Patient Background

Mrs. Harleen Kaur, a 44-year-old boutique owner from Mohali, Punjab, lived an active and independent life before her symptoms began. She managed her boutique daily, handled clothing and fabrics regularly, and maintained her household without difficulty. Her husband, Mr. Gurpreet Singh, and her sister, Mrs. Manpreet Kaur, formed her primary and secondary support network.

Several months before her diagnosis, Harleen noticed that her skin had become unusually fragile. Small blisters appeared on her hands after minor friction, such as handling fabric or gripping objects. At first, she attributed the changes to seasonal sensitivity or contact irritation. However, the blisters did not resolve. Over time, similar lesions appeared over her elbows, knees, feet, and other areas exposed to repeated pressure or friction.

The blisters were painful. They made dressing, walking, and handling everyday objects progressively difficult. Tasks she once performed without thinking, such as folding clothes, carrying shopping bags, or walking to her boutique, became sources of discomfort and anxiety.

Harleen had no known history of diabetes, chronic kidney disease, or other systemic conditions that might complicate wound healing. However, blood tests revealed mild iron-deficiency anemia, which the treating team associated with prolonged inflammatory stress and possible nutritional gaps during her illness.

Clinical Diagnosis

After dermatological evaluation and specialized testing, including immunofluorescence studies, Harleen was diagnosed with Epidermolysis Bullosa Acquisita. The diagnosis explained why her skin had become vulnerable to separation and blister formation from routine contact.

Presenting Symptoms at Diagnosis

• Recurrent skin blisters over hands, elbows, knees, feet, and pressure-prone areas
• Fragile skin that blistered after minor friction or pressure
• Painful skin erosions where blisters had ruptured
• Increased skin sensitivity to touch and contact
• Difficulty wearing tight or fitted clothing
• Pain during walking when foot lesions were active
• Reduced hand function during periods of active blistering
• Psychological distress and fear of accidental skin trauma

Associated Conditions

Hospital Treatment

Harleen was hospitalized for 7 days after developing multiple painful blisters with several areas of skin erosion that required supervised wound care. The decision to admit was based on the extent of skin involvement, the need for specialized wound assessment, and the requirement to initiate treatment under close observation.

In-Hospital Assessment and Management

During her 7-day admission, the hospital team performed a comprehensive evaluation. This included detailed skin mapping of all blisters and erosions, wound depth assessment, swab cultures where infection was suspected, baseline blood investigations, pain scoring, and nutritional review. The dermatology team initiated immunosuppressive and anti-inflammatory medication as appropriate for EBA, along with a structured wound-care protocol using non-adherent dressings.

Discharge Plan

Harleen was discharged with a detailed plan that included dermatologist-prescribed medication, specific wound dressings and supplies, skin protection guidelines, pain management instructions, infection surveillance parameters, and scheduled dermatology follow-up appointments. The family was specifically instructed not to puncture, drain, or treat new blisters independently unless the treating team had provided clear guidance to do so.

Why Home Healthcare Was Needed

At the time of discharge, Harleen’s condition had stabilized from the acute phase, but she was far from fully recovered. Her skin remained fragile, several erosions were still healing, and the risk of new blister formation was ongoing. Sending her home without professional support would have left several critical needs unmet.

Specifically, Harleen still had:

• Fragile skin vulnerable to new blister formation from routine contact
• Multiple healing erosions requiring regular dressing changes
• Mild wound pain that needed ongoing assessment
• Difficulty gripping objects due to blisters on her fingers
• Difficulty walking when foot lesions were tender
• Significant anxiety about causing new skin damage

Her husband managed his own work commitments, and while her sister provided additional support, neither had the clinical training to perform wound assessments, recognize early signs of infection, or manage dressing changes according to the dermatologist’s specifications. Choosing the right caregiver matters because the gap between domestic help and professional nursing can directly affect wound outcomes.

Home Care Plan by AtHomeCare

The home healthcare plan was structured around Harleen’s specific needs. Each service was chosen based on a clear clinical reason, not as a standard package. The plan was coordinated with her treating dermatologist and adjusted as her condition evolved over the 12-week period.

Home Nursing

A trained home nurse was assigned to provide daily clinical support. The nurse’s responsibilities were clearly defined and focused on the areas where professional training was essential.

• Skin inspection: Full-body skin check every morning to identify new blisters, areas of redness, or early signs of skin breakdown before they progressed
• Wound assessment: Evaluation of each healing erosion for size, drainage, odor, surrounding redness, swelling, and healing progression
• Dressing changes: Application of non-adherent dressings as prescribed by the dermatologist, using techniques that minimized additional skin trauma during removal and application
• Infection surveillance: Monitoring for increasing redness, warmth, pus-like discharge, increasing pain, fever, or rapidly worsening wounds
• Pain assessment: Regular pain scoring and communication with the treating doctor about any changes in pain patterns
• Medication adherence: Ensuring prescribed medications were taken correctly and on schedule
• Nutritional monitoring: Tracking oral intake and encouraging adequate nutrition to support wound healing
• Family education: Teaching safe handling techniques, dressing principles, and warning signs that required medical attention

The home nursing service provided the clinical backbone of the entire plan. Without skilled nursing input, wound care would have relied on the family’s interpretation of discharge instructions, which is a common source of complications.

Patient Attendant

A patient attendant was assigned to support Harleen with activities that could otherwise cause skin friction or strain. The attendant’s role was distinct from the nurse’s role. While the nurse handled clinical tasks, the attendant helped with:

• Household tasks such as cleaning and organizing to reduce Harleen’s need to handle objects
• Grocery shopping and errands that would otherwise require walking or carrying
• Laundry management, including selecting and preparing soft clothing
• Transportation to dermatology follow-up appointments
• Meal preparation according to nutritional guidance
• Any activity involving significant friction, lifting, or prolonged standing

The patient attendant service filled the practical gap between what the nurse could do and what Harleen could safely do for herself. This separation of clinical and non-clinical tasks is an important principle in patient care services.

Physiotherapy

Physiotherapy was introduced carefully and conservatively. The goal was to prevent deconditioning and maintain joint mobility without creating unnecessary skin friction or pressure. This balance required close communication between the physiotherapist, the nurse, and the patient.

The physiotherapy plan included:

• Gentle range-of-motion exercises for all major joints, performed without equipment that pressed against the skin
• Light strengthening exercises in seated positions to avoid pressure on elbows, knees, or feet
• Seated exercise routines that maintained cardiovascular fitness without walking on tender foot lesions
• Short-distance walking practice, gradually increased as foot lesions healed
• Functional activity practice, such as simulated dressing or light object handling, to build confidence

The physiotherapist deliberately avoided exercises, mats, or equipment that could cause excessive friction or pressure on affected areas. Home physiotherapy was preferred over clinic visits because it allowed the therapist to see Harleen’s actual home environment and modify exercises based on real-world conditions.

Doctor Home Visit

A doctor home visit was arranged as a safety net for situations that required clinical judgment beyond the nurse’s scope. The doctor home visit service was available for:

• New extensive blistering that suggested a possible disease flare
• Worsening wounds despite appropriate dressing care
• Fever or systemic signs suggesting infection
• Increasing pain that was not controlled by the current medication plan
• Suspected wound infection requiring antibiotic assessment
• Medication concerns such as possible side effects or adherence issues
• Reduced functional ability that suggested the care plan needed adjustment

Disease-Specific Assessment Protocols

The home healthcare team followed structured assessment protocols tailored to EBA. These went beyond standard vital sign monitoring to address the specific vulnerabilities of autoimmune blistering disease.

Skin Assessment Protocol

Every morning, the nurse performed a systematic skin inspection. This was not a casual glance but a methodical examination of all body surfaces, with particular attention to areas most vulnerable in EBA.

• Hands, especially fingers and palms where gripping creates friction
• Feet, including soles and heels where walking creates pressure
• Elbows and knees where resting surfaces create sustained contact
• Ankles where footwear may rub
• Areas exposed to clothing friction, such as waistbands, bra straps, and seams
• Any area where Harleen reported new sensitivity or discomfort

The nurse documented the location, size, and appearance of every new blister and compared findings with previous days to identify patterns or progression. This skin care and moisture management approach helped detect problems before they became wounds.

Wound Assessment Protocol

Healing wounds were assessed using a consistent framework. For each wound, the nurse evaluated:

Dressings were changed according to the dermatologist’s wound-care plan. The nurse used non-adherent materials and removal techniques designed to avoid stripping fragile skin. This wound cleaning and dressing protocol was critical because inappropriate dressing changes can cause more damage than the original wound in EBA patients.

Infection Surveillance Protocol

The family was educated to recognize and immediately report specific warning signs. The nurse reinforced this education during every visit and documented the family’s understanding. The infection prevention approach was proactive rather than reactive.

Functional Assessment at Start of Home Care

Understanding Harleen’s functional baseline was important for setting realistic goals and measuring progress. The assessment looked at mobility, hand function, and her ability to perform activities of daily living independently.

Mobility Status

At the beginning of home care, Harleen could walk independently but with noticeable limitations. She walked slowly and deliberately to avoid friction on her feet. She avoided prolonged walking entirely. When foot lesions were active, she experienced discomfort that made her reluctant to move. She required assistance with some outdoor activities, such as walking to her vehicle or navigating uneven surfaces.

Hand Function

Blisters on her fingers temporarily limited several important functions:

• Opening containers and jars
• Carrying heavy objects
• Prolonged typing or phone use
• Handling clothing, especially buttons and zippers
• Fine manual tasks such as writing or using scissors

Activities of Daily Living

Equipment and Supplies Used

The home setup was kept simple and focused. Unlike complex conditions requiring ventilators or cardiac monitors, EBA management primarily needed wound-care supplies and comfort modifications. Some equipment was arranged through medical equipment rental to avoid unnecessary purchase costs for items needed only during the recovery period.

Daily Care Plan

The daily routine was structured to provide consistent care while allowing Harleen as much normalcy as possible. The schedule ensured that clinical tasks were performed at optimal times and that rest periods were protected.

Risks Being Monitored

The home healthcare team maintained a continuous risk register throughout the 12-week care period. Each risk was monitored with specific indicators, and any change triggered a predefined response pathway.

Home Care Goals

Family Education

Family education was not a single session but an ongoing process throughout the 12 weeks. The nurse used each visit as an opportunity to reinforce key principles and address new questions as they arose. Comprehensive care guides can help families understand their role, but in EBA, the education needs to be highly specific to skin handling.

Skin Protection Education

• Avoid unnecessary friction by handling Harleen’s skin gently during any contact
• Use only soft, loose-fitting clothing without tight seams, buttons, or fasteners that press against the skin
• Avoid tight or rigid footwear; use only soft, seam-free options approved by the treating team
• Protect pressure-prone areas with soft padding during rest
• Keep fingernails trimmed short to avoid accidental scratches
• Use patting motions rather than rubbing when drying the skin after washing

Wound Care Education

Infection Prevention Education

The family was taught to monitor for and immediately report specific signs:

• Fever, even low-grade
• Increasing redness around any wound or blister
• Warmth felt on the skin near a lesion
• Swelling that extends beyond the immediate wound area
• Pus-like or cloudy drainage from any wound
• Increasing wound pain that is not relieved by prescribed medication

Nutrition Guidance

The family was encouraged to support adequate nutritional intake according to the treating team’s recommendations. Wound healing requires protein, vitamins, and minerals, and the inflammatory burden of EBA can increase nutritional demands. The attendant’s meal preparation role was important here, as Harleen’s ability to cook was limited during active flares. Nutrition and hydration in care is often underestimated but directly affects wound healing timelines.

Mobility Guidance

Harleen was encouraged to remain gently active while avoiding movements that created significant friction or pressure on affected skin. Complete immobility was discouraged because deconditioning would create its own set of problems. The balance between activity and protection was individually calibrated based on her skin status each day.

Recovery Timeline

Clinical Evidence Summary

Vital Signs Throughout Care Period

Functional Status Progression

Wound Status Summary

Recovery Outcome

Medical Authority

Dr. Ekta Fageriya, MBBS

RMC Reg. No. 44780 Geriatric Medicine 7 Years Clinical Experience

Specialized in geriatric care and home-based clinical management of complex patients with chronic conditions, wound care needs, and post-hospitalization recovery.

Key Clinical Learnings

The following insights emerged from this case and may be relevant for healthcare professionals managing similar patients at home.

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