Information on the following diseases can be found in the Related Disorders section of this report:

• herpes simplex virus
• epidermolytic hyperkeratosis
• bullous impetigo
• incontinetia pigmenti

Epidermolysis bullosa is divided into three subdivisions, and each subdivision has subtypes.

Epidermolysis bullosa simplex (EBS) is usually dominantly inherited, and involves disorders of the genes for Keratins 5 and 14 and plectin. Blistering occurs within the uppermost layer of the skin, the epidermis. EBS may be localized to the hands and feet or there may be a generalized distribution, with relatively mild internal involvement. Those with EBS may have thickened calluses on the palms and soles, oral blistering during infancy and rough, thickened fingernails/toenails. EBS does not usually scar.

In junctional epidermolysis bullosa (JEB), is recessively inherited, and involves disorders of the several components of the junction between the epidermis and dermis such as Laminin 332 (previously known as Laminin 5), plectin, and a6b4integrin. There are two major subtypes, Herlitz JEB and JEB- other (includes non-Herlitz JEB, and several other subtypes). Junctional Herlitz EB is a very severe form of EB. Death often occurs during infancy due to overwhelming infection (sepsis), malnutrition, dehydration, electrolyte imbalance or obstructive airway complications. There is a wide spectrum of JEB- O. Oral cavity involvement and irregular pitting of the surfaces of the teeth is common in all subtypes. Infants presenting with pyloric atresia will have trouble with feeding and abdominal distension as neonates and present as surgical emergencies in the newborn period.

Dystrophic epidermolysis bullosa (DEB) can be either dominantly or recessively inherited, and involve defects in Type VII collagen. Blisters occur within the lower layer of the skin. There are two major subtypes, Dominant DEB (DDEB) and Recessive DEB (RDEB).

Dominant dystrophic EB (DDEB): DDEB is usually mild. Blistering may be localized to the hands, feet, elbows and knees or it may be generalized. Common findings include scarring, milia (tiny white bumps), mucous membrane involvement, and abnormal or absent nails. Some family members may only have nail dystrophy.

Recessive dystrophic EB (RDEB): RDEB is typically more generalized and severe than DDEB. In addition to scarring, milia, mucous membrane involvement and nail dystrophy, common manifestations include malnutrition, anemia, esophageal strictures, growth retardation, webbing or fusion of the fingers and toes causing mitten deformity (pseudosyndactyly) with loss of function, development of contractures, malformation of teeth, microstomia and corneal abrasions. Severe generalized RDEB (formerly Hallopeau-Siemens RDEB) tends to the most severe form.

Inherited epidermolysis bullosa is the focus of this report. The inherited forms follow either autosomal dominant or autosomal recessive inheritance. There is also a rare acquired autoimmune disorder called epidermolysis bullosa aquisita. A mutation in any of several genes encoding the proteins in the epidermis, basement membrane or dermis causes poor integrity of the skin leading to fragility.

Recessive genetic disorders occur when an individual inherits two copies of an abnormal gene for the same trait, one from each parent. If an individual receives one normal gene and one gene for the disease, the person will be a carrier for the disease but usually will not show symptoms. The risk for two carrier parents to both pass the defective gene and have an affected child is 25% with each pregnancy. The risk to have a child who is a carrier like the parents is 50% with each pregnancy. The chance for a child to receive normal genes from both parents and be genetically normal for that particular trait is 25%. The risk is the same for males and females.

All individuals carry 4-5 abnormal genes. Parents who are close relatives (consanguineous) have a higher chance than unrelated parents to both carry the same abnormal gene, which increases the risk to have children with a recessive genetic disorder.

Dominant genetic disorders occur when only a single copy of an abnormal gene is necessary to cause a particular disease. The abnormal gene can be inherited from either parent or can be the result of a new mutation (gene change) in the affected individual. The risk of passing the abnormal gene from affected parent to offspring is 50% for each pregnancy. The risk is the same for males and females.

Some type of EB occurs in an estimated 1 out of every 50,000 live births. The disorder occurs in every racial and ethnic group throughout the world and affects both sexes equally.

Any blistering disorder in the new born period may mimic EB. These include herpes simplex virus, epidermolytic hyperkeratosis, bullous impetigo and incontinetia pigmenti.

Diagnosis
Diagnosis of the type of EB based on presentation in the neonatal period should be avoided as all types of EB may look alike in this age group. When EB is suspected, a skin biopsy should be obtained and sent to an appropriate laboratory to confirm the diagnosis with transmission electron microscopy (TEM) and/ or immunofluorescent antibody/antigen mapping. Molecular genetic testing for mutations in most of the genes known to be associated with the various types of EB is clinically available.

Treatment
By definition, inherited EB is a genetically transmitted disorder characterized by marked fragility of the skin. Any trauma, no matter how minimal it may seem, is likely to cause the skin of an EB child or adult to tear or blister. The following are recommended ways to avoid or minimize this problem:

1. Reducing Friction: Extreme care should be employed in handling the skin of any patient with EB.

2. Non-Adhesive Bandages and Dressings: Adhesive or semi-adhesive dressings, bandages, Band-aids, or tape should not be used on the surface of the skin. Instead, wounds should be covered with an appropriate non-adhesive dressing and then further wrapped loosely with rolled gauze. This can be secured by using a tubular dressing retainer.

3. Keeping the Skin Cool: Nothing hot should ever be applied to the skin of a patient with EB. In particular, bath water should be no warmer than body temperature. Patients should avoid prolonged exposure to ambient heat and humidity. If possible, air conditioned environments should be sought whenever possible.

4. Managing Blisters: Because blisters in EB are not self limiting, and can fill with fluid and grow quite large, they need to be drained.

5. Clothing: In younger children, diapers may require additional padding at the legs and waist. Whenever possible, loose-fitting garments should be worn. If blisters develop from the seams of clothing, garments may be worn inside-out and tags, cuffs and necklines may be removed. Loose fitted, padded shoes are generally better tolerated.

6. Nutritional deficiencies: Many children with EB become anemic due to a chronic loss of blood through wounds, poor nutritional intake and poor absorption of iron. It is important to wok with a Nutritionist experienced in the care of special needs patients. Treatment for iron deficiency anemia is often necessary. Other patients have selenium and carnitine or vitamin D deficiencies which may predispose them to cardiomyopathy and osteoporosis.

7. Monitoring for Cancer: Squamous Cell Carcinoma is the leading cause of death in EB usually occurring after the 2nd decade of life. Patients with Recessive dystrophic EB (RDEB) are at increased risk of developing skin cancers during their lifetimes. It is very important that all EB patients have at least yearly examination of all skin areas.

Stem cell transplant therapy trials for recessive dystrophic epidermolysis bullosa are being conducted at two institutions. For further information contact the following :

University of Minnesota
Center for Translational Medicine
Tim Krepski, RN
612-273-2800
Toll-free: 1-888-601-0787
Email: bmt@umn.ed

Morgan Stanley Children's Hospital
Columbia University Medical Center
Mitchell S Cairo, MD, 212-305-8316, Email: mc1310@columbia.edu
Claire Fanelli, RN, 212-305-2050, Email: cf2370@columbia.edu

Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. Government funding, and some supported by private industry, are posted on this government web site.

For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:

Tollfree: (800) 411-1222
TTY: (866) 411-1010
Email: prpl@cc.nih.gov

For information about clinical trials sponsored by private sources, contact:
www.centerwatch.com

TEXT BOOKS
Fine JD, Hintner H., eds. Life with Epidermolysis Bullosa (EB): Etiology, Diagnosis, Multidisciplinary Care and Therapy, New York: Springer Wien; 2009.

Fine JD, Bauer E, McGuire J , Moshell A, eds.Epidermolysis Bullosa: Clinical, Epidemiologic, and Laboratory Advances and the Findings of the National Epidermolysis Bullosa Registry 1st edition The Johns Hopkins University Press; 1999.

Weston WL, Lane AT, Morelli JG, eds. Color Textbook of Pediatric Dermatology, 4th Edition Mosby/Elsevier, 2007: 348-354.

RECENT REVIEW ARTICLES
Ellen G. Pfendner PhD, Anna Bruckner MD, Paulette Conget PhD, Jemima Mellerio MBBS, Francis Palisson MD, Anne W. Lucky MD Basic science of epidermolysis bullosa and diagnostic and molecular characterization: Proceedings of the IInd International Symposium on Epidermolysis Bullosa. Santiago, Chile, 2005 International Journal of Dermatology 2007 46 (8), 781–794.

Richard G. Azizkhan MD, Jacqueline E. Denyer RGN, RSCN, RHV, Jemima E. Mellerio BSc, MD, MRCP, Robinson González MD, Magdalena Bacigalupo, Arturo Kantor MD, Gianfranco Passalacqua DDS, Francis Palisson MD, Anne W. Lucky MD Surgical management of epidermolysis bullosa: Proceedings of the IInd International Symposium on Epidermolysis Bullosa, Santiago, Chile, 2005. International Journal of Dermatology 2007 46 (8), 801–808.

Jemima E. Mellerio BSc, MD, MRCP, Madeline Weiner RNBSN, Jacqueline E. Denyer RGNRSCNRHV, Elizabeth I. Pillay RGNRMRHV, Anne W. Lucky MD, Anna Bruckner MD, Francis Palisson MD (2007) Medical management of epidermolysis bullosa: Proceedings of the IInd International Symposium on Epidermolysis Bullosa, Santiago, Chile, 2005 International Journal of Dermatology 2007 46 (8), 795–800.

Anne W. Lucky MD, Ellen Pfendner PhD, Elizabeth Pillay RN, Judy Paskel, Madeline Weiner RN, Francis Palisson MD Psychosocial aspects of epidermolysis bullosa: Proceedings of the IInd International Symposium on Epidermolysis Bullosa, Santiago, Chile, 2005 International Journal of Dermatology 2007 46 (8), 809–814.

FROM THE INTERNET
Epidermolysis Bullosa by Marinkovich, MP Updated: Nov 12, 2008
http://emedicine.medscape.com/article/1062939-overview

Epidermolysis Bullosa Simplex by Pfendner, E, Bruckner, A Updated 8/11/08
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=gene&part=ebs

Dystrophic Epidermolysis Bullosa by Pfendner, E, Lucky, AW Updated 10/4/07.
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=gene&part=ebd

Junctional Epidermolysis Bullosa by Pfendner, E, Lucky, AW Posted: 2/22/08.
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=gene&part=ebj

Epidermolysis Bullosa with Pyloric Atresia by Pfendner, E, Lucky, AW Posted: 2/22/08
http://www.ncbi