Hereditary epidermolysis bullosa: clinical-epidemiological profile of 278 patients at a tertiary hospital in São Paulo, Brazil

BACKGROUND

Epidermolysis bullosa (EB) is a group of rare hereditary diseases, characterized by fragility of the skin and mucous membranes. Epidemiological data on EB in Brazil are scarce.

OBJECTIVES

To describe epidemiological aspects of patients with EB diagnosed in the Dermatology Department of a tertiary hospital, from 2000 to 2022.

METHODS

An observational and retrospective study was conducted through the analysis of medical records. The evaluated data included clinical form, sex, family history, consanguinity, age at diagnosis, current age, time of follow-up, comorbidities, histopathology and immunomapping, presence of EB nevi and squamous cell carcinomas (SCC), cause of and age at death.

RESULTS

Of 309 patients with hereditary EB, 278 were included. The most common type was dystrophic EB (DEB), with 73% (28.4% dominant DEB, 31.7% recessive DEB and 12.9% pruriginous DEB). Other types were junctional EB with 9.4%, EB simplex with 16.5% and Kindler EB with 1.1%. Women accounted for 53% and men for 47% of cases. Family history was found in 35% and consanguinity in 11%. The mean age at diagnosis was 10.8 years and the current age was 26 years. The mean time of follow-up was nine years. Esophageal stenosis affected 14%, dental alterations affected 36%, malnutrition 13% and anemia 29%. During diagnostic investigation, 72.6% underwent histopathological examination and 92% underwent immunomapping. EB nevi were identified in 17%. Nine patients had SCC. Eleven patients died.

STUDY LIMITATIONS

Insufficient data included to medical records, loss to follow-up, and unavailability of genetic testing.

CONCLUSIONS

In this study, dystrophic EB predominated and the need for multidisciplinary care for comorbidities and complications was highlighted.

Oral health status in patients with inherited epidermolysis bullosa: a comparative multicenter study

OBJECTIVE

Epidermolysis bullosa (EB) is a rare genetic mucocutaneous disorder characterized by epithelial fragility leading to blister formation on skin and mucous membranes with even minor mechanical trauma. Most EB oral health publications give fragmented information, focusing on only one oral health aspect or one EB type. The aim of this study was to expand the knowledge of the overall oral health status of individuals with dystrophic, junctional, and simplex EB.

METHOD AND MATERIALS

A comparative multicenter study, including a control group, and based on questionnaires and clinical examinations, was undertaken in three EB expert centers.

RESULTS

Most EB (90.2%) participants brushed their teeth at least once a day despite the pain. The prevalence of enamel defects and caries experience did not differ between the 42 EB participants and the 42 age-/sex-matched healthy controls. Gingival inflammation unrelated to dental plaque accumulation was found in EB participants. Blisters, erythema, and erosion/ulceration mainly involved gingiva, buccal mucosa, lips, and palate, with different topographic patterns according to EB type. EB patients whatever the age showed a similar lesion distribution. Simplex and dystrophic EB patients under 12 years old displayed higher lesion severity than junctional EB ones. Only dystrophic type exhibited microstomia and ankyloglossia.

CONCLUSION

Oral health status seemed to benefit from a close collaboration between dental practitioner and dermatologist, and from regular dental examination, starting at a young age and with a focus on prevention. The new appreciation of oral health involvement highlighted by this study is essential for EB patients care, regarding comorbidities and quality of life.

Inherited epidermolysis bullosa: epidemiology and patient care in Slovenia with a review of the updated classification

INTRODUCTION

Inherited epidermolysis bullosa (EB) is a heterogeneous group of rare genetic skin disorders characterized by fragility of the skin and mucous membranes. The prevalence of all types of EB is estimated at approximately 11 per million, based on recent data from the American National Epidermolysis Bullosa Registry.

METHODS

A national registry of EB has not yet been established in Slovenia. Because all cases of EB are diagnosed and treated at our department, we have collected data on all known cases of EB in Slovenia.

RESULTS

Based on our data, the prevalence of all EB types in Slovenia is about 20 per million. As of December 2020, our data consist of 29 EB simplex, three junctional EB, 10 dominant dystrophic EB, and four recessive dystrophic EB patients.

CONCLUSIONS

The prevalence of all EB types in Slovenia is higher compared to the estimated prevalence in the United States. The multidisciplinary care of EB patients in Slovenia has been developed based on patients' needs, including a wide group of various specialists, and it has been adapted to the resources and treatment options available. This article also reviews the up-to-date classification and diagnostic protocol for EB, and international recommendations for interdisciplinary patient care.

Epidermolysis bullosa in German black headed mutton sheep

In three flocks, 13 pure- and 1 crossbred German black headed mutton lambs were ascertained which had clinical signs of epidermolysis bullosa (EB). The three farmers reported of further 20 affected lambs with similar signs in their flocks in the past lambing seasons. The affected lambs were progeny of six rams and 17 ewes. Two rams and six ewes with affected offspring from two farms were used for a breeding trial. In the course of these experimental matings, 21 lambs were born, six of which were affected by EB. All lambs born in this trial underwent clinical and haematological examination and all the affected lambs had to be euthanised due to severe and progressing clinical symptoms. Clinical examinations in 20 affected lambs revealed shedding of claw horn, erosions and ulcers of skin and mucous membranes. Histopathology showed subepidermal splitting and blistering with intact basal keratinocytes. These findings together with the premature death of affected lambs within the first two months of life made a Herlitz type of junctional EB most likely. The results of the test matings demonstrated the genetic transmission and indicated an autosomal recessive mode of inheritance for this lethal condition.

Epidermolysis bullosa care in Hungary

Hereditary EB is a rare skin disease that occurs worldwide and in all racial groups. There are currently 60 families affected and about 150 patients with EB under care in Hungary. The care of patients with EB in Hungary is discussed.

Epidermolysis bullosa care in Canada

Based on the described prevalence and size of the population, approximately 300 to 500 patients with epidermolysis bullosa (EB) reside in Canada. There are specific challenges faced by patients and families as well as the practitioners looking after patients with EB.

Genetic counseling in epidermolysis bullosa

This article contains the author's views on genetic counseling in cases concerning the epidermolysis bullosa syndromes. The provision of genetic counseling entails absolutes such as diagnosis, natural history, treatment, mode of inheritance, recurrence risks/prenatal diagnosis and referral. The genetic counselor needs to be informed and informative and answer all the needs of the patients and their families reliably both at the initial consultation and subsequently as needed over the course of the patient's life.

Inherited epidermolysis bullosa

Inherited epidermolysis bullosa (EB) encompasses a number of disorders characterized by recurrent blister formation as the result of structural fragility within the skin and selected other tissues. All types and subtypes of EB are rare; the overall incidence and prevalence of the disease within the United States is approximately 19 per one million live births and 8 per one million population, respectively. Clinical manifestations range widely, from localized blistering of the hands and feet to generalized blistering of the skin and oral cavity, and injury to many internal organs. Each EB subtype is known to arise from mutations within the genes encoding for several different proteins, each of which is intimately involved in the maintenance of keratinocyte structural stability or adhesion of the keratinocyte to the underlying dermis. EB is best diagnosed and subclassified by the collective findings obtained via detailed personal and family history, in concert with the results of immunofluorescence antigenic mapping, transmission electron microscopy, and in some cases, by DNA analysis. Optimal patient management requires a multidisciplinary approach, and revolves around the protection of susceptible tissues against trauma, use of sophisticated wound care dressings, aggressive nutritional support, and early medical or surgical interventions to correct whenever possible the extracutaneous complications. Prognosis varies considerably and is based on both EB subtype and the overall health of the patient.

Pyloric atresia associated with epidermolysis bullosa

We present 5 cases of pyloric atresia associated with junctional epidermolysis bullosa, from 2003 to 2005. Patients underwent laparatomy after stabilization. Four neonates had gastroduodenostomy, and the other had excision of membrane and pyloroplasty. Four survived and one died from fulminant septicemia. Although the association of pyloric atresia with epidermolysis bullosa has been reported to be fatal, our study showed good survival rate.

Tracheolaryngeal Complications of Inherited Epidermolysis Bullosa: Cumulative Experience of the National Epidermolysis Bullosa Registry

OBJECTIVES/HYPOTHESIS

To accurately determine the frequency with which complications arise in the ears, noses, and throats of patients with inherited epidermolysis bullosa (EB) as well as the cumulative risk of tracheolaryngeal stenosis or stricture.

STUDY DESIGN

Cross-sectional study (3,280 patients) with a nested, randomly sampled longitudinal subcohort (n=450), representing data collection, stratified by major EB subtype, of the National EB Registry, an epidemiologic project focused on enrolling all EB patients within the continental United States from 1986 to 2002, to permit generalization of findings to the entire American EB population.

METHODS

Systematic epidemiologic case finding and data collection were performed throughout the continental United States, followed by subclassification of patients by EB subtype. ENT complications were quantified via contingency tables (as frequencies) and lifetable analyses. Frequencies of surgical procedures were also determined.

RESULTS

The most important clinical ENT complication in inherited EB was tracheolaryngeal stenosis or stricture, arising during early childhood and primarily within infants and children with junctional EB (JEB) (cumulative risk of 39.8% and 12.8% in Herlitz and non-Herlitz JEB, respectively, by ages 6 and 9). Other uncommon complications included chronic otitis media, chronic otitis externa, and hearing loss.

CONCLUSIONS

Given the potential risk for sudden airway occlusion and death, meticulous surveillance by a pediatric otolaryngologist is a critical part of the overall management of infants and children with EB, especially those with JEB and two rare subtypes of generalized EB simplex. Elective tracheostomy should be considered in EB infants and children with evidence of airway embarrassment.

Epidermolysis bullosa: a genetic disease of altered cell adhesion and wound healing, and the possible clinical utility of topically applied thymosin beta4

Inherited epidermolysis bullosa (EB), having an overall incidence of only about 19 in every 1 million live births, encompasses many phenotypically and genotypically distinct diseases characterized by the presence of recurrent blisters, mechanical fragility of the skin and other epithelial structures (most notably the cornea and gastrointestinal tract), and scar formation. Each disease is the result of mutations within any of 10 specific structural proteins (keratins, laminins, collagens, integrins) within the basilar keratinocyte or the skin basement membrane zone. Two of the more severe subtypes, junctional and dystrophic EB, often involve many extracutaneous tissues. If severe, these conditions may be life threatening. Recent studies in wounds that had been artificially induced on normal skin, both in rodents and in human volunteers, have suggested that thymosin beta4 may be effective in promoting epithelial migration across the wounds. A randomized double-blind clinical trial has been recently organized to determine whether this novel biologic agent may be beneficial in promoting wound healing in patients with junctional and dystrophic EB. To do so, a solitary noninfected cutaneous wound of standardized size will be treated topically on a daily basis with either one of three concentrations of thymosin beta4 or a placebo control. Serial wound healing will be quantitated by computerized digital-imaging technique. At the same time, the occurrence of adverse effects will be sought, so as to confirm the safety of thymosin beta4 when applied to EB skin, both in children and in adults. Although as yet unproven, topically applied thymosin beta4 may prove to be an extremely important addition to the overall management of patients with this potentially devastating disease.

The management of general and disease specific ENT problems in children with Epidermolysis Bullosa--a retrospective case note review

OBJECTIVE

Epidermolysis Bullosa encompasses a group of inherited disorders characterized by excessive susceptibility of the skin and mucosa to separate from underlying tissues following mechanical trauma. Information in the literature and guidance on the management of Ear, Nose and Throat problems in such children is scarce. The aim of this study is to report the experience of an Ear, Nose and Throat department in a tertiary paediatric hospital linked to a national Epidermolysis Bullosa unit, describing how children have presented and the care that has been given including a theatre protocol aimed at reducing shearing forces.

METHODS

Retrospective case note review of Epidermolysis Bullosa patients referred to Otolaryngology over an 8-year period.

RESULTS

Reviewing notes of 307 EB patients identified 15 that had been referred to the ENT department. Four children with middle ear effusions were effectively treated by watchful waiting or grommets. Three children with otitis externa had some relief from careful microsuction but reinfection from ulcers on other parts of the children's bodies tended to occur. One child with profound sensorineural hearing loss benefited from cochlear implantation but later passed away from unrelated sepsis. One child with intrinsic rhinitis was treated with steroid and then a salt-water nasal spray. Five children had nasal crusting documented, although this was not a specific reason for referral. When severe this had been treated with topical steroids by the dermatology team. One patient with obstructive sleep aponea had tonsillectomy and examination of the post-nasal space. Of the five patients referred with glottic or supraglottic scarring, the management of four included a tracheostomy. When carried out tracheostomy sites healed well in each case. With repeated endoscopic procedures it was subsequently possible to remove the tracheostomy in the two of the children. Using a special theatre protocol no new ulcers were recorded as being precipitated by any of the procedures children underwent.

CONCLUSIONS

Optimal management depends on the support of a multidisciplinary team, including otolaryngologists, pediatricians, dermatologists, anaesthetists, and specialist nurses. Adherence to a protocol for theatre management can help avoid intraoperative complications.

Molecular epidemiology of hereditary epidermolysis bullosa in a Middle Eastern population

Epidermolysis bullosa (EB) encompasses a large group of inherited blistering skin disorders caused by mutations in at least 10 genes. Numerous studies, mainly performed in European and US families with EB, have revealed a number of characteristic epidemiological and genetic features, which form the basis for current diagnostic and counseling strategies. However, little is currently known about the molecular epidemiology of EB in Middle East populations. In the present study, we assessed 55 EB families for pathogenic sequence alterations in the 10 genes known to be associated with EB. Our results show unique EB subtype distribution and patterns of inheritance in our cohort. We also failed to detect recurrent mutations frequently encountered in Europe and the US, and did not consistently observe genotype-phenotype correlations formerly established in Western populations. Thus, the molecular epidemiology of EB in the Middle East is significantly different from that previously delineated in Europe and the US. Our data raise the possibility that similar differences may also be found in other genetically heterogeneous groups of disorders, and indicate the need for population-specific diagnostic and management approaches.

Artificial skin as a valuable adjunct to surgical treatment of a large squamous cell carcinoma in a patient with epidermolysis bullosa

BACKGROUND

Among tissue-engineered skins, two bilayered cellular constructs and one cryopreserved dermal substitute have been approved for the treatment of epidermolysis bullosa. Nevertheless, the application of artificial skin technology to surgical treatment of squamous cell carcinomas in a patient with epidermolysis bullosa has never been reported.

OBJECTIVE

To reconstruct the large defect remaining after squamous cell carcinoma excision in a patient with dominantly inherited dystrophic epidermolysis bullosa.

METHODS

To apply a 10 x 15 cm Integra sheet (Integral Life-sciences Corporation, Plainsboro, NJ, USA) (an acellular collagen matrix coated with a thin polysiloxane elastomer) to the excised area and 3 weeks later to cover the Integra sheet with an ultrathin meshed skin graft.

RESULTS

The graft take was complete, and the donor site totally regenerated, except for three small bullae at 7 weeks postoperatively.

CONCLUSION

Integra offers the advantage of filling huge defects with its dermal layer of collagen fibers and provides an optimal graft bed. This first step makes it possible to use very thin grafts 3 weeks later.

[Hereditary epidermolysis bullosa in Tunisia: an epidemio-clinical and ultrastructural study]

Hereditary epidermolysis bullosa (EB) are a group of genodermatoses whose common primary feature is formation of blisters following minor trauma. The aim of the present study was to assess epidemiological, clinical, genetical and histological particularities of patients with hereditary epidermolysis bullosa.

Quality of life in epidermolysis bullosa

The quality of life of people with epidermolysis bullosa (EB) living in Scotland was assessed by postal questionnaire using the Dermatology Life Quality Index (DLQI) and the Children's Dermatology Life Quality Index (CDLQI). There were 143 people with EB simplex (EBS) and 99 individuals with non-Hallopeau--Siemens subtypes of dystrophic EB (DEB). A further six individuals had the severe Hallopeau--Siemens subtype of DEB (RDEB-HS). The overall response was 48% (EBS 52%, DEB 40% and RDEB-HS 83%). Impairment of quality of life (QOL) was greatest in those with RDEB-HS, mean scores (adults, 18; children, 22) exceeding those of any skin disorder previously assessed. The effect on QOL of EBS and other subtypes of DEB was similar to that of moderately severe psoriasis and eczema. EBS had a greater impact on QOL than the non-Hallopeau--Siemens subtypes of DEB (EBS adults mean score, 10.7; EBS children mean score, 15; DEB adults mean score, 7.5; DEB children mean score, 11.5).

Epidermolysis bullosa: scientific advances and therapeutic challenges

Epidermolvsis bullosa (EB) is a heterogeneous group of inherited skin fragility and blistering disorders. Over the last 25 years research in EB has progressed from descriptive morphological studies through quantitative ultrastructural and biochemical analysis to molecular genetic approaches, including linkage analysis, gene cloning and sequencing, and mutation screening. Currently, 10 distinct causative genes are known to underlie different forms of EB, and this knowledge has been translated to improving the clinical management of patients with these disorders. For example, first trimester DNA-based prenatal diagnosis is now available in a number of centres in different countries, including Japan, the USA and the UK, and preimplantation genetic diagnosis is also possible. The development of novel forms of treatment for enhancing wound healing and reducing blistering are the subject of an international research effort. Programmes aimed at developing gene therapy for the major forms of EB have already reached the preclinical testing stages. Despite these impressive scientific advances, EB continues to be a devastating disease, in which the high incidence of aggressive squamous cell carcinoma has a major influence on both morbidity and life expectancy, especially in patients with the severe mutilating form of dystrophic EB.

Pyloric atresia: five new cases, a new association, and a review of the literature with guidelines

BACKGROUND/PURPOSE

Pyloric atresia is an uncommon condition occurring in 1 of 100,000 live births. When occurring in isolation, the clinical course usually is uncomplicated after surgical treatment. However, it may occur in association with other congenital abnormalities. The authors present 5 new cases, 3 of associated abnormalities including 1 of esophageal atresia and 2 of agenesis of the gall bladder and malrotation. Agenesis of the gall bladder has not been described previously in combination with pyloric atresia. The literature has been reviewed and guidelines are suggested for the management.

METHODS

The case records of 4 neonates who presented to the author's institution between January 1998 and June 1999 and 1 who presented at another center in 1991 were reviewed. A Medline literature search was performed, and guidelines were developed for the management of this condition based on our cases and the literature review.

RESULTS

Patients 1 and 5 had no associated anomalies. Patient 2 had associated esophageal atresia, tracheoesophageal fistula, atrial septal defect, crossed renal ectopia, malrotation, and absent gall bladder. Patient 3 had a rectovestibular fistula, vaginal atresia, atrial septal defect, malrotation absent gallbladder, and absent extrahepatic portal vein. Patient 4 had epidermolysis bullosa. Patients 2 and 5 had unremarkable recoveries, patients 2 and 3 had markedly delayed gastric emptying that responded to cisapride. Patient 3 has portal hypertension and remains under close follow-up. Patient 4 died at 22 days of age of pseudomonas sepsis.

CONCLUSIONS

Based on our cases and literature review, we have adopted the following guidelines: (1) All children with pyloric atresia should be screened for multiple anomalies. (2) Delayed gastric emptying should be considered early and may respond to prokinetic agents. (3) Association with Epidermolysis bullosa should not preclude surgical treatment. (4) A skin biopsy specimen should be taken at the time of surgery for electron microscopy if there is a family history of epidermolysis bullosa.

[Epidermolysis bullosa]

The epidermolysis bullosa are a group of genodermatoses in which there is congenital fragility of the skin which produce blisters with the least of traumas. The group includes up to thirty clinical-genetical entities. They are classified according to the level where the blister is found into simplex or epidermolytic (intraepitelial blister), junctional (blister in the dermoepidermal junction) and dystrophic or dermolytic (subepidermal blister) epidermolysis bullosa. The symptoms, classic or Mendelian genetics and the recent findings in the most frequent forms of each one of these groups are reviewed. In most of them, the gene that produces the mutations and the chromosome in which its locus is found are known. In the simplex forms, the disorders lies in the genes that codify the different keratins. In the junctional ones, mutations are found in the laminin genes that act in the development of the anchoring filaments or in those of the other components of the basement membrane. In the dystrophic ones, which are the most serious, the mutations affect the collagen VII gene that codify the development of the anchoring fibrils. There is no treatment for any of the forms of epidermolysis bullosa. It is possible that the future advances in genetic engineering can contribute to their prophylaxis.

Mutations in keratin K9 in kindreds with epidermolytic palmoplantar keratoderma and epidemiology in Northern Ireland

Epidermolytic palmoplantar keratoderma (EPPK, MIM #144200) is an autosomal dominant disorder in which hyperkeratosis confined to the palms and soles is characterized histologically by cytolysis of suprabasal keratinocytes. Mutations in the keratin 9 gene (KRT9), a type 1 keratin expressed exclusively in the suprabasal keratinocytes of palmoplantar epidermis, have previously been demonstrated in this disorder. Here, we have studied four Northern Irish kindreds presenting with EPPK. By direct sequencing of polymerase chain reaction products, heterozygous missense mutations in exon 1 of KRT9 were detected in all the families. These included a novel mutation M156T; as well as M156V in two kindreds; and R162Q in the remaining family. All mutations were confirmed by reverse strand sequencing and restriction enzyme analysis. The point prevalence of EPPK in Northern Ireland was found to be 4.4 per 100,000. To date, all reported EPPK mutations occur in the helix initiation motif at the start of the central coiled-coil rod domain of K9.

[Bullous IgA linear dermatosis of children in Mali]

INTRODUCTION

Bullous IgA linear dermatosis is relatively frequent in children in Africa. The aim of this study was to evaluate the frequency of this disease among autoimmune bullous diseases in children in Mali.

PATIENTS AND METHODS

Children with chronic bullous disease seen at the Marchoux Institute in Bamako and for whom direct immunofluorescence of the perilesional skin demonstrated immunoglobulin and/or complement deposits were included in the study population.

RESULTS

Twelve children were included. Direct immunofluorescence showed linear IgA deposit along the dermo-epidermal junction in 10, once with a pemphigoid aspect and once with a pemphigus aspect. The skin lesions in the children with linear IgA deposits were stereotypic: disseminated bullae, rosettes (9 out of 10), involving the external genital organs (10/10), the limbs, the face and the trunk. Histology showed subepidermal bullae (10/10), with neutrophil papillar abscesses (9/10). Indirect immunofluorescence of the cleaved skin NaCl in 5 patients showed that the cleavage always lied at the roof of the cleavage. All the children responded to dapsone (1 to 2.5 mg/kg/d) which gave complete (7/10), or incomplete remission. Local corticosteroids were used in 2 patients and general corticosteroids in 1.

DISCUSSION

This confirms the frequency of bullous IgA linear dermatosis in Africa, in contrast with uncommon dermatitis herpetiformis. Diagnosis is facilitated with immunofluorescence. The low cost of this test makes it a useful diagnostic tool in these countries.

The prevalence of epidermolysis bullosa in Scotland

The prevalence of epidermolysis bullosa (EB) in Britain and most other countries is unknown. Patients suffering from the inherited forms of EB and living in Scotland have been traced. Two hundred and fifty-nine affected people from 76 families have been identified, of whom 211 were clinically assessed. One-third of these Scottish EB sufferers had never been seen by a dermatologist. In Lothian, where there appears to be a relatively high prevalence of EB, 75% of patients were unknown to their general practitioners. The point prevalence of all forms of EB at the outset of the study was 49.0 per million, comprising EB simplex 28.6 per million and dystrophic EB 20.4 per million. Extrapolation of accurate data available for the Lothians suggests that the point prevalence of all forms of EB in Scotland is in excess of these figures.

Epidermolysis bullosa. Application of epidemiologic principles to the study of a group of rare diseases via a disease registry

The study of rare diseases may provide unique insights into new mechanisms of disease. Such research is difficult to perform, however, owing to a variety of problems associated with patient recruitment and classification, and the biases that are frequently associated with the study of rare diseases. Despite its many limitations, establishment of disease registries may facilitate this research, as evidenced by the depth and breadth of findings recently obtained in inherited epidermolysis bullosa via such a mechanism.

International symposium on epidermolysis bullosa. The William and Ida Friday Continuing Education Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, April 25-26, 1994. Abstracts

An international symposium on inherited epidermolysis bullosa was held at the University of North Carolina at Chapel Hill on April 25-26, 1994. All areas currently of clinical and research interest pertinent to this disease were discussed, ranging from basic epidemiologic issues to the definition of molecular defects in each of the three major types of epidermolysis bullosa and the potential for gene therapy. A major focus of this meeting was the presentation of data collected by the National Epidermolysis Bullosa Registry.

Dental caries risk in hereditary epidermolysis bullosa

Epidermolysis bullosa (EB) is a clinically diverse group of conditions characterized by skin fragility and, in certain types, marked dental involvement. The purpose of this study was to determine the prevalence of dental caries in EB and control populations. Healthy individuals and participants from the Southern Clinical Center of the National EB Registry were examined with artificial light and a #23 dental explorer. Caries levels were evaluated by chi-square analysis, regression analyses, and ANOVA (P < 0.05 being significant). The study included 252 individuals with EB, aged 2.3-71 years, and 57 similarly aged controls. The prevalence of dental caries, scored as DMFS (decayed, missing, filled surfaces), was significantly higher in the junctional (mean = 58.6) and recessive dystrophic (mean = 37.6) EB types than controls (mean = 23.2). The simplex (mean = 25.6) and dominant dystrophic (mean = 21.6) EB groups had DMFS levels similar to the control group. Individuals with recessive dystrophic EB had the most severe oral blistering and scarring and did not have generalized enamel hypoplasia. In contrast, junctional EB always was associated with generalized enamel hypoplasia yet the intraoral blistering rarely involved scarring. This study shows that dental caries is increased in dystrophic and junctional EB compared with unaffected individuals or other EB types. While rampant caries appears related to the soft tissue and enamel involvement in these two EB types, other as yet unclear cofactors also must be involved.

The National Epidermolysis Bullosa Registry

Since its inception in 1986, the NEBR has proved to be an excellent example of how a relatively small allocation of federal research funds for the development of a registry of cases of a single rare disease can have a major impact on the rapid expansion in the depth of knowledge of not only the disease itself but of a number of associated biologic principles, including keratinization and epithelial cell-extracellular matrix interactions. At present, the NEBR is generating extensive clinical, laboratory, and demographic data, both from cross-sectional and longitudinal perspectives, as well as establishing a centralized cell and tissue bank that will serve the scientific community at large as a valuable resource for future basic research on this oftentimes devastating genetic disease.

Epidermolysis bullosa in the eastern province of Saudi Arabia

BACKGROUND

Epidermolysis bullosa is recognized to be rare, but its prevalence in the Eastern Province of Saudi Arabia had not been previously established.

METHODS

We reviewed 49,902 dermatology cases seen in our clinic over a 7-year period (1984 through 1990) and carried out a therapeutic trial of oral phenytoin in three severe cases of epidermolysis bullosa dystrophica (Recessive dystrophic type).

RESULTS

Sixteen cases of epidermolysis bullosa were found in this series, ten (62.5%) of which were of the dermolytic type (epidermolysis bullosa dystrophica), and four (25%) of the epidermolytic type (epidermolysis bullosa simplex). Parental consanguinity was established in fourteen (87.5%) of these cases. All ten cases of epidermolysis bullosa dystrophica developed complications. Three severe cases were treated with oral phenytoin and managed with meticulous nursing and nutrition with blended foods and protein and vitamin supplements and responded satisfactorily.

CONCLUSIONS

This study confirmed the rarity of epidermolysis bullosa in this province (population 3,000,000), and demonstrated the usefulness of oral phenytoin therapy, meticulous nursing, and good nutrition in the management of epidermolysis bullosa dystrophica.

The cellular and molecular biology of keratins: beginning a new era

The past year has been extremely fruitful for research on intermediate filaments in general, and keratins in particular. Unprecedented progress has been made in our understanding of the structural requirements for keratin filament assembly and network formation, the dynamism characterizing keratin filaments, their function, and implication in human genetic disorders primarily affecting the skin. These exciting findings have several implications for future research.

Epidermolysis bullosa in Northern Ireland

Cases of epidermolysis bullosa (EB) diagnosed in Northern Ireland during a 23-year period (1962-84) were identified from dermatology clinic files, paediatric hospital notes and cases known by general practitioners. A total of 48 confirmed new cases of EB were diagnosed during the screening period. This involved 31 families, with identification of 36 further cases. The distribution of incident EB subtypes was: simplex 31 (65%), junctional 1 (2%), dystrophic 12 (25%) and acquisita 4 (8%). The incidence rate of new cases of EB diagnosed per year is 1.4/million and prevalence of all forms estimated at 32/million. The prevalence of simplex, junctional and dystrophic forms is 28, 0.7 and 3/million, respectively.

Prevalence of congenital anomaly syndromes in a Spanish gypsy population

We analysed the sample of gypsies included in the Spanish Collaborative Study of Congenital Malformations (ECEMC), a hospital based, case-control study and surveillance system. Special emphasis was placed on the birth prevalence of recessive multiple congenital anomaly syndromes, comparing their frequency in the gypsy population with that observed among non-gypsies. We observed an increased prevalence of birth defects, mostly because of groups of children with patterns of multiple anomalies and with autosomal recessive syndromes. The latter were approximately seven times more frequent in gypsies than in non-gypsies. We also estimated the carrier frequency in both groups (gypsy and non-gypsy). We consider that the frequent occurrence of the conditions observed reflects the high rate of consanguineous couples among the Spanish gypsy population.

Occurrence of hereditary bullous epidermolyses in Croatia

To determine the occurrence of hereditary bullous epidermolyses (EB) in Croatia, Yugoslavia, from 1960 to 1987, cases were gathered from the hospital files of dermatologic and pediatric clinics and departments throughout the area. The diagnosis of EB type was made on the basis of clinical features, patients' histories, and light microscopy and electron microscopy findings. Fifty families with 58 patients were registered; 44 patients were examined personally by one of the authors. The most frequent type of EB in Croatia was recessive dystrophic EB Hallopeau-Siemens, occurring in 35 of the 58 individuals. Regional accumulation of cases within the Varazdin area was noted (13 patients). Prevalence of EB in Croatia is 0.956 cases per 100,000 inhabitants. One case of recessive dystrophic EB Hallopeau-Siemens occurred in about every 52,000 live births.

Epidermolysis bullosa acquisita. Incidence in patients with basement membrane zone antibodies

We examined the incidence of epidermolysis bullosa acquisita in patients with circulating basement membrane zone antibodies. Serum samples from 100 sequential patients with basement membrane zone antibodies were tested by indirect immunofluorescence against 1 mol/L sodium chloride split skin and by Western immunoblot against epidermal and dermal extracts of skin. Ninety-two (92%) serum samples stained only the epidermal side of split skin, 5 (5%) stained only the dermal side, and 3 (3%) stained both sides. Four of the 5 serum samples with dermal staining but none of the serum samples with epidermal or combined staining reacted with the 290-kd epidermolysis bullosa acquisita antigen by Western immunoblot. These results indicate that approximately 5% of unselected patients with basement membrane zone antibodies have epidermolysis bullosa acquisita or bullous lupus erythematosus rather than bullous pemphigoid.

[A study on the estimation of prevalence of epidermolysis bullosa in Japan]

An estimation of the prevalence of epidermolysis bullosa was carried out in Japan. A questionnaire was sent by mail to the departments of dermatology and pediatrics in 644 main hospitals throughout Japan requesting confirmation of the number of epidermolysis bullosa cases experienced. The response rate was 63.0% or 406 hospitals. Based on the secondary questionnaire survey, we confirmed 393 cases of epidermolysis bullosa, and then divided them into the five following groups: "simplex" type 182 (48.2%), "junctional" type 23 (6.0%), "dominant dystrophic" type 72 (18.7%), "recessive dystrophic" type 109 (28.2%), unclassified 7 (1.8%). Using the respondent rate by geographic region and clinical department, the estimated prevalence of each type of epidermolysis bullosa was calculated as follows: "simplex" type 340-470 (0.29-0.40 per 100,000 population), "junctional" type 18-24 (0.015-0.020), "dominant dystrophic" type 130-180 (0.11-0.15) and "recessive dystrophic" type 180-250 (0.15-0.21). The total number of epidermolysis bullosa patients in Japan was estimated as being more than 670 in 1983.

[Hereditary epidermolysis bullosa. Epidemiology and clinical classification of 23 cases]

The authors report 23 cases of hereditary epidermolysis bullosa (EB). An attempt has been made to classify them. It was based only on the clinical and genetic criteria. The EB simplex has been found in 14 patients, 5 cases were of the Köbner type. The other 9 cases were of the Cockayne-Weber type. EB dystrophica was isolated in 9 cases, 7 cases of which were carriers of the Hallopeau-Siemens form, one case of the pretibial form and one case of Bart syndrome. The frequencies obtained are largely above the values reported in the literature.

The generalized atrophic benign form of junctional epidermolysis bullosa. Experience with four patients in the United States

We encountered four patients in the United States with the generalized atrophic benign form of junctional epidermolysis bullosa (epidermolysis bullosa atrophicans generalisata mitis, nonlethal junctional epidermolysis bullosa). Prior to the performance of definitive diagnostic studies, each patient had been thought for at least a decade to have either a dystrophic or simplex form of epidermolysis bullosa. Each patient had generalized blisters since birth that healed with atrophy and mild scarring but without milia or contractures. Two of the four patients had experienced laryngeal involvement during childhood. In each patient, correct diagnosis was finally established by either electron microscopic examination or immunofluorescence mapping of skin sections from induced blisters.

A study of the linkage relations of epidermolysis bullosa dystrophica

Two large families from the Faroe Islands presenting epidermolysis bullosa of the dystrophic type were subjected to extensive linkage analyses with 22 serological markers. No significant evidence in support of linkage with any of these loci was provided. It was found to be very unlikely that the gene or genes causing the present types of epidermolysis bullosa belong to the EBS1 locus known to be closely linked to the GPT locus.