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Pain care for patients with epidermolysis bullosa: best care practice guidelines



Inherited epidermolysis bullosa (EB) comprises a group of rare disorders that have multi-system effects and patients present with a number of both acute and chronic pain care needs. Effects on quality of life are substantial. Pain and itching are burdensome daily problems. Experience with, and knowledge of, the best pain and itch care for these patients is minimal. Evidence-based best care practice guidelines are needed to establish a base of knowledge and practice for practitioners of many disciplines to improve the quality of life for both adult and pediatric patients with EB.


The process was begun at the request of Dystrophic Epidermolysis Bullosa Research Association International (DEBRA International), an organization dedicated to improvement of care, research and dissemination of knowledge for EB patients worldwide. An international panel of experts in pain and palliative care who have extensive experience caring for patients with EB was assembled. Literature was reviewed and systematically evaluated. For areas of care without direct evidence, clinically relevant literature was assessed, and rounds of consensus building were conducted. The process involved a face-to-face consensus meeting that involved a family representative and methodologist, as well as the panel of clinical experts. During development, EB family input was obtained and the document was reviewed by a wide variety of experts representing several disciplines related to the care of patients with EB.


The first evidence-based care guidelines for the care of pain in EB were produced. The guidelines are clinically relevant for care of patients of all subtypes and ages, and apply to practitioners of all disciplines involved in the care of patients with EB. When the evidence suggests that the diagnosis or treatment of painful conditions differs between adults and children, it will be so noted.


Evidence-based care guidelines are a means of standardizing optimal care for EB patients, whose disease is often times horrific in its effects on quality of life, and whose care is resource-intensive and difficult. The guideline development process also highlighted areas for research in order to improve further the evidence base for future care.

Peer Review reports


Inherited epidermolysis bullosa (EB) comprises a group of rare disorders, generally thought of as skin diseases. However, EB has multi-system effects and patients present with a number of both acute and chronic pain care needs [1]. Effects on quality of life are substantial [2],[3]. Due to its low prevalence, expertise in pain care for patients with this disease is often restricted to a few specialized care centers. Even then, evidence-based pain care is limited by a near absence of scientific literature specific to EB. This set of guidelines was requested by Dystrophic Epidermolysis Bullosa Research Association International (DEBRA International) to help standardize the approach to pain care for both adult and pediatric patients with EB in all parts of the world. Consequently, a group of clinical pain care experts from a few countries have come together to lend their experience to the limited scientific literature to create these guidelines.

The present guidelines on pain care for patients with EB are based on a review and synthesis of the available literature, guided by expert consensus and thoughtful application of theory. The guidelines are divided into four topics: psychological treatment of pain and pruritus, acute pain, chronic and recurrent pain, and special topics. The Psychological and Integrative Treatments section leads off because the information it contains applies to all the topics that follow. The Acute Pain section focuses on postoperative pain. The Chronic and Recurrent Pain section includes dressing changes, baths, skin pain and joint and other body pains. The Special Topics section includes pain care in infants with EB and pain care at the end of life. While not pain per se, itching is a major source of discomfort [4] and is also discussed.

The aim of the guidelines is to provide the user with information on pain care for children and adults with EB. These guidelines can be applied to all patients diagnosed with hereditary forms of EB. Patients with acquired forms are not included in the guidelines. The guidelines contain two types of guidance. Recommendations are graded and highlighted in text boxes at the end of the manuscript. Good Practice Points are located at the end of each topical section and summarize concepts and best practices, based on the clinical experience of the guidelines development group.

The daily routine of many patients with severe forms of EB will have a number of painful events, each of which may suggest the need for intervention. However, addressing each one pharmacologically may lead to a level of sedation that prevents a meaningful level of productivity. It is important to discuss the needs of the patient and the options for caring for those needs with the patient and family. Together, the patient, family and practitioner can transform the guidelines into an individualized care plan. It is to be expected that each patient’s needs will be dynamic; periodic review of the needs and goals will optimize care at each step of the patient's life.

Of note, the term `EB’ will be used throughout the text. However, four major types of EB are known and are categorized as Simplex (EBS), Junctional (JEB), dystrophic types (DEB) and Kindler Syndrome. A recent consensus statement was released that reclassified the subtypes further based on anatomic location within the skin and pattern of involvement, and discouraged the use of eponyms (with the exception of Kindler Syndrome). EBS is sub-typed as EBS suprabasal and EBS basal, JEB as JEB generalized and JEB localized, DEB as Recessive DEB and Dominant DEB (RDEB and DDEB, respectively) [5]. Additionally, there are at least 18 genes associated with the different types of EB [5]. The proposed new classification does not address the relation to painful conditions, and, thus, the four major types will be referenced throughout the guidelines. There is a wide range of severity within the types. EBS is usually due to autosomal dominant mutations in keratin 5 or 14 or in plectin and is often of milder severity. JEB can result from mutations in any of six different basement membrane components, is inherited as an autosomal recessive disorder, and can range from mild to fatal early in life. DEB can be in a mild dominant form (DDEB) or a more severe recessive one (RDEB), both due to mutations in collagen 7. The recommendations that follow are intended to be generally applicable to all patients with EB who experience pain. The pain conditions vary in prevalence among the types of EB, and readers will find relevant guidelines to apply in the care of the particular pain problems they and their patients face. Resources (for example, particular medications and formulations, trained medical, nursing and therapy personnel) will vary by location, and practitioners and families will, therefore, need to adapt the recommendations based on what is available in their locale. DEBRA International [6] is an optimal facilitating organization that can aid implementation of the guidelines by way of providing information, support and means of contacting expert care providers.


In 2011, a multidisciplinary working group formed to develop best care practice guidelines for pain associated with EB. The group comprised representatives from nursing, medicine and psychology who were expert in the clinical care of patients with EB. Guidelines topics and subtopics were chosen by the multidisciplinary group with input from outside clinicians, based on issues presented in the literature, seen clinically and raised for discussion at DEBRA International Congress meetings. Individuals or small groups were assigned to the various subtopics. After relevant literature was reviewed, preliminary recommendations for each subsection were made. Recommendations were circulated by email among the entire panel of experts for review and input/feedback was incorporated. Initial citations were added or removed as required for accuracy and appropriateness, and criticism made of areas of weakness. Thus, the group formed the first iteration of expert consensus. The revised recommendations were recirculated to the group for review, to establish consensus more firmly. A panel of outside reviewers, comprising both clinicians and patients/families, then reviewed the document for comprehensibility, omissions and applicability.

Following external review (see Acknowledgements for reviewers), funding became available and a subsequent systematic evidence review was conducted by a trained methodologist (author DSL). Clinical questions and the systematic search strategy were developed, based on the guideline topics and subtopics from the working group. The population of interest comprises patients with pain who have any variant of EB. The interventions included, but were not limited to, pharmacological, holistic, psychological, psychical therapy and/or environmental interventions. Outcomes of interest were improvement in symptom control (for example, pain, itch) and level of function.

Systematic literature searches were conducted using MedLine, CINAHL, PsycInfo and The Cochrane Library. Search terms for `epidermolysis bullosa’ and `pain’, `regional anesthesia’, or `nerve block’ were used as medical subject headings and/or keywords in all databases. The search was only limited to articles published in English. No other restrictions, limits or filters were used. Publication dates were not restricted for any topic or subtopic, as the diagnosis is rare and there were few studies of higher level, directly-related evidence (that is, systematic reviews, meta-analyses, randomized controlled trials). Reference lists were searched to identify studies. Studies submitted by the working group and used in the initial consensus processes were also reviewed. The most recent systematic search for pediatric acute, chronic, or recurrent pain management in EB patients was conducted in December 2011.

Citations from the evidence searches were reviewed by title and abstract for potential inclusion, regardless of study design (n = 1,061). Evidence related to the clinical questions from systematic reviews, meta-analyses and RCTs as well as observational studies, case reports and expert opinion articles were reviewed (see Figure 1). A total of 57 references were found and evaluated that were specific to the cross match of EB and the pain-related keywords (see above), of which only 8 were included into specific recommendations. The rationale for including and excluding these references is found in Table 1 and in Additional file 1.

Figure 1

Flow of information through the evidence evaluation process.

Table 1 EB-specific articles used in producing recommendations

All included articles were critically appraised using evidence appraisal forms from the LEGEND (Let Evidence Guide Every New Decision) evidence evaluation system [7],[8]. The methodologist assessed risk of bias in the included studies by evaluating quality for all individual studies by domain and study design. The quality levels for included studies were recorded (see Table 2). The reader will find the evidence level for each article used to directly support each recommendation noted after its citation in the Reference section of the Summary of recommendations (Table 3). Age specificity of each recommendation is also noted. Data were collected on descriptive characteristics of patients, characteristics of the pain management interventions, and associated outcomes of reported pain management interventions. Using the Grade for the Body of Evidence tool in the LEGEND system [7] provided objective criteria for evaluating evidence related to each recommendation (see Table 4).

Table 2 Evidence levels[8]
Table 3 Summary of recommendations
Table 4 Table for judging the strength of a recommendation[8]

Given the paucity of data for statistical analysis, it was deemed appropriate to conduct a face-to-face consensus meeting on 4, 5 May 2012 in Cincinnati, OH. The LEGEND tool for Judging the Strength of a Recommendation (see Table 4) was used as a guide for finalizing recommendation statements by discussing the body of evidence and discussing safety/harm and other dimensions [7]. The overall GRADE (A, B, C, D) for each recommendation statement was then determined, based on this process and the established criteria for GRADE [9],[10].

Updating procedure

The guidelines will be updated every three years after the first version. If new relevant evidence is detected before the update, the information will be published on the web page for DEBRA International that is dedicated to clinical the Pain guidelines [11].

Results and discussion

Psychological and integrative approaches


A biopsychosocial approach emphasizing medical, psychological and physical therapies for pain management has been suggested to be the most useful for adults and children with acute and chronic pain [12]. This approach has also been advocated for EB patients [3] and should be initiated from early in youth and modified with maturation. It is recommended that psychological interventions be used in conjunction with physical and pharmacologic therapies.

Types of therapies

Psychological therapies for pain management have been shown to modify pain intensity, reduce related distress, decrease pain-related functional disability and improve pain coping. Painful experiences amenable to treatment include acute pain related to procedures (for example, whirlpool treatments) or medical routines (for example, bandage changes, bathing), and chronic pain conditions such as headache, abdominal pain or other disease-related conditions. Psychological therapies include cognitive behavioral therapy (CBT), hypnosis, biofeedback and relaxation training, among others. CBT focuses on changing the catastrophic thinking and negative emotions surrounding pain as well as modifying lifestyle to promote wellness behavior despite chronic pain [13]. Hypnosis is a psychological state of heightened awareness and focused attention, in which critical faculties are reduced and susceptibility and receptiveness to ideas are greatly enhanced [14]. Relaxation training usually includes techniques, such as diaphragmatic breathing, muscle relaxation and visualization/imagery, that assist in adaptive coping via distraction, reduced emotional arousal and activation of the parasympathetic nervous system. While these interventions are frequently patient-focused, CBT can also include parent/family training related to behavioral management, reducing caregiver distress and enhancing environmental factors necessary for positive coping [15].

As an adjunct to relaxation training, biofeedback monitors physiological functions (for example, heart rate, muscle tension, temperature) in order to improve control of bodily processes that might ease chronic pain. Frequently, sensors are attached to the skin by adhesive, which is relatively contraindicated in EB. Clip on pulse oximeter probes can be safely used in patients with EB to track heart rate, and provide an alternative method of biofeedback.

Efficacy of psychological interventions in chronic and acute pain management

Psychological therapies have been shown to be effective in decreasing pain intensity and frequency in other pediatric chronic pain conditions [16],[17] with emerging evidence showing improvement in pain-related functional disability as well [17],[18]. The addition of biofeedback to relaxation training does not necessarily result in superior pain outcomes [17]. Modest data support the use of CBT in adults with chronic pain and disability [19] (see Box 1).

Psychological interventions are useful for the management of acute pediatric pain (see Box 1) although evidence for their efficacy varies depending on the type of pain. For procedure related pain, particularly needle procedures, distraction, hypnosis and CBT are effective, evidence based interventions [20]-[24].

In a review of non-pharmacological treatments to reduce the distress due to acute wound care in burn patients, some evidence has been shown that healthcare provider interventions (massage and maximizing patient control and predictability), child interventions (for example, virtual reality gaming [25] and therapist coaching of stress management techniques [26]) are beneficial.

For postoperative pain, there is insufficient evidence for the efficacy of most psychological interventions, but preparation, guided imagery and CBT are promising [27].

Psychological interventions for itch

Patients with EB may experience severe itch, which not only intensifies their suffering but can also be a source of social embarrassment secondary to the appearance of the excoriated skin and the preoccupation with scratching in social situations. Beyond this, damage of the integrity of the skin can create a portal of entry for systemic infections. Regardless of the underlying cause, itch evokes the behavior of scratching that increases inflammation and stimulates nerve fibers, leading to more itching and scratching [28]. Perpetuation of the itch-scratch cycle alters the integrity of skin leading to barrier damage. Scratching also causes undesirable changes in skin, such as lichenification and prurigo nodule formation. Successful treatment of itch requires interruption of this cycle. Non-pharmacological treatments, such as CBT, hypnosis, meditation, prayer, biofeedback and eye movement desensitization and reprocessing (EMDR), have been used with some success in both adults and children with conditions such as atopic dermatitis [29]. Habit reversal is a specific behavioral intervention whereby habitual behaviors are brought into conscious awareness and specific behavioral techniques are developed as a competing response to the urge to itch [30],[31] (see Box 1). In practice, this technique is frequently combined with CBT and relaxation as part of a treatment package applicable to patients of all ages [29],[32].

Integrative medicine therapies

Complementary and alternative medicine (CAM) practices constitute therapies that are often requested by patients and families for a variety of chronic pain conditions. This class of treatments includes, but is not limited to: acupuncture, meditation, massage, herbal preparations, yoga and chiropractic work. The evidence for therapies such as acupuncture [33], music therapy [34], chiropractic care, or yoga [35] is modest in the pediatric and adult pain populations, with no specific studies in EB. Prima facie evidence would suggest that massage and chiropractic interventions might be harmful given the skin fragility and the osteopenia that is often seen in EB. With regard to herbal supplementation, one of the chief side effects for a number of these preparations is bleeding, although the evidence is not clear [36]. Thus, this treatment may be contraindicated in patients having surgery, open wounds or a history of gastrointestinal tract bleeding. The active ingredients in the herbal preparations may also have interactions with any other prescribed medication; attention to potential drug-drug interactions should be considered.

Good practice points

Assessment of the suitability of psychological therapies for EB patients experiencing chronic and acute pain should always take into account developmental issues including age, cognitive level and psychopathology [37]. Include parents in behavioral pain management interventions [38] for children and adolescents.

Acute pain care: postoperative pain management


As a multisystem disorder, EB causes a variety of disruptions to body systems that are amenable to surgical intervention. While there are no controlled trials of postoperative pain therapies in EB, general principles of pain care apply.


As for all patients, pain should be regularly assessed, and then reassessed after intervention to evaluate analgesic efficacy and detect side effects. Numeric rating scales have been shown to be effective for children of a developmental level above eight years who can verbalize their pain scores as well as for adults. Pain assessment in younger or nonverbal patients can be completed using the Face Legs Arms Cry Consolability (FLACC) and Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) [39],[40] augmented by reports of parents or other close family care-givers.

Systemic therapies

Analgesic treatment starts before and during surgery and includes the use of opioids, non-steroidal anti-inflammatory drugs, acetaminophen and, when appropriate for the type of surgery, regional anesthesia [41],[42]. Patient controlled analgesia (PCA) technology is a safe and useful way to deliver opioids to patents of all ages with EB, as it is for non-EB patients (see Box 2).

In the postoperative period, EB patients may be slow to resume oral intake, especially after oropharyngeal procedures, such as esophageal dilatation or dental rehabilitation. For patients lacking gastrostomy tubes, intravenous analgesia may be required. Intravenous analgesia should be multimodal and may include opioids (for example, morphine or hydromorphone), nonsteroidal anti-inflammatory drugs (NSAIDS; when postoperative bleeding is not a risk and renal function is normal (for example, ketorolac)) and acetaminophen (enteral or intravenous). Given the high rate of superficial bleeding from skin wounds, cyclooxygenase-2 inhibitors may have a role to play, given they have prothrombotic features in some studies [43]. Due to the risk of blister formation with rectal manipulation, there is controversy regarding whether the rectal route of administration may be used in EB patients [44]. Intranasal opioids can be effective for short-term treatment, if other routes are not available [45]-[47], and may be particularly helpful for procedures of short duration when rapid-acting analgesia is desired in the absence of intravenous access. Oral disintegrating and trans-buccal formulations may be helpful as well, although they presume intact mucosa, which may not be applicable (see Box 2).

Patients with prolonged postoperative pain because of extensive surgery may benefit from the use of opioid-based PCA with dose adjustments that take into consideration prior opioid use. While no EB-specific literature exists, this modality is standard treatment in many centers for patients old enough to understand the concept (typically seven years of age or older). Activation of the dosing button may be limited by pseudosyndactyly, so use should be determined on a case-by-case basis. PCA-by-proxy (dose administered by a nurse or designated family member) is practiced in some pediatric centers and may be an alternative approach to PCA dosing for children.

Preoperative tolerance

The preoperative pain status of the patient should be taken into consideration when choosing opioid dose, both intra- and post-operatively. Many EB patients have recurring acute and/or chronic pain and may be taking opioids daily, either prior to bathing/dressing changes or for ongoing pain. These patients require increased doses of opioids for adequate analgesic effect, due to the development of tolerance. Their usual daily opioid intake should be considered the baseline opioid dose to which the postoperative analgesia should be added (see Box 2). Drug pharmacokinetics may be altered in patients chronically exposed to sedatives and opioids. Flexibility in dosing, review of prior anesthetic records and discussion with the patient or family can aid appropriate dosing.

Regional anesthesia

Some common procedures (and the corresponding regional anesthesia technique used) in EB patients include: fundoplication (epidural) [48]-[50], hand and foot surgery (peripheral nerve block, either single shot or continuous peripheral nerve catheter infusion following bolus injection) and hand surgery (both axillary and infraclavicular approaches have been used for brachial plexus block) [51],[52].

Regional anesthesia techniques should be modified in patients with EB to minimize damage to the skin. Skin preparation may be performed by pouring prep solution (povidone-iodine or chlorhexidine) on the site without rubbing, then blotting and allowing the solution to dry. Ultrasound guidance can be used for peripheral nerve blocks with generous use of gel to minimize skin abrasion when moving the probe. When a catheter is placed (epidural or peripheral nerve), it may be tunnelled subcutaneously if desired [53] then secured to the skin using silicone-based tapes and dressings (Mepitac®, Mepitel®, Mepilex®) or other soft non-adhesive dressings. Adhesive dressings and adhesive adjuncts should be avoided. If there is any doubt about the safety of using a dressing, it should be tested on a small area of skin with patient or parental consent. With local infection being a relative contraindication to regional anesthesia, examination of the skin overlying the point of entry is mandatory prior to attempting a catheter placement. If leaving a catheter in the epidural space is undesirable, then a single injection of a long-acting form of opioid (DepoDur®) may be a good option when available [54],[55], although monitoring is important due to risk of hypoventilation [56]. Lidocaine infiltration may be used by dentists/oral surgeons when extractions are necessary, but care must be taken when injecting to avoid mucosal blister formation (see Box 2).

Non-pharmacologic therapies

Non-pharmacologic techniques should also be employed in combination with the pharmacologic techniques listed above. These include, but are not limited to, distraction (music, reading, video games and movies), visualization, imagery/virtual reality and breathing techniques (see Efficacy of Psychological Interventions in Chronic and Acute Pain Management, above and Box 1). Effective approaches used in the past should be discussed with the patient or parents and their use supported whenever possible.

Good practice points

Postoperative pain can be managed as for other patients in the same setting, with modifications to account for the ability to self-administer medications, prior drug exposure, and the condition of the skin at potential regional anesthesia injection/catheter sites.

Chronic and recurrent pain care

EB has a large number of painful complications, some chronic and others acute but repetitive. Care of EB involves painful interventions on a daily basis. Almost every organ system can be affected, but the following are the major sources of pain: skin, gastrointestinal tract, musculoskeletal system, eyes.

Skin and wound pain


The classic presentation of EB is the development of skin wounds that are painful in their own right, but which often become infected, heal poorly and frequently lead to scarring. This combination makes skin and wound pain a prominent complaint of patients with EB.

Environmental and behavioral approaches

Dressings that are non-adhesive upon removal, such as silicone-based products, are helpful in reducing skin-trauma pain. Different subtypes of EB and different individuals seem to have varying dressing requirements [57]. Nutrition is important in promoting wound healing, and anecdotally, patients with poor nutritional status have more wounds and slower healing, which lead to increased pain. Experience suggests that attention to good nutrition, surveillance for superficial infection and aggressive treatment of infection reduce pain. As discussed in the section on psychological interventions, CBT is helpful for a number of painful conditions and should be applied in EB.

Systemic approaches

The pharmacological treatment of skin and wound pain is non-specific, with no evidence in the EB population to promote one treatment over another. NSAIDs, acetaminophen, tramadol and opioids are used with success. Cannabinoids have some anecdotal support. Itch is a major problem (see below) that can lead to increased scratching and subsequent development of painful wounds. Hence, managing pruritus is important to prevent wound-related pain.

Many patients with severe types of EB use long-acting opioid preparations to provide a basal comfort level. Of note, there are no clear guidelines that long-acting opioids are preferable to use of intermittent opioids for non-cancer pain [58], although there is modest evidence for opioid use, in general, for non-cancer pain in adults [58],[59]. Individualization of therapy is recommended.

Regular and frequent dosing of opioids is common and merits special attention. Regardless of the opioid chosen, chronic use of opioids may have endocrinologic effects, such as hypogonadism [60]. Monitoring should be considered, especially given the propensity for osteopenia and delayed puberty in adolescents and young adults with EB. In the absence of data, the use of opioids is recommended as clinically indicated (see Box 3).

Methadone merits particular consideration. Dose titration can be unpredictable due to long and variable half-life as well as to saturable plasma protein binding [61]. The long and variable half-life, as well as the risk of methadone-induced prolonged QT syndrome [62],[63], mandates care in its use alone and with other drugs that may also prolong the QT interval. Guidelines on electrocardiographic screening are limited [64] (especially for adult patients of smaller stature and children). Given the risk of prolonged QT and methadone’s complex and variable pharmacokinetics, it is recommended that methadone only be prescribed by practitioners with experience evaluating and monitoring its use [65]. Methadone use is, therefore, best done with input from a pain management and/or palliative care specialist.

Among the common side effects of opioids, constipation [66] and pruritus are particularly significant. Both are significant baseline problems in EB and the reader is referred to the sections on gastrointestinal pain and pruritus.

The pain of extensive wounds has a quality suggestive of neuropathic pain; both are often described as `burning’ in quality. There is evidence supporting the use of gabapentin for neuropathic pain in other conditions [67]. Medications such as tricyclic antidepressants and gabapentin have shown anecdotal success in EB skin pain in a child [68], as well as for adult patients with acute skin pain due to burns [69]. The potential for tricyclic antidepressants to prolong the QT interval means that caution should be taken using this class of medications in RDEB patients, who are at risk for developing cardiomyopathy [70], as a lethal outcome in this setting has been reported [71].

Topical approaches

For localized wounds, topical lidocaine jelly (2% concentration) has been used anecdotally. Morphine mixed in hydrogel formulations has been used in different types of localized painful wounds [72],[73] but has only limited anecdotal experience in EB wounds [74] (see Box 3). Use of these medication vehicles raises questions of absorption and systemic effects that require further investigation before full recommendations can be made. Limited anecdotal evidence supports the use of keratinocyte hydrogel dressings for poorly healing wounds and RDEB [75].

Blood draws and intravenous access as well as the need for skin biopsies are minor technical procedures that can be very distressing, especially for children. Topical anesthetics are commonly used in non-EB populations with good effect. Amethocaine appears to be more effective than a eutectic mixture of local anesthetics (EMLA®) [76]. These may have a role when applied to intact skin, but cannot be recommended for use on wounds due to unknown rate and extent of absorption of lidocaine. Blistering as a localized allergic reaction to EMLA® (or its contents) has been rarely observed, indicating caution in its use even on intact skin. Lidocaine injected with a small gauge needle is a standard approach to superficial analgesia in all age groups. Additionally, it is recommended that bicarbonate be added to buffer the pH of the lidocaine to reduce the pain of injection [77]. As noted above, CBT (for example, distraction and relaxation) is effective in the acute pain setting [21] and should be employed whenever possible in conjunction with medication management (see Box 1).

Good practice points

Prevention and rapid healing of wounds through non-adherent dressings, optimal nutrition and infection control are priorities.

Bathing and dressing changes


Bathing and bandage changes are a source of significant recurrent pain and anxiety for patients with EB.

Environmental treatment

Oatmeal and salt have been added to bath water to reduce the pain of immersion [78]. The former may have anti-pruritic, cleansing and protective properties for dermatologic conditions in general [79] that may be similarly effective in EB. Salt is added to make the water isotonic, which has anecdotal support from many families of patients with EB including preliminary survey data from EB families [80]. Isotonic saline (0.9% NaCl) is 9 grams of salt/1 liter of water; total amount of salt varying according to the desired water volume. Bleach and vinegar are anecdotally helpful in drying the skin and reducing bacterial colonization, which some patients find comforting while others report increased pain at the wound sites. The salt water does not require plain water rinse, whereas vinegar and bleach baths require rinsing to reduce the risk of itch. Many patients elect to reduce the frequency of bathing as a simple measure to minimize bath-related pain. Anecdotally, starting the bath by immersing the patient still in his/her bandages can ease the transition into the water and help reduce the pain of removing the dressings. Other patients find drafts from heating and cooling systems to be painful on open wounds, so attention to general environmental factors is recommended (see Box 4).


Analgesics used by patients with EB have included enteral opioids, NSAIDs and acetaminophen. The nasal route may permit administration of medications when intravenous access is absent [81]. Fentanyl works well by this route for non-EB patients in the perioperative setting [45], for breakthrough cancer pain (see section on Breakthrough pain medication at the end of life) and has been used for acute pain management in the emergency department with success [46]. Butorphanol is a mixed agonist-antagonist that can be used via the intranasal route and is effective both for pain (for example, dental postoperative pain [47]) as well as for opioid-induced pruritus. Fixed dose spray is available for outpatient use in the United States, which limits the ability to adjust for patient size. Timing of medication administration should be adjusted to match expected peak analgesia with anticipated peak pain (see Box 4).

Ketamine can be administered enterally for wound care pain, for which there are data from adult and pediatric burn populations [82],[83] but not for EB patients. The IV form of ketamine given orally has been used with variable success for other chronic pain conditions [84] as well as in cancer patients [85] and in pediatric palliative care [86].

Inhaled nitrous oxide has been suggested for pediatric wound care in EB in some texts and review articles [44],[87], but its use in EB patients has not been studied or reported. Nitrous oxide has been used for painful procedures in other settings [88] and is available in both fixed 50:50 and variable combinations with oxygen. Depending on the delivery system (mouth piece, face mask, or nasal mask) concerns arise about environmental pollution and exposure of health care personnel [89]. In the absence of evidence of efficacy, concern must be raised about repeated use for wound care or dressing changes because of longstanding evidence of megaloblastic bone marrow changes and neurologic abnormalities due to inhibition of methionine synthase and cobalamin activity with repeated exposure to nitrous oxide [90],[91].


The pain caused by baths and dressing changes is commonly cited by families as generating anxiety in the patient, which in turn is stressful for the caregiver. Medications used for acute anxiolysis in this population include midazolam, diazepam and lorazepam and are considered good treatment for acute anxiety in other populations (for example, children for dental procedures, [92],[93]; prior to adult burn procedures [94]). In addition to anxiolysis, the pre-procedural use of benzodiazepines offers the possibility of anterograde amnesia which may prevent the development of increased anxiety with repeated procedures. When using benzodiazepines in combination with opioids, care must be taken to avoid over sedation (see Box 4). As response to each medication will have individual variation, dose adjustments should be made carefully and preferably one drug at a time, when more than one is being administered.

Other behavioral comfort measures

In addition to medication management, recommendations from caregivers include preparing all materials ahead of bandage removal to reduce the amount of time wounds are exposed to air. Involving children in the process at as early an age as possible helps them to develop a sense of control. Maintaining room temperature at a moderately warm level has also been recommended. CBT can be applied to treating the anxiety and pain associated with bathing and bandage changes (see section on psychological approaches, above).

Good practice points

Bathing and dressing changes are recurrent sources of both pain and anxiety. Therapy should focus on both symptoms, using environmental, psychological and pharmacologic approaches.

Pain related to the gastrointestinal tract


Gastrointestinal complications are common in children and adults with EB with specific complications linked to different subtypes [95]-[97].

Upper gastrointestinal tract

Topical treatments

Oral ulceration, blistering and mucositis are the most frequent gastrointestinal complications in patients with EB [98]. While oral ulceration can occur in all types of EB, it is most common and problematic in patients with the severe types of this disease. Oral ulceration can be extremely painful and lead to difficulties in feeding and maintaining dental hygiene. Apart from oral analgesics, topical preparations are available. Sucralfate suspension has been used to prevent and manage oral blisters in five children, 6- to 11-years-old, with RDEB when applied four times a day for six months [99]. The number of blisters reduced within three weeks and pain reduced within one week (see Box 5).

Polyvinylpyrrolidone-sodium hyaluronate gel (Gelclair®) either used as a mouth rinse or applied directly to a mouth lesion in children, has been used anecdotally in EB. Secondary evidence comes from two recent reviews which showed that Gelclair® may be useful as an adjunctive therapy in decreasing the painful lesions of oral mucositis in cancer patients [100],[101]. Chlorhexidine gluconate and benzydamine hydrochloride mouth spray is used regularly in EB patients at the London centers with reported benefit but has not been evaluated systematically. Secondary evidence for the potential efficacy of this intervention exists for treating the pain of acute viral pharyngitis in adults [102].

Gastroesophageal reflux

Patients with EB are at high risk for gastroesophageal reflux disease (GERD) - especially infants with generalized EBS, JEB and patients with severe generalized RDEB who can develop esophagitis [95]. While children with GERD may not complain of dyspeptic symptoms until they are older, crying and sleep disturbance are commonly associated with this symptom. Management is guided by standard treatment in non-EB patients, and may involve treating the reflux with antacids, histamine H2-blockers and proton pump inhibitors and, rarely, surgery [103],[104] (see Box 5).

Esophageal strictures

Esophageal stricture formation and dysphagia are most common in patients with severe generalized RDEB with a cumulative risk of developing strictures or stenosis rising steadily from 6.73% at age 1 year to 94.72% at age 45 years [105]. However, strictures can also be seen in other subtypes of EB including Kindler syndrome [106]. Dysphagia and delayed progression of food through the stricture can present with retrosternal chest pain. Esophageal strictures, if symptomatic, require treatment with a fluoroscopically guided balloon dilatation with peri- and post-operative steroids administered to reduce the recurrent stenosis rate [107]-[109] (see Box 5). Acute symptoms can respond temporarily to oral dexamethasone or nebulized budesonide, based on anecdotal evidence. A recent case report examined the use of daily oral viscous budesonide therapy (0.5 mg/2 mL budesonide nebulizer solution mixed with 5 g of sucralose and maltodextrin) in two children with RDEB who had recurrent proximal esophageal strictures [110]. Both children had a reduction in the rate of stricture formation and symptoms of dysphagia.

Lower gastrointestinal tract


Constipation has been shown to be present in 35% of children with all types of EB [95] and can cause abdominal pain and pain on defecation as well as lead to perianal trauma. A case of colonic perforation and early death resulting from severe constipation in DEB has been described [111]. Chronic perianal pain during defecation can produce stool withholding behavior which exacerbates constipation. Chronic opioid use may contribute to poor bowel motility. First line management is prevention with dietary manipulation; however, patients with severe types of EB often require the regular use of a laxative (see Box 5). Polyethylene glycol is effective clinically in treating constipation in children and adults with EB, with empiric evidence of efficacy in adult [112] and pediatric [113] non-EB cohorts.


A subgroup of children with RDEB may develop colitis, presenting with abdominal pain and other symptoms [95],[114]. Dietary restriction and anti-inflammatory drugs, such as sulfasalazine, have been used but with variable effects on controlling the colitis [95].

Perianal pain

Perianal blistering and ulceration is common and debilitating in children and adults with severe types of EB. Topically, sucralfate has been shown to be superior to petroleum jelly in facilitating anal fistulotomy healing and lessening wound pain [115]. Sucralfate suspension has also been used to lessen the pain of oral and genital ulceration in patients with Behcet's disease [116]. Anecdotally, topical sucralfate combined with Cavilon™ (an alcohol-free liquid barrier film that dries quickly to form a breathable, transparent coating on the skin, containing hexamethyldisiloxane, isooctane, acrylate terpolymer, polyphenylmethylsiloxane) appears to improve pain in perianal lesions of some patients with EB. Non-surgical treatment is of small benefit for both pain and healing of chronic anal fissures [117], with recommendations of topical diltiazem and glyceryl trinitrate followed by surgery if needed in adults [118]. No data on anal fissure treatment in EB patients exist (see Box 5).

Good practice points

EB affects the gastrointestinal tract in its entirety. Pain that originates from ulcerative lesions may respond to topical therapy. GERD and esophageal strictures have nutritional as well as comfort implications and should be addressed promptly when found. Maintaining good bowel habits and reducing iatrogenic causes of constipation are crucial.

Musculoskeletal pain


Musculoskeletal complications are common and frequently painful for patients with EB. These conditions include pseudosyndactyly, osteopenia, back pain, fractures and occasional co-morbid rheumatologic disorders.

Joint pain

Pseudosyndactyly affects hands, feet, ankles and wrists. Painful hyperkeratotic lesions develop on the soles of patients with EBS. Occupational therapy approaches can improve function and decrease pain via use of adaptive equipment and specially designed orthotics and clothing. Physical and occupational therapy play crucial roles in encouraging patient mobility. For weight-bearing patients, careful attention to footwear, nails, orthotics and hyperkeratosis management are important aspects of pain care [119]. Referring patients to programs to maintain or regain strength, to prevent or minimize joint contractures, and to optimize mobility is recommended based on anecdotal evidence (see Box 6). Coping skills training and activity pacing can enhance effectiveness of therapy [120].Surgical intervention has had some success in increasing mobility and reducing pain [121]. EB patients can also have inflammatory arthritis [122],[123]; appropriate imaging can be helpful in determining inflammatory causes of pain. Given that inflammatory markers are usually elevated in EB patients, these markers alone are not likely to be useful to diagnose joint pathology.

Bone pain

Osteopenia, osteoporosis and fractures are now well recognized and commonly seen in patients with the severest types of EB [124]-[126], as a cause of bone and joint pain. The causes are multifactorial and include reduced mobility, delayed puberty, limited exposure of the skin to sunlight, inadequate nutritional intake for metabolic requirements and chronic inflammation. Chronic inflammation causes increased osteoclast activity [127],[128].

As a consequence of the osteoporosis, a significant proportion of patients develop fractures. The incidence of vertebral fractures in patients with RDEB is unknown, but may be underestimated due to the fact that fractures of the lumbar and thoracic spine may be clinically silent, or present without overt or localized back pain on palpation [125]. Anecdotally, however, some patients can present with back pain, in which case a high index of suspicion should be maintained. Treatment of osteoporosis and derivative pain is based upon standard treatment of osteoporosis in non-EB patients, which relies on vitamin D and calcium supplementation, exercise and bisphosphonate treatment [129] (see Box 6).

Anecdotally, bisphosphonates have been found useful in treating patients with evidence of osteoporosis without fracture. Bisphosphonates appear to improve fractures on annual X-rays and lead to a noticeable improvement in pain. Indirect support for the use of bisphosphonates comes from its use in rheumatologic and other pediatric conditions, associated with osteopenia [130],[131] and resolution of back pain [131],[132], but efficacy specifically in patients with EB has not been formally studied.

Back pain

Older patients with EB can have back pain. Beyond osteopenia-related issues, biomechanical causes can be involved. Foot blisters and painful hyperkeratosis can cause abnormal gait and compensatory postures. Further, impaired mobility can add a myofascial component to pain. Management of back pain includes optimal foot care, assessment of primary and secondary mechanical factors, evaluation and treatment of osteopenia and fractures, physical therapy, standard analgesics and CBT interventions. Back pain treatment in the EB population is extrapolated from basic principles recommended for the general population [133], for lack of EB-specific evidence (see Box 6).

NSAIDs are routinely used for bone and joint pain of a variety of types and are appropriate for these types of pain in EB. Care should be taken to monitor for side effects, and the cyclooxygenase-2 inhibitors may be useful in those patients who experience improved pain control but note increasing blood loss from wounds, or who have gastrointestinal upset with standard NSAIDs. Acetaminophen does not affect bleeding and can be useful. Tramadol and opioids are also useful for more severe pain. Some prefer use of long-acting opioid preparations, with methadone being the only one available in liquid form. Limitations in methadone use are discussed in sub-section on systemic approaches under Skin and Wound Pain.

Good practice points

Bone health should be optimized with calcium and vitamin D supplements as needed, maintenance of maximum mobility, minimization of joint deformity and monitoring for/treatment of pubertal delay. Routine screening for bone mineral density may be useful to ascertain cases of osteopenia before they progress to osteoporosis and fractures. Care must be taken not to overlook inflammatory joint disease, as pain secondary to this will respond to disease modifying therapy. Multidisciplinary treatment modalities are helpful in addressing back pain and apply to such pain in the EB population as well.

Eye pain

Ophthalmologic involvement is pervasive in EB [134],[135]. Eye pain is often caused by corneal abrasions. Comfort measures such as avoiding bright light (a natural reaction to the photophobia that results from the trauma), lubricating eye drops, NSAIDs and antibiotic drops have been used. Evidence for these treatments for recurrent corneal abrasions of other etiologies is modest [136]. The use of eye patches in non-EB patients does not aid pain relief and, therefore, is not recommended for use in EB patients either [137]. There is some evidence that topical NSAIDs provide analgesia for acute, traumatic corneal abrasions [138] (see Box 7).

Good practice points

Corneal abrasions are painful and common in EB; prevention and supportive care are appropriate.

Special Topics

Pain care in infants with EB


In the severe forms of EB, pain starts immediately, and great care needs to be taken in most of the activities of daily living. Infants with EB require careful attention to environmental factors at a higher level than for older children but otherwise can receive pain care using guidelines for specific types of discomfort.

Pain assessment

Pain assessment should be completed on all neonates with EB at regular intervals and as needed (see Box 8). A valid neonatal pain scale should be used, considering both physiologic and behavioral measures. Some examples include: the Premature Infant Pain Profile (PIPP) [139],[140], the Neonatal Pain Agitation and Sedation Scale (N-PASS) [141], the Crying, Requires oxygen, Increased vital signs, Expression and Sleepless pain scale (CRIES) [142], and the Neonatal Infant Pain Scale (NIPS) [143]. The Face Legs Arms Cry Consolability (FLACC) scale is recommended for infants between 1 to 12 months [144]. These pain scales have been validated for use by nurses, although training could be generalized to non-nurse care givers and family members. Pain should be reassessed frequently during and after interventions and until comfort is achieved based on a combination of one of the above scales and clinical judgment. Analgesic interventions should match degree or level of pain. Of note, infants, especially neonates, seem to be a higher risk for respiratory compromise [145],[146] due to reduced clearance of opioids in infants younger than two months [147],[148]. Therefore, careful clinical and cardiopulmonary monitoring is crucial when providing opioids to this population (see Box 8).

Procedural pain

As for older patients, procedures are one of the major sources of pain for infants with EB. Wound care specifically requires a multidisciplinary team approach to ensure consistent and optimized pain control. There is evidence that a variety of pharmacologic and non-pharmacologic interventions are helpful in both term and pre-term infants [149]. Therefore, pain management interventions should precede all scheduled painful procedures, such as dressing changes, bathing and venipuncture. The range of analgesics and the routes by which they can be administered are the same as for older patients. Oral sucrose is an analgesic unique to young infants and can be used alone for mild pain (for example, immunization pain [150]) or in conjunction with other analgesics as well as physical and environmental interventions for more severe acute pain [40],[151].

Bathing and dressing changes

To maintain appropriate moisture levels and facilitate the healing of wounds, dressings should be non-adherent as for older patients and appropriate in size. Infected wounds will require more frequent dressing changes [57],[152]. Changing dressings one limb at a time is advocated in infants, to reduce the likelihood of having the skin rubbed off the opposite limb by feet kicking together, causing new, painful lesions (see Box 8). This approach also decreases the chance of bacterial spread from a colonized wound to an uncontaminated area [57],[78]. For baths, adding salt to the water is recommended as for older patients (see subsection on environmental treatment under Bathing and Dressing Changes).

In addition to environmental adjustments, many infants will require analgesics with bath and dressing changes. NSAIDs, acetaminophen and opioids are all used, as for older patients (see Section-Bathing and Dressing Changes) (see Box 8). Codeine is not recommended, when alternatives are available, as neonates lack the capacity to metabolize the drug into active metabolites, and clinical responses are highly variable at all ages, due to polymorphisms in codeine’s metabolic pathway [153],[154].

Severely affected hospitalized infants

Severely affected newborns with deep tissue damage may require extensive pharmacologic support to achieve a level of comfort (see Box 8). These infants may require around the clock or continuous infusion of opioids and an adjuvant. A transition to methadone for better steady state levels should be considered (refer to sub-section on systemic approaches under Skin and Wound Pain) for caveats about methadone use). A case study has shown effective pain control in an infant with severe chronic pain (and possibly pruritus) when treated with gabapentin [155]. Patients receiving frequent opioid treatment may require extra care in avoiding opioid-induced constipation and in maintaining adequate caloric intake.

Oral ketamine has been used to supplement opioids when pain associated with dressing changes is severe [156]. Use of ketamine raises concerns due to findings of adverse neurodevelopmental effects in young animals who received prolonged intravenous infusions of ketamine [157]. However, these effects are not known to occur in human infants and are unlikely to occur with small doses administered at intervals.

Good practice points

Infants benefit from the same range of analgesics as older patients. They can uniquely benefit from oral sucrose for brief painful episodes. Careful monitoring is crucial in infants receiving sedating medications. Babies with EB and their parents benefit from close physical contact like any other families. Holding and cuddling can be done safely, with scrupulous attention to lifting and handling in order to prevent new lesions and pain.

End of life pain care


The epidemiology of death in EB varies by type [158], but is not limited to dermatologic causes. Patients with JEB, generalized severe type are at greatest risk of fatality early in life from a range of causes [159],[160]. Persons with RDEB may succumb in early to mid-adulthood from multiple causes [161]-[163] whereas patients with generalized types of EB simplex are at risk of laryngotracheal complications [164].

The palliative approach to pain experienced by individuals who are facing life-threatening illness addresses the physical, emotional and spiritual suffering of the patient and includes support for the whole family [165]-[167] (see Box 9). Squamous cell carcinoma is frequently diagnosed in patients with severe subtypes [168] and can present challenges typical of cancer-related pain when it metastasizes. The World Health Organization ladder approach to pain care for those patients with cancer and other persistent illnesses recommends a two-step `ladder’ as a framework for pain care [169].


Opioids have a role in EB pain management, as previously indicated in these guidelines (see Box 9). Patients in the palliative phase of their illness may be given an oral opioid sustained release medication [170]. Opioids should be titrated against pain and side effects, with differences in approach needed depending on issues such as opioid tolerance and rate of development of new pain problems [170]. However, if appropriate opioid increases are not effective, it is important to consider pharmacologic tolerance, poor absorption and neuropathic pain. Tolerance can be addressed by rotating the opioid to capitalize upon incomplete cross-tolerance [171],[172]. In the face of poor absorption, parenteral therapy may be needed (see below). If neuropathic pain is suspected, methadone may be an option to consider. It has N-methyl-D-aspartate (NMDA) antagonist action in addition to mu-agonist properties common to standard opioids, and can be beneficial for neuropathic pain [173] and does not rely on renal excretion [61], which may be reduced in the palliative phase of EB [87]. Although a recent meta-analysis could not establish differences in efficacy among types of opioids for neuropathic pain, it was determined that intermediate term (weeks to months) use of opioids for neuropathic pain may be helpful [174]. Cautions in the use of methadone are discussed in the sub-section on systemic approaches under Skin and Wound Pain.

Adjunctive measures for neuropathic pain

Many EB patients will have been treated with adjunctive agents such as amitriptyline or gabapentin earlier in their illness, often with good effect [87],[155]. These both may take a period of time to achieve full analgesic effect and usually need to be given by the enteral route. Ketamine is more rapidly effective and can be given orally [84]-[86],[175] or used subcutaneously (see below). It should be noted that when ketamine by-passes hepatic first pass metabolism, the relative proportion of norketamine is reduced and the patient may experience more sedation and hallucinations and less analgesia for a given dose [175]. Other options for addressing neuropathic pain (see Box 9) in terminal care include opioid rotation to methadone (see above), which can also be included in a subcutaneous infusion (see below).

Infusions and issues of drug delivery

Parenteral administration of analgesia may be needed in the palliative phase, when ability to take enteral medications is no longer an option or if rapid escalation of therapy is needed. There has been an historic reluctance to use continuous subcutaneous infusions, due to the fear of precipitating further blistering. However, subcutaneous infusions have been reported to be tolerated in the final days of life in an adult EB patient [176] (see Box 9).

In non-EB patients with cancer pain, the subcutaneous route of morphine is effective to a similar degree as the intravenous [177]. Other alternatives, such as adherent transdermal delivery systems, need regular removal and replacement. Repeated subcutaneous/intramuscular injections are very frightening for children, as are attempts to obtain IV access. Alternatively, sites of subcutaneous needle insertion last reasonably well [87],[177]. If subcutaneous sites do become inflamed, some benefit has been shown from adding low dose dexamethasone to the infusion [178], although this has not been used to our knowledge in children with EB.

Breakthrough pain medication at the end of life

Even when good baseline pain relief has been achieved, most patients will require occasional `breakthrough’ doses of analgesia. Uniformly effective breakthrough dosing protocols have not been determined for children with EB at end of life, although there are general recommendations from several international sources [169],[179] and data to support the use of up to 20% of total daily opioid consumption [180],[181] in adults with cancer. In general, a short-acting, immediate release form of opioid should be given at approximately 10% to 15% of the total background opioid dose of the previous 24 hours. If rescue dosing is used frequently and consistently, then the baseline opioid dosing needs to be increased. Individual patient factors should be taken into consideration (including prior opioid exposure, renal and hepatic function, other medication use) and consultation with an expert in pain management and/or palliative care is recommended. The same principle is recommended for opioids given via all routes of administration. When very rapid onset is needed, transmucosal administration of opioids may be preferable (see Box 9). Commercially available transmucosal preparations of fentanyl are available in doses likely to be suitable for older children and adults. Evidence supports the use of transbuccal fentanyl for breakthrough pain in cancer patients [182]. An additional benefit of fentanyl is that it is not dependent on renal excretion. In some centers, the injectable formulations of morphine or diamorphine have been used buccally at around a third of the standard enteral dose (equivalent to the intravenous dose), allowing more flexibility of dosing. It is also important to remember that extreme anxiety may confound pain perception or expression and that there may be benefit in offering additional doses of buccal midazolam where this is felt to be a significant factor. Therapy should be targeted at specific symptoms whenever possible, although combination therapy is not unusual. Breakthrough analgesia should be offered in the face of unexplained `agitation’ in case of undiagnosed pain, after which medication for primary agitation/anxiety may be considered. While it is likely that both of these would cause a degree of sedation at higher doses, this should not be the primary aim of treatment.

Good practice points

Palliative pain care is an expected part of care for EB, which in many cases is life-limiting in nature. All basic principles of palliative care apply as they do for other terminal disease states.



Itch is a prominent, debilitating and damaging symptom for children with EB, but the mechanisms which lead to the manifestation of pruritus are poorly understood [183]. Promising new insights into the causes and potential treatments of chronic itch in animal models [184], in human chronic itch generally [185] and in recovering burn patients [186] may hold potential for application in the EB population.

Non-pharmacological approaches

Multiple environmental and behavioral approaches to address itch have been suggested [183],[187] and include: prevention of dry skin (systemic hydration and emollients), gentle debridement of dry/dead/crusted skin, prevention and treatment of skin wound infection; maintaining/supporting the healing process by attention to anemia and nutritional status, limiting damage to the skin by avoiding shear forces imposed by scratching (short nails, occlusive barriers, patting rather than pulling or tearing at a site), avoiding overheating and using measures to keep the body cool (see Box 10). CBT is useful to reduce habitual scratching behaviors (see section on psychological approaches). It is important to avoid and treat secondary causes when present (such as drugs, environmental itch triggers, underlying co-morbidities). Opioid-induced itch in EB can be a problem and a difficult side effect to balance against the desired analgesia; opioid rotation may be helpful.

Pharmacological therapies

Pharmacological therapies include traditional oral antihistaminic medications (see Box 10). Some patients prefer sedating formulations at bedtime (for example, diphenhydramine, hydroxyzine, chlorpheniramine) and others non-sedating preparations during the day (for example, cetirizine, loratadine and fexofenadine). Efficacy is variable and recommendations are based on anecdotal experience for lack of good evidence in EB and other dermatologic conditions. Centrally acting medications, such as gabapentin and pregabalin, have evidence for efficacy from the burn literature [186],[188],[189] and may have application in EB. Many of these medications have also been used successfully for neuropathic pain (see sub-section on adjunctive measures for neuropathic pain under End of Life Pain). Antidepressants with nortriptyline re-uptake inhibitory actions have been used for various pruritic conditions with some evidence for efficacy, with mirtazapine showing promise [190]-[193]. Low-dose cyclosporine has been used in a single case of dominant dystrophic EB to reduce generalized itching [185],[194]. Anecdotal success has been reported with ondansetron in EB; however, the same had been reported for pruritus from cholestatic jaundice, although controlled trials did not confirm efficacy [195]. Similar suggestions were made related to the pruritus of uremia [196],[197], leading to recommendations that ondansetron should be considered, although clinical trials are needed in EB.

Other medications that have shown sporadic clinical success in treating itch in EB include: cyproheptadine; selective serotonin re-uptake inhibitors (SSRIs; fluoxetine, paroxetine, sertraline, fluvoxamine) [193]; tricyclic antidepressants (doxepin, amitriptyline, nortriptyline) [192]; opioid antagonists (naloxone, naltrexone); kappa receptor agonists (butorphanol, dextromethorphan, nalbuphine); other 5-HT3 receptor antagonists (granisetron, dolasetron); antipsychotic agents (olanzapine, pimozide) and cannabinoids. These agents and the NK-1 receptor antagonist aprepitant may prove to be useful in certain subsets of patients, although evidence to guide therapy is lacking [198] and practitioners are encouraged to pursue the aforementioned therapies based on patient response to prior medications, potential interactions within the patient's medication list and medication availability (see Box 10).

It is common practice for medications from different drug classes to be used concurrently and for agents in the same class to be rotated due to the observation that a particular medication may have improved efficacy after intermittent drug holiday.

Good practice points

A combination of environmental, cognitive-behavioral and pharmacologic therapies is available for use for EB-related pruritus, which can be a severe symptom of the disease.


These guidelines represent the initial effort to organize pain management for patients with EB based on existing evidence. While the guidelines were developed using current evidence and a rigorous evaluation process, there are limitations in the clinical use of the recommendations. The two broad areas of concern involve practical limitations of implementation and the level of available evidence. Tables 5 and 6 identify issues for implementation of the guidelines as well as general recommendations areas for research to enhance the level of evidence.

Table 5 Implementation barriers
Table 6 Areas of research

Authors' contributions

This work was initiated and led by KRG with active input from all authors. JG, EH, CL, ALJ, AEM, LGM and DSL participated in the review process and recommendation/guideline draft, see text for details. DSL led the systematic evidence analysis and provided methodological support and guidance. Multi-disciplinary clinician input was obtained as was input from patients and families early in the process (see Acknowledgments, below). The consensus meeting (see text) was attended in person or via Skype by KRG, ALJ, EH, JG, CL, LGM and BK (see Acknowledgements). All authors read and approved the final manuscript.

Additional file



cognitive behavioral therapy/techniques


Children's Hospital of Eastern Ontario Pain Scale


Crying, requires oxygen, Increased vital signs, Expression and Sleepless Pain Scale


dominant dystrophic epidermolysis bullosa


dystrophic epidermolysis bullosa (dominant and recessive types)


epidermolysis bullosa


epidermolysis bullosa simplex (basal and suprabasal types)


Face Legs Arms Cry Consolability Pain Scale


gastroesophageal reflux disease


junctional epidermolysis bullosa (generalized and localized)


Neonatal Infant Pain Scale




non-steroidal anti-inflammatory drugs


Neonatal Pain Agitation and Sedation Scale


patient controlled analgesia


Premature Infant Pain Profile


recessive dystrophic epidermolysis bullosa


  1. 1.

    Fine JD, Johnson LB, Weiner M, Suchindran C: Assessment of mobility, activities, and pain in different subtypes of epidermolysis bullosa. Clin Exp Dermatol. 2004, 29: 122-127.

    PubMed  Google Scholar 

  2. 2.

    Tabolli S, Sampogna F, Di Pietro C, Paradisi A, Uras C, Zotti P, Castiglia D, Zambruno G, Abeni D: Quality of life in patients with epidermolysis bullosa. Br J Dermatol. 2009, 161: 869-877.

    CAS  PubMed  Google Scholar 

  3. 3.

    Margari F, Lecce PA, Santamato W, Ventura P, Sportelli N, Annicchiarico G, Bonifazi E: Psychiatric symptoms and quality of life in patients affected by epidermolysis bullosa. J Clin Psychol Med Settings. 2010, 17: 333-339.

    PubMed  Google Scholar 

  4. 4.

    Van Scheppingen C, Lettinga AT, Duipmans JC, Maathius CG, Jonkman MF: Main problems experienced by children with Epidermolysis Bullosa: a qualitative study with semi-structured interviews. Acta Derm Venerol. 2008, 88: 143-150.

    PubMed  Google Scholar 

  5. 5.

    Fine J, Bruckner-Tuderman L, Eady RA, Bauer EA, Bauer JW, Has C, Heagerty A, Hintner H, Hovnanian A, Jonkman MF, Leigh I, Marinkovich P, Martinez AE, McGrath JA, Mellerio JE, Moss C, Murrell DF, Shimizu H, Uitto J, Woodley D, Zambruno G: Inherited epidermolysis bullosa: updated recommendations on diagnosis and classification. J Am Acad Dermatol. 2014, 70: 1103-1126.

    PubMed  Google Scholar 

  6. 6.

    Debra International [], []

  7. 7.

    Clark E, Burkett K, Stanko-Lopp D: Let Evidence Guide Every New Decision (LEGEND): an evidence evaluation system for point-of-care clinicians and guideline development teams. J Eval Clin Pract. 2009, 15: 1054-1060.

    PubMed  Google Scholar 

  8. 8.

    Cincinnati Children's Hospital Medical Center: LEGEND documents. 2013. ., []

  9. 9.

    Brozek JL, Akl EA, Alonso-Coello P, Lang D, Jaeschke R, Williams JW: Grading quality of evidence and strength of recommendations in clinical practice guidelines. Part 1 of 3. An overview of the GRADE approach and grading quality of evidence about interventions. Allergy. 2009, 64: 669-677.

    CAS  PubMed  Google Scholar 

  10. 10.

    Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ: GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008, 336: 924-926.

    PubMed  PubMed Central  Google Scholar 

  11. 11.

    Debra International pain management guidelines page [], []

  12. 12.

    Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC: The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007, 133: 581-624.

    PubMed  Google Scholar 

  13. 13.

    Gerik SM: Pain management in children: developmental considerations and mind-body therapies. South Med J. 2005, 98: 295-302.

    PubMed  Google Scholar 

  14. 14.

    Green JP, Barabasz AF, Barrett D, Montgomery GH: Forging ahead: the 2003 APA Division 30 definition of hypnosis. Int J Clin Exp Hypn. 2005, 53: 259-264.

    PubMed  Google Scholar 

  15. 15.

    Palermo TM, Chambers CT: Parent and family factors in pediatric chronic pain and disability: an integrative approach. Pain. 2005, 119: 1-4.

    PubMed  Google Scholar 

  16. 16.

    Eccleston C, Palermo TM, Williams AC, Lewandowski A, Morely S: Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Syst Rev. 2009, 2.

    Google Scholar 

  17. 17.

    Palermo TM, Eccleston C, Lewandowski AS, Williams AC, Morley S: Randomized controlled trials of psychological therapies for management of chronic pain in children and adolescents: an updated meta-analytic review. Pain. 2010, 148: 387-397.

    PubMed  Google Scholar 

  18. 18.

    Kashikar-Zuck S, Swain NF, Jones BA, Graham TB: Efficacy of cognitive-behavioral intervention for juvenile primary fibromyalgia syndrome. J Rheumatol. 2005, 32: 1594-1602.

    PubMed  Google Scholar 

  19. 19.

    Eccleston C, Williams AC, Morley S: Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2009, 2.

    Google Scholar 

  20. 20.

    Richardson J, Smith JE, McCall G, Pilkington K: Hypnosis for procedure-related pain and distress in pediatric cancer patients: a systematic review of effectiveness and methodology related to hypnosis interventions. J Pain Symptom Manage. 2006, 31: 70-84.

    PubMed  Google Scholar 

  21. 21.

    Uman LS, Chambers CT, McGrath PJ, Kisely S: Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev. 2006, 4.

    Google Scholar 

  22. 22.

    Chambers CT, Taddio A, Uman LS, McMurtry CM: Psychological interventions for reducing pain and distress during routine childhood immunizations: a systematic review. Clin Ther. 2009, 31: S77-S103.

    PubMed  Google Scholar 

  23. 23.

    Kleiber C, Harper DC: Effects of distraction on children's pain and distress during medical procedures: a meta-analysis. Nurs Res. 1999, 48: 44-49.

    CAS  PubMed  Google Scholar 

  24. 24.

    Liossi C, White P, Hatira P: A randomized clinical trial of a brief hypnosis intervention to control venepuncture-related pain of paediatric cancer patients. Pain. 2009, 142: 255-263.

    PubMed  Google Scholar 

  25. 25.

    Malloy KM, Milling LS: The effectiveness of virtual reality distraction for pain reduction: a systematic review. Clin Psychol Rev. 2010, 30: 1011-1018.

    PubMed  Google Scholar 

  26. 26.

    Hanson MD, Gauld M, Wathen CN, Macmillan HL: Nonpharmacological interventions for acute wound care distress in pediatric patients with burn injury: a systematic review. J Burn Care Res. 2008, 29: 730-741.

    PubMed  Google Scholar 

  27. 27.

    Liossi C, Franck L: Psychological interventions for acute pediatric pain. Clinical Pain Management Acute Pain. Edited by: Macintyre P, Rowbotham D, Walker S. 2008, Hodder Arnold, London, 308-323.

    Google Scholar 

  28. 28.

    Hagermark O, Wahlgren C: Treatment of itch. Semin Dermatol. 1995, 14: 320-325.

    CAS  PubMed  Google Scholar 

  29. 29.

    Chida Y, Steptoe A, Hirakawa N, Sudo N, Kubo C: The effects of psychological intervention on atopic dermatitis. A systematic review and meta-analysis. Int Arch Allergy Immunol. 2007, 144: 1-9.

    PubMed  Google Scholar 

  30. 30.

    Azrin NH, Nunn RG: Habit-reversal: a method of eliminating nervous habits and tics. Behav Res Ther. 1973, 11: 619-628.

    CAS  PubMed  Google Scholar 

  31. 31.

    Rosenbaum MS, Ayllon T: The behavioral treatment of neurodermatitis through habit-reversal. Behav Res Ther. 1981, 19: 313-318.

    CAS  PubMed  Google Scholar 

  32. 32.

    Ehlers A, Stangier U, Gieler U: Treatment of atopic dermatitis: a comparison of psychological and dermatological approaches to relapse prevention. J Consult Clin Psychol. 1995, 63: 624-635.

    CAS  PubMed  Google Scholar 

  33. 33.

    Hopton A, MacPherson H: Acupuncture for chronic pain: is acupuncture more than an effective placebo? A systematic review of pooled data from meta-analyses. Pain Pract. 2010, 10: 94-102.

    PubMed  Google Scholar 

  34. 34.

    Cepeda MS, Carr DB, Lau J, Alvarez H: Music for pain relief. Cochrane Database Syst Rev. 2006, 2.

    Google Scholar 

  35. 35.

    Bussing A, Ostermann T, Ludtke R, Michalsen A: Effects of yoga interventions on pain and pain-associated disability: a meta-analysis. J Pain. 2012, 13: 1-9.

    PubMed  Google Scholar 

  36. 36.

    Cordier W, Steenkamp V: Herbal remedies affecting coagulation: a review. Pharm Biol. 2012, 50: 443-452.

    CAS  PubMed  Google Scholar 

  37. 37.

    Kashikar-Zuck S, Lynch AM: Psychological interventions for chronic pain. Pain in Children: A Practical Guide for Primary Care. Edited by: Walco GA, Goldschneider KR. 2008, Humana Press, Totowa, NJ, 145-152.

    Google Scholar 

  38. 38.

    Power N, Liossi C, Franck L: Helping parents to help their child with procedural and everyday pain: practical, evidence-based advice. J Spec Pediatr Nurs. 2007, 12: 203-209.

    PubMed  Google Scholar 

  39. 39.

    von Baeyer CL, Spagrud LJ: Systematic review of observational (behavioral) measures of pain for children and adolescents aged 3 to 18 years. Pain. 2007, 127: 140-150.

    PubMed  Google Scholar 

  40. 40.

    Stinson JN, Kavanagh T, Yamada J, Gill N, Stevens B: Systematic review of the psychometric properties, interpretability and feasibility of self-report pain intensity measures for use in clinical trials in children and adolescents. Pain. 2006, 125: 143-157.

    PubMed  Google Scholar 

  41. 41.

    Goldschneider K, Lucky AW, Mellerio JE, Palisson F, del Carmen Viñuela Miranda M, Azizkhan RG: Perioperative care of patients with epidermolysis bullosa: proceedings of the 5th international symposium on epidermolysis bullosa, Santiago Chile, December 4-6, 2008. Pediatr Anaesth. 2010, 20: 797-804.

    Google Scholar 

  42. 42.

    Goldschneider KR, Lucky AW: Pain management in epidermolysis bullosa. Dermatol Clin. 2010, 28: 273-282.

    CAS  PubMed  Google Scholar 

  43. 43.

    Steffel J, Luscher TF, Ruschitzka F, Tanner FC: Cyclooxygenase-2 inhibition and coagulation. J Cardiovasc Pharmacol. 2006, 47: S15-S20.

    CAS  PubMed  Google Scholar 

  44. 44.

    Herod J, Denyer J, Goldman A, Howard R: Epidermolysis bullosa in children: pathophysiology, anaesthesia and pain management. Paediatr Anaesth. 2002, 12: 388-397.

    PubMed  Google Scholar 

  45. 45.

    Manjushree R, Lahiri A, Ghosh BR, Laha A, Handa K: Intranasal fentanyl provides adequate postoperative analgesia in pediatric patients. Can J Anaesth. 2002, 49: 190-193.

    PubMed  Google Scholar 

  46. 46.

    Borland M, Jacobs I, King B, O'Brien D: A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the emergency department. Ann Emerg Med. 2007, 49: 335-340.

    PubMed  Google Scholar 

  47. 47.

    Desjardins PJ, Norris LH, Cooper SA, Reynolds DC: Analgesic efficacy of intranasal butorphanol (Stadol NS) in the treatment of pain after dental impaction surgery. J Oral Maxillofac Surg. 2000, 58: 19-26.

    CAS  PubMed  Google Scholar 

  48. 48.

    Kelly RE: Regional anesthesia in children with epidermolysis bullosa dystrophica. Anesthesiology. 1988, 68: 469.

    CAS  PubMed  Google Scholar 

  49. 49.

    Sopchak AM, Thomas PS, Clark WR: Regional anesthesia in a patient with epidermolysis bullosa. Reg Anesth. 1993, 18: 132-134.

    CAS  PubMed  Google Scholar 

  50. 50.

    Yee LL, Gunter JB, Manley CB: Caudal epidural anesthesia in an infant with epidermolysis bullosa. Anesthesiology. 1989, 70: 149-151.

    CAS  PubMed  Google Scholar 

  51. 51.

    Diwan R, Vas L, Shah T, Raghavendran S, Ponde V: Continuous axillary block for upper limb surgery in a patient with epidermolysis bullosa simplex. Paediatr Anaesth. 2001, 11: 603-606.

    CAS  PubMed  Google Scholar 

  52. 52.

    Englbrecht JS, Langer M, Hahnenkamp K, Ellger B: Ultrasound-guided axillary plexus block in a child with dystrophic epidermolysis bullosa. Anaesth Intensive Care. 2010, 38: 1101-1105.

    CAS  PubMed  Google Scholar 

  53. 53.

    Doi S, Horimoto Y: Subcutaneous tunnelling of an epidural catheter in a child with epidermolysis bullosa. Acta Anaesth Scand. 2006, 50: 394-395.

    CAS  PubMed  Google Scholar 

  54. 54.

    Viscusi ER, Martin G, Hartrick CT, Singla N, Manvelian G: Forty-eight hours of postoperative pain relief after total hip arthroplasty with a novel, extended-release epidural morphine formulation. Anesthesiology. 2005, 102: 1014-1022.

    CAS  PubMed  Google Scholar 

  55. 55.

    Mhuircheartaigh RJ, Moore RA, McQuay HJ: Analysis of individual patient data from clinical trials: epidural morphine for postoperative pain. Br J Anaesth. 2009, 103: 874-881.

    CAS  PubMed  Google Scholar 

  56. 56.

    Hartrick CT, Hartrick KA: Extended-release epidural morphine (DepoDur): review and safety analysis. Expert Rev Neurother. 2008, 8: 1641-1648.

    CAS  PubMed  Google Scholar 

  57. 57.

    Denyer JE: Wound management for children with epidermolysis bullosa. Dermatol Clin. 2010, 28: 257-264.

    CAS  PubMed  Google Scholar 

  58. 58.

    Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, Donovan MI, Fishbain DA, Foley KM, Fudin J, Gilson AM, Kelter A, Mauskop A, O'Connor PG, Passik SD, Pasternak GW, Portenoy RK, Rich BA, Roberts RG, Todd KH, Miaskowski C: Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009, 10: 113-130.

    CAS  PubMed  PubMed Central  Google Scholar 

  59. 59.

    Noble M, Treadwell JR, Tregear SJ, Coates VH, Wiffen PJ, Akafomo C, Schoelles KM: Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev. 2010, 1.

    Google Scholar 

  60. 60.

    Katz N, Mazer NA: The impact of opioids on the endocrine system. Clin J Pain. 2009, 25: 170-175.

    PubMed  Google Scholar 

  61. 61.

    Davies D, Vlaming D, Haines C: Methadone analgesia for children with advanced cancer. Pediatr Blood Cancer. 2008, 51: 393-397.

    PubMed  Google Scholar 

  62. 62.

    Huh B, Park CH: Retrospective analysis of low-dose methadone and QTc prolongation in chronic pain patients. Korean J Anesthesiol. 2010, 58: 338-343.

    CAS  PubMed  PubMed Central  Google Scholar 

  63. 63.

    Cruciani RA: Methadone: to ECG or not to ECG…That is still the question. J Pain Symptom Manage. 2008, 36: 545-552.

    CAS  PubMed  Google Scholar 

  64. 64.

    Martin JA, Campbell A, Killip T, Kotz M, Krantz MJ, Kreek MJ, McCarroll BA, Mehta D, Payte JT, Stimmel B, Taylor T, Haigney MC, Wilford BB: QT interval screening in methadone maintenance treatment: report of a SAMHSA expert panel. J Addict Dis. 2011, 30: 283-306.

    PubMed  PubMed Central  Google Scholar 

  65. 65.

    Nicholson AB: Methadone for cancer pain. Cochrane Database Syst Rev. 2009, 4.

    Google Scholar 

  66. 66.

    Camilleri M: Opioid-induced constipation: challenges and therapeutic opportunities. Am J Gastroenterol. 2011, 106: 835-842.

    CAS  PubMed  Google Scholar 

  67. 67.

    Moore RA, Wiffen PJ, Derry S, McQuay HJ: Gabapentin for chronic neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev. 2011, 3.

    Google Scholar 

  68. 68.

    Chiu YK, Prendiville JS, Bennett SM, Montgomery CJ, Oberlander TF: Pain management of junctional epidermolysis bullosa in an 11-year-old boy. Pediatr Dermatol. 1999, 16: 465-468.

    CAS  PubMed  Google Scholar 

  69. 69.

    Gray P, Williams B, Cramond T: Successful use of gabapentin in acute pain management following burn injury: a case series. Pain Med. 2008, 9: 371-376.

    PubMed  Google Scholar 

  70. 70.

    Lara-Corrales I, Mellerio JE, Martinez AE, Green A, Lucky AW, Azizkhan RG, Murrell DF, Agero AL, Kantor PF, Pope E: Dilated cardiomyopathy in epidermolysis bullosa: a retrospective, multicenter study. Pediatr Dermatol. 2010, 27: 238-243.

    PubMed  Google Scholar 

  71. 71.

    Taibjee SM, Ramani P, Brown R, Moss C: Lethal cardiomyopathy in epidermolysis bullosa associated with amitriptyline. Arch Dis Child. 2005, 90: 871-872.

    CAS  PubMed  PubMed Central  Google Scholar 

  72. 72.

    Twillman RK, Long TD, Cathers TA, Mueller DW: Treatment of painful skin ulcers with topical opioids. J Pain Symptom Manage. 1999, 17: 288-292.

    CAS  PubMed  Google Scholar 

  73. 73.

    LeBon B, Zeppetella G, Higginson IJ: Effectiveness of topical administration of opioids in palliative care: a systematic review. J Pain Symptom Manage. 2009, 37: 913-917.

    PubMed  Google Scholar 

  74. 74.

    Watterson G, Howard R, Goldman A: Peripheral opioids in inflammatory pain. Arch Dis Child. 2004, 89: 679-681.

    CAS  PubMed  PubMed Central  Google Scholar 

  75. 75.

    Than MP, Smith RA, Cassidy S, Kelly R, Marsh C, Maderal A, Kirsner RS: Use of a keratin-based hydrogel in the management of recessive dystrophic epidermolysis bullosa. J Dermatol Treat. 2013, 24: 290-291.

    Google Scholar 

  76. 76.

    Lander JA, Weltman BJ, So SS: EMLA and amethocaine for reduction of children's pain associated with needle insertion. Cochrane Database Syst Rev. 2006, 3.

    Google Scholar 

  77. 77.

    Cepeda MS, Tzortzopoulou A, Thackrey M, Hudcova J, Arora Gandhi P, Schumann R: Adjusting the pH of lidocaine for reducing pain on injection. Cochrane Database Syst Rev. 2010, 12.

    Google Scholar 

  78. 78.

    Arbuckle HA: Bathing for individuals with Epidermolysis bullosa. Dermatol Clin. 2010, 28: 265-266.

    CAS  PubMed  Google Scholar 

  79. 79.

    Cerio R, Dohil M, Jeanine D, Magina S, Mahé E, Stratigos AJ: Mechanism of action and clinical benefits of colloidal oatmeal for dermatologic practice. J Drugs Dermatol. 2010, 9: 1116-1120.

    PubMed  Google Scholar 

  80. 80.

    Peterson B, Berman S, Arbuckle A: The effectiveness of saltwater baths in the treatment of patients with epidermolysis bullosa.Poster presented at the 37th Annual Meeting of the Society of Pediatric Dermatology, Baltimore July 7-10, 2011..

  81. 81.

    Wolfe TR, Braude DA: Intranasal medication delivery for children: a brief review and update. Pediatrics. 2010, 126: 532-537.

    PubMed  Google Scholar 

  82. 82.

    Ezike HA, Odiakosa MC: Oral ketamine for wound care procedures in adult patients with burns. South Afr J Anaesth Analg. 2011, 17: 242-248.

    Google Scholar 

  83. 83.

    Humphries Y, Melson M, Gore D: Superiority of oral ketamine as an analgesic and sedative for wound care procedures in the pediatric patient with burns. J Burn Care Rehabil. 1997, 18: 34-36.

    CAS  PubMed  Google Scholar 

  84. 84.

    Blonk MI, Koder BG, van den Bemt PM, Huygen FJ: Use of oral ketamine in chronic pain management: a review. Eur J Pain. 2010, 14: 466-472.

    CAS  PubMed  Google Scholar 

  85. 85.

    Bell RF, Eccleston C, Kalso EA: Ketamine as an adjuvant to opioids for cancer pain. Cochrane Database Syst Rev. 2012, 11.

    Google Scholar 

  86. 86.

    Ugur F, Gulcu N, Boyaci A: Oral ketamine for pain relief in a child with abdominal malignancy. Pain Med. 2009, 10: 120-121.

    PubMed  Google Scholar 

  87. 87.

    Watterson G, Denyer J, Hain R: Skin Symptoms. Oxford Textbook of Palliative Care for Children. Edited by: Goldman A, Hain R, Liben S. 2005, Oxford University Press, Oxford, UK, 448-459.

    Google Scholar 

  88. 88.

    Burton JH, Auble TE, Fuchs SM: Effectiveness of 50% nitrous oxide/50% oxygen during laceration repair in children. Acad Emerg Med. 1998, 5: 112-117.

    CAS  PubMed  Google Scholar 

  89. 89.

    Rowland AS, Baird DD, Shore DL, Weinberg CR, Savitz DA, Wilcox AJ: Nitrous oxide and spontaneous abortion in female dental assistants. Am J Epidemiol. 1995, 141: 531-538.

    CAS  PubMed  Google Scholar 

  90. 90.

    Nunn JF, Chanarin I, Tanner AG, Owen ER: Megaloblastic bone marrow changes after repeated nitrous oxide anaesthesia. Reversal with folinic acid. Br J Anaesth. 1986, 58: 1469-1470.

    CAS  PubMed  Google Scholar 

  91. 91.

    Sanders RD, Weimann J, Maze M: Biologic effects of nitrous oxide: a mechanistic and toxicologic review. Anesthesiology. 2008, 109: 707-722.

    CAS  PubMed  Google Scholar 

  92. 92.

    Lourenço-Matharu L, Ashley PF, Furness S: Sedation of children undergoing dental treatment. Cochrane Database Syst Rev. 2012, 3.

    Google Scholar 

  93. 93.

    Tyagi P, Dixit U, Tyagi S, Jain A: Sedative effects of oral midazolam, intravenous midazolam and oral diazepam. J Clin Pediatr Dent. 2012, 36: 383-388.

    PubMed  Google Scholar 

  94. 94.

    Patterson DR, Ptacek JT, Carrougher GJ, Sharar SR: Lorazepam as an adjunct to opioid analgesics in the treatment of burn pain. Pain. 1997, 72: 367-374.

    CAS  PubMed  Google Scholar 

  95. 95.

    Freeman EB, Köglmeier J, Martinez AE, Mellerio JE, Haynes L, Sebire NJ, Lindley KJ, Shah N: Gastrointestinal complications of epidermolysis bullosa in children. Br J Dermatol. 2008, 158: 1308-1314.

    CAS  PubMed  Google Scholar 

  96. 96.

    Fine JD, Mellerio JE: Extracutaneous manifestations and complications of inherited epidermolysis bullosa: part I. Epithelial associated tissues. J Am Acad Dermatol. 2009, 61: 367-384.

    PubMed  Google Scholar 

  97. 97.

    Travis SP, McGrath JA, Turnbull AJ, Schofield OM, Chan O, O'Connor AF, Mayou B, Eady RA, Thompson RP: Oral and gastrointestinal manifestations of epidermolysis bullosa. Lancet. 1992, 340: 1505-1506.

    CAS  PubMed  Google Scholar 

  98. 98.

    Ergun GA, Lin AN, Dannenberg AJ, Carter DM: Gastrointestinal manifestations of epidermolysis bullosa. A study of 101 patients. Medicine. 1992, 71: 121-127.

    CAS  PubMed  Google Scholar 

  99. 99.

    Marini I, Vecchiet F: Sucralfate: a help during oral management in patients with epidermolysis bullosa. J Periodontol. 2001, 72: 691-695.

    CAS  PubMed  Google Scholar 

  100. 100.

    Buchsel PC: Gelclair oral gel. Clin J Oncol Nurs. 2003, 7: 109-110.

    PubMed  Google Scholar 

  101. 101.

    Buchsel PC: Polyvinylpyrrolidone-sodium hyaluronate gel (Gelclair): a bioadherent oral gel for the treatment of oral mucositis and other painful oral lesions. Expert Opin Drug Metab Toxicol. 2008, 4: 1449-1454.

    CAS  PubMed  Google Scholar 

  102. 102.

    Cingi C, Songu M, Ural A, Yildirim M, Erdogmus N, Bal C: Effects of chlorhexidine/benzydamine mouth spray on pain and quality of life in acute viral pharyngitis: a prospective, randomized, double-blind, placebo-controlled, multicenter study. Ear Nose Throat J. 2010, 89: 546-549.

    PubMed  Google Scholar 

  103. 103.

    Vandenplas Y, Rudolph CD, Di Lorenzo C, Hassall E, Liptak G, Mazur L, Sondheimer J, Staiano A, Thomson M, Veereman-Wauters G, Wenzl TG: Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr. 2009, 49: 498-547.

    PubMed  Google Scholar 

  104. 104.

    Nwokediuko SC: Current trends in the management of gastroesophageal reflux disease: a review. ISRN Gastroenterol. 2012, 2012: 391631.

    PubMed  PubMed Central  Google Scholar 

  105. 105.

    Fine JD, Johnson LB, Weiner M, Suchindran C: Gastrointestinal complications of inherited epidermolysis bullosa: cumulative experience of the National Epidermolysis Bullosa Registry. J Pediatr Gastroenterol Nutr. 2008, 46: 147-158.

    PubMed  Google Scholar 

  106. 106.

    Lai-Cheong JE, McGrath JA: What is Kindler syndrome?. Skinmed. 2011, 9: 145-146.

    PubMed  Google Scholar 

  107. 107.

    Azizkhan RG, Stehr W, Cohen AP, Wittkugel E, Farrell MK, Lucky AW, Hammelman BD, Johnson ND, Racadio JM: Esophageal strictures in children with recessive dystrophic epidermolysis bullosa: an 11-year experience with fluoroscopically guided balloon dilatation. J Pediatr Surg. 2006, 41: 55-60.

    PubMed  Google Scholar 

  108. 108.

    Anderson SH, Meenan J, Williams KN, Eady RA, Prinja H, Chappiti U, Doig L, Thompson RP: Efficacy and safety of endoscopic dilation of esophageal strictures in epidermolysis bullosa. Gastrointest Endosc. 2004, 59: 28-32.

    PubMed  Google Scholar 

  109. 109.

    Mortell AE, Azizkhan RG: Epidermolysis bullosa: management of esophageal strictures and enteric access by gastrostomy. Dermatol Clin. 2010, 28: 311-318.

    CAS  PubMed  Google Scholar 

  110. 110.

    Dohil R, Aceves SS, Dohil MA: Oral viscous budesonide therapy in children with epidermolysis bullosa and proximal esophageal strictures. J Pediatr Gastroenterol Nutr. 2011, 52: 776-777.

    CAS  PubMed  Google Scholar 

  111. 111.

    Hsieh CH, Huang CJ, Lin GT: Death from colonic disease in epidermolysis bullosa dystrophica. BMC Dermatol. 2006, 6: 2.

    PubMed  PubMed Central  Google Scholar 

  112. 112.

    Belsey JD, Geraint M, Dixon TA: Systematic review and meta analysis: polyethylene glycol in adults with non-organic constipation. Int J Clin Pract. 2010, 64: 944-955.

    CAS  PubMed  Google Scholar 

  113. 113.

    Hanson S, Bansal N: The clinical effectiveness of Movicol in children with severe constipation: an outcome audit. Paediatr Nurs. 2006, 18: 24-28.

    PubMed  Google Scholar 

  114. 114.

    Shah N, Freeman E, Martinez A, Mellerio J, Smith VV, Lindley KJ, Sebire NJ: Histopathological features of gastrointestinal mucosal biopsy specimens in children with epidermolysis bullosa. J Clin Pathol. 2007, 60: 843-844.

    CAS  PubMed  PubMed Central  Google Scholar 

  115. 115.

    Gupta PJ, Heda PS, Shrirao SA, Kalaskar SS: Topical sucralfate treatment of anal fistulotomy wounds: a randomized placebo-controlled trial. Dis Colon Rectum. 2011, 54: 699-704.

    PubMed  Google Scholar 

  116. 116.

    Alpsoy E, Er H, Durusoy C, Yilmaz E: The use of sucralfate suspension in the treatment of oral and genital ulceration of Behҫet disease: a randomized, placebo-controlled, double-blind study. Arch Dermatol. 1999, 135: 529-532.

    CAS  PubMed  Google Scholar 

  117. 117.

    Nelson RL, Thomas K, Morgan J, Jones A: Non surgical therapy for anal fissure. Cochrane Database Syst Rev. 2012, 2.

    Google Scholar 

  118. 118.

    Poh A, Tan KY, Seow-Choen F: Innovations in chronic anal fissure treatment: a systematic review. World J Gastrointest Surg. 2010, 27: 231-241.

    Google Scholar 

  119. 119.

    Khan MT: Podiatric management in epidermolysis bullosa. Dermatol Clin. 2010, 28: 325-333.

    CAS  PubMed  Google Scholar 

  120. 120.

    Thastum M, Herlin T, Zachariae R: Relationship of pain-coping strategies and pain-specific beliefs to pain experience in children with juvenile idiopathic arthritis. Arthritis Rheum. 2005, 53: 178-184.

    PubMed  Google Scholar 

  121. 121.

    Terrill PJ, Mayou BJ, McKee PH, Eady RA: The surgical management of dystrophic epidermolysis bullosa (excluding the hand). Br J Plast Surg. 1992, 45: 426-434.

    CAS  PubMed  Google Scholar 

  122. 122.

    Maritsi D, Martinez AE, Mellerio JE, Eleftheriou D, Pilkington CA: An unusual case of epidermolysis bullosa complicated by persistent oligoarticular juvenile idiopathic arthritis; lessons to be learned. Pediatr Rheumatol Online J. 2011, 9: 13.

    PubMed  PubMed Central  Google Scholar 

  123. 123.

    Gubinelli E, Angelo C, Pacifico V: A case of dystrophic epidermolysis bullosa improved with etanercept for concomitant psoriatic arthritis. Am J Clin Dermatol. 2010, 11: 53-54.

    PubMed  Google Scholar 

  124. 124.

    Fewtrell MS, Allgrove J, Gordon I, Brain C, Atherton D, Harper J, Mellerio JE, Martinez AE: Bone mineralization in children with epidermolysis bullosa. Br J Dermatol. 2006, 154: 959-962.

    CAS  PubMed  Google Scholar 

  125. 125.

    Martinez AE, Mellerio JE: Osteopenia and osteoporosis in epidermolysis bullosa. Dermatol Clin. 2010, 28: 353-355.

    CAS  PubMed  Google Scholar 

  126. 126.

    Bruckner AL, Bedocs LA, Keiser E, Tang JY, Doernbrack C, Arbuckle HA, Berman S, Kent K, Bachrach LK: Correlates of low bone mass in children with generalized forms of epidermolysis bullosa. J Am Acad Dermatol. 2011, 65: 1001-1009.

    PubMed  Google Scholar 

  127. 127.

    Lacativa PG, Farias ML: Osteoporosis and inflammation. Arq Bras Endocrinol Metabol. 2010, 54: 123-132.

    PubMed  Google Scholar 

  128. 128.

    Tilg H, Moschen AR, Kaser A, Pines A, Dotan I: Gut, inflammation and osteoporosis: basic and clinical concepts. Gut. 2008, 57: 684-694.

    CAS  PubMed  Google Scholar 

  129. 129.

    Levis S, Theodore G: Summary of AHRQ’s comparative effectiveness review of treatment to prevent fractures in men and women with low bone density or osteoporosis: update of the 2007 report. J Manag Care Pharm. 2012, 18: S1-15. discussion S13

    PubMed  Google Scholar 

  130. 130.

    Noguera A, Ros JB, Pavía C, Alcover E, Valls C, Villaronga M, González E: Bisphosphonates, a new treatment for glucocorticoid-induced osteoporosis in children. J Pediatr Endocrinol Metab. 2003, 16: 529-536.

    CAS  PubMed  Google Scholar 

  131. 131.

    Gandrud LM, Cheung JC, Daniels MW, Bachrach LK: Low-dose intravenous pamidronate reduces fractures in childhood osteoporosis. J Pediatr Endocrinol Metab. 2003, 16: 887-892.

    CAS  PubMed  Google Scholar 

  132. 132.

    Falcini F, Trapani S, Ermini M, Brandi ML: Intravenous administration of alendronate counteracts the in vivo effects of glucocorticoids on bone remodeling. Calcif Tissue Int. 1996, 58: 166-169.

    CAS  PubMed  Google Scholar 

  133. 133.

    Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, Owens DK: Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007, 147: 478-491.

    PubMed  Google Scholar 

  134. 134.

    Fine JD, Johnson LB, Weiner M, Stein A, Cash S, Deleoz J, Devries DT, Suchindran C: Eye involvement in inherited epidermolysis bullosa: experience of the National Epidermolysis Bullosa Registry. Am J Ophthalmol. 2004, 138: 254-262.

    PubMed  Google Scholar 

  135. 135.

    Figueira EC, Murrell DF, Coroneo MT: Ophthalmic involvement in inherited epidermolysis bullosa. Dermatol Clin. 2010, 28: 143-152.

    CAS  PubMed  Google Scholar 

  136. 136.

    Watson SL, Lee MH, Barker NH: Interventions for recurrent corneal erosions. Cochrane Database Syst Rev. 2012, 9.

    Google Scholar 

  137. 137.

    Turner A, Rabiu M: Patching for corneal abrasion. Cochrane Database Syst Rev. 2006, 2.

    Google Scholar 

  138. 138.

    Calder LA, Balasubramanian S, Fergusson D: Topical nonsteroidal anti-inflammatory drugs for corneal abrasions: meta-analysis of randomized trials. Acad Emerg Med. 2005, 12: 467-473.

    PubMed  Google Scholar 

  139. 139.

    Gibbins S, Stevens BJ, Yamada J, Dionne K, Campbell-Yeo M, Lee G, Caddell K, Johnston C, Taddio A: Validation of the Premature Infant Pain Profile-Revised (PIPP-R). Early Hum Dev. 2014, 90: 189-193.

    PubMed  Google Scholar 

  140. 140.

    Stevens BJ, Gibbins S, Yamada J, Dionne K, Lee G, Johnston C, Taddio A: The Premature Infant Pain Profile-Revised (PIPP-R): initial validation and feasibility. Clin J Pain. 2014, 2014: 238-243.

    Google Scholar 

  141. 141.

    Hummel P, Puchalski M, Creech SD, Weiss MG: Clinical reliability and validity of the N-PASS: neonatal pain, agitation and sedation scale with prolonged pain. J Perinatol. 2008, 28: 55-60.

    CAS  PubMed  Google Scholar 

  142. 142.

    Krechel SW, Bildner J: CRIES: a new neonatal postoperative pain measurement score. Initial testing of validity and reliability. Paediatr Anaesth. 1995, 5: 53-61.

    CAS  PubMed  Google Scholar 

  143. 143.

    Lawrence J, Alcock D, McGrath P, Kay J, MacMurray SB, Dulberg C: The development of a tool to assess neonatal pain. Neonatal Netw. 1993, 12: 59-66.

    CAS  PubMed  Google Scholar 

  144. 144.

    Manworren RC, Hynan LS: Clinical validation of FLACC: preverbal patient pain scale. Pediatr Nurs. 2003, 29: 140-146.

    PubMed  Google Scholar 

  145. 145.

    Gill AM, Cousins A, Nunn AJ, Choonara IA: Opiate-induced respiratory depression in pediatric patients. Ann Pharmacother. 1996, 30: 125-129.

    CAS  PubMed  Google Scholar 

  146. 146.

    Purcell-Jones G, Dormon F, Sumner E: The use of opioids in neonates. A retrospective study of 933 cases. Anaesthesia. 1987, 42: 1316-1320.

    CAS  PubMed  Google Scholar 

  147. 147.

    Lynn AM, Slattery JT: Morphine pharmacokinetics in early infancy. Anesthesiology. 1987, 66: 136-139.

    CAS  PubMed  Google Scholar 

  148. 148.

    Kart T, Christrup LL, Rasmussen M: Recommended use of morphine in neonates, infants and children based on a literature review: part 1 pharmacokinetics. Paediatr Anaesth. 1997, 7: 5-11.

    CAS  PubMed  Google Scholar 

  149. 149.

    Yamada J, Stinson J, Lamba J, Dickson A, McGrath PJ, Stevens B: A review of systematic reviews on pain interventions in hospitalized infants. Pain Res Manag. 2008, 13: 413-420.

    CAS  PubMed  PubMed Central  Google Scholar 

  150. 150.

    Harrison D, Stevens B, Bueno M, Yamada J, Adams-Webber T, Beyene J, Ohlsson A: Efficacy of sweet solutions for analgesia in infants between 1 and 12 months of age: a systematic review. Arch Dis Child. 2010, 95: 406-413.

    PubMed  Google Scholar 

  151. 151.

    Cignacco EL, Sellam G, Stoffel L, Gerull R, Nelle M, Anand KJ, Engberg S: Oral sucrose and “facilitated tucking” for repeated pain relief in preterms: a randomized controlled trial. Pediatrics. 2012, 129: 299-308.

    PubMed  Google Scholar 

  152. 152.

    Mellerio JE, Weiner M, Denyer JE, Pillay EI, Lucky AW, Bruckner A, Palisson F: Medical management of epidermolysis bullosa: Proceedings of the IInd International Symposium of Epidermolysis Bullosa, Santiago, Chile, 2005. Int J Dermatol. 2007, 46: 795-800.

    PubMed  Google Scholar 

  153. 153.

    Tremlett M, Anderson BJ, Wolf A: Pro-con debate: is codeine a drug that still has a useful role in pediatric practice?. Paediatr Anaesth. 2010, 20: 183-194.

    PubMed  Google Scholar 

  154. 154.

    MacDonald N, MacLeod SM: Has the time come to phase out codeine?. CMAJ. 2010, 182: 1825.

    PubMed  PubMed Central  Google Scholar 

  155. 155.

    Allegaert K, Naulaers G: Gabapentin as part of multimodal analgesia in a newborn with epidermolysis bullosa. Paediatr Anaesth. 2010, 20: 972-973.

    PubMed  Google Scholar 

  156. 156.

    Saroyan JM, Tresgallo ME, Farkouh C, Morel KD, Schecter WS: The use of oral ketamine for analgesia with dressing change in an infant with epidermolysis bullosa: report of a case. Paediatr Dermatol. 2009, 26: 764-766.

    Google Scholar 

  157. 157.

    Jevtovic-Todorovic V: Anesthesia and the developing brain: are we getting closer to understanding the truth?. Curr Opin Anaesthesiol. 2011, 24: 395-399.

    PubMed  Google Scholar 

  158. 158.

    Fine JD, Johnson LB, Weiner M, Suchindran C: Cause-specific risks of childhood death in epidermolysis bullosa. J Pediatr. 2008, 152: 276-280.

    PubMed  Google Scholar 

  159. 159.

    Yuen WY, Duipmans JC, Molenbuur B, Herpertz I, Mandema JM, Jonkman MF: Long-term follow-up of patient with Herlitz-type junctional epidermolysis bullosa. Br J Dermatol. 2012, 167: 374-382.

    CAS  PubMed  Google Scholar 

  160. 160.

    Kho YC, Rhodes LM, Robertson SJ, Su J, Varigos G, Robertson I, Hogan P, Orchard D, Murrell DF: Epidemiology of epidermolysis bullosa in the antipodes: the Australasian epidermolysis bullosa registry with a focus on Herlitz junctional epidermolysis bullosa. Arch Dermatol. 2010, 146: 635-640.

    PubMed  Google Scholar 

  161. 161.

    Fine JD, Johnson LB, Weiner M, Li KP, Suchindran C: Epidermolysis bullosa and the risk of life-threatening cancers: the National EB Registry experience, 1986-2006. J Am Acad Dermatol. 2009, 60: 203-211.

    PubMed  Google Scholar 

  162. 162.

    Fine JD, Johnson LB, Weiner M, Stein A, Cash S, DeLeoz J, Devries DT, Suchindran C: Inherited epidermolysis bullosa and the risk of death from renal disease: experience of the National Epidermolysis Bullosa Registry. Am J Kidney Dis. 2004, 44: 651-660.

    PubMed  Google Scholar 

  163. 163.

    Fine JD, Hall M, Weiner M, Li KP, Suchindran C: The risk of cardiomyopathy in inherited epidermolysis bullosa. Br J Dermatol. 2008, 159: 677-682.

    PubMed  PubMed Central  Google Scholar 

  164. 164.

    Fine JD, Johnson LB, Weiner M, Suchindran C: Tracheolaryngeal complications of inherited epidermolysis bullosa: cumulative experience of the National Epidermolysis Bullosa Registry. Laryngoscope. 2007, 117: 1652-1660.

    PubMed  Google Scholar 

  165. 165.

    Craig F, Abu-Saad Huijer H, Benini F, Kuttner L, Wood C, Feraris PC, Zernikow B: IMPaCCT: standards of paediatric palliative care. Eur J Pall Care. 2007, 14: 1-7.

    Google Scholar 

  166. 166.

    Palliative care for children. Pediatrics. 2000, 106: 351-357.

  167. 167.

    World Health Organization Definition of Palliative Care. Available at: ., []

  168. 168.

    Mallipeddi R: Epidermolysis bullosa and cancer. Clin Exp Dermatol. 2002, 27: 616-623.

    CAS  PubMed  Google Scholar 

  169. 169.

    WHO Guidelines on the Pharmacological Treatment of Persisting Pain in Children with Medical Illnesses. 2012, WHO Press, World Health Organization, Geneva, Switzerland

  170. 170.

    Mercadante S: Opioid titration in cancer pain: a critical review. Eur J Pain. 2007, 11: 823-830.

    CAS  PubMed  Google Scholar 

  171. 171.

    Bruera E, Pereira J, Watanabe S, Belzile M, Kuehn N, Hanson J: Opioid rotation in patients with cancer pain: a retrospective comparison of dose ratios between methadone, hydromorphone, and morphine. Cancer. 1996, 78: 852-857.

    CAS  PubMed  Google Scholar 

  172. 172.

    Quigley C: Opioid switching to improve pain relief and drug tolerability. Cochrane Database Syst Rev. 2004, 3.

    Google Scholar 

  173. 173.

    Gagnon B, Almahrezi A, Schreier G: Methadone in the treatment of neuropathic pain. Pain Res Manag. 2003, 8: 149-154.

    PubMed  Google Scholar 

  174. 174.

    McNicol ED, Carr DB, Eisenberg E: Opioids for neuropathic pain. Cochrane Database Syst Rev. 2006, 8.

    Google Scholar 

  175. 175.

    Clements JA, Nimmo WS, Grant IS: Bioavailability, pharmacokinetics and analgesic activity of ketamine in humans. J Pharm Sci. 1982, 71: 539-542.

    CAS  PubMed  Google Scholar 

  176. 176.

    O’Neil B, Lucas C, Gannon C: Use of a subcutaneous syringe driver in epidermolysis bullosa. Palliat Med. 2001, 15: 77-78.

    Google Scholar 

  177. 177.

    Elsner F, Radbruch L, Loick G, Gaertner J, Sabatowski R: Intravenous versus subcutaneous morphine titration in patients with persisting exacerbation of cancer pain. J Palliat Med. 2005, 8: 743-750.

    CAS  PubMed  Google Scholar 

  178. 178.

    Reymond L, Charles MA, Bowman J, Treston P: The effect of dexamethasone on the longevity of syringe driver subcutaneous sites in palliative care patients. Med J Aust. 2003, 178: 486-489.

    PubMed  Google Scholar 

  179. 179.

    Association of Paediatric Palliative Medicine: Master Formulary. Available at: ., []

  180. 180.

    Mercadante S, Intravaia G, Villari P, Ferrera P, Riina S, Mangione S: Intravenous morphine for breakthrough (episodic-) pain in an acute palliative care unit: a confirmatory study. J Pain Symptom Manage. 2008, 35: 307-313.

    CAS  PubMed  Google Scholar 

  181. 181.

    Mercadante S, Villari P, Ferrera P, Mangione S, Casuccio A: The use of opioids for breakthrough pain in acute palliative care unit by using doses proportional to opioid basal regimen. Clin J Pain. 2010, 26: 306-309.

    PubMed  Google Scholar 

  182. 182.

    Zeppetella G, Davies AN: Opioids for the management of breakthrough (episodic) pain in cancer patients. Cochrane Database Syst Rev. 2013, 10.

    Google Scholar 

  183. 183.

    Nischler E, Diem A: Pruritis in epidermolysis bullosa. Life with Epidermolysis Bullosa: Etiology, Diagnosis, Multidisciplinary Care and Therapy. Edited by: Fine JD, Hinter H. 2008, Springer-Verlag/Wein, Austria, 233-240.

    Google Scholar 

  184. 184.

    Jeffry J, Seungil K, Chen ZF: Itch signalling in the nervous system. Physiology. 2011, 26: 286-292.

    CAS  PubMed  PubMed Central  Google Scholar 

  185. 185.

    Raap U, Stander S, Metz M: Pathophysiology of itch and new treatments. Curr Opin Allergy Clin Immunol. 2011, 11: 420-427.

    CAS  PubMed  Google Scholar 

  186. 186.

    Goutos I, Eldardiri M, Khan AA, Dziewulski P, Richardson PM: Comparative evaluation of antipruritic protocols in acute burns. The emerging value of gabapentin in the treatment of burns pruritis. J Burn Res. 2010, 31: 57-63.

    Google Scholar 

  187. 187.

    EB Nurse. Itching [], []

  188. 188.

    Ahuja RB, Gupta R, Gupta G, Shrivastava P: A comparative analysis of cetirizine, gabapentin and their combination in the relief of post-burn pruritus. Burns. 2011, 37: 203-207.

    PubMed  Google Scholar 

  189. 189.

    Hundley JL, Yosipovitch G: Mirtazapine for reducing nocturnal itch in patients with chronic pruritus: a pilot study. J Am Acad Dermatol. 2004, 50: 889-891.

    PubMed  Google Scholar 

  190. 190.

    Davis MP, Frandsen JL, Walsh D, Andresen S, Taylor S: Mirtazapine for pruritus. J Pain Symptom Manage. 2003, 25: 288-291.

    PubMed  Google Scholar 

  191. 191.

    Shaw RJ, Dayal S, Good J, Bruckner AL, Joshi SV: Psychiatric medications for the treatment of pruritis. Psychosom Med. 2007, 69: 970-978.

    PubMed  Google Scholar 

  192. 192.

    Zylicz Z, Krainik M: Serotonin reuptake inhibitors and other antidepressants in the treatment of chronic pruritus. Pruritus. 2010, 3: 301-306.

    Google Scholar 

  193. 193.

    Calikoglu E, Anadolu R: Management of generalized pruritus in dominant dystrophic epidermolysis bullosa using low-dose oral cyclosporin. Acta Derm Venereol. 2002, 82: 380-382.

    PubMed  Google Scholar 

  194. 194.

    Jones EA: Pruritus and fatigue associated with liver disease: is there a role for ondansetron?. Expert Opin Pharmacother. 2008, 9: 645-651.

    CAS  PubMed  Google Scholar 

  195. 195.

    Deshpande PV: Ondansetron for paediatric uraemic pruritus: a case report. Pediatr Nephrol. 2004, 19: 694-696.

    PubMed  Google Scholar 

  196. 196.

    Murphy M, Reaich D, Pai P, Finn P, Carmichael AJ: A randomized, placebo-controlled, double-blind trial of ondansetron in renal itch. Br J Dermatol. 2003, 148: 314-317.

    CAS  PubMed  Google Scholar 

  197. 197.

    Tey HL, Yosipovitch G: Targeted treatment of pruritus: a look into the future. Br J Dermatol. 2011, 165: 5-17.

    CAS  PubMed  PubMed Central  Google Scholar 

  198. 198.

    Ahuja RB, Gupta GK: A four arm, double blind, randomized and placebo controlled study of pregabalin in the management of post-burn pruritus. Burns. 2013, 39: 24-29.

    PubMed  Google Scholar 

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Guideline development was supported by a small grant from DEBRA USA to defray the costs of travel, accommodation and preparation related to the consensus meeting, held on 4, 5 May 2012 in Cincinnati, Ohio, USA. The following members of the original guidelines development committee helped with initial content development and recommendations: Beverly Inge Walti, Kara Malcolm, Teresa Mingrone, and Stacy Shipley.

The following Clinician Reviewers are gratefully acknowledged: Anna L. Bruckner, MD, Elizabeth Ely, RN, PhD, Kim Hazelbaker, RN, Barbara Hoggart, MD, Richard F. Howard, BSc, FRCA, Anne Lucky, MD, Geraldine Mancuso-Kelly, RN, Elena Pope, MD, Susan Rowe, RN, Alexandra Szabova, MD, Jean Whalen, RN.

Warm thanks to the following Family and Patient Reviewers: Patsy DiGiovanna, Michelle Starkey, Natasha Starkey and *Brett Kopelan (*participated in consensus meeting).

Special thanks to Andrea Ayers (administrative assistant to KRG), Brett Kopelin (DEBRA USA), Francis Palisson (DEBRA Chile) and Avril Keenan (DEBRA Ireland) for their support.

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Correspondence to Kenneth R Goldschneider.

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Goldschneider, K.R., Good, J., Harrop, E. et al. Pain care for patients with epidermolysis bullosa: best care practice guidelines. BMC Med 12, 178 (2014).

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  • Epidermolysis bullosa
  • Pain
  • Practice guidelines
  • RDEB
  • Acute pain
  • Chronic pain
  • Recessive dystrophic epidermolysis bullosa
  • Dystrophic Epidermolysis Bullosa Research Association International