Treatment - Epidermolysis bullosa

There's currently no cure for epidermolysis bullosa (EB), but treatment can help ease and control symptoms.

Treatment also aims to:

• avoid skin damage
• improve quality of life
• reduce the risk of developing complications, such as infection and malnutrition

Specialist centres

Parents and children are usually referred to a specialist centre that employs staff with expertise and experience in treating the condition.

In England, there are 4 specialist centres:

• Birmingham Women's and Children's Hospital
• Solihull Hospital
• Great Ormond Street Hospital for Children, London
• Guy's and St Thomas' Hospital, London

After the initial diagnosis, it's likely that you and your child will have regular follow-up appointments at a specialist centre so a detailed treatment plan can be drawn up.

Once your child's symptoms improve or stabilise, it may be possible to arrange for treatment to be provided locally, so you'll only need to visit the specialist centre occasionally.

But with more severe types of EB, this arrangement may not always be possible.

Treatment team

Children with EB often have complex needs, particularly if they have a severe form of the condition. They'll need to be treated by a diverse team of medical specialists working together.

This team can include:

• a doctor who specialises in treating skin conditions (a dermatologist)
• a dentist
• a dietitian
• a physiotherapist
• a play specialist, who uses playful activities to help improve a child's physical and psychological wellbeing
• a specialist nurse, who usually acts as the contact between you and other members of the team

General advice

An important part of your child's treatment plan will be practical advice about how to prevent trauma or friction to your child's skin to reduce the frequency of blistering.

This advice will vary depending on the type of EB and the severity of your child's symptoms.

This advice may include:

• not walking long distances (this can cause blisters to form on the soles of your child's feet)
• avoiding everyday knocks, bumps and scratches
• avoiding rubbing your child's skin (you may have to change the way you lift your child)
• keeping your child as cool as possible in warm weather
• avoiding clothes that fit tightly or rub against the skin to try to prevent blistering
• wearing clothes made from natural fabrics, like cotton (this will also help keep your child cool)
• choosing comfortable shoes that fit well and don't have lumpy seams inside

Your child may have to have a carer when they're out in the playground and avoid playing contact sports.

But it's important that they don't avoid physical activities or contact with other children altogether.

Your physiotherapist should be able to recommend activities unlikely to result in blistering, such as swimming.

Skin care

Your treatment team will be able to advise about caring for your child's skin.

For example:

• when and how to puncture new blisters
• how to care for wounds left by blisters and prevent infection
• whether to leave wounds uncovered or use dressings
• what types of dressing to use, how to apply and remove them, and how often to change them
• whether to use moisturising creams on your child's skin

It's usually recommended that new blisters are punctured (lanced) using a sterile needle. Your GP will be able to provide you with a supply of sterile needles.

Lancing the blisters will prevent them getting bigger. Large blisters can leave large, painful wounds that take longer to heal.

It's usually recommended to leave the skin on top of the blister to protect the lower layers of skin.

If an open wound needs a dressing, it's best to use one that doesn't stick to the skin and is easy to remove.

To hold a non-stick dressing in place, you may be advised to use a sock, cotton bandage or tubular bandage.

Regular sticking plasters should be avoided.

Infections

Open wounds or raw patches of skin can often become infected and need to be treated.

Signs that an area of skin has become infected include:

• heat or redness around the area, but redness can be harder to see on brown and black skin
• the area leaking pus or a watery discharge
• crusting on the surface of the wound
• a wound not healing
• a red streak or line spreading away from a blister, or a collection of blisters
• a high temperature

If you think your child has a skin infection, let your GP know as soon as possible.

Left untreated, a skin infection can often quickly spread to other parts of the body, particularly with the more severe forms of EB.

Treatment for skin infections include:

• antiseptic creams or ointments
• antibiotic creams or lotions
• antibiotic tablets
• specially designed dressings to help stimulate the healing process

Pain relief

The blisters and wounds can be painful and make simple activities such as moving and walking difficult.

Over-the-counter painkillers, such as paracetamol, might be enough for milder forms of EB.

For more severe types of EB, stronger painkillers such as morphine may be needed, either for background pain or for procedures like dressings, changes, or bathing.

Children under the age of 16 should never be given aspirin as there's a small risk it could trigger a serious condition called Reye's syndrome.

You may need stronger medicines, such as amitriptyline or gabapentin, for types of EB that cause long-term pain.

Dental care

Soreness caused by blisters inside your child's mouth can make cleaning their teeth difficult.

But good dental hygiene, using a soft toothbrush and a mouthwash that contains fluoride (as well as regular visits to a dentist), is important.

Nail care

Your child's fingernails and toenails may become thicker than normal and difficult to cut, especially if blisters form under the nail.

Your hospital team should be able to recommend creams that soften nails and make them easier to cut.

Eye care

Children with severe types of EB can experience blistering and irritation in and around their eyes.

This usually requires treatment with eyedrops and ointments to keep the eyes moist.

Feeding and nutrition

If your baby has blisters in their mouth, it can cause problems with feeding. Your treatment team can give you advice about how to overcome feeding problems.

For example:

• feeding a baby or infant using a syringe, eyedropper or "artificial nipple"
• adding liquid to mashed food to make it easier to swallow (once your child is old enough to eat solids)
• including lots of soft food in your child's diet
• not serving food too hot, as it could cause further blistering

If your child is older, your treatment team can also give you advice about their diet.

The healing process makes great demands on the body, and a healthy diet is important to help heal your child's skin wounds and avoid malnutrition.

Your child may also need supplements in the form of milk-based drinks or puddings that have high levels of protein and calories.

Supplements of vitamins, iron or zinc may also be required if they're found to be deficient in these on blood tests. Your dietitian will be able to advise about this.

Constipation is a common problem for children with EB, because of blistering around the bottom which makes it painful to poo. It's also a side affect of some types of painkillers.

If your child regularly experiences constipation, they may benefit from having a fibre supplement or laxative.

Surgery

Surgery may be needed to treat some complications that can arise in severe cases of EB.

The different types of surgery are described below:

• If your child's fingers and toes have become fused together by scar tissue, creating a "mitten" effect, surgery may be needed to separate them.
• If your child's oesophagus (the tube that connects the mouth and stomach) has become narrowed by scarring, surgery may be needed to widen it. This is done by placing a balloon inside the oesophagus and inflating it to widen the narrowed area.
• If your child is underweight and not growing properly because symptoms of EB make eating impossible, surgery can be used to implant a feeding tube into their tummy.

Research

Research is being carried out to try to find a cure, or at least more effective treatments, for EB.

Initial results have been promising, but it may take several years until researchers come up with safe and effective treatments.

The DEBRA website has more information on current EB research and clinical trials.