
5
|
Ebens CL, McGrath JA, Tamai K, Hovnanian A, Wagner JE, Riddle MJ, Keene DR, DeFor TE, Tryon R, Chen M, Woodley DT, Hook K, Tolar J. Bone marrow transplant with post-transplant cyclophosphamide for recessive dystrophic epidermolysis bullosa expands the related donor pool and permits tolerance of nonhaematopoietic cellular grafts. Br J Dermatol 2019; 181:1238-1246. [PMID: 30843184 DOI: 10.1111/bjd.17858] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Recessive dystrophic epidermolysis bullosa (RDEB) is a severe systemic genodermatosis lacking therapies beyond supportive care for its extensive, life-limiting manifestations. OBJECTIVES To report the safety and preliminary responses of 10 patients with RDEB to bone marrow transplant (BMT) with post-transplant cyclophosphamide (PTCy BMT) after reduced-intensity conditioning with infusions of immunomodulatory donor-derived mesenchymal stromal cells (median follow-up 16 months). METHODS BMT toxicities, donor blood and skin engraftment, skin biopsies, photographic and dynamic assessments of RDEB disease activity were obtained at intervals from pre-BMT to 1 year post-BMT. RESULTS Related donors varied from haploidentical (n = 6) to human leucocyte antigen (HLA)-matched (n = 3), with one HLA-matched unrelated donor. Transplant complications included graft failure (n = 3; two pursued a second PTCy BMT), veno-occlusive disease (n = 2), posterior reversible encephalopathy (n = 1) and chronic graft-versus-host disease (n = 1; this patient died). In the nine ultimately engrafted patients, median donor chimerism at 180 days after transplant was 100% in peripheral blood and 27% in skin. Skin biopsies showed stable (n = 7) to improved (n = 2) type VII collagen protein expression by immunofluorescence and gain of anchoring fibril components (n = 3) by transmission electron microscopy. Early signs of clinical response include trends toward reduced body surface area of blisters/erosions from a median of 49·5% to 27·5% at 100 days after BMT (P = 0·05), with parental measures indicating stable quality of life. CONCLUSIONS PTCy BMT in RDEB provides a means of attaining immunotolerance for future donor-derived cellular grafts (ClinicalTrials.gov identifier NCT02582775). What's already known about this topic? Severe, generalized recessive dystrophic epidermolysis bullosa (RDEB) is marked by great morbidity and early death. No cure currently exists for RDEB. Bone marrow transplant (BMT) is the only described systemic therapy for RDEB. What does this study add? The first description of post-transplant cyclophosphamide (PTCy) BMT for RDEB. PTCy was well tolerated and provided excellent graft-versus-host disease prophylaxis, replacing long courses of calcineurin inhibitors in patients receiving human leucocyte antigen-matched sibling BMT. What is the translational message? The PTCy BMT platform permits identification of a suitable related donor for most patients and for subsequent adoptive transfer of donor nonhaematopoietic cells after establishment of immunological tolerance.
Collapse
Affiliation(s)
- C L Ebens
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, MN, U.S.A
| | - J A McGrath
- St John's Institute of Dermatology, King's College London, London, U.K
| | - K Tamai
- Department of Stem Cell Therapy Science, Graduate School of Medicine, University of Osaka, Osaka, Japan
| | - A Hovnanian
- INSERM UMR1163, Imagine Institute, Department of Genetics, University Paris Descartes, Necker Hospital, Paris, France
| | - J E Wagner
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, MN, U.S.A
| | - M J Riddle
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, MN, U.S.A
| | - D R Keene
- Microimaging Center, Shriners Hospital for Children, Portland, OR, U.S.A
| | - T E DeFor
- Biostatistic Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN, U.S.A
| | - R Tryon
- Genetics Division, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, U.S.A
| | - M Chen
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA, U.S.A
| | - D T Woodley
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA, U.S.A
| | - K Hook
- Department of Dermatology, Medical School, University of Minnesota, Minneapolis, MN, U.S.A
| | - J Tolar
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, MN, U.S.A
| |
Collapse
|
6
|
Li AW, Prindaville B, Bateman ST, Gibson TE, Wiss K. Inpatient management of children with recessive dystrophic epidermolysis bullosa: A review. Pediatr Dermatol 2017; 34:647-655. [PMID: 28944966 DOI: 10.1111/pde.13276] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Recessive dystrophic epidermolysis bullosa is a disorder marked by skin and mucosal blistering after minimal trauma. Even the most routine procedures in the hospital, if done incorrectly, can precipitate extensive skin loss, pain, and scarring. Most providers have little experience working with patients with this degree of skin fragility. When a person with recessive dystrophic epidermolysis bullosa is admitted to the hospital, there are multiple considerations to keep in mind while strategizing an effective care plan: avoidance of new blisters with a "hands-off" approach; careful consideration of all indwelling devices; symptomatic management of pain, itch, and anxiety; coordination of dressing changes; aggressive treatment of skin infections; environmental and staffing considerations; and awareness of other chronic complications that affect care, such as anemia, malnutrition, and chronic pain. To minimize discomfort for patients with recessive dystrophic epidermolysis bullosa during the hospital stay, inpatient care teams should understand these considerations and modify the care plan accordingly. Prior preparation by the hospital facility and inpatient care team will facilitate the delivery of safe and effective care and greatly improve the overall patient experience.
Collapse
Affiliation(s)
- Alvin W Li
- School of Medicine, Yale University, New Haven, CT, USA
| | - Brea Prindaville
- Department of Dermatology, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Scot T Bateman
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Timothy E Gibson
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Karen Wiss
- Department of Dermatology, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA
| |
Collapse
|
7
|
Rashidghamat E, McGrath JA. Novel and emerging therapies in the treatment of recessive dystrophic epidermolysis bullosa. Intractable Rare Dis Res 2017; 6:6-20. [PMID: 28357176 PMCID: PMC5359356 DOI: 10.5582/irdr.2017.01005] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Epidermolysis bullosa (EB) is a clinically and genetically heterogeneous group of inherited blistering diseases that affects ∼ 500,000 people worldwide. Clinically, individuals with EB have fragile skin and are susceptible to blistering following minimal trauma, with mucous membrane and other organ involvement in some subtypes. Within the spectrum of EB, ∼ 5% of affected individuals have the clinically more severe recessive dystrophic (RDEB) variant with a prevalence of 8 per one million of the population. RDEB is caused by loss-of-function mutations in the type VII collagen gene, COL7A1, which leads to reduced or absent type VII collagen (C7) and a paucity of structurally effective anchoring fibrils at the dermal-epidermal junction (DEJ). Currently, there is no cure for RDEB, although considerable progress has been made in testing novel treatments including gene therapy (lentiviral and gamma retroviral vectors for COL7A1 supplementation in keratinocytes and fibroblasts), as well as cell therapy (use of allogeneic fibroblasts, mesenchymal stromal cells (MSCs), and bone marrow transplantation (BMT)). Here, we review current treatment modalities available as well as novel and emerging therapies in the treatment of RDEB. Clinical trials of new translational therapies in RDEB offer hope for improved clinical management of patients as well as generating broader lessons for regenerative medicine that could be applicable to other inherited or acquired abnormalities of wound healing or scarring.
Collapse
Affiliation(s)
- Ellie Rashidghamat
- St. John's Institute of Dermatology, King's College London, London, United Kingdom
| | - John A. McGrath
- St. John's Institute of Dermatology, King's College London, London, United Kingdom
- Address correspondence to: Dr. John A. McGrath, Dermatology Research Laboratories, Floor 9 Tower Wing, Guy's Hospital, Great Maze Pond, London SE1 9RT, United Kingdom. E-mail:
| |
Collapse
|
8
|
Al-Abadi A, Al-Azri SA, Bakathir A, Al-Riyami Y. Dental and Anaesthetic Challenges in a Patient with Dystrophic Epidermolysis Bullosa. Sultan Qaboos Univ Med J 2016; 16:e495-e499. [PMID: 28003899 DOI: 10.18295/squmj.2016.16.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Revised: 06/19/2016] [Accepted: 06/23/2016] [Indexed: 11/16/2022] Open
Abstract
Epidermolysis bullosa is a group of rare genetic disorders characterised by skin and mucous membrane fragility and systemic manifestations of variable severity. We report a case of dystrophic epidermolysis bullosa in an 18-year-old male patient who presented to the Department of Oral Health at Sultan Qaboos University Hospital, Muscat, Oman, in 2015 with recurrent dental pain and infections. Due to the poor dental status of the patient and anticipated operative difficulties due to microstomia and limited mouth opening, the patient underwent full dental clearance under general anaesthesia. This article discusses the dental and anaesthetic challenges encountered during the management of this patient and provides a brief literature review.
Collapse
Affiliation(s)
- Ali Al-Abadi
- Department of Anaesthesia & ICU, Sultan Qaboos University Hospital, Muscat, Oman
| | - Salah A Al-Azri
- Oral & Maxillofacial Surgery Residency Program, Oman Medical Specialty Board, Muscat, Oman
| | - Abdulaziz Bakathir
- Department of Oral Health, Sultan Qaboos University Hospital, Muscat, Oman
| | - Yusra Al-Riyami
- Oral & Maxillofacial Surgery Residency Program, Oman Medical Specialty Board, Muscat, Oman
| |
Collapse
|
9
|
Denyer J, Gibson E. Use of fibre dressings in children with severe epidermolysis bullosa. ACTA ACUST UNITED AC 2015; 24:S38, S40-3. [PMID: 25816002 DOI: 10.12968/bjon.2015.24.sup6.s38] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This non-comparative study explored the benefits of a natural gelling fibre dressing in 10 children with epidermolysis bullosa (EB). The clinical challenge in managing these children is that they often present with recalcitrant wounds that are perpetuated by critical colonisation, presence of biofilms and infection. KytoCel® (Aspen Medical) is a highly absorbent dressing composed of natural, biodegradable acylated chitosan. These fibres bond with wound exudate to form a clear gel that locks in fluid absorbs pathogens and is conformable to the wound bed. It also has haemostatic properties. ( Dutta PK et al, 2004 ; Lee et al, 2009 ; Stephen Haynes et al, 2014 ). Factors considered were whether the dressing could aid healing, reduce bleeding, reduce bioburden, be atraumatic and comfortable during wear time and removal.
Collapse
|
10
|
Grocott P, Blackwell R, Currie C, Pillay E, Robert G. Co-producing novel wound care products for Epidermolysis bullosa; an empirical case study of the use of surrogates in the design and prototype development process. Int Wound J 2012; 10:265-73. [PMID: 22487491 DOI: 10.1111/j.1742-481x.2012.00972.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The Woundcare for Epidermolysis bullosa (WEB) project aims to enable people with Epidermolysis bullosa (EB), their carers and clinicians to co-produce wound care products to meet their needs. EB is an inherited disorder causing extensive, painful skin blistering and wounds. It is relatively rare, with approximately 300 000 patients worldwide, but it incurs high costs (up to £50 000 per month on products alone). During the course of four workshops, adults with EB, their carers and specialist nurses gave detailed accounts of their experiences with pre-sized, pre-shaped dressings, including the need to patchwork individual dressings over large areas of broken skin. Five themes were identified from the workshop data relating to the limitations of existing products for EB wounds: dressing fit, stability, comfort, temperature and exudate. Novel designs were generated from these themes and although the intention was to develop the designs iteratively with the workshop participants, issues arose necessitating the interim use of surrogates. Our account of the design process is given, presenting the arguments for and against the use of surrogates, with suggestions for incorporating surrogate input into product development in a way that does not undermine the integrity of patient experiences or the co-production process.
Collapse
Affiliation(s)
- Patricia Grocott
- Florence Nightingale School of Nursing and Midwifery, King's College London, London SE1 8WA, UK.
| | | | | | | | | |
Collapse
|
11
|
Grocott P, Blackwell R, Weir H, Pillay E. Living in dressings and bandages: findings from workshops with people with Epidermolysis bullosa. Int Wound J 2012; 10:274-84. [PMID: 22487531 DOI: 10.1111/j.1742-481x.2012.00973.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Epidermolysis bullosa (EB) is an inherited disorder causing extensive, painful skin blistering and wounds. Currently, there is no cure and the focus of care is on the clinical management of the skin and other affected body systems, together with supportive care to individuals and families. The wound care for Epidermolysis bullosa (WEB) project is a collaboration with adults with EB, carers, clinical nurse specialists, a designer and manufacturers to develop novel products for EB wound care. This article reports the findings from workshops with adults with EB, their carers and clinical nurse specialists, together with observations of dressing changes. A cluster of significant limitations were revealed in the performance of wound care products, designed to cover a single wound, when they are used to cover extensive and whole body wounds. A working hypothesis for EB wound care was developed from the findings, together with design concepts and new products for EB wound care. In addition, a model of user engagement in medical device development and evaluation has been tested.
Collapse
Affiliation(s)
- Patricia Grocott
- King's College London, Florence Nightingale School of Nursing and Midwifery, London SE1 8WA, UK.
| | | | | | | |
Collapse
|
12
|
Bolt LA, O'Sullivan G, Rajasingham D, Shennan A. A review of the obstetric management of patients with epidermolysis bullosa. Obstet Med 2010; 3:101-5. [PMID: 27579070 DOI: 10.1258/om.2010.100009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2010] [Indexed: 11/18/2022] Open
Abstract
Epidermolysis bullosa (EB) is a rare inherited skin condition characterized by the development of blisters after minor mechanical friction or trauma. There are few reported pregnancies in the literature in these women. We describe a pregnancy we recently managed. The collated series of pregnancies show that there are no additional antenatal or postnatal problems and that the skin itself does not worsen during pregnancy. Vaginal delivery is most favourable, but if a caesarean section is required, regional anaesthesia should be attempted. A multidisciplinary team should be active throughout the pregnancy of these women and a well-documented labour plan should be made in advance.
Collapse
Affiliation(s)
- L A Bolt
- Maternal and Fetal Research Unit, King's College London , Division of Reproduction and Endocrinology, St Thomas' Hospital, London , UK
| | - G O'Sullivan
- Departments of Obstetric Anaesthesia, St Thomas' Hospital , London , UK
| | - D Rajasingham
- Maternal and Fetal Research Unit, King's College London , Division of Reproduction and Endocrinology, St Thomas' Hospital, London , UK
| | - A Shennan
- Maternal and Fetal Research Unit, King's College London , Division of Reproduction and Endocrinology, St Thomas' Hospital, London , UK
| |
Collapse
|
13
|
Wagner JE, Ishida-Yamamoto A, McGrath JA, Hordinsky M, Keene DR, Woodley DT, Chen M, Riddle MJ, Osborn MJ, Lund T, Dolan M, Blazar BR, Tolar J. Bone marrow transplantation for recessive dystrophic epidermolysis bullosa. N Engl J Med 2010; 363:629-39. [PMID: 20818854 PMCID: PMC2967187 DOI: 10.1056/nejmoa0910501] [Citation(s) in RCA: 261] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Recessive dystrophic epidermolysis bullosa is an incurable, often fatal mucocutaneous blistering disease caused by mutations in COL7A1, the gene encoding type VII collagen (C7). On the basis of preclinical data showing biochemical correction and prolonged survival in col7 −/− mice, we hypothesized that allogeneic marrow contains stem cells capable of ameliorating the manifestations of recessive dystrophic epidermolysis bullosa in humans. METHODS Between October 2007 and August 2009, we treated seven children who had recessive dystrophic epidermolysis bullosa with immunomyeloablative chemotherapy and allogeneic stem-cell transplantation. We assessed C7 expression by means of immunofluorescence staining and used transmission electron microscopy to visualize anchoring fibrils. We measured chimerism by means of competitive polymerase-chain-reaction assay, and documented blister formation and wound healing with the use of digital photography. RESULTS One patient died of cardiomyopathy before transplantation. Of the remaining six patients, one had severe regimen-related cutaneous toxicity, with all having improved wound healing and a reduction in blister formation between 30 and 130 days after transplantation. We observed increased C7 deposition at the dermal-epidermal junction in five of the six recipients, albeit without normalization of anchoring fibrils. Five recipients were alive 130 to 799 days after transplantation; one died at 183 days as a consequence of graft rejection and infection. The six recipients had substantial proportions of donor cells in the skin, and none had detectable anti-C7 antibodies. CONCLUSIONS Increased C7 deposition and a sustained presence of donor cells were found in the skin of children with recessive dystrophic epidermolysis bullosa after allogeneic bone marrow transplantation. Further studies are needed to assess the long-term risks and benefits of such therapy in patients with this disorder. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT00478244.)
Collapse
Affiliation(s)
- John E Wagner
- Blood and Marrow Transplant Program, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Ly L, Su JC. Dressings used in epidermolysis bullosa blister wounds: a review. J Wound Care 2009; 17:482, 484-6, 488 passim. [PMID: 18978687 DOI: 10.12968/jowc.2008.17.11.31476] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
There is little rigorous evidence on the management of epidermolysis bullosa, so management is based on the patient's and clinician's preferences. However, there is a consensus that advanced dressings help promote healing and reduce pain.
Collapse
Affiliation(s)
- L Ly
- Western Hospital, Footscray, Victoria, Australia
| | | |
Collapse
|
15
|
Abercrombie EM, Mather CA, Hon J, Graham-King P, Pillay E. Recessive dystrophic epidermolysis bullosa. Part 2: care of the adult patient. ACTA ACUST UNITED AC 2008; 17:S6, S8, S10 passim. [PMID: 18521993 DOI: 10.12968/bjon.2008.17.sup3.28911] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
16
|
Stephen-Haynes J. Skin integrity and silicone: Appeel® ‘no-sting’ medical adhesive remover. ACTA ACUST UNITED AC 2008; 17:792-5. [DOI: 10.12968/bjon.2008.17.12.30312] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|