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

Background: 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.Methods: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.Results: 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.Conclusions: 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.

# Background
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 [bib_ref] Assessment of mobility, activities, and pain in different subtypes of epidermolysis bullosa, Fine [/bib_ref]. Effects on quality of life are substantial [bib_ref] Quality of life in patients with epidermolysis bullosa, Tabolli [/bib_ref] [bib_ref] Psychiatric symptoms and quality of life in patients affected by epidermolysis bullosa, Margari [/bib_ref]. 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 [bib_ref] Main problems experienced by children with Epidermolysis Bullosa: a qualitative study with..., Van Scheppingen [/bib_ref] 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) [bib_ref] Inherited epidermolysis bullosa: updated recommendations on diagnosis and classification, Fine [/bib_ref]. Additionally, there are at least 18 genes associated with the different types of EB [bib_ref] Inherited epidermolysis bullosa: updated recommendations on diagnosis and classification, Fine [/bib_ref]. 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 Internationalis an optimal facilitating organization that can aid implementation of the guidelines by way of providing information, support and means of contacting expert care providers.

# Methods
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 [fig_ref] Figure 1: Flow of information through the evidence evaluation process [/fig_ref]. A total of 57 references were found and evaluated that were specific to the cross match of EB and the painrelated keywords (see above), of which only 8 were included into specific recommendations. The rationale for including and excluding these references is found in [fig_ref] Table 1: EB-specific articles used in producing recommendations [/fig_ref] and in Additional file 1.
All included articles were critically appraised using evidence appraisal forms from the LEGEND (Let Evidence Guide Every New Decision) evidence evaluation system [bib_ref] Let Evidence Guide Every New Decision (LEGEND): an evidence evaluation system for..., Clark [/bib_ref]. 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. 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 [fig_ref] Table 3: Summary of recommendations Psychological therapies offer effective approaches to management of chronic... [/fig_ref]. 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 LE-GEND system [bib_ref] Let Evidence Guide Every New Decision (LEGEND): an evidence evaluation system for..., Clark [/bib_ref] provided objective criteria for evaluating evidence related to each recommendation (see [fig_ref] Table 4 Table: for judging the strength of a recommendation[8] For acute pain management, offer... [/fig_ref].
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 LE-GEND tool for Judging the Strength of a Recommendation (see [fig_ref] Table 4 Table: for judging the strength of a recommendation[8] For acute pain management, offer... [/fig_ref] was used as a guide for finalizing recommendation statements by discussing the body of evidence and discussing safety/harm and other dimensions [bib_ref] Let Evidence Guide Every New Decision (LEGEND): an evidence evaluation system for..., Clark [/bib_ref]. The overall GRADE (A, B, C, D) for each recommendation statement was then determined, based on this process and the established criteria for GRADE [bib_ref] Grading quality of evidence and strength of recommendations in clinical practice guidelines...., Brozek [/bib_ref].

## 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 [bib_ref] Histopathological features of gastrointestinal mucosal biopsy specimens in children with epidermolysis bullosa, Shah [/bib_ref] 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 [bib_ref] The biopsychosocial approach to chronic pain: scientific advances and future directions, Gatchel [/bib_ref]. This approach has also been advocated for EB patients [bib_ref] Psychiatric symptoms and quality of life in patients affected by epidermolysis bullosa, Margari [/bib_ref] 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 [bib_ref] Pain management in children: developmental considerations and mind-body therapies, Gerik [/bib_ref]. 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 [bib_ref] Forging ahead: the 2003 APA Division 30 definition of hypnosis, Green [/bib_ref]. 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 [bib_ref] Parent and family factors in pediatric chronic pain and disability: an integrative..., Palermo [/bib_ref]. 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 [bib_ref] Psychological therapies for the management of chronic and recurrent pain in children..., Eccleston [/bib_ref] [bib_ref] Randomized controlled trials of psychological therapies for management of chronic pain in..., Palermo [/bib_ref] with emerging evidence showing improvement in pain-related functional disability as well [bib_ref] Randomized controlled trials of psychological therapies for management of chronic pain in..., Palermo [/bib_ref] [bib_ref] Efficacy of cognitivebehavioral intervention for juvenile primary fibromyalgia syndrome, Kashikar-Zuck [/bib_ref]. The addition of biofeedback to relaxation training does not necessarily result in superior pain outcomes [bib_ref] Randomized controlled trials of psychological therapies for management of chronic pain in..., Palermo [/bib_ref]. Modest data support the use of CBT in adults with chronic pain and disability [bib_ref] Psychological therapies for the management of chronic pain (excluding headache) in adults, Eccleston [/bib_ref] (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 [bib_ref] Hypnosis for procedure-related pain and distress in pediatric cancer patients: a systematic..., Richardson [/bib_ref] [bib_ref] Psychological interventions for needle-related procedural pain and distress in children and adolescents, Uman [/bib_ref] [bib_ref] HELPinKIDS Team: Psychological interventions for reducing pain and distress during routine childhood..., Chambers [/bib_ref] [bib_ref] Effects of distraction on children's pain and distress during medical procedures: a..., Kleiber [/bib_ref] [bib_ref] A randomized clinical trial of a brief hypnosis intervention to control venepuncture-related..., Liossi [/bib_ref].
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 [bib_ref] The effectiveness of virtual reality distraction for pain reduction: a systematic review, Malloy [/bib_ref] and therapist coaching of stress management techniques [bib_ref] Nonpharmacological interventions for acute wound care distress in pediatric patients with burn..., Hanson [/bib_ref] are beneficial.
For postoperative pain, there is insufficient evidence for the efficacy of most psychological interventions, but preparation, guided imagery and CBT are promising [bib_ref] Psychological interventions for acute pediatric pain, Liossi [/bib_ref].

## 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 [bib_ref] Treatment of itch, Hagermark [/bib_ref]. Perpetuation of the itchscratch 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 [bib_ref] The effects of psychological intervention on atopic dermatitis. A systematic review and..., Chida [/bib_ref]. 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 [bib_ref] Habit-reversal: a method of eliminating nervous habits and tics, Azrin [/bib_ref] [bib_ref] The behavioral treatment of neurodermatitis through habit-reversal, Rosenbaum [/bib_ref] (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 [bib_ref] The effects of psychological intervention on atopic dermatitis. A systematic review and..., Chida [/bib_ref] [bib_ref] Treatment of atopic dermatitis: a comparison of psychological and dermatological approaches to..., Ehlers [/bib_ref].

## 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 [bib_ref] Acupuncture for chronic pain: is acupuncture more than an effective placebo? A..., Hopton [/bib_ref] , music therapy [bib_ref] Music for pain relief, Cepeda [/bib_ref] , chiropractic care, or yoga [bib_ref] Effects of yoga interventions on pain and pain-associated disability: a meta-analysis, Bussing [/bib_ref] 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 [bib_ref] Herbal remedies affecting coagulation: a review, Cordier [/bib_ref]. 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. Include parents in behavioral pain management interventions [bib_ref] Helping parents to help their child with procedural and everyday pain: practical,..., Power [/bib_ref] for children and adolescents.
Acute pain care: postoperative pain management Introduction
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.

## Assessment
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) [bib_ref] Systematic review of observational (behavioral) measures of pain for children and adolescents..., Von Baeyer [/bib_ref] [bib_ref] Systematic review of the psychometric properties, interpretability and feasibility of self-report pain..., Stinson [/bib_ref] 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 antiinflammatory drugs, acetaminophen and, when appropriate for the type of surgery, regional anesthesia [bib_ref] Pain management in epidermolysis bullosa, Goldschneider [/bib_ref]. 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 .
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 [bib_ref] Cyclooxygenase-2 inhibition and coagulation, Steffel [/bib_ref]. 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 [bib_ref] Epidermolysis bullosa in children: pathophysiology, anaesthesia and pain management, Herod [/bib_ref]. Intranasal opioids can be effective for short-term treatment, if other routes are not available [bib_ref] Intranasal fentanyl provides adequate postoperative analgesia in pediatric patients, Manjushree [/bib_ref] [bib_ref] A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing..., Borland [/bib_ref] [bib_ref] Analgesic efficacy of intranasal butorphanol (Stadol NS) in the treatment of pain..., Desjardins [/bib_ref] , 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 transbuccal formulations may be helpful as well, although they presume intact mucosa, which may not be applicable (see .
Patients with prolonged postoperative pain because of extensive surgery may benefit from the use of opioidbased 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. PCAby-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 . 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) [bib_ref] Regional anesthesia in children with epidermolysis bullosa dystrophica, Kelly [/bib_ref] [bib_ref] Regional anesthesia in a patient with epidermolysis bullosa, Sopchak [/bib_ref] [bib_ref] Caudal epidural anesthesia in an infant with epidermolysis bullosa, Yee [/bib_ref] , 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) [bib_ref] Continuous axillary block for upper limb surgery in a patient with epidermolysis..., Diwan [/bib_ref] [bib_ref] Ultrasound-guided axillary plexus block in a child with dystrophic epidermolysis bullosa, Englbrecht [/bib_ref].
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 [bib_ref] Subcutaneous tunnelling of an epidural catheter in a child with epidermolysis bullosa, Doi [/bib_ref] then secured to the skin using silicone-based tapes and dressings (Mepitac W , Mepitel W , Mepilex W ) 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 W ) may be a good option when available [bib_ref] EREM Study Group: Forty-eight hours of postoperative pain relief after total hip..., Viscusi [/bib_ref] [bib_ref] Analysis of individual patient data from clinical trials: epidural morphine for postoperative..., Mhuircheartaigh [/bib_ref] , although monitoring is important due to risk of hypoventilation [bib_ref] Extended-release epidural morphine (DepoDur): review and safety analysis, Hartrick [/bib_ref]. 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 .

## 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
Introduction 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 siliconebased products, are helpful in reducing skin-trauma pain. Different subtypes of EB and different individuals seem to have varying dressing requirements [bib_ref] Wound management for children with epidermolysis bullosa, Denyer [/bib_ref]. 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 longacting opioid preparations to provide a basal comfort level. Of note, there are no clear guidelines that longacting opioids are preferable to use of intermittent opioids for non-cancer pain [bib_ref] American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel: Clinical guidelines..., Chou [/bib_ref] , although there is modest evidence for opioid use, in general, for noncancer pain in adults [bib_ref] American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel: Clinical guidelines..., Chou [/bib_ref] [bib_ref] Long-term opioid management for chronic noncancer pain, Noble [/bib_ref]. 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 [bib_ref] The impact of opioids on the endocrine system, Katz [/bib_ref]. 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 halflife as well as to saturable plasma protein binding [bib_ref] Methadone analgesia for children with advanced cancer, Davies [/bib_ref]. The long and variable half-life, as well as the risk of methadone-induced prolonged QT syndrome [bib_ref] Retrospective analysis of low-dose methadone and QTc prolongation in chronic pain patients, Huh [/bib_ref] [bib_ref] Methadone: to ECG or not to ECG...That is still the question, Cruciani [/bib_ref] , mandates care in its use alone and with other drugs that may also prolong the QT interval. Guidelines on electrocardiographic screening are limited [bib_ref] Substance Abuse and Mental Health Services Administration: QT interval screening in methadone..., Martin [/bib_ref] (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 [bib_ref] Methadone for cancer pain, Nicholson [/bib_ref]. 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 [bib_ref] Opioid-induced constipation: challenges and therapeutic opportunities, Camilleri [/bib_ref] 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 [bib_ref] Gabapentin for chronic neuropathic pain and fibromyalgia in adults, Moore [/bib_ref]. Medications such as tricyclic antidepressants and gabapentin have shown anecdotal success in EB skin pain in a child [bib_ref] Pain management of junctional epidermolysis bullosa in an 11-year-old boy, Chiu [/bib_ref] , as well as for adult patients with acute skin pain due to burns [bib_ref] Successful use of gabapentin in acute pain management following burn injury: a..., Gray [/bib_ref]. 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 [bib_ref] Dilated cardiomyopathy in epidermolysis bullosa: a retrospective, multicenter study, Lara-Corrales [/bib_ref] , as a lethal outcome in this setting has been reported [bib_ref] Lethal cardiomyopathy in epidermolysis bullosa associated with amitriptyline, Taibjee [/bib_ref].
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 [bib_ref] Treatment of painful skin ulcers with topical opioids, Twillman [/bib_ref] [bib_ref] Effectiveness of topical administration of opioids in palliative care: a systematic review, Lebon [/bib_ref] but has only limited anecdotal experience in EB wounds [bib_ref] Peripheral opioids in inflammatory pain, Watterson [/bib_ref] (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 [bib_ref] Use of a keratin-based hydrogel in the management of recessive dystrophic epidermolysis..., Than [/bib_ref].
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 W ) [bib_ref] EMLA and amethocaine for reduction of children's pain associated with needle insertion, Lander [/bib_ref]. 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 W (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 [bib_ref] Adjusting the pH of lidocaine for reducing pain on injection, Cepeda [/bib_ref]. As noted above, CBT (for example, distraction and relaxation) is effective in the acute pain setting [bib_ref] Psychological interventions for needle-related procedural pain and distress in children and adolescents, Uman [/bib_ref] 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
Introduction 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 [bib_ref] Bathing for individuals with Epidermolysis bullosa, Arbuckle [/bib_ref]. The former may have anti-pruritic, cleansing and protective properties for dermatologic conditions in general [bib_ref] Mechanism of action and clinical benefits of colloidal oatmeal for dermatologic practice, Cerio [/bib_ref] 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 [bib_ref] The effectiveness of saltwater baths in the treatment of patients with epidermolysis..., Peterson [/bib_ref]. 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 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 [bib_ref] Intranasal medication delivery for children: a brief review and update, Wolfe [/bib_ref]. Fentanyl works well by this route for non-EB patients in the perioperative setting [bib_ref] Intranasal fentanyl provides adequate postoperative analgesia in pediatric patients, Manjushree [/bib_ref] , 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 [bib_ref] A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing..., Borland [/bib_ref]. 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 [bib_ref] Analgesic efficacy of intranasal butorphanol (Stadol NS) in the treatment of pain..., Desjardins [/bib_ref] as well as for opioidinduced 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 .
Ketamine can be administered enterally for wound care pain, for which there are data from adult and pediatric burn populations [bib_ref] Oral ketamine for wound care procedures in adult patients with burns, Ezike [/bib_ref] [bib_ref] Superiority of oral ketamine as an analgesic and sedative for wound care..., Humphries [/bib_ref] but not for EB patients. The IV form of ketamine given orally has been used with variable success for other chronic pain conditions [bib_ref] Use of oral ketamine in chronic pain management: a review, Blonk [/bib_ref] as well as in cancer patients [bib_ref] Ketamine as an adjuvant to opioids for cancer pain, Bell [/bib_ref] and in pediatric palliative care [bib_ref] Oral ketamine for pain relief in a child with abdominal malignancy, Ugur [/bib_ref].
Inhaled nitrous oxide has been suggested for pediatric wound care in EB in some texts and review articles [bib_ref] Epidermolysis bullosa in children: pathophysiology, anaesthesia and pain management, Herod [/bib_ref] , but its use in EB patients has not been studied or reported. Nitrous oxide has been used for painful procedures in other settings [bib_ref] Effectiveness of 50% nitrous oxide/50% oxygen during laceration repair in children, Burton [/bib_ref] 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 [bib_ref] Nitrous oxide and spontaneous abortion in female dental assistants, Rowland [/bib_ref]. 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 [bib_ref] Megaloblastic bone marrow changes after repeated nitrous oxide anaesthesia. Reversal with folinic..., Nunn [/bib_ref] [bib_ref] Biologic effects of nitrous oxide: a mechanistic and toxicologic review, Sanders [/bib_ref].
Anxiolysis 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, [bib_ref] Sedation of children undergoing dental treatment, Lourenco-Matharu [/bib_ref] [bib_ref] Sedative effects of oral midazolam, intravenous midazolam and oral diazepam, Tyagi [/bib_ref] ; prior to adult burn procedures [bib_ref] Lorazepam as an adjunct to opioid analgesics in the treatment of burn..., Patterson [/bib_ref]. 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 . 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
Introduction Gastrointestinal complications are common in children and adults with EB with specific complications linked to different subtypes [bib_ref] Gastrointestinal complications of epidermolysis bullosa in children, Freeman [/bib_ref] [bib_ref] Extracutaneous manifestations and complications of inherited epidermolysis bullosa: part I. Epithelial associated..., Fine [/bib_ref] [bib_ref] Oral and gastrointestinal manifestations of epidermolysis bullosa, Travis [/bib_ref].

## Upper gastrointestinal tract
Topical treatments Oral ulceration, blistering and mucositis are the most frequent gastrointestinal complications in patients with EB [bib_ref] Gastrointestinal manifestations of epidermolysis bullosa. A study of 101 patients, Ergun [/bib_ref]. 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 [bib_ref] Sucralfate: a help during oral management in patients with epidermolysis bullosa, Marini [/bib_ref]. The number of blisters reduced within three weeks and pain reduced within one week (see .
Polyvinylpyrrolidone-sodium hyaluronate gel (Gelclair W ) 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 W may be useful as an adjunctive therapy in decreasing the painful lesions of oral mucositis in cancer patients [bib_ref] Gelclair oral gel, Buchsel [/bib_ref] [bib_ref] Polyvinylpyrrolidone-sodium hyaluronate gel (Gelclair): a bioadherent oral gel for the treatment of..., Buchsel [/bib_ref]. 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 [bib_ref] Effects of chlorhexidine/benzydamine mouth spray on pain and quality of life in..., Cingi [/bib_ref].
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 [bib_ref] Gastrointestinal complications of epidermolysis bullosa in children, Freeman [/bib_ref]. 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 H 2 -blockers and proton pump inhibitors and, rarely, surgery [bib_ref] North American Society for Pediatric Gastroenterology Hepatology and Nutrition, European Society for..., Vandenplas [/bib_ref] [bib_ref] Current trends in the management of gastroesophageal reflux disease: a review, Nwokediuko [/bib_ref] (see .
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 [bib_ref] Gastrointestinal complications of inherited epidermolysis bullosa: cumulative experience of the National Epidermolysis..., Fine [/bib_ref]. However, strictures can also be seen in other subtypes of EB including Kindler syndrome. 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 [bib_ref] Esophageal strictures in children with recessive dystrophic epidermolysis bullosa: an 11-year experience..., Azizkhan [/bib_ref] [bib_ref] Efficacy and safety of endoscopic dilation of esophageal strictures in epidermolysis bullosa, Anderson [/bib_ref] [bib_ref] Epidermolysis bullosa: management of esophageal strictures and enteric access by gastrostomy, Mortell [/bib_ref] (see . 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 [bib_ref] Oral viscous budesonide therapy in children with epidermolysis bullosa and proximal esophageal..., Dohil [/bib_ref]. Both children had a reduction in the rate of stricture formation and symptoms of dysphagia.

## Lower gastrointestinal tract
Constipation Constipation has been shown to be present in 35% of children with all types of EB [bib_ref] Gastrointestinal complications of epidermolysis bullosa in children, Freeman [/bib_ref] 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 [bib_ref] Death from colonic disease in epidermolysis bullosa dystrophica, Hsieh [/bib_ref]. 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 . Polyethylene glycol is effective clinically in treating constipation in children and adults with EB, with empiric evidence of efficacy in adult [bib_ref] Systematic review and meta analysis: polyethylene glycol in adults with non-organic constipation, Belsey [/bib_ref] and pediatric [bib_ref] The clinical effectiveness of Movicol in children with severe constipation: an outcome..., Hanson [/bib_ref] non-EB cohorts.
Colitis A subgroup of children with RDEB may develop colitis, presenting with abdominal pain and other symptoms [bib_ref] Gastrointestinal complications of epidermolysis bullosa in children, Freeman [/bib_ref] [bib_ref] Histopathological features of gastrointestinal mucosal biopsy specimens in children with epidermolysis bullosa, Shah [/bib_ref]. Dietary restriction and anti-inflammatory drugs, such as sulfasalazine, have been used but with variable effects on controlling the colitis [bib_ref] Gastrointestinal complications of epidermolysis bullosa in children, Freeman [/bib_ref].
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 [bib_ref] Topical sucralfate treatment of anal fistulotomy wounds: a randomized placebo-controlled trial, Gupta [/bib_ref]. Sucralfate suspension has also been used to lessen the pain of oral and genital ulceration in patients with Behcet's disease [bib_ref] The use of sucralfate suspension in the treatment of oral and genital..., Alpsoy [/bib_ref]. Anecdotally, topical sucralfate combined with CavilonTM (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 [bib_ref] Non surgical therapy for anal fissure, Nelson [/bib_ref] , with recommendations of topical diltiazem and glyceryl trinitrate followed by surgery if needed in adults [bib_ref] Seow-Choen F: Innovations in chronic anal fissure treatment: a systematic review, Poh [/bib_ref]. No data on anal fissure treatment in EB patients exist (see .
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
Introduction 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 [bib_ref] Podiatric management in epidermolysis bullosa, Khan [/bib_ref]. 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 . Coping skills training and activity pacing can enhance effectiveness of therapy [bib_ref] Relationship of pain-coping strategies and pain-specific beliefs to pain experience in children..., Thastum [/bib_ref]. Surgical intervention has had some success in increasing mobility and reducing pain [bib_ref] The surgical management of dystrophic epidermolysis bullosa (excluding the hand), Terrill [/bib_ref]. EB patients can also have inflammatory arthritis [bib_ref] An unusual case of epidermolysis bullosa complicated by persistent oligoarticular juvenile idiopathic..., Maritsi [/bib_ref] [bib_ref] A case of dystrophic epidermolysis bullosa improved with etanercept for concomitant psoriatic..., Gubinelli [/bib_ref] ; 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 [bib_ref] Bone mineralization in children with epidermolysis bullosa, Fewtrell [/bib_ref] [bib_ref] Osteopenia and osteoporosis in epidermolysis bullosa, Martinez [/bib_ref] [bib_ref] Correlates of low bone mass in children with generalized forms of epidermolysis..., Bruckner [/bib_ref] , 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 [bib_ref] Osteoporosis and inflammation, Lacativa [/bib_ref] [bib_ref] Gut, inflammation and osteoporosis: basic and clinical concepts, Tilg [/bib_ref].
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 [bib_ref] Osteopenia and osteoporosis in epidermolysis bullosa, Martinez [/bib_ref]. 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 [bib_ref] Summary of AHRQ's comparative effectiveness review of treatment to prevent fractures in..., Levis [/bib_ref] (see . 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 [bib_ref] Bisphosphonates, a new treatment for glucocorticoid-induced osteoporosis in children, Noguera [/bib_ref] [bib_ref] Low-dose intravenous pamidronate reduces fractures in childhood osteoporosis, Gandrud [/bib_ref] and resolution of back pain [bib_ref] Low-dose intravenous pamidronate reduces fractures in childhood osteoporosis, Gandrud [/bib_ref] [bib_ref] Intravenous administration of alendronate counteracts the in vivo effects of glucocorticoids on..., Falcini [/bib_ref] , 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 [bib_ref] Clinical Efficacy Assessment Subcommittee of the American College of Physicians, American College..., Chou [/bib_ref] , for lack of EB-specific evidence (see .
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 [bib_ref] Eye involvement in inherited epidermolysis bullosa: experience of the National Epidermolysis Bullosa..., Fine [/bib_ref] [bib_ref] Ophthalmic involvement in inherited epidermolysis bullosa, Figueira [/bib_ref]. 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 [bib_ref] Interventions for recurrent corneal erosions, Watson [/bib_ref]. 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 [bib_ref] Patching for corneal abrasion, Turner [/bib_ref]. There is some evidence that topical NSAIDs provide analgesia for acute, traumatic corneal abrasions [bib_ref] Topical nonsteroidal anti-inflammatory drugs for corneal abrasions: meta-analysis of randomized trials, Calder [/bib_ref] (see .
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 Introduction 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 . A valid neonatal pain scale should be used, considering both physiologic and behavioral measures. Some examples include: the Premature Infant Pain Profile (PIPP) [bib_ref] Validation of the Premature Infant Pain Profile-Revised (PIPP-R), Gibbins [/bib_ref] [bib_ref] The Premature Infant Pain Profile-Revised (PIPP-R): initial validation and feasibility, Stevens [/bib_ref] , the Neonatal Pain Agitation and Sedation Scale (N-PASS) [bib_ref] Clinical reliability and validity of the N-PASS: neonatal pain, agitation and sedation..., Hummel [/bib_ref] , the Crying, Requires oxygen, Increased vital signs, Expression and Sleepless pain scale (CRIES) [bib_ref] CRIES: a new neonatal postoperative pain measurement score. Initial testing of validity..., Krechel [/bib_ref] , and the Neonatal Infant Pain Scale (NIPS) [bib_ref] The development of a tool to assess neonatal pain, Lawrence [/bib_ref]. The Face Legs Arms Cry Consolability (FLACC) scale is recommended for infants between 1 to 12 months [bib_ref] Clinical validation of FLACC: preverbal patient pain scale, Manworren [/bib_ref]. 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 [bib_ref] Opiate-induced respiratory depression in pediatric patients, Gill [/bib_ref] [bib_ref] The use of opioids in neonates. A retrospective study of 933 cases, Dormon [/bib_ref] due to reduced clearance of opioids in infants younger than two months [bib_ref] Recommended use of morphine in neonates, infants and children based on a..., Kart [/bib_ref]. Therefore, careful clinical and cardiopulmonary monitoring is crucial when providing opioids to this population (see .
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 [bib_ref] A review of systematic reviews on pain interventions in hospitalized infants, Yamada [/bib_ref]. 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 [bib_ref] Efficacy of sweet solutions for analgesia in infants between 1 and 12..., Harrison [/bib_ref] or in conjunction with other analgesics as well as physical and environmental interventions for more severe acute pain [bib_ref] Systematic review of the psychometric properties, interpretability and feasibility of self-report pain..., Stinson [/bib_ref] [bib_ref] Oral sucrose and "facilitated tucking" for repeated pain relief in preterms: a..., Cignacco [/bib_ref].
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 [bib_ref] Wound management for children with epidermolysis bullosa, Denyer [/bib_ref]. 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 . This approach also decreases the chance of bacterial spread from a colonized wound to an uncontaminated area [bib_ref] Wound management for children with epidermolysis bullosa, Denyer [/bib_ref] [bib_ref] Bathing for individuals with Epidermolysis bullosa, Arbuckle [/bib_ref]. 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 . 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 [bib_ref] Pro-con debate: is codeine a drug that still has a useful role..., Tremlett [/bib_ref] [bib_ref] Has the time come to phase out codeine?, Macdonald [/bib_ref].
Severely affected hospitalized infants Severely affected newborns with deep tissue damage may require extensive pharmacologic support to achieve a level of comfort (see . 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 [bib_ref] Gabapentin as part of multimodal analgesia in a newborn with epidermolysis bullosa, Allegaert [/bib_ref]. 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 [bib_ref] The use of oral ketamine for analgesia with dressing change in an..., Saroyan [/bib_ref]. Use of ketamine raises concerns due to findings of adverse neurodevelopmental effects in young animals who received prolonged intravenous infusions of ketamine [bib_ref] V: Anesthesia and the developing brain: are we getting closer to understanding..., Jevtovic-Todorovic [/bib_ref]. 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
Introduction The epidemiology of death in EB varies by type [bib_ref] Cause-specific risks of childhood death in epidermolysis bullosa, Fine [/bib_ref] , 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 [bib_ref] Long-term follow-up of patient with Herlitz-type junctional epidermolysis bullosa, Yuen [/bib_ref]. Persons with RDEB may succumb in early to mid-adulthood from multiple causes [bib_ref] Epidermolysis bullosa and the risk of life-threatening cancers: the National EB Registry..., Fine [/bib_ref] [bib_ref] Inherited epidermolysis bullosa and the risk of death from renal disease: experience..., Fine [/bib_ref] [bib_ref] The risk of cardiomyopathy in inherited epidermolysis bullosa, Fine [/bib_ref] whereas patients with generalized types of EB simplex are at risk of laryngotracheal complications [bib_ref] Tracheolaryngeal complications of inherited epidermolysis bullosa: cumulative experience of the National Epidermolysis..., Fine [/bib_ref].
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 [bib_ref] IMPaCCT: standards of paediatric palliative care, Craig [/bib_ref] (see . Squamous cell carcinoma is frequently diagnosed in patients with severe subtypes [bib_ref] Epidermolysis bullosa and cancer, Mallipeddi [/bib_ref] 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.
Opioids Opioids have a role in EB pain management, as previously indicated in these guidelines (see . Patients in the palliative phase of their illness may be given an oral opioid sustained release medication [bib_ref] Opioid titration in cancer pain: a critical review, Mercadante [/bib_ref]. 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 [bib_ref] Opioid titration in cancer pain: a critical review, Mercadante [/bib_ref]. 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 [bib_ref] Opioid rotation in patients with cancer pain: a retrospective comparison of dose..., Bruera [/bib_ref] [bib_ref] Opioid switching to improve pain relief and drug tolerability, Quigley [/bib_ref]. 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 [bib_ref] Methadone in the treatment of neuropathic pain, Gagnon [/bib_ref] and does not rely on renal excretion [bib_ref] Methadone analgesia for children with advanced cancer, Davies [/bib_ref] , which may be reduced in the palliative phase of EB.
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 [bib_ref] Opioids for neuropathic pain, Mcnicol [/bib_ref]. 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 [bib_ref] Gabapentin as part of multimodal analgesia in a newborn with epidermolysis bullosa, Allegaert [/bib_ref]. 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 [bib_ref] Use of oral ketamine in chronic pain management: a review, Blonk [/bib_ref] [bib_ref] Ketamine as an adjuvant to opioids for cancer pain, Bell [/bib_ref] [bib_ref] Oral ketamine for pain relief in a child with abdominal malignancy, Ugur [/bib_ref] [bib_ref] Grant IS: Bioavailability, pharmacokinetics and analgesic activity of ketamine in humans, Clements [/bib_ref] 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 [bib_ref] Grant IS: Bioavailability, pharmacokinetics and analgesic activity of ketamine in humans, Clements [/bib_ref]. 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 [bib_ref] Use of a subcutaneous syringe driver in epidermolysis bullosa, O&apos;neil [/bib_ref] (see .
In non-EB patients with cancer pain, the subcutaneous route of morphine is effective to a similar degree as the intravenous [bib_ref] Intravenous versus subcutaneous morphine titration in patients with persisting exacerbation of cancer..., Elsner [/bib_ref]. 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 [bib_ref] Intravenous versus subcutaneous morphine titration in patients with persisting exacerbation of cancer..., Elsner [/bib_ref]. If subcutaneous sites do become inflamed, some benefit has been shown from adding low dose dexamethasone to the infusion [bib_ref] The effect of dexamethasone on the longevity of syringe driver subcutaneous sites..., Reymond [/bib_ref] , 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 sourcesand data to support the use of up to 20% of total daily opioid consumption [bib_ref] Intravenous morphine for breakthrough (episodic-) pain in an acute palliative care unit:..., Mercadante [/bib_ref] [bib_ref] The use of opioids for breakthrough pain in acute palliative care unit..., Mercadante [/bib_ref] 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 . 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 [bib_ref] Opioids for the management of breakthrough (episodic) pain in cancer patients, Zeppetella [/bib_ref]. 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.

## Pruritus
Introduction 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 [bib_ref] Pruritis in epidermolysis bullosa, Nischler [/bib_ref]. Promising new insights into the causes and potential treatments of chronic itch in animal models [bib_ref] Itch signalling in the nervous system, Jeffry [/bib_ref] , in human chronic itch generallyand in recovering burn patients [bib_ref] Comparative evaluation of antipruritic protocols in acute burns. The emerging value of..., Goutos [/bib_ref] may hold potential for application in the EB population.
Non-pharmacological approaches Multiple environmental and behavioral approaches to address itch have been suggested [bib_ref] Pruritis in epidermolysis bullosa, Nischler [/bib_ref] 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 . 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 . 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 [bib_ref] Comparative evaluation of antipruritic protocols in acute burns. The emerging value of..., Goutos [/bib_ref] [bib_ref] A comparative analysis of cetirizine, gabapentin and their combination in the relief..., Ahuja [/bib_ref] [bib_ref] Mirtazapine for reducing nocturnal itch in patients with chronic pruritus: a pilot..., Hundley [/bib_ref] 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 [bib_ref] Mirtazapine for pruritus, Davis [/bib_ref] [bib_ref] Psychiatric medications for the treatment of pruritis, Shaw [/bib_ref] [bib_ref] Management of generalized pruritus in dominant dystrophic epidermolysis bullosa using low-dose oral..., Calikoglu [/bib_ref]. Low-dose cyclosporine has been used in a single case of dominant dystrophic EB to reduce generalized itching [bib_ref] Pruritus and fatigue associated with liver disease: is there a role for..., Jones [/bib_ref]. 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 [bib_ref] Ondansetron for paediatric uraemic pruritus: a case report, Deshpande [/bib_ref]. Similar suggestions were made related to the pruritus of uremia [bib_ref] A randomized, placebo-controlled, double-blind trial of ondansetron in renal itch, Murphy [/bib_ref] [bib_ref] Targeted treatment of pruritus: a look into the future, Tey [/bib_ref] , 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) [bib_ref] Management of generalized pruritus in dominant dystrophic epidermolysis bullosa using low-dose oral..., Calikoglu [/bib_ref] ; tricyclic antidepressants (doxepin, amitriptyline, nortriptyline); 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 [bib_ref] A four arm, double blind, randomized and placebo controlled study of pregabalin..., Ahuja [/bib_ref] 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 .
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.

# Conclusions
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. [fig_ref] Table 5: Implementation barriers 1 [/fig_ref] identify issues for implementation of the guidelines as well as general recommendations areas for research to enhance the level of evidence.

## Additional file
Additional file 1: EB-specific articles that were excluded from use in making recommendations, with rationales. 3. Limited and uneven distribution of knowledge and expertise 4. International dissemination of guidelines and EB-related information to local care providers and families (includes translation and access to electronic and print media) Areas of research Psychological and integrative approaches:
[fig] Figure 1: Flow of information through the evidence evaluation process. Introduction [/fig]
[fig] Box 2: Recommendations for acute pain care in EB 1. Basic perioperative pain assessment and treatments should be used as for non-EB patients, with modification. (Grade: A) 2. Transmucosal (including intranasal fentanyl and trans buccal opioids) should be considered for short procedures and pain of brief duration when intravenous and enteral routes are unavailable. (Grade: B) 3. Perioperative opioid use must take preoperative exposure into consideration, with appropriate dose increases to account for tolerance. (Grade: B) 4. Regional anesthesia is appropriate for pain resulting from a number of major surgeries. Dressing of catheters must be non-adhesive and monitored carefully. (Grade: C) [/fig]
[fig] Box 3: Recommendations for wound pain treatment 1. Maintain optimal nutrition and mobility and treat infections as indicated (Grade: D) 2. Consider topical therapies for pain (Grade: C) 3. Systemic pharmacologic therapy should be adapted to treat both acute and chronic forms of skin pain. (Grade: B) 4. Monitor potential long-term complications of chronically administered medications. (Grade: C) [/fig]
[fig] Box 4: Recommendations for bathing and dressing change pain treatment 1. Anxiolytics and analgesics should be used for procedural pain and fear. Care must be taken when combining such medications due to cumulative sedative effects (Grade: B). [/fig]
[fig] 2: Cognitive behavioral techniques should be implemented as the child becomes old enough to use them effectively. Specifically, distraction should be used for younger children (Grade: B). [/fig]
[fig] 3: Environmental comfort measures are recommended; these include adding salt to the water to make it isotonic and keeping the room warm (Grade: B). [/fig]
[fig] Box 5: Recommendations for gastrointestinal pain treatment 1. Topical treatments are recommended for oral and perianal pain. (Grade: C)2. Therapy should be directed to manage gastroesophageal reflux and esophageal strictures using standard treatments. [/fig]
[fig] Box 6: Recommendations for musculoskeletal pain treatment 1. Joint pain should be treated with mechanical interventions, physical therapy, cognitive behavioral therapy and surgical correction (Grade: C). [/fig]
[fig] Box 7: Recommendations for eye pain treatment 1. Care should include general supportive and analgesic care, protecting the eye from further damage and topical therapies (Grade: C). [/fig]
[fig] Box 8: Recommendations for infant pain care 1. Assess patients as needed and prior to and after interventions; health care workers should use validated measures. (Grade: A) 2. Sucrose solutions should be administered for mild to moderate pain alone or as an adjunct. (Grade: B) 3. Standard analgesics should be used in infants as in older patients with careful attention to dosing and monitoring. (Grade: B) [/fig]
[fig] Box 9: Recommendations for end of life pain treatment 1. Assess and manage physical, emotional and spiritual suffering of the patient, while providing support for the whole family. [/fig]
[fig] Box 10: Recommendations for itch treatment 1. Use environmental and behavioral interventions for itch control. (Grade: C) 2. Antihistamines are recommended and can be chosen depending upon desirability of sedating effects. (Grade: D) 3. Gabapentin, pregabalin, TCA, serotonin norepinephrine reuptake inhibitors (SNRIs) and other non-traditional antipruritic agents should be strongly considered for itch treatment. (Grade: C) [/fig]
[table] Table 1: EB-specific articles used in producing recommendations [/table]
[table] Table 4 Table: for judging the strength of a recommendation[8] For acute pain management, offer the patient distraction, hypnosis, visualization, relaxation or other forms of CBT. [/table]
[table] Table 5: Implementation barriers 1. Availability of resources (for example, medications and equipment) 2. Legal and social restrictions on the use of various medications and therapies. [/table]