Topical and systemic gene therapy for recessive dystrophic EB: beremagene geperpavec and beyond for COL7A1 p.Gly1569Arg

For COL7A1 c.4705G>A (p.Gly1569Arg), a likely pathogenic Gly-to-Arg substitution in the collagenous domain that disrupts the Gly-X-Y triple helix repeat essential for type VII collagen assembly, gene therapy has reached an unprecedented milestone: beremagene geperpavec (Vyjuvek, Krystal Biotech) became the first FDA-approved topical gene therapy for any disease in May 2023. This HSV-1-based vector delivers functional COL7A1 directly to wound beds and surrounding skin, enabling local type VII collagen restoration and anchoring fibril formation at the dermal-epidermal junction. The Gly1569Arg substitution disrupts the obligate Gly-X-Y tripeptide repeat in the collagenous domain, preventing proper triple helix folding — gene replacement that provides full-length wild-type COL7A1 is therefore the most direct therapeutic approach.

The Phase 3 GEM-3 trial (NCT04491604) demonstrated that beremagene geperpavec achieved complete wound closure significantly more often than placebo at 6 months in patients with recessive and dominant DEB. The therapy uses a replication-deficient HSV-1 vector capable of carrying the large COL7A1 cDNA (~8.9 kb), which exceeds AAV packaging capacity. Immunofluorescence confirmed restoration of type VII collagen expression at the basement membrane zone and formation of anchoring fibrils on electron microscopy. The topical redosing capability is a major advantage — HSV-1 does not integrate and expression is transient, but repeated application maintains collagen expression without the anti-vector immunity issues that plague AAV. Systemic approaches including ex vivo keratinocyte gene correction and autologous grafting (De Luca et al., 2017) have also demonstrated proof-of-concept in individual patients.

Beremagene geperpavec requires repeated topical application (typically weekly to wound beds) and does not address systemic manifestations of DEB including esophageal strictures, corneal erosions, and extracutaneous scarring. The treatment is local — each wound must be individually treated, which is burdensome for patients with widespread disease. HSV-1 vector expression is transient (non-integrating), necessitating chronic redosing. For p.Gly1569Arg specifically, if this variant produces a dominant-negative collagen chain (as some glycine substitutions do), gene replacement alone may not fully restore anchoring fibril function since mutant chains can incorporate into heterotrimers and disrupt assembly. Systemic gene therapy approaches (AAV or mRNA-based) that could address extracutaneous disease remain in early preclinical stages. Cost and access remain significant barriers — beremagene geperpavec carries a high per-application cost.