Epidermolysis bullosa

DEBRIDING 

Although there are multiple basic and/or advanced debridement techniques, in EB wounds this should be the least aggressiveand invasive as possible.

• Autolytic debridement. This type of debridement is a natural process by which the body's own enzymes remove waste or necrotic material. There are dressings or products that can speed up this process. It is a slow but very well accepted method.
• Enzymatic debridement. This method uses the effect of enzymes, which are a type of protein that has the function of breaking down non-viable tissue. These enzymes are available in topical creams that are applied to the area to be debrided. However, since there is a greater risk of damaging the periwound skin due to excessive humidity, we will avoid applying them to areas of healthy skin. One of the most used compounds is collagenase, which should be applied every 12 hours.
• Osmotic debridement. It is a physical effect through which the remains of waste and the non-viable tissue of the wound are destroyed by the difference in concentration between the substances that are in the wound and in the product that is applied. In these cases, we must protect the perilesional skin from maceration and bear in mind that it can become slightly painful. Some examples are honey-based products and polymeric membranes with surfactant products.
• Sharp debridement. This type of debridement must be performed by trained professionals and is performed with cutting tools (scissors, tweezers, and/or scalpels). Surgical debridement is not usually an option for people with EB since most wounds can be very painful and bleeding.
• Mechanical debridement can be simple, such as cleansing wounds with water, or complex, such as the use of more aggressive debridement pads or whirlpool baths. There is evidence of improvement in its use in people with EB, but it is important to do it under supervision and professional advice.

BLISTERS MANAGEMENT 

Since blisters are one of the most common skin lesions in most of the different types of EB, we consider that it is necessary to make a special mention about their management. EB blisters are caused by a build-up of fluid that creates tension between the layers of the skin, so it tends to grow if they are not drainedor emptied. In some cases, this tension can cause pain. The larger the blister, the larger the subsequent wound will be, so we must empty it as soon as we see it, regardless of its size. For this reason, in cases where the blister is "intact" and without signs of infection, it is recommended to empty it using the needle puncture technique (Figure 8):

1. Prepare the dressings we will use to cover the blister, adapting the size.
2. Clean and disinfect the blister to reduce the number of microorganisms that might enter the wound after.
3. Use a sterile needle with an upwardsbezel to punction the blisterparallel to the skin base, on its lowermost point, creating an entrance and exit hole so that the liquid can exit.
4. Apply soft pressure with a clean gauze to help the liquid to exit and avoid the blister to refill and create a bigger one.
5. Whenever possible, keep the roof of the blister (the skin that we have punctured and when it is emptied has become more wrinkled) to naturally protect the wound. The blisters where the skin is removed create an open wound that is more painful and has a higher risk of infection. In cases where there are signs of infection or where the skin is damaged (wet or macerated, abraded or broken, etc.), it should be removed with sharp debridement.
6. Evaluate the rest of the wound and clean the remaining of dead skin surrounding the open wound.
7. Cover and protect the blister.

An alternative is the use of clean or sterile scissors instead of needles, although it is usually a more complex procedure. It is common to do the bath and the cleaning of all the wounds at the same time and do the individual debridement of each lesion after. It is recommended to leave the more contaminated and/or infected wounds last, to minimize the risk of infection of other wounds.