Podiatrists should be routinely included in the multidisciplinary management of epidermolysis bullosa, according to new evidence-based guidelines on foot care for EB patients.

The guidelines working panel included health professionals and people living with EB from Australia, the UK and US.

Panel member Dr Adam Harris, a Sydney dermatologist, told the limbic the condition was so rare that many dermatologists and podiatrists would rarely see cases.

However 90% of EB patients have one or more podiatric manifestation, including blistering, hyperkeratosis, flat feet, nail dystrophy or structural abnormality affecting foot positioning, the guidelines said.

“All EB patients require nail management from birth, plus wound care and footwear advice and insoles as they become older,” it said.

However interventions had to be tailored to the subtype of EB.

Dr Harris said supportive care, aimed at minimising friction and mechanical trauma to the skin, was the mainstay of management.

The guidelines included evidence-based recommendations around:

• podiatry education programs to prevent blistering and wounds
• the management of dystrophic nails including the use of keratolytics and trimming reducing or removal of nails
• monitoring and management of hyperkeratosis
• suitable footwear, insoles and orthotics to minimise blistering and improve foot function
• assessment and monitoring of mobility, and
• surgery for correction of pseudosyndactyly, mitten deformities and contractures.

Dr Harris said there was evidence of short-term benefit from surgical correction however many of the problems e.g. contractures would recur due to the nature of dystrophic EB.

Practical points included in the guidelines said:

• healthcare professionals and patients have reported the benefit of using cornflour on the soles of the feet and between the toes to help control excessive moisture and reduce friction both of which can help control blistering. However evidence in the literature was lacking.
• plantar injections of botulinum toxin were a long-lasting and safe treatment for painful blistering and callosities in EB simplex which effectively reduced pain from walking. However, the procedure is painful and not tolerated by all patients.
• Patients have reported bad experiences from over-debridement of hyperkeratosis which can make the underlying skin more susceptible to blistering and tenderness.

The guidelines concluded with a call for further high quality research.

Dr Harris added that the role of the dermatologist in EB foot care was in providing overall advice, coordinating care and referrals, and providing access to subsidised EB dressing and clinical trials when available.