Asian Journal of Anesthesiology 2020 1 Asian Journal of Anesthesiology: 1-4, 2020 DOI:10.6859/aja.202007/PP.0004 Brief Communication Optimize General Anesthesia for a Dystrophic Epidermolysis Bullosa Patient That Cannot Be Intubated Wan-Ting Chia 1 , Yen-Chin Liu 1,† , Tak-Wah Wong 2,3,4,† 1 Department of Anesthesiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan 2 Department of Dermatology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan 3 Department of Biochemistry and Molecular Biology, College of Medicine, National Cheng Kung University, Tainan, Taiwan 4 Center of Applied Nanomedicine, National Cheng Kung University, Tainan, Taiwan Dystrophic epidermolysis bullosa (DEB) is a rare genetic skin disease characterized by blisters and ulcers on the skin and mucosa after minor friction. The risk of invasive squamous cell carcinoma on the unhealed ulcers increases with age. Tracheal intubation during general anesthesia may induce tracheal stricture due to blister formation and/or scarring in DEB patients and cause severe airway obstruction. There is no consensus for handling DEB patients’ fragile mucosa and skin during general anesthesia. We report an adult DEB patient who received two operations under different general anesthesia methods. The experience from this particular patient and her response to anesthesia may provide a satisfactory guide to avoid complications and improve the outcome for DEB patients receiving general anesthesia. Keywords: dystrophic epidermolysis bullosa, general anesthesia, intubation Received: 27 February 2020; Received in revised form: 4 May 2020; Accepted: 2 June 2020. Corresponding Author: Tak-Wah Wong, M.D., Ph.D, Department of Dermatology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Shengli Rd., North Dist., Tainan City 70403, Taiwan (Dr.kentwwong@gmail.com; twwong@mail.ncku.edu.tw); Yen-Chin Liu, M.D., Ph.D, Department of Anesthesiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Shengli Rd., North Dist., Tainan City 70403, Taiwan (anesliu@gmail.com) † Tak-Wah Wong and Yen-Chin Liu contributed equally to this work. Introduction Dystrophic epidermolysis bullosa (DEB) is an inherited severe bullous disease characterized by ex- treme skin fragility and blistering formation between the junction of dermis and epidermis in response to minor trauma. 1 For anesthesiologists, it presents chal- lenges of skin care, venous access establishing during anesthesia, as well as the scarring of skin and mucosa resulting in difficult intubation. We report a patient who received two different types of general anesthe- sia for skin surgeries. Our experience may provide possible guidance of modern anesthetic management for DEB patients. Case Presentation A 54-year-old lady was diagnosed with DEB since birth. She presented with many blisters and chronic ulcers over her occipital scalp, oral mucosa, shoulder, trunk, and extremities (Figure 1). She also had oral and pharyngeal blisters and poor dentition. She refused local anesthesia for her skin grafts from the scalp to improve multiple chronic skin ulcers on the shoulders because of the painful injections of local anesthetics. Her skin was very sensitive to pain, probably related to daily wound dressings since birth. The pre-anesthetic evaluation revealed anemia (hemoglobin level 10.1 g/dL). She was also a chron- ic hepatitis B carrier without an active flare-up. For airway evaluation, she suffered from limited mouth opening (< 2 fngerbreadth) due to oral mucosa scar-