Inherited epidermolysis bullosa dystrophica and squamous cell carcinoma- A case report.

Epidermolysis bullosa dystrophica (EBD) is an inherited disease of the structural proteins in the upper dermis, characterized by blister formation at the site of trauma followed by scarring. Skin fragility and blistering are the hallmarks of this disease. Cutaneous squamous cell carcinoma (cSCC) is a dreadful complication in the epidermolysis bullosa (EB) patients and common cause of death. The recent advances in distinct tumor microenvironment explain the aggressive nature of SCC in recessive Recessive Dystrophic Epidermolysis Bullosa (RDEB) patients and the use of collagen VII re-expression as a possible therapeutic measure. Regular follow-up is a must in preventing complications.

Case Report: Diagnostic and Therapeutic Challenges in Severe Mechanobullous Epidermolysis Bullosa Acquisita.

Collagen VII is the main constituent of the anchoring fibrils, important adhesive structures that attach the epidermis to the dermal extracellular matrix. Two disorders are caused by dysfunction of collagen VII, both characterized by skin and mucosa fragility, epidermolysis bullosa acquisita (EBA) and dystrophic epidermolysis bullosa (DEB). EBA and DEB share high clinical similarities with significant difference in patients' age of onset and pathogenesis. Our patients presented with severe and recalcitrant mechanobullous EBA with characteristic DIF, IIF and ELISA diagnostics. But in both women recessive COL7A1 variants were also found, in a monoallelic state. Collagen VII from EBA keratinocytes of our cases was significantly more vulnerable to proteolytic degradation than control keratinocytes, hinting that the heterozygous pathogenic variants were sufficient to destabilize the molecule in vitro. Thus, even if the amount and functionality of mutant and normal type VII collagen polypeptides is sufficient to assure dermal-epidermal adhesion in healthy individuals, the functionally-impaired proteins are probably more prone to development of autoantibodies against them. Our work suggests that testing for COL7A1 genetic variants should be considered in patients with EBA, which either have a patient history hinting towards underlying dystrophic epidermolysis bullosa or pose therapeutic challenges.

Generation of the induced pluripotent stem cell line (ZSPHARi001-A) from a patient with recessive dystrophic epidermolysis bullosa carrying compound heterozygous mutation in the COL7A1 gene.

The COL7A1 gene mutation causes type VII collagen dysfunction, which subsequently leads to recessive dystrophic epidermolysis bullosa (RDEB). Patients who suffer from RDEB experience severe blisters and chronic trauma, which can eventually result in serious infection and the development of fatal squamous cell carcinoma. In our study, peripheral blood mononuclear cells (PBMCs) from an RDEB patient with the COL7A1 compound heterozygous mutation were collected and then reprogrammed into induced pluripotent stem cells (iPSC). The RDEB iPSC line can provide a cellular resource for the study of pathogenesis and drug screening.

[Wound therapy with cold atmospheric plasma in severe recessive dystrophic epidermolysis bullosa : A pilot study]. / Wundtherapie mit kaltem Plasma bei Epidermolysis bullosa dystrophica : Eine Pilotuntersuchung.

BACKGROUND: Cold atmospheric pressure plasma (CAP) has antimicrobial and wound-healing properties. Patients affected by severe autosomal recessive dystrophic epidermolysis bullosa (RDEB) suffer from widespread, difficult-to-treat wounds, which require complex wound management. OBJECTIVE: In a pilot project, we investigated over a period of 5 months the response and tolerability of a CAP wound therapy in a 21-year-old and a 28-year-old female patient with severe generalized RDEB and following cutaneous squamous cell cancer (cSSC) in the older patient. MATERIALS AND METHODS: In both patients, diagnosis of RDEB was confirmed by molecular genetics. Individual- and patient-specific wound therapy was continued during the study period, and additionally CAP therapy with a dielectric barrier discharge (DBE) device was initiated. CAP treatment was performed for 90 s per wound and could be applied every day or every other day. Clinical evaluation included photographic documentation and regular interviews of patients and parents. RESULTS: CAP-treated wounds largely demonstrated improved wound healing and signs of a reduced bacterial contamination. Furthermore, CAP proved to prevent wound chronification. When applied on a polyester mesh, it was well-tolerated on most body sites. CONCLUSION: The introduction of CAP could improve the wound management of EB patients and should be evaluated in clinical studies. The effect of CAP on cSSC development should be particularly studied.

The clinical efficacy and safety of anti-IgE therapy in recessive dystrophic epidermolysis bullosa.

The treatment of recessive dystrophic epidermolysis bullosa (RDEB) remains challenging. Elevated IgE levels have previously been reported in several RDEB patients. In this prospective, single-centre, open intervention study, elevated IgE levels were seen in 11 out of 12 patients with intense pruritus, and the patients with elevated IgE levels received anti-IgE therapy every 4 weeks for at least three cycles. Compared with the baseline, 10 patients with RDEB had good clinical outcomes with enhanced wound healing, a reduction in Birmingham (epidermolysis bullosa) EB severity score by 15%, a reduction in affected body surface area by 23.3%, amelioration of skin inflammation, and an increase in type VII collagen deposition by 13.1-fold. All the patients had a good tolerance to anti-IgE therapy. Furthermore, patients with higher IgE levels tended to have higher disease severity and more favorable clinical outcomes. Our report also suggested the potential role of IgE in the pathogenesis of inflammatory conditions associated with RDEB. (ChiCTR1900021437).

Epidermolysis Bullosa: Pediatric Perspectives.

Epidermolysis bullosa (EB) is a group of rare congenital genetic conditions that result in painful blistering of the skin and mucous membranes, which occur with minor trauma or friction. There are many types and subtypes of EB that need to be distinguished, as the management and prognosis of each can vary significantly. We aim to perform an up-to-date literature review on congenital EB for healthcare providers in pediatrics. We performed a review of existing literature in the English language on EB via PubMed Clinical Queries, using key words such as "epidermolysis bullosa", "congenital" and "children". We reviewed EB based on the following subheadings: epidemiology, diagnosis, therapy, prognosis, and clinical prediction guidelines. EB is due to mutation in a number of genes, some types are autosomal dominant while others are autosomal recessive. The underlying mechanism is a defect in attachment between or within the epidermis and dermis of the skin. There are four main types: epidermolysis bullosa simplex, dystrophic epidermolysis bullosa, junctional epidermolysis bullosa, and Kindler syndrome. The diagnosis is suspected based on symptoms and confirmed by skin biopsy and definitive genetic testing. The severity of EB can range from mild to fatal. Severe complications may arise in some EB types and subtypes within the eye, ear, nose, upper airway, gastrointestinal and genitourinary tracts. There is no cure for the condition to date. Optimal management must be multidisciplinary, and involves wound care, pain control, controlling infections, nutritional support, and prevention and treatment of complications. EB presents in different forms. Treatment is supportive. The prognosis of milder forms is good. Children severely affected with EB and their families live a misery life with impaired quality of life. Health care workers must be aware of the suffering in these families and proactively support them.

Cutaneous Squamous Cell Carcinoma in Epidermolysis Bullosa: a 28-year Retrospective Study.

Epidermolysis bullosa (EB), notably severe recessive dystrophic EB (RDEB-S), is associated with increased risk of aggressive mucocutaneous squamous cell carcinomas, the major cause of mortality in early adulthood. This observational, retrospective case review describes a series of EB patients with cutaneous squamous cell carcinomas over a 28-year period. Forty-four EB patients with squamous cell carcinomas were identified with a total of 221 primary tumours. They comprised: 31 (70%) with RDEB-S, 4 (9%) with other RDEB subtypes, 5 (11.4%) with dominant dystrophic EB, 3 (6.8%) with intermediate junctional EB and 1 (2.3%) with Kindler EB. Squamous cell carcinomas occurred earlier in RDEB-S (median age 29.5 years; age range 13-52 years) than other groups collectively (median age 47.1 years; age range 30-89 years) and most had multiple tumours (mean 5.8; range 1-44). Squamous cell carcinoma-associated mortality was high in RDEB-S (64.5%), with median survival after first squamous cell carcinoma of 2.4 years (range 0.5-12.6 years), significantly lower than previous reports, highlighting the need for early surveillance and better treatments.

Epidermolysis bullosa dystrophica pretibialis - Clinical snapshot and management of a rare orphan disease.

If blistering occurs in childhood, the possibility of hereditary epidermolysis bullosa should be considered even if the symptoms are mild. Besides clinical and histological examination, molecular genetic screening is diagnostically relevant. For localized forms, symptomatic, topical therapy options are currently still the primary choice. Of particular interest is the new option of topical therapy with diacerein 1 % cream. In the case of a pronounced clinical picture with extracutaneous organ involvement, multidisciplinary management is required. In the future, new forms of therapy such as autologous epidermal stem cell transplantation and gene therapeutic procedures may be applied. Human genetic counselling is indispensable.

A Case Report of an Infant with Autosomal Recessive Dystrophic Epidermolysis Bullosa: COL7A1 Gene Mutations at C2005T and G7922A.

A male infant was born by spontaneous delivery on February 7, 2020, with a gestational age of 40 weeks and a birth weight of 4.1 kg. After birth, the infant presented with appearance of skin loss on the bilateral lower limbs, feet, left wrist, face, and lips. Large areas of skin defects, erosion, and exudation were noted on the extensor side of the bilateral lower limbs and feet, and some skin loss with a small amount of exudation was observed on the left wrist, face, and lips, which was accompanied by dorsal hyperextension of the right foot and oral mucosal ulceration (Figure 1). Because the parents refused invasive examinations (skin biopsy, i.e., transmission electron microscopy and immunofluorescence examination (1)) and the child was hospitalized in a period during which the strictest prevention and control measures for novel coronavirus pneumonia were enacted, the hospital canceled the invasive examinations; therefore, skin biopsy was not performed. The infant's parents were healthy and nonconsanguineous. They reported that neither of them had skin defects at birth. They also denied nail dystrophy or complete absence of the nail and a history of recurrent oral herpes or ulcers, and no other family members had such symptoms. The mother had multiple scheduled prenatal examinations during the pregnancy, and the sick infant delivered via natural birth was her first child. She did not have a history of previous miscarriage and underwent a thyroid function test and ultrasound B-mode examinations, which did not show obvious abnormalities. Ultrasound B-mode examination in the second trimester suggested bilateral renal sinus separation and excessive dorsiflexion of both feet of the fetus. A nuchal translucency (NT) scan, a noninvasive prenatal DNA test, and an oral glucose tolerance test (OGTT) showed no significant abnormalities. Ultrasound B-mode findings indicated that the infant had congenital dysplasia, suggesting that he may have a genetic disease. In a subsequent genetic test, compound heterozygous variations of c.C2005T (the nucleotide at position 2005 in the coding region was mutated from C to T) and c.G7922A (the nucleotide at position 7922 in the coding region was mutated from G to A) were detected in the child's collagen type VII alpha 1 chain (COL7A1) gene, and the mutations were from the child's parents' genes (Table 1). The COL7A1 gene is a well-established causative gene for autosomal recessive dystrophic epidermolysis bullosa. Based on these results, COL7A1 gene mutations may have been the cause of the disease in the child; thus, the child was definitively diagnosed with autosomal recessive dystrophic epidermolysis bullosa. CASE REPORT After admission, the child received aggressive nutritional support. For treatment, cefmetazole was given for anti-infection, aseptic dressings were applied on the body surface with skin defects, iodophor disinfection was carried out, recombinant human epidermal growth factor gel and chlortetracycline eye ointment were applied externally, petrolatum was used to cover the skin defects, sterile gauze was used to wrap the lesions, and the dressings were changed daily or every other day. The wounds were kept dry, prolonged compression was avoided, and secondary bacterial infection was actively prevented and treated symptomatically as necessary. At discharge, the child's vital signs were stable, some epidermal defects were visible on the extensor side of the bilateral lower limbs, feet, and left wrist as well as on the face and lips with reduced exudation, and fresh epidermal coverage was observed (Figure 2). DISCUSSION Congenital epidermolysis bullosa must be differentiated from other diseases such as staphylococcal scalded skin syndrome (SSSS), neonatal impetigo, congenital bullous ichthyosiform erythroderma, congenital syphilis, and neonatal herpes simplex. Among these diseases, SSSS is a severe acute generalized exfoliative pustulosis that occurs in neonates and is characterized by the development of flaccid scalded bullae and large areas of skin exfoliation due to generalized erythema throughout the body (2). SSSS mostly occurs with sudden onset 1-5 weeks after birth. Initially, erythema occurs around the mouth or eyelids and then rapidly spreads to the trunk and proximal extremities or even to the entire body, which usually heals after 7-14 days. SSSS is a blistering and desquamative skin disease caused by the exfoliative toxins of staphylococcus aureus. It is a toxin-mediated condition (3), so the blisters and erosions are usually sterile. In this case, the child had three consecutive negative common bacterial culture test results during hospitalization, enabling exclusion of SSSS. Neonatal impetigo, congenital bullous ichthyosiform erythroderma, congenital syphilis, and neonatal herpes simplex all have associated specific pathogenic infections or are accompanied by other typical clinical manifestations, but in this case the child had no obvious infection manifestations except for specific skin lesions, allowing exclusion of the above diseases. Autosomal recessive dystrophic epidermolysis bullosa was first reported in 1966 by Bart et al. (4) and was confirmed to be caused by mutations in COL7A1 by Chrlstiano et al. in 1996 (5,6). The disease takes the form of dystrophic epidermolysis bullosa (7), and patients have congenital local skin defects, mucocutaneous blisters, and nail abnormalities (8). This disease is mostly sporadic, but familial predisposition has also been reported. In this case, the defective skin had begun to heal without complications at discharge. Based on our experience, nutritional support and infection prevention should be prioritized. The child was isolated from other patients during hospitalization, his blankets and clothes were autoclaved, and strict aseptic practices were carried out (9). Dressings were changed as needed by a designated person, and secretions were managed in a timely manner. The wounds were protected, and the child was carefully monitored and supported to improve his immunity and protect the function of his organs. This case once again demonstrates the crucial importance of prenatal diagnosis, genetic counseling, and genetic testing, which are effective measures to prevent the birth of children with genetic diseases, and early intervention can minimize the pain of the family.

Self-improving dystrophic epidermolysis bullosa: First report of clinical, molecular, and genetic characterization of five patients from Southeast Asia.

Self-improving dystrophic epidermolysis bullosa is a rare subtype of dystrophic epidermolysis bullosa (DEB) characterized by significant improvement in skin fragility within the first few years of life. Genetic inheritance has previously been reported as autosomal dominant or recessive with both forms harboring mutations in COL7A1. To date, there have been no reports of this rare clinical entity from various Southeast Asian ethnicities. Here, we describe the clinical and molecular features of five patients from the Southeast Asia region who presented with predominantly acral-distributed blisters and erosions in the first few days of life. Blistering resolved over several months, without appearance of new blisters. By immunofluorescence, intraepidermal retention of Type VII collagen was observed in all patient skin biopsies when investigated with antibody staining. Genetic analysis of four patients revealed pathogenic variants in COL7A1 which have not been previously reported. The clinical diagnosis in these rare patients is confirmed with molecular histology and genetic characterization.

Dominant pretibial dystrophic epidermolysis bullosa in an Italian family.

We describe a case of pretibial dystrophic epidermolysis bullosa in a 5-year-old girl, her mother, and maternal great aunt. All subjects had trauma-induced blisters and erosions, with scarring, on the knees and lower legs, and nail dystrophy of variable severity. Genetic analysis in all three patients showed a 6849del18 mutation in the COL7A1 gene, causing the production of shortened collagen VII polypeptides and resulting in a mild phenotype, with localized acral blisters and nail involvement.

Electrochemotherapy, a local treatment for squamous cell carcinoma in patients with recessive dystrophic epidermolysis bullosa.

Epidermolysis Bullosa (EB) is a rare group of diseases caused by genetic variants in skin structural proteins. EB is characterized by varying degrees of skin fragility, blisters and impaired wound healing, and is classified based on the ultrastructural levels of skin cleavage-simplex, junctional, dystrophic, and Kindler Syndrome. Squamous cell carcinoma (SCC) is the most severe complication and most common cause of death of patients with EB, particularly in those with recessive dystrophic Epidermolysis Bullosa (RDEB). To date, the first line of treatment of SCC in patients with RDEB is surgery, despite the high risk of recurrence. Radiotherapy and systemic therapy have been avoided due to its skin toxicity. Recently, electrochemotherapy (ECT) has been proposed as a potential treatment. We report eight sessions of ECT using bleomycin for treatment of SCC in five patients with EB. After 8 weeks all patients showed an objective response. Four patients (seven ECT sessions) had a complete response. The treatment was well tolerated, with mild adverse effects, such as local pain, erythema, and ulceration. Our results demonstrate that ECT is a potential treatment for SCC in patients with RDEB.

Epidermolysis bullosa with congenital absence of skin: Review of the literature.

BACKGROUND/OBJECTIVES: Bart syndrome was initially described as association of congenital absence of skin (CAS), nail abnormalities, and epidermolysis bullosa (EB). Further reports of patients with CAS and EB have been made with wide clinical heterogeneity among them. Current guidelines recommend the elimination of eponyms and use of the descriptive term EB with CAS. METHODS: We performed a PubMed and Medline database search of patients with Bart syndrome or EB with CAS. We included case reports or case series that contained clinical and demographic information. RESULTS: After review, 55 articles were included, reporting 96 patients. CAS involved the lower extremities in all patients, with additional upper limb, trunk, or head involvement in 17%. In all patients, the time to healing ranged from 2 weeks to 6 months; most received only conservative treatment. The subtype and frequency of associated EB most frequently reported were recessive dystrophic EB (41.4%) and dominant dystrophic EB (22.8%). Extracutaneous features were present in 29 patients; with pyloric atresia and ear malformations being the most common. The prognosis varied based on the subtype of EB and the presence of additional comorbidities; 50% of the patients with junctional EB with pyloric atresia and CAS died during the first months of life, while mortality among those with recessive dystrophic EB was 6.8%. CONCLUSION: Epidermolysis bullosa with CAS is a clinically heterogeneous disorder, most often associated with recessive dystrophic EB, but other EB subtypes may occur. Further investigations are necessary to better establish a pathological mechanism for CAS, and its association with EB.

Phase I/II open-label trial of intravenous allogeneic mesenchymal stromal cell therapy in adults with recessive dystrophic epidermolysis bullosa.

BACKGROUND: Recessive dystrophic epidermolysis bullosa (RDEB) is a hereditary blistering disorder due to a lack of type VII collagen. At present, treatment is mainly supportive. OBJECTIVES: To determine whether intravenous allogeneic bone marrow-derived mesenchymal stromal/stem cells (BM-MSCs) are safe in RDEB adults and if the cells improve wound healing and quality of life. METHODS: We conducted a prospective, phase I/II, open-label study recruiting 10 RDEB adults to receive 2 intravenous infusions of BM-MSCs (on day 0 and day 14; each dose 2-4 × 106 cells/kg). RESULTS: BM-MSCs were well tolerated with no serious adverse events to 12 months. Regarding efficacy, there was a transient reduction in disease activity scores (8/10 subjects) and a significant reduction in itch. One individual showed a transient increase in type VII collagen. LIMITATIONS: Open-label trial with no placebo. CONCLUSIONS: MSC infusion is safe in RDEB adults and can have clinical benefits for at least 2 months.

Epidermolysis bullosa pruriginosa: A rare entity which responded well to thalidomide.

Epidermolysis bullosa pruriginosa is an unusual clinical variant of dystrophic epidermolysis bullosa characterized by sublamina densa blistering and intense pruritus leading to hypertrophic lichenoid nodules, plaques, milia, and variable presence of albopapuloid lesions. Most cases are sporadic but a few cases have autosomal dominant or recessive inheritance. Treatment has been quite disappointing and failed to produce satisfactory or sustained results. We report a case of 39-years-old male with epidermolysis bullosa pruriginosa and its response to thalidomide.

Bart's syndrome in a family affected three consecutive generations with mutation c.6007G>A in COL7A1.

Bart's syndrome (BS), characterized by aplasia cutis congenita (ACC, also called congenital localized absence of skin) and epidermolysis bullosa (EB), is diagnosed clinically based on the disorder's unique signs and symptoms. We report the case of a family, three members of which presented with ACC at birth and one had blisters on the mucous membranes. The patient was treated conservatively with topical antibacterial ointment and wet gauze dressing. Periodic follow up showed complete healing with minimal scarring. Whole-exome sequencing confirmed a heterozygous mutation (rs121912832, c.6007G>A, p.G2003R) within exon 73 of COL7A1, which was confirmed by the only two genetic studies available, is suggested to be the molecular basis for the family's disorder. As a consequence, we suggest that c.6007G>A within exon 73 of COL7A1 could be a specific mutation for BS in antenatal screening. It is of great value to extend the genetic test among affected families and uncover the mechanism behind this unique syndrome.