Introduction
Methods
Results
Summary of included studies
Clinical burden
Symptoms
Symptom | % | n/N | Design, country |
---|---|---|---|
Blisters/lesions | |||
Blisters at or within 1 week of birth | 94 | 15/16 | Registry analysis, Australia/NZ [35] |
86 | 12/14 | Registry analysis, UK [33] | |
70 | 7/10 | Single-center, Saudi Arabia [16] | |
Oral lesions | |||
Any oral lesions | 100 | 35/35a | Multicenter, Spain [48] |
92 | 33/35b | Multicenter, Spain [48] | |
89 | 8/9c | Registry analysis, UK [33] | |
79 | 22/28 | Single-center, Japan [43] | |
Lingual lesions | 77 | 27/35 | Multicenter, Spain [48] |
Dental lesions | 61 | 17/28 | Single-center, Japan [43] |
Soft palate lesions | 60 | 21/35 | Multicenter, Spain [48] |
Oral bullae | 59 | 10/17d | Case-review, Serbia [21] |
Lesions on lips, mouth, tongue or ear | 53 | 32/60 | Single-center, Brazil [22] |
Hard palate lesions | 53 | 18/35 | Multicenter, Spain [48] |
Labial lesions | 46 | 16/35 | Multicenter, Spain [48] |
Palatal milium cysts | 46 | 16/35 | Multicenter, Spain [48] |
Jugal mucosa | 34 | 12/35 | Multicenter, Spain [48] |
Other lesions | |||
Nail lesions | 75 | 21/28 | Single-center, Japan [43] |
Lip lesions | 53 | 32/60 | Single-center, Brazil [22] |
Esophageal lesions | 47 | 28/60 | Single-center, Brazil [22] |
Nostril lesions | 18 | 11/60 | Single-center, Brazil [22] |
Eyelid blisters | 7 | 5/72 | Single-center, UK [51] |
External ear canal lesions | 3 | 2/60 | Single-center, Brazil [22] |
Larynx lesions | 2 | 1/60 | Single-center, Brazil [22] |
Strictures/stenoses | |||
Esophageal strictures/stenosis | 86 | 6/7 | Single-center, US [52] |
81 | 43/53 | Survey, US [53] | |
65 | 37/57 | Single-center, UK [31] | |
64 | 100/157 | Single-center, Germany [55] | |
64 | 53/83 | Survey, International [54] | |
51 | 216/424 | Registry analysis, US [30] | |
Other strictures/stenoses | |||
Anal strictures | 15 | 62/422 | Registry analysis, US [30] |
Pulmonary artery stenosis | 14 | 1/7 | Single-center, US [52] |
Nostril stenoses | 5 | 3/60 | Single-center, Brazil [22] |
Urethral meatal stenoses | 3 | 14/425 | Registry analysis, US [27] |
Anterior commissure stenoses | 2 | 1/60 | Single-center, Brazil [22] |
Pyloric stenoses or atresia | 1 | 5/419 | Registry analysis, US [30] |
Laryngeal stenoses | 0.7 | 3/412 | Registry analysis, US [29] |
Rectal strictures | 0.2 | 1/422 | Registry analysis, US [30] |
Malnutrition/failure to thrive | |||
Malnutrition/nutritional problems | 72 | 38/53 | Survey, US [53] |
50 | 12/24 | Single-center, France [20] | |
Failure to thrive | 39 | 22/57 | Single-center, UK [31] |
25 | 21/83 | Survey, International [54] | |
Growth problems diagnosed by physician | 34 | 18/53 | Survey, US [53] |
Negative height standard deviation scores | 94 | 17/18 | Single-center, UK [44] |
Negative height velocity standard deviation scores | 89 | 16/18 | Single-center, UK [44] |
Nutritional deficiencies | |||
Selenium deficiency | 94 | NR | Single-center, Germany [55] |
Vitamin D deficiency | 67 | NR | Single-center, Germany [55] |
Low albumin levels | 56 | NR | Single-center, Germany [55] |
Zinc deficiency | 55 | NR | Single-center, Germany [55] |
Anemia | |||
Any anemia | 100 | 10/10 | Single-center, Saudi Arabia [16] |
91 | 143/157 | Single-center, Germany [55] | |
76 | 40/53 | Survey, US [53] | |
68 | 17/25 | Registry, Australia [34] | |
60 | 47/79 | Registry, UK [17] | |
52 | 43/83 | Survey, International [54] | |
50 | 3/6 | Single-center, US [52] | |
Pseudosyndactyly | |||
Any pseudosyndactyly | 71 | 5/7 | Single-center, Japan [43] |
50 | 14/28 | Single-center, US [52] | |
22 | 2/9 | Single-center, Saudi Arabia [16] | |
Pseudosyndactyly of foot | 55 | 46/83 | Survey, International [54] |
Pseudosyndactyly of hand | 65 | NR/425 | Registry, US [28] |
13 | 11/83 | Survey, International [54] | |
Ocular symptoms | |||
Any ocular symptoms | 68 | 36/53 | Survey, US [53] |
52 | 16/31 | NR, Chile [42] | |
52 | 43/83 | Survey, International [54] | |
51 | 37/72 | Single-center, UK [51] | |
Corneal complications in those with ocular symptoms | 100 | 16/16 | NR, Chile [42] |
68 | 25/37 | Single-center, UK [51] | |
63 | 5/8c | Registry analysis, UK [33] | |
Other ocular symptoms in those experiencing ocular involvement | |||
Anterior blepharitis and collarettes | 94 | 15/16 | NR, Chile [42] |
Corneal erosions | 63 | 5/8c | Registry analysis, UK [33] |
Symblepharon | 59 | 8/16 | NR, Chile [42] |
Ectropion | 38 | 6/16 | NR, Chile [42] |
13 | 1/8c | Registry analysis, UK [33] | |
Conjunctival complications | 14 | 5/37 | Single-center, UK [51] |
Exposure keratitis associated with upper and lower eyelid extropian’s | 8 | 3/37 | Single-center, UK [51] |
Other commonly reported symptoms | |||
Nail dystrophy and loss | 100 | 10/10 | Single-center, Saudi Arabia [16] |
100 | 12/12 | Registry analysis, UK [33] | |
Milia | 100 | 9/9 | Single-center, Saudi Arabia [16] |
93 | 49/53 | Survey, US [53] | |
21 | 6/28 | Single-center, Japan [43] | |
Constipation | 75 | 9/12 | Registry, UK [33] |
72 | 38/53 | Survey, US [53] | |
60 | 254/422 | Registry analysis, US [30] | |
40 | 23/57 | Single-center, UK [31] | |
Musculoskeletal contractures | 87 | 46/53 | Survey, US [53] |
67 | 4/6 | Single-center, US [52] | |
30 | 3/10 | Single-center, Saudi Arabia [16] | |
Dental caries | 24 | 54/225e | Case-review, Serbia [21] |
Infections | |||
Any infection | 64 | 53/83 | Survey, International [54] |
Skin infection | 90 | 9/10 | Single-center, Saudi Arabia [16] |
Recurrent respiratory infection | 50 | 5/10 | Single-center, Saudi Arabia [16] |
Bacterial septicemia | 20 | 2/10 | Single-center, Saudi Arabia [16] |
Candida septicemia | 10 | 1/10 | Single-center, Saudi Arabia [16] |
Symptom, study | Country, registry (date of data collection) | RDEB population (N) | Overall incidence (%) | Cumulative risk (%) at | |||||
---|---|---|---|---|---|---|---|---|---|
1 year | 10 years | 15 years | 20 years | 40 years | 60 years | ||||
General symptoms | |||||||||
Esophageal stenoses and strictures | US, NEBR (1986–2002) | Severe (134) | 79 | 7 | 57 | 72 | 79 | 89 | 95 |
Fine [30] | Intermediate (261) | 37 | 4 | 27 | 34 | 40 | 62 | 70 | |
Inversa (15) | 87 | 0 | 33 | 56 | 56 | 89 | NR | ||
Laryngeal stenoses and strictures | US, NEBR (1986–2002) | Severe (138) | 2 | 0 | 1 | 1 | 1 | 5 | 5 |
Fine [29] | Intermediate (263) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
Inversa (17) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
Pseudosyndactyly of the hands | US, NEBR (1986–2002) | Severe (142) | 95 | 16 | 92 | 93 | 98 | 98 | 98 |
Fine [28] | Intermediate (266) | 51 | 13 | 43 | 49 | 50 | 55 | 55 | |
Inversa (17) | 41 | 0 | 8 | 26 | 26 | 26 | 26 | ||
Musculoskeletal contractures | US, NEBR (1986–2002) | Severe (142) | NR | 13 | 83 | 92 | 99 | NR | NR |
Fine [28] | Intermediate (266) | NR | 4 | 37 | 46 | 46 | 49 | 78 | |
Inversa (17) | NR | 0 | 8 | 25 | 25 | 43 | NR | ||
CHF or cardiomyopathy | US, NEBRa (1986–2002) | Severe (140) | 7 | 1 | 2 | 4 | 7 | 19 | 19 |
Fine [25] | Intermediate (267) | 1 | 0 | 0 | 0 | 1 | 3 | 3 | |
Growth retardation | US, NEBR (1986–2002) | Severe (141) | NR | 14 | 67 | 75 | 80 | 80 | NR |
Fine [30] | Intermediate (266) | NR | 3 | 10 | 12 | 13 | 13 | 13 | |
Inversa (17) | NR | 6 | 20 | 20 | 20 | 20 | NR | ||
Premature mortality | |||||||||
Death from sepsis | US, NEBRb (1986–2002) | Intermediate (262) | NR | 0.4 | 0.4 | 0.4 | NR | NR | NR |
Fine [63] | |||||||||
Death from pneumonia | US, NEBR (1986–2002) | Severe (138) | NR | 0 | 0 | 1.8 | NR | NR | NR |
Fine [63] | Intermediate (262) | NR | 0.4 | 0.4 | 1.1 | NR | NR | NR | |
Inversa (17) | 0 | 0 | 0 | 0 | NR | NR | NR | ||
Death from respiratory failure | US, NEBRa (1986–2002) | Severe (138) | NR | 0 | 0 | 0.4 | NR | NR | NR |
Fine [63] | Intermediate (262) | NR | NR | NR | 1.1 | NR | NR | NR | |
Death from renal failure | US, NEBR (1986–2002) | All RDEB (417) | NR | 0 | 0 | 0 | NR | NR | NR |
Fine [63] | |||||||||
Death from failure to thrive | US, NEBR (1986–2002) | All RDEB (417) | NR | 0 | 0 | 0 | NR | NR | NR |
Fine [63] | |||||||||
Death from SCC | US, NEBR (1986–2002) | All RDEB (417) | NR | 0 | 0 | 0 | NR | NR | NR |
Fine [63] | |||||||||
SCC-related | |||||||||
Development of SCC | UK, NEBR (2000–2015) | Children (79) | 0 | NR | NR | NR | NR | NR | NR |
Alband [17] | |||||||||
Development of SCC | US, Survey (2017) | Children (caregiver-reported) (34) | 0 | NR | NR | NR | NR | NR | NR |
Bruckner [53] | |||||||||
Adults (19) | 16 | NR | NR | NR | NR | NR | NR | ||
Development of SCC | Australia, AEBRa (2009–2016) | Severe (11) | NR | NR | NR | NR | 26 | 76c | NR |
Kim [6] | Intermediate (5) | NR | NR | NR | NR | NR | 10c | 67d | |
Development of SCC | US, NEBR (1986–2002) | Severe (141) | 23 | 0 | 0 | 0 | 8 | 74 | NR |
Fine [26] | Intermediate (263) | 9 | 0 | 0 | 1 | 4 | 24 | 36 | |
Inversa (17) | 18 | 0 | 0 | 0 | 0 | 8 | NR | ||
SCC-related death | Australia, AEBRa (2009–2016) | Severe (11) | NR | NR | NR | NR | 30e | 84f | NR |
Kim [6] | Intermediate (5) | NR | NR | NR | NR | NR | 17c | 67 g | |
SCC-related death (all patients with RDEB) | US, NEBR (1986–2002) | Severe (141) | NR | 0 | 0 | 0 | 1 | 59 | NR |
Intermediate (263) | NR | 0 | 0 | 0 | 0 | 8 | 22 | ||
Fine [26] | Inversa (17) | NR | 0 | 0 | 0 | 0 | 0 | NR | |
SCC-related death (history of SCC) | US, NEBR (1986–2002) | Severe (32) | NR | 0 | 0 | 0 | 13 | 81 | NR |
Fine [26] | Intermediate (24) | NR | 0 | 0 | 4 | 4 | 31 | 60 | |
Inversa (3) | NR | 0 | 0 | 0 | 0 | 0 | NR |
Wound burden
Pain and itch
Strictures and stenoses
Malnutrition/failure to thrive
Anemia
ReferenceS | Population (N) | Mean (SD) hemoglobin (g/dL) | Mean (SD) reticulocytes (%) | Mean (SD) ferritin (µg/L) | Mean (SD) transferrin (mg/L) | Mean (SD) transferin saturation (%) | Mean (SD) iron (µg/L) |
---|---|---|---|---|---|---|---|
Reimer [55] | Children with RDEB (157) | 9.7 (2.23) | 17.8 (16.3) | 63.0 (140.8) | 241.7 (60.6) | 9.9 (8.85) | 27.6 (23.7) |
Normal range (NA) | 12.55–16.55 | 4.8–16.4 | 22.5–275 | 200–360 | 16–45 | 26–151.5 | |
Hwang [34] | Children with RDEB (NR) | 10.19 (3.08) | NR | NR | NR | NR | NR |
Mellerio [62] | RDEB severe, 0–16 years (NR) | 10.84 (NR) | NR | NR | NR | NR | NR |
RDEB severe, 17–25 years (NR) | 12.30 (NR) | NR | NR | NR | NR | NR | |
RDEB severe, 26–35 years (NR) | 11.09 (NR) | NR | NR | NR | NR | NR | |
RDEB severe, 36–45 years (NR) | 8.80 (NR) | NR | NR | NR | NR | NR | |
RDEB severe, 46–55 years (NR) | 9.30 (NR) | NR | NR | NR | NR | NR |
Pseudosyndactyly
Microstomia
Congestive heart failure and cardiomyopathy
Ocular manifestations
Other common symptoms and complications
Premature mortality
Squamous cell carcinoma
Procedures
Variable | Data | Design, Country |
---|---|---|
Esophageal dilation (ED) | ||
Proportion undergoing ED, % (n/N) | 74 (23/31) | NR, Chile [42] |
56 (157/283) | Registry analysis, US [23] | |
43 (34/79) | Registry analysis, UK [17] | |
38 (NR/25e) | Single-center, US [66] | |
33 (134/411) | Registry analysis, US [30] | |
29 (45/157) | Single-center, Germany [55] | |
Average EDs performed per patient, mean/median (N) | Mean, 7 [14] | Single-center, UK [65] |
Median, 6 (77) | Single-center, UK [41] | |
Median, 5 (17, inversa subtype) | Registry analysis, US [30] | |
Median, 3 (136, severe subtype) | ||
Median, 2 (258, intermediate subtype) | ||
Maximum number of EDs performed per patient, no (N) | 14 (14) | Single-center, UK [65] |
41 (77) | Single-center, UK [41] | |
50 (411) | Registry analysis, US [30] | |
Age at first ED, years (N) | 5.5 (77) | Single-center, UK [41] |
Gastrostomy tube | ||
Proportion undergoing GT, % (n/N) | 58 (33/57) | Single-center, UK [31] |
37 (104/283) | Registry analysis, US [23] | |
33 (27/83) | Survey, International [54] | |
32 (25/79) | Registry analysis, UK [17] | |
24 (97/412) | Registry analysis, US [30] | |
14 (22/157) | Single-center, Germany [55] | |
8 (2/25e) | Single-center, US [66] | |
Average GTs performed per patient, median (N) | Median, 1 (412) | Registry analysis, US [30] |
Maximum GTs performed per patient, no (N) | 10 (412) | Registry analysis, US [30] |
Age at first GT, years (N) | 6 (6a) | Single-center, UK24 |
8 (44a) | Single-center UK36` |
Pseudosyndactyly release
Diagnostic procedures
Humanistic burden
Patient-reported outcome measures (PROMs)
PROM | Brief description | Study, country | Patients w RDEB (n) | Results |
---|---|---|---|---|
Dermatology-specific instruments | ||||
QOLEB | First disease-specific QOL tool for EB 17 items with scores ranging from 0 (least impact) to 3 (most impact) Overall QOL scores range from 0 to 51 Lower values indicate better function/higher QOL | Cestari [69], Brazil | 13 (child) 6 (adult) | Children with RDEB reported lowest overall QOL (14.3 [SD, 9.7]) followed by EBS (10.6 [7.1]), DDEB (9.7 [7.9]), and JEB (5.0 [NA]); non-significant difference Adults with RDEB (20.2 [9.2]) reported lowest overall QOL followed by EBS (12.5 [10.0]), DDEB (12.0 [5.8]), and JEB (2.0 [NA]); non-significant difference |
Choi [61], US | 32 | Patients reported frequent or constant pain (69%) and a high or severe level of psychological and social impact on finances (50%), friendships (41%), anxiety (41%), depression (31%), family (22%), and embarrassment (16%) Patients reported severely impaired function in eating (63%), bathing (53%), moving outside the home (38%), writing (28%), and moving around the home (22%) | ||
Eismann [70], US | 32 | Children with RDEB reported lowest overall QOL (23 [IQR, 13–27]) followed by JEB (21 [13–26]), EBS (19 [5–30]), and DDEB (13 [6–18]); significance not measured Items associated with the worst QOL (score ≥ 2) include bathing/showing (2.45 [SD, 2.45]), sports (2.45 [0.68]), physical pain (2.06 [0.95]), and eating (2.06 [0.95]) | ||
Eng [54], International | 81 | QOLEB score in patients with RDEB did not vary significantly by patient-reported disease severity (mild [mean, 19, SD, 3.4], moderate [7, 20], severe [6, 24]); p = 0.36 QOLEB score significantly differed by the size of patients’ predominant wounds; patients with large wounds (> 7.5 cm) had worse QOL (median score, 27) than patients with medium wounds (2.5–7.5 cm; median score, 22.5) or small wounds (< 2.5 cm; median score, 14); p = 0.02 | ||
Frew [71], Australia | 16 | Patients with RDEB reported worst overall QOL (35.5 [SD, 12.7]) followed by JEB (31.5 [17.6]), DDEB (18.1 [10.9]), and EBS (13.7 [8.7]); significance not reported | ||
Jeon [59], South Korea | 13 | Patients with severe subtype of RDEB (N = 7) reported worse overall QOL (30.1 [SD, 8.8]) than those with intermediate (N = 6; 23.2 [3.8]); non-significant difference Patients with very severe perceived disease (N = 11) reported lower overall QOL (28 [7.8]) than those with severe perceived disease (N = 2; 21 [NA]); p < 0.05 Patients with RDEB hospitalized for > 7 days (N = 5) in the past year reported lowest overall QOL (29.8 [8.7]) compared to patients hospitalized 1–6 days (N = 1; 25 [NA]) or 0 days (N = 7; 25.14 [7.35]); non-significant difference | ||
iscorEB | Comprised of clinical score (5 domains) and patient score (7 domains) Scores range from 0–120 Designed to capture changes over time Higher score indicates worse burden | Bruckner [68], US | 16 | Mean clinical and patient scores significantly higher in patients with RDEB (clinical, 19.9; patient, 41.0) than other subtypes of EB (clinical, 3.2; patient, 24.7) p < 0.0001 (clinical difference) and p = 0.004 (patient difference) |
Schwieger-Briel [72], Canada | NR | Patients with severe subtypes of EB significantly lower QOL (64.5 [SD, 22.6]) than those with moderate (41.0 [19.4]) or mild subtypes (17.3 [9.6]); p < 0.001 Patients with DEB report significantly lower QOL (57.2 [24.6]) than patients with EB (30.6 [19.2]); p = 0.007 | ||
Birmingham EB Severity score | Method of scoring clinical severity Scores range from 0–100 Higher score indicates worse burden | Moss [74], UK | 34 | Patients with the severe subtype of RDEB had higher median score (22.9 [range, 2.8–27.8]) than those with non-severe subtype (7.8 [2.8–27.8]) Scores in the severe subtype of RDEB were significantly associated with age (demonstrating disease progression); p = 0.001 |
FDLQI | Measures adverse impact of HRQOL on family members with disease 10 questions on 4-point scale Scores range from 0–30, higher score indicates worse QOL Not specific to EB | Sampogna [47], Italy | 62 | QOL was significantly worse in patients with severe disease (14.3) or moderate disease (11.4) than mild disease (3.4); p < 0.001 QOL was significantly worse in patients with > 30% of their body involved (14.4) and 10–30% involved (10.9) than < 10% involved (6.3); p = 0.003 QOL was significantly worse in caregivers who were mothers (10.6) than non-mother caregivers (5.4); p = 0.025 QOL was significantly worse in patients with probable anxiety or depression (measured via GHQ-12; 13.9) than in those without (8.2); p = 0.003 QOL was similar between male (9.4) and female sex (10.1); non-significant difference QOL was slightly worse in patients with a disease duration of 10 years or more (10.9) compared to a duration of less than 10 years (7.7); non-significant difference Most frequently reported problems include time spent looking after the patient, emotional distress, affected physical well-being, and increased household expenditure (exact frequencies not reported) |
InToDermQOL | Parent-reported measure for children with skin diseases aged 0–4 years Undergoing item testing and validation Not specific to EB | Chernyshov [19], Ukraine and Romania | 12 | Over half of parents of infants and toddlers with RDEB mentioned itching (12/12 [100%]), problems with defecation (11/12 [92%]), problems with feeding (9/12 [75%]), pain (8/12 [67%]), sleep problems (7/12 [58%]), and treatment (7/12 [58%]), |
Skindex-29 | 29 items comprising 3 scales (symptom, functioning, emotional burden) Scores range from 0–100 Higher scores indicate worse QOL Not specific to EB | Jeon (59), South Korea | 13 | Patients with RDEB had the highest symptom scale score (86 [SD, 10]; Fig. 2b) compared to patients with vulvodynia (50 [17]), eczema (48 [23]), dermatomyositis (42 [25]), psoriasis (42 [21]), rosacea (33 [20]), alopecia (31 [24]), and acne vulgaris (30 [19]) as well as people without skin disease (14 [2]); significance not reported Patients with RDEB had the highest emotion scale score (75 [16]; Fig. 2b) compared to patients with vulvodynia (50 [20]), dermatomyositis (45 [27]), eczema (41 [27]), acne vulgaris (41 [25]), psoriasis (39 [27]), rosacea (33 [20]), and alopecia (27 [33]) as well as people without skin disease (9 [13]); significance not reported Patients with RDEB had the highest function scale score (77 [12]; Fig. 2b) compared to patients with vulvodynia (44 [22]), dermatomyositis (28 [29]), eczema (26 [26]), psoriasis (23 [27]), acne vulgaris (16 [16]), rosacea (16 [18]), and alopecia (14 [23]) as well as people without skin disease (4 [8]); significance not reported |
Generic instruments | ||||
Instruments measuring physical functioning | ||||
ABILIHAND | Individual item scores range from 0 (impossible) to 2 (easy) Overall hand function score ranges from 0 to 42 Higher score indicates better hand function | Eismann [70], US | 32 | Difficult to impossible items (score ≤ 1) for children with RDEB included opening a jar of jam (0.17 [SD, 0.38]), buttoning up pants (0.43 [0.57]), opening a bag of chips (0.43 [0.63]), buttoning up a shirt or sweater (0.45 [0.57]), unscrewing a bottle cap (0.50 [0.72]), fastening the snap of a jacket (0.77 [0.63]), zipping up pants (0.90 [0.76]), switching on a bedside lamp (0.93 [0.74]), zipping up a jacket (0.97 [0.65]), sharpening a pencil (0.97 [0.78], rolling up a sleeve of a sweater (0.97 [0.82]) Children with RDEB reported lowest hand function (21 [IQR, 17–29]), followed by EBS (28 [21–36]; p = 0.031), JEB (30 [22–37]; p = 0.014), then DDEB (40 [36–42]; p < 0.001) |
ADLs | First application in skin diseases 109 items Rates levels of independence in performing activities of daily living | Fine [58], US | 45 | Children with RDEB reported being totally dependent at bathing (27%), grooming (20%), dressing (13%), and walking (13%) Children with RDEB reported being totally independent at feeding (73%), toileting (71%), bathing (47%), dressing (42%), grooming (42%), and walking (24%) Children with RDEB reported high levels of dependence in bathing (27% totally dependent), grooming (20%), dressing (13%), and walking (13%), similar to children with DEB (bathing, 27%; grooming, 19%; dressing, 15%; walking, 8%); significance not reported Children with DEB and EBS reported low levels of dependence (DDEB, 0% throughout; EBS, 2% totally dependent in bathing, grooming and walking) |
Instruments measuring performance and mental health | ||||
Achenbach’s Child Behavior Checklist | Parent-reported measure T-scores for respective sex/age group available (50 being normal) | Feldmann [24], Germany | 9a | Parents of children with RDEB severe subtype and children with other subtypes of EBS (including RDEB intermediate) reported no significant differences between groups in total competence score (38.3 [SD, 14.3] vs. 43.3 [7.8]), internalizing (62.4 [8.9] vs. 57.1 [15.1]), externalizing (49.9 [7.7] vs. 56.9 [10.3]), and total problem score (59.3 [8.8] vs. 58.8 [12.5]); non-significant difference All scores were in the normal range |
GHQ-12 | 12-items Designed to detect presence of minor non-psychotic psychiatric disorders | Sampogna [47], Italy | 62 | QOL was significantly worse in patients with probable anxiety or depression (measured via GHQ-12; 13.9) than in those without (8.2); 0.003 |
Graphic tests | Projective test designed to measure personality | Andreoli [67], Italy | 11 | When measuring intellectual development, all children with RDEB were labeled normal (18%) or above normal (82%) intellectual development. All children with EBS, JEB and DDEB were labeled as above normal; significance not reported When measuring affective development, a higher proportion of children with RDEB were labeled with immaturity (46%) than maturity (36%) or forced growth (18%). All patients with EBS and DEDB and 80% of patients with JEB were labeled as mature; significance not reported When measuring scholastic/working efficiency, a higher proportion of children with RDEB were labeled as adequate or high (73%) than inadequate (27%). All patients with EBS, JEB and DDEB were labeled as adequate or high; significance not reported When measuring drive display, a higher proportion of children with RDEB were labeled as adequate (64%) than coarctate (18%) or excessive (18%). All patients with DDEB, 80% of patients with JEB, and 33% of patients with EBS were labeled as adequate; significance not reported When measuring psychosocial development, a higher proportion of children with RDED were labeled with accommodating adjustment (46%) or assimilative adjustment (36%) than reported maladjustment (18%). All patients with EBS and DDEB and 80% of patients with JEB were labeled as accommodating or assimilative adjustment; significance not reported |
Strengths and difficulties questionnaire | Completed by caregiver Includes 6 subscales and combined total difficulties scale | Soon [73], UK | 18 | Parents reported higher proportion of children with RDEB than children with EBS scored in clinical range for emotional symptoms (66% vs. 50%) and peer-relationship problems (50% vs. 40%); significance not reported Children with RDEB 2–3 × more likely to have clinically significant difficulties in these areas than a non-RDEB population |
Wechsler Intelligence Scale | Separate scales for children and adults | Feldmann [24], Germany | 9a | Children with the RDEB severe subtype reported significantly lower performance (75.6 [SD, 18.1] vs. 99.2 [14.7]), verbal (77.6 [16.7] vs. 101.6 [9.4]) and full scale scores (74.3 [18.0] vs. 100.6 [12.5]) than patients with other subtypes of EB (including RDEB intermediate subtype); p < 0.05 |
Instruments measuring pain and itch | ||||
Pain and pruritus scalesb | Measured on a scale of 1 to 10 with higher scores indicating higher/more frequent pain or itch | Bruckner [53], US | 19 (patient) 34 (caregiver) | Patients with RDEB reported higher acute pain (5.6 [SD NR]) than patients with DDEB (4.4), JEB (4.4), or EBS subtypes (4.3); significance not reported Patients with RDEB reported similar chronic pain (5.3) to patients with JEB (5.3) and higher chronic pain than patients with DDEB (4.6) or EBS (3.2); significance not reported Patients with RDEB reported similar levels of itch (6.7) to patients with JEB (6.5) and higher levels of itch than patients with DDEB (5.5) or EBS (4.4); significance not reported Caregivers reported their patients with RDEB had similar levels of acute pain (6.4) to patients with JEB (6.3) and higher levels of acute pain than patients with EBS (5.3) or DEB (5.0); significance not reported Caregivers reported their patients with RDEB had similar levels of chronic pain (4.2) to patients with JEB (4.0) and higher levels of chronic pain than patients with EBS (3.6) or DDEB (3.4); significance not reported Caregivers reported their patients with RDEB had higher levels of itch (7.2) than patients with EBS (4.4), DDEB, (4.3), and JEB (4.0); significance not reported |
Measured on a 5-point Likert scale with higher scores indicating more frequent itch | Danial [57] | 77 | When asked frequency of itch per day, patients with RDEB reported the highest scores (3.9 [SD, 0.8]) compared to patients with JEB (3.6 [0.8]), DDEB (3.5 [1.2]), and significantly higher than EBS (3.1 [1.0]); p = 0.01 Patients with RDEB reported highest itch at bedtime (4.0 [NR]) Itch was the most bothersome symptom of EB (3.3 [1.1]), compared to acute pain (2.9 [1.3]), chronic pain (2.7 [1.5]), and problems eating (2.7 [1.4]) Itch was more bothersome in RDEB patients (3.5) than DDEB (3.1) and EBS (2.7) Itch was most severe in patients with self-reported severe disease (4.0 [0.8]), compared with moderate EB (3.8 [0.9]), and mild EB (3.2 [1.0]) | |
PQAS | Scores range from 0 (no pain/sensation) to 10 (most pain/sensation) | Schräder [60], Netherlands | 5 | Patients with RDEB (compared to EBS) reported significantly higher levels of unpleasant (6.4 [3.5] vs. 3.5 [2.6]), intense (5.4 [2.8] vs. 2.4 [2.4]), surface (5.2 [2.6] vs. 2.4 [2.3]), itchy (4.8 [3.3] vs. 2.1 [2.5]), sharp (5.8 [2.9] vs. 1.7 [2.1]) and shooting pain (5.2 [2.5] vs. 1.3 [2.2]); p < 0.05 Patients with RDEB reported higher unpleasant (6.4 [3.5] vs. 4.5 [3.0]), sharp (5.8 [2.9] vs. 3.4 [3.3]), intense (5.4 [2.8] vs. 3.8 [3.1]), tender (5.4 [3.6] vs. 3.7 [2.9]), surface (5.2 [2.6] vs. 3.7 [2.9]), deep (5.2 [4.0] vs. 3.4 [3.1]), shooting (5.2 [2.5] vs. 2.7 [3.2]), itchy (4.8 [3.3] vs. 3.5 [3.5]), heavy (4.8 [3.4] vs. 3.3 [3.7]), hot (4.6 [3.9] vs. 2.8 [3.0]), aching (4.4 [3.2] vs. 3.4 [3.2]), sensitive (4.0 [2.6] vs. 3.4 [2.6]), dull (4.0 [3.9] vs. 2.5 [2.9]), tingling (4.0 [3.4] vs. 2.5 [2.8]), throbbing (3.8 [3.6] vs. 3.0 [2.9]), radiating (3.8 [3.8] vs. 2.1 [2.87]), cramping (3.6 [3.5] vs. 1.7 [2.3]), and cold pain (2.0 [2.3] vs. 1.0 [1.9]) than all EB types; significance not reported |
VAS | Linear, visual analog scale from 0 (no pain/itch) to 10 (most severe pain/itch) Differences of 6–10 mm considered clinically meaningful | Fine [58], US | 45 (child) 35 (adult) | A higher proportion of adults with RDEB reported an average pain severity of greater than 5 points (26%) than adults with EBS (18%), DDEB (8%), but a lower proportion than adults with JEB (33%); significance not reported A higher proportion of children with RDEB reported an average pain severity of greater than 5 points (32%) than children with EBS (19%), DDEB (14%), or JEB (15%); significance not reported |
Jeon [59], South Korea | 13 | Patients with RDEB reported a higher mean score on the VAS-pain (6.54 [SD, 1.56]) than patients with herpes zoster (5.20 [1.61]) or oral lichen planus (4.12 [0.36]); significance not reported Patients with RDEB reported a similar but slightly lower mean score on the VAS-pruritus (7.54 [2.07]) than patients with prurigo nodularis (8.0 [1.7]), chronic urticaria (7.9 [1.44]), and atopic dermatitis (7.9 [2.2]) |
Functioning and social activities
Impact on families and caregivers
Economic burden
Direct costs and healthcare resource use
Citation, study design | Country | Patient population | Sample size, N | Cost per patient per yeara | Cost year | Definition |
---|---|---|---|---|---|---|
Dressing costs | ||||||
Jeon [59] | South Korea | RDEB | 13 | $4296 | 2016 USDc | Dressings, fixing materials, topical agents and medicines used during changes |
Patient surveyb | ||||||
Mellerio [62] | United Kingdom | RDEB | 40 | $9049 | 2016 GBPc | Cost of dressing |
Patient and caregiver surveyb | RDEB, severe | 17 | $17,151 | Cost of dressings | ||
RDEB | 11 | $15,293 | Cost of hours spent dressing wounds | |||
Grocott [76], single-center, cross-sectional surveyb | United Kingdom | RDEB, with wounds difficult to manage with conventional dressings | 11 | $28,727 | 2012 GBP | Dressing materials, costs estimated via monthly dressing orders |
Kirkorkian [77], | United States | RDEB, neonate | NA | $4,000–$47,000 | 2014 USD | Cost of wound care products obtained from Amazon.com (August 2012 prices) based on body-size |
Cost exercise model | RDEB, infant | $8,000–$99,000 | ||||
RDEB, 10 year old | $20,000–$245,000 | |||||
Flannery [78], Patient surveyb | Ireland | EB | 5 (4 RDEB) | $32,256 | 2020 EURc | Median wound and drugs cost |
Medical, non-dressing-related costs | ||||||
Jeon [59], Patient surveyb | South Korea | RDEB | 13 | $3096 | 2016 USD | All RDEB expenses excluding dressing costs |
Mellerio [62], Patient and caregiver surveyb | United Kingdom | RDEB | 10 | $1249d | 2016 GBPc | Cost per hospital stay, assuming ₤212 per day |
Flannery [78], Patient surveyb | Ireland | EB | 5 (4 RDEB) | $84,534 | 2020 EURc | Median total medical costs |
$33,679 | Median overnight hospital costs, assuming €813 per night | |||||
$2890 | Median day clinic costs, assuming €407 per visit | |||||
$1304 | Median other primary care costs, including GP visits, physiotherapy, occupational therapy, public health nurse visits |
Non-direct medical costs
Frequency of dressing changes
Duration of dressing changes
Bruckner [53] | Jeon [59] | Shayegan [79] | |
---|---|---|---|
N, patients with RDEB | 53 | 13 | 90 |
Definition | Whole body wound care including preparation and cleanup | Dressing change | Dressing change |
Time required for dressing change, n (%) | |||
< 2 h | 19 (36) | 11 (85) | NR |
2–3 h | 21 (40) | 2 (15) | 27 (30)a |
> 4 h | 13 (25) | 0 (0) | NR |