Overview of Epidermolysis Bullosa

Epidermolysis bullosa is a group of rare diseases that cause the skin to be fragile and to blister easily. Tears, sores, and blisters in the skin happen when something rubs or bumps the skin. They can appear anywhere on the body. In severe cases, blisters may also develop inside the body, such as in the mouth, esophagus, stomach, intestines, upper airway, bladder, and genitals.

Most people who have epidermolysis bullosa inherit a mutated (changed) gene from their parents. The gene mutation changes how the body makes proteins that help the skin bind together and remain strong. If you have epidermolysis bullosa, one of these proteins does not form correctly. The layers of the skin do not bind normally, making it easy for the skin to tear and blister.

The primary symptom of epidermolysis bullosa is fragile skin that leads to blistering and tearing. The symptoms of the disease usually begin at birth or during infancy and range from mild to severe.

There is no cure for the disease; however, scientists continue to research possible treatments and cures for epidermolysis bullosa. Your doctor treats the symptoms, which may include managing pain, treating wounds caused by the blisters and tears, and helping you cope with the disease.

Who Gets

Who Gets Epidermolysis Bullosa?

Anyone can get epidermolysis bullosa. It occurs in all racial and ethnic groups and affects males and females equally.


Types of Epidermolysis Bullosa

There are four major types of epidermolysis bullosa. The skin has a top or outer layer, called the epidermis, and a dermis layer that is underneath the epidermis. The basement membrane is where the layers of skin meet. Doctors determine the type of epidermolysis bullosa based on the location of the changes in the skin and the gene mutation identified. The types of epidermolysis bullosa include:

  • Epidermolysis bullosa simplex: Blisters occur in the lower part of the epidermis.
  • Junctional epidermolysis bullosa: Blisters occur in the top portion of the basement membrane, due to problems in attachment between the epidermis and basement membrane.
  • Dystrophic epidermolysis bullosa: Blisters occur in the upper dermis due to problems in attachment between the basement membrane and the upper dermis.
  • Kindler syndrome: Blisters happen in multiple layers of the skin, including the basement membrane.

Researchers have identified more than 30 subtypes of the disease, which are groupings under the four major types of epidermolysis bullosa. By knowing more about the subtypes, doctors can focus treatment of the disease.  

A fifth type of the disease, epidermolysis bullosa acquisita, is a rare autoimmune disorder that causes the body’s immune system to attack a certain type of collagen in the person’s skin. Sometimes, it happens with another disease such as inflammatory bowel disease. Very rarely, a medication causes the disease. Unlike the other types of epidermolysis bullosa, the symptoms may begin at any age, but many people develop symptoms during middle age.


Symptoms of Epidermolysis Bullosa

The symptoms of epidermolysis bullosa vary depending on the type you have. Everyone with the disease has fragile skin that blisters and tears easily. Other symptoms, by type and subtype, include the following.

  • Epidermolysis bullosa simplex is the most common form of the disease. People who have a mild subtype develop blisters on the palms of the hands and soles of the feet. In other more severe subtypes, the blisters occur over the entire body. Depending on the subtype of the disease, other symptoms may include:
    • Thickened skin on the palms of the hands and soles of the feet.
    • Rough, thickened, or absent fingernails or toenails.
    • Blisters inside the mouth.
    • Changes in the pigmentation (color) of the skin.
  • Junctional epidermolysis bullosa is usually severe. People who have the most serious form can have open blisters on the face, trunk, and legs, which may become infected or cause severe dehydration due to fluid loss. Blisters also can develop in the mouth, esophagus, upper airway, stomach, intestines, urinary system, and genitals. Other symptoms and problems related to the disease may include:
    • Rough and thickened or absent fingernails and toenails.
    • Thin appearance to the skin.
    • Blisters on the scalp or loss of hair with scarring.
    • Malnutrition resulting from poor intake of calories and vitamins due to blistering in the mouth and gastrointestinal tract. 
    • Anemia.
    • Slow overall growth.
    • Poorly formed tooth enamel.
  • Dystrophic epidermolysis bullosa has slightly different symptoms, depending upon whether the disease is dominant or recessive; however, most people have the recessive subtype.
    • Recessive subtype: Symptoms vary from mild to severe and may include:
      • Blisters usually appear over large areas of the body; in some milder cases of the disease, blisters may only appear on feet, elbows, and knees.
      • Loss of nails or rough or thick nails.
      • Skin scarring, which may cause the skin to be thick or thin.
      • Milia, which are small white bumps on the skin.
      • Itching.
      • Anemia.
      • Slow overall growth.

Severe forms of the recessive subtype may lead to eye damage, tooth loss, blistering inside the mouth and gastrointestinal tract, and fusing together of the fingers or toes. There is also a high risk of developing skin cancer. This cancer tends to grow and spread faster in people with epidermolysis bullosa than in those without the disease.

    • Dominant subtype: Symptoms may include:
      • Blisters only on the hands, feet, elbows, and knees.
      • Change in shape of nails or nail loss.
      • Milia.
      • Blisters inside the mouth.
  • Kindler syndrome does not have any subtypes, and the blisters can form in all layers of the skin. The blisters usually appear on the hands and feet and, in severe cases, spread to other areas of the body, including the esophagus and bladder. Other symptoms include thin, wrinkled skin; scarring; milia; and sensitivity of the skin to sun damage.


Causes of Epidermolysis Bullosa

Mutations (changes) to genes that you inherit from your parents cause most forms of epidermolysis bullosa. Genes carry information that determines which features are passed to you from your parents. We have two copies of most of our genes—one from each parent. People with the disease have one or more genes that carry the incorrect instructions to make certain proteins in the skin.

There are two types of inheritance patterns:

  • Dominant, which means you inherit one normal copy and one copy of the gene that causes epidermolysis bullosa. The abnormal copy of the gene is stronger or “dominant” over the normal copy of the gene, causing the disease. A person with a dominant mutation has a 50% chance (1 in 2) of passing on the disorder to each of his or her children.
  • Recessive, which means that your parents do not have the disease, but both parents have an abnormal gene that causes epidermolysis bullosa. When both parents carry the recessive genes, there is a 25% chance (1 out of 4) per pregnancy of having a child with the disease. There is a 50% chance (2 out of 4) per pregnancy of having a child who inherits one abnormal recessive gene, making them a carrier. If one parent has a recessive mutation of the gene, all their children will carry an abnormal gene but will not necessarily have epidermolysis bullosa.

Researchers know that epidermolysis bullosa acquisita is an autoimmune disease, but they do not know what causes the body to attack the collagen in a person’s skin. Sometimes, people with autoimmune inflammatory bowel disease also develop epidermolysis bullosa acquisita. Rarely, medications cause the disease.


Diagnosis of Epidermolysis Bullosa

Doctors usually diagnose epidermolysis bullosa by:

  • Asking about family and medical history, because most types of epidermolysis bullosa are inherited.  
  • Completing a physical exam and closely examining the skin, which can help doctors identify where the skin is separating to form blisters.
  • Performing a skin biopsy and reviewing the tissue sample using special microscopic techniques, which helps doctors identify which layers of the skin are affected and determine the type of epidermolysis bullosa you have.
  • Ordering genetic testing to identify specifically which gene mutations you may have. This helps doctors diagnose the specific type and subtype of the disease. People who have genetic testing should see a specialist or genetic counselor to help them understand the test results.  


Treatment of Epidermolysis Bullosa

There is no cure for epidermolysis bullosa. The goals of treatment are to prevent and control symptoms by:

  • Managing pain and itch.
  • Protecting skin and caring for blisters and wounds.
  • Treating and preventing infection.
  • Maintaining or restoring mobility.
  • Maintaining good nutrition.

Managing Pain and Itch

Your doctor may recommend a pain medication to help manage pain due to blisters and open wounds on the skin or in other areas of the body.

Some types of epidermolysis bullosa cause itching. To help prevent scratching, which can cause fragile skin to tear, your doctor may prescribe medications to help control itch.

Protecting Skin and Caring for Blisters and Wounds

Skin care is an important part of treating epidermolysis bullosa. Because the blisters can be large, it is important to care for the blisters and wounds to help prevent loss of body fluid from the blister and prevent infection of any wounds.

Changing bandages is an important step in protecting the skin and caring for blisters and wounds. Your health care team will give you directions on changing the bandages. When possible, use non-adhesive bandages. Sometimes, bandages still stick to the skin. If this happens, your doctor may recommend soaking the area in warm water to help loosen the bandages. 

Treating and Preventing Infection

Some wounds and blisters can become infected. To treat infection, your doctor may prescribe oral or topical antibiotics. Wounds that are not healing may require medicated coverings or bandages.

You can help lower the chance of developing an infection by staying as healthy as possible by:

  • Washing your hands before providing skin care or changing dressings.
  • Applying topical antibiotic creams as recommended by your doctor.
  • Staying healthy by eating a nutritious diet and following your doctor’s recommendations.

Even if you take precautions, an infection may still develop. If you see any signs of infection, including increased redness, increased pain in a skin lesion, red streaks coming from the wound or blister, pus, or fevers, contact your doctor right away.

Maintaining and Restoring Mobility

For some people, scarring can create contractures (abnormal tightening and shortening of muscles, tendons, or ligaments). This may happen in the hands and feet and limit your ability to move or use those muscles. A physical or occupational therapist can help improve, restore, or maintain your ability to move. 

Maintaining Good Nutrition

Some people with epidermolysis bullosa may have blisters in the mouth, esophagus, and intestines, making it difficult to chew, swallow, and digest foods and drinks. Your health care provider may refer you to a dietician to help identify recipes and foods that are nutritious and easy to consume. Some options may include:

  • Soft foods that are easy to chew and swallow.
  • Foods that are warm or cool; you should avoid hot foods and drinks.
  • Foods that help prevent constipation or diarrhea.

Some people may need additional treatments to treat and correct problems from epidermolysis bullosa.

  • If you develop anemia, your doctor may recommend specific treatments to manage the complication.
  • If scarring causes narrowing in the body, such as the esophagus or urinary tract, surgery can widen and open up the passageways. 
  • People who are not getting proper nutrition may need surgery to insert a tube that provides a direct access for food to go directly into the stomach.
  • Some scarring can cause fingers or toes to fuse together. If this happens, surgery may be needed to release them.

Who Treats

Who Treats Epidermolysis Bullosa?

You may see one of the following specialists:

  • Dermatologists, who specialize in conditions of the skin, hair, and nails.
  • Clinical geneticists, who diagnose and treat children and adults with genetic disorders.
  • Nurse educators, who specialize in helping people understand their overall condition and set up their treatment plans.
  • Occupational therapists, who teach how to perform activities of daily living safely.
  • Pediatricians, who diagnose and treat children.
  • Physical therapists, who teach ways to build muscle strength while keeping the skin protected.
  • Primary care physicians, who diagnose and treat adults.
  • Registered dietitians, who teach about nutrition and meal planning. 

Living With

Living With Epidermolysis Bullosa

Living with epidermolysis bullosa can be hard; however, taking steps to care for your skin to help prevent blisters from forming and getting help to cope can help.

To minimize friction, and to stop tears and blisters from forming, your health care team may recommend the following:

  • Keep your skin cool. Never apply anything hot to the skin, and avoid using water warmer than your body temperature when bathing.
  • Wear loose-fitting, soft clothing to avoid rubbing against the skin or causing friction.
  • Avoid overheating by keeping rooms at a cool, even temperature.
  • Apply lotion to the skin to reduce friction and keep the skin moist.
  • Use sheepskin on car seats and other hard surfaces.
  • Wear mittens at bedtime to help prevent scratching while asleep.

Managing and caring for epidermolysis bullosa may be hard. You may find it helpful to find a community or online support group. Some people may find it helpful to speak to a mental health professional about coping with the disease.  

Research Progress

Research Progress Related to Epidermolysis Bullosa

The NIAMS supports translational and clinical research at universities and other organizations throughout the country who are studying epidermolysis bullosa to understand better the cause and treatments, in hopes to prevent and cure the disease. Topics include:

  • Studying the genes and their effect on the skin and its different layers.
  • Researching new medications to help treat the disease.  
  • Exploring the use of stem cells to treat the disease.
  • Looking at healthy skin for clues as to why development goes wrong to cause diseases.

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