Epidermolysis bullosa

Water is the safest cleaning agent, except in obviously infected wounds. It is recommended to bath at a temperature of 37ºC, avoiding too much time passing during washing so that the body does not get cold. The person in charge of the cure will previously check the water temperature. In case of not having drinking water available, saline solutions like physiologic saline can be used on non-infected wounds. There is also the possibility of bathing in other substances:

• Vinegar baths. It serves to reduce the microbial load of wounds, especially when there is contamination by Pseudomonas bacteria (since they are very resistant to antibiotics). Common white vinegar should be diluted in water and rinsed with plenty of water after use, as it can cause great itching.
• Baths with diluted bleach. In contaminated wounds, it is recommended to mix 15 litres of warm water with bleach (proportion: 15 litres of water with 30 ml of household bleach (2.1%)) and apply carefully without coming into contact with eyes and other mucous membranes. After use, it should be rinsed with plenty of water to avoid itching. It is not recommended for use in children under 1 year of age.
• Salt baths. In painful wounds, the use of water with salt (0.9% solution, such as common saline, which would be 90 grams of common salt in 10 litres of water) can be effective. In some people it can cause itching, so it is important to assess individually and always rinse with clean water after bathing.
• Antiseptic products prescribed by the reference dermatologist. It is important to strictly follow the medical guidelines, since these substances can be very irritating or drying for the skin, as well as generate resistance to microorganisms if not used properly.

When the wounds are more complex and the microorganisms’ numbers increases, it is recommended to use antiseptic products and surfactants under professional indication like, for example: polyhexamethylin biguanide (PHMB), Octenidine, super oxidized agents with a low concentration of hypochlorous acid (Microdacyn®), polyhexanide (Prontosan®), etc. Antiseptics such as povidone-iodine or chlorhexidine should not be applied to open wounds.

After the bath we must dry the skin, especially for babies and small children, to avoid a sudden cooling.The drying should be done with the use of soft tissue towels without rubbing, but by soft touches. In some cases, this process cannot be done due to severe pain, so we will let the skin air dry, but it is important to make sure that the skin does not spend too much time wet and that no moisture remains in the folds or on the skin. the areas to be covered.

Right after bathing, a thorough skin and wound assessment is essential. The objective is to detect warning signs of infection that should make us consult with our medical team (Figure 6):

• Infection. We know a wound might be infected because the area’s temperature increases, increases the exudate, there might be swelling, change of odour, the wounds do not cicatrize as they usually do, the pain might have increased, there might be fever and/or discomfort.
• Factors which delay cicatrization (see section 2.3).
• Intense bleeding. If there is bleeding, we shall press the area softly but firmly to stop it. Cold water can also help. There are products which reduce bleeding, like tranexamic acid (always prescribed by the reference professional). If bleeding does not stop and is very abundant, it is recommended to go to the closest health centre.
• Suspicion of carcinoma. Since squamous cell carcinoma is a serious complication in some adolescents and adults with advanced EB (especially recessive dystrophic EB), early detection is essential. It is recommended to be especially vigilant in the areas of greatest risk: knees, ankles, hands or wrists, cheeks, elbows, feet and in places where blisters, wounds or scars appear recurrently. The signs that should make us consult with our reference medical team are (Figure 7):
• Wounds that do not heal normally or behave differently or unusual for you.
• When the wound feels “different” or has a strange sensation, especially when there is tingling, very intense and unusual pain, or no pain at all.
• Rapid wound growth, especially cauliflower-shaped (from the wound bed upwards).
• Presence of “digs” in the wound, such as deep perforations with raised or rolled edges.
• Very thick and/or raised scabs, which cannot be removed despite performing the appropriate and usual care.