In vivo depletion of CD8+ T cells restores hair growth in the DEBR model for alopecia areata

Summary Alopecia areata (AA) is a putative autoimmune disease in which anagen hair follicles are the target of immune cell attack. While both CD4⁺ and CD8⁺ T lymphocytes are prominent in the infiltrate, their respective roles in the pathogenesis of AA remain unknown. Here we directly investigated the activity of CD8⁺ cells in the inhibition of hair growth using the Dundee experimental bald rat (DEBR) model for AA. Eight lesional DEBRs were fully depleted of their CD8⁺ cells by intraperitoneal injection of OX-8 monoclonal antibody (MoAb) specific for these cells over a 15-day therapy course. A control group of eight lesional rats was injected with the irrelevant MoAb OX-21. Sequential blood samples were analysed by flow cytometry to observe changes in the CD8⁺ cell population and macropliotography used to record changes in hair growth activity.
All eight CD8⁺ depleted rats started to regrow hair within 29 days from the start of treatment, the tinal response ranging from sparse regrowth to a near normal coal. While two rats maintained their new pelage, the remainder lost hair as the CD8⁺ population in peripheral blood increased. Two of the control rats also showed hair regrowth over the experimental period of 156 days. These results suggest that CD8⁺ cells play an active part in the pathogenesis of AA. As hair production did not fully recover in all animals, immune mechanisms other than CD8⁺ cells may be involved in effecting hair loss. However, analysis of CD8⁺ cell levels in the skin of CD8⁺ depleted rats may help resolve their full importance in AA.     

CD28 T-cell costimulatory molecule expression in pemphigus vulgaris

Background  CD28 superfamily of immune costimulatory molecules could play an important role in autotolerance control. CD28 costimulation seems to be necessary for regulatory T cell (Treg) activation and successive suppressive activities involved in autoimmunity protection. This study investigates CD28 expression, especially inducible costimulator fraction, on T lymphocytes in pemphigus vulgaris (PV) patients.
Methods  CD28 expression on T lymphocytes was assessed in 16 PV patients during acute attack. All patients and 10 healthy control subjects were tested for lymphocyte populations, T-cell subpopulations (T-CD4⁺, T-CD8⁺), Treg and CD28 expression on T-cell subpopulations.
Results  T, B and natural killer cells average values in PV patients were close to the control group values. Compared with control group, PV values showed lower Treg (2.2% compared with 4.7%), slightly decreased CD4⁺ CD28⁺ T cells (91% compared with 95%), higher CD4⁺ CD28⁻ T cells (9% compared with 5%), decreased CD8⁺ CD28⁺ T cells (57% and 73%, respectively) and significantly enhanced CD8⁺ CD28⁻ T cells (43% compared with 27%).
Conclusions  These data suggest that Treg-mediated suppressor T-cell effects could be diminished in PV, together with an abnormal or ineffective subsequent helper T-cell suppression. CD28 high expression on helper T cells and low expression on suppressor T cells are arguments for a potential CD28 role in PV autoimmune response mechanism.

Conflicts of interest

None declared     

Mycosis fungoides skin lesions contain CD8+ tumor-infiltrating lymphocytes expressing an activated, MHC-restricted cytotoxic T-lymphocyte phenotype

In prior studies, we showed that most CD8⁺ cells infiltrating skin lesions of CD3⁺CD4⁺ mycosis fungoides were CD3⁺ T-line-age tumor-infiltrating lymphocytes (TIL) whose overall phenotype was suggestive of MHC-restricted cytotoxic T lymphocytes (CTL). However, their lack of cytotoxic-associated granzyme A mRNA suggested that they might be inactivated CTL precursors. In this study, we used single- and double-label immunohistologic techniques to assess the expression of TlA-1-reactive protein and HLA-DR by these CD8⁺TIL. Monoclonal antibody TIA-1 recognises a novel family of proteins expressed preferentially by cytotoxic cells, including some that lack grauzyme A. HLA-DR is a marker of T-cell activation. Single-label studies of 32 cases showed that CD8⁺TIL and TIA-1⁺ cells constituted a variable minority of the total cellular infiltrate and had a similar distribution. Double-label studies of 14 cases showed that in most instances the aggregate phenotype of the majority of CD8⁺TIL was CD3⁺TIA-1⁺HLA-DR⁺CD56⁻CD57⁻. These findings suggest that many of the CD8⁺TIL within skin lesions of CD3⁺CD4⁺ mycosis fungoides are activated, MHC-restricted CTL.     

EFFECT OF RETINOL ON MURINE EPIDERMAL DENDRITIC CELLS

Numerous immunoregulatory activities have been attributed to retinoids. The present study examined the effect of a single application of retinol (RO) on immunocompetent cells in murine epidermis. The inner epidermis of the left ear of C57/BL6J mice was painted with RO (50 ug/ml) in ethanol, while the right (control) ear received ethanol alone. Mice were sacrified at 0,12,24,36 or 48 hours, and epithelial sheets of the treated areas prepared. Two cell populations were detected using enzyme histochemistry and indirect immunofluorescence: Langerhans cells (ATPase⁺, Ia⁺), and cells expressing Thy 1.2 antigen (ATPase-, la-). In all cases ATPase⁺ cells were more numerous that Ia⁺ cells, however, neither RO nor alcohol treatment modulated la⁺or ATPase⁺ expression on Langerhans cells. In contrast, R O treatment increased the number of Thy 1.2⁺ cells detected at 12 and 24 hr post-treatment when compared to baseline and alcohol controls. These results indicate that retinol is capable of modulating antigen expression on murine dendritic cells in vivo.     

Plasminogen activator system in pemphigus vulgaris

Summary Pemphigus vulgaris (PV) is caused by autoantibodies against desmosomes and is characterized by intra-epidermal blisters. The pathology of PV has been linked with plasminogen activation in lesional epidermis. The plasminogen activator system (PA system) consists of urokinase-type plasminogen activator (uPA). tissue-type PA (tPA). as well as the two types of plasminogen activator inhibitors (PAI-1 and PAI-2). In keratinocytes. uPA binds to a specific cell surface receptor for uPA (uPA-R = CD87) in an autocrine manner. Cell-bound uPA is regulated by PAIs. The central PA system component plasminogen, which is present in plasma and interstitial fluids, is bound to the keratinocyte surface via plasmin(ogen) binding sites, where it can be activated by uPA-R-bound uPA. Cell surface-associated plasmin then mediates pericellular proteolysis. As the topographical organization of the distinct PA system components in lesional epidermis of PV remained elusive, we have performed the present immunohistological analysis of lesional and non-lesional epidermis of PV. In keratinocytes directly involved in the epidermal split formation, plasmin(ogen) was stained in nine of 10 cases, uPA-R and uPA in four of 10 cases and PAI-2 in seven of 10 cases. Together, acantholytic plasmin(ogen)⁺ keratinocytes appeared in three different phenotypes: uPA-R⁺/uPA⁺ and PAI-2⁺, uPA-R^-/uPA^- and PAI-2⁺. as well as uPA-R^-/uPA^- and PAI-2^-. Our findings demonstrate that, in acantholytic keratinocytes of PV. PAs and PAIs appear as differentially regulated components of the PA system.     

Lichen striatus – a chameleon: An histopathological and immunohistological study of forty-one cases

Lichen striatus (LS) is an uncommon dermatosis that generally affects children. The histopathology of LS often shows a polymorphic epidermal reaction process of variable lichenoid and spongiotic changes having no specific histopathological criteria or simulating other diseases. In the present study, we have evaluated the histopathological features of 41 biopsy specimens and the immunohistochemical aspects of 10 cases of LS. In 50% of the cases, we found histopathological and immunopathological features constantly present and allowing a correct diagnosis. In 9 cases, the histopathology was not specific, and in 10 cases, a clear differentiation from other diseases was not possible. Immunohistochemical study demonstrated a CD3⁺ T-lymphocytic infiltration in which CD8⁺ cells surrounded necrotic keratinocytes and intraepidermal vesicles filled with Langerhans cells. These findings seem to corroborate the hypothesis that a somatic mutation of a keratinocytic clone could induce an autoimmune response of the host.     

Allergy to phosphorus sesquisulfide: 0.5% pet. is a more appropriate concentration for patch testing

Patch testing was performed with phosphorus sesquisulfide P₄S₃ in 2 groups containing equal numbers of patients using different concentrations (0.5% P₄S₃ in pet. and 1% P₄S₃ in pet., the usual suggested test concentration as recommended by the International Contact Dermatitis Research Group). We found that there was a statistically significant increase in the number of clinically irrelevant irritant reactions in the group tested with the concentration (χ²= 16, P < 0.0004). We recommend that patch testing with phosphorous sesquisulfide should he at a reduced concentration of 0.5% pet.     

Pyoderma Gangrenosum in childhood

Pyoderma Gangrenosum is a rare, ulcerative, necrotizing cutaneous disorder of unknown etiology. ¹ The lesions usually present as a painful nodule or pustule that breaks down to form a progressively enlarging ulcer with a raised tender, undermined edge. ¹ Pyoderma Gangrenosum was first described by Brunsting et al. in 1930, ² but the pathogenesis is still not clear. Local infection does not appear to be an etiologic factor even though Brunsting initially suggested this may be the cause. ^1–3 Its association with various autoimmune diseases and its response to immunosuppressive therapy suggests an immunologic basis for the disease. ^4,5 The characteristic feature of pyoderma gangrenosum is the development of lesions at sites of trauma: also known as pathergy phenomenon. Most cases of pyoderma gangrenosum occur mainly between the third and fifth decades of life, though disease can occur anytime between the first and ninth decades of life. ⁶ We present a case of pyoderma gangrenosum in a 3-year-old boy, and review the features of pyoderma gangrenosum in children.     

IgE‐independent atopic dermatitis is associated with a β‐2 adrenergic receptor gene polymorphism

IgE levels are not elevated in about 20% of patients with atopic dermatitis (AD). In this intrinsic AD (IAD), allergic mechanisms are not very important and pathogeny could be mainly neurogenic. β2-adrenergic receptors are localized on cells involved in AD: Langerhans' cells, keratinocytes and lymphocytes. We wondered whether IAD could be associated with gene polymorphisms 16 and 27 of this receptor. We studied 98 healthy subjects and 83 subjects suffering from DA (UKWP criteria). IgE levels were normal in 12 of them and elevated in 71 (EAD). After DNA extraction, the genotyping was done by PCR and Direct Sequencing of candidate gene. Statistical analysis was performed with EPI-INFO 6.04 for χ² test. We found a significant association of Gln27Glu polymorphism with IAD ( P  = 0.00071 and χ² = 14.51). There was no difference between healthy subjects and EAD patients. Adrenergic receptor agonists are known to attenuate the proliferative response of human lymphocytes after activation, through the inhibition of interleukin-2 release. It is known that catecholamines inhibit the antigen-presenting capability of epidermal Langerhans' cells. Long-term agonist-promoted downregulation of receptor number is absent when glu is at position 27. We suggest that the suppression of inhibiting effects of catecholamines could be involved in IAD pathogeny. Dichotomic nature of AD (EAD and IAD) is also associated with polymorphisms (SNP) of the interleukin-4/interleukin-13 receptor gene and the differences of cutaneous variables (transepidermal water loss, capacitance and pH). Altogether, these findings indicate that IAD patients exhibit phenotypic and also genotypic features which differ from those patients with EAD. Otherwise, the presence of this polymorphism could provide an explication of rarity of hypertension with AD, because Glu27Gln has been identified as a susceptibility polymorphism for HTA.     

Clinical effectiveness and safety experience with alefacept in the treatment of patients with moderate-to-severe chronic plaque psoriasis in Taiwan: results of an open-label, single-arm, multicentre pilot study

Background  The effectiveness and safety of alefacept for the treatment of moderate-to-severe chronic plaque psoriasis has been established in several clinical trials conducted in the United States and Europe. No clinical trial of alefacept has been conducted in Asia.
Objective  To determine the effectiveness and safety of alefacept in the treatment of psoriasis in Chinese population.
Design and methods  This was an open-label, single-arm, multicentre pilot study conducted at three centres. Patients with a body surface area ≥ 10% and psoriasis area and severity Index (PASI) ≥ 12 were given 15 mg alefacept intramuscularly once a week for 12 weeks and were then followed up for a further 12 weeks.
Results  A total of 46 patients was enrolled. Only one subject (2%) achieved a ≥ 75% improvement in PASI at week 14. The median improvement in PASI at week 14 after the 12-week treatment was 39%. At any time during the 6-month course, 3 subjects (7%) achieved a Physician Global Assessment (PGA) of 'almost clear', and a ≥ 50% and ≥ 75% improvement in PASI was seen in 46% and 9%, respectively. There is a trend for decreased counts of CD4⁺ and CD8⁺ cells after alefacept treatment, but subjects who achieved PASI50 showed a lesser degree of decrease in CD4⁺ and CD8⁺ counts compared with those in patients who did not achieve PASI50.
Conclusions  This small pilot study indicated that intramuscular alefacept was effective and safe in psoriasis in Chinese patients over 12 weeks of treatment. Further studies are needed to clarify the reason for low PASI 75 effectiveness and the paradoxical lesser decline of CD4⁺ and CD8⁺ T cells in those who responded.     

Protracted cutaneous disorders in association with low CD4+ lymphocyte counts

Summary We report two patients with skin disorders usually associated with severe immunosuppression, who had low CD4⁺ lymphocyte counts but normal immunoglobulin levels. The patients were HIV negative, and had CD4⁺ lymphocyte counts just above 300/mm³, but they presented with cutaneous manifestations of profound immunodeficiency. Idiopathic CD4⁺ lymphocyte deficiency is a recently described syndrome which may present with dermatological disease. We discuss the symptom complex of our patients in relationship to the diagnosis of idiopathic CD4⁺ lymphocyte deficiency.     

DEFICIENT FOLATE ACTIVITY DURING TREATMENT OF PSORIASIS WITH METHOTREXATE DIAGNOSED BY DETERMINATION OF SERINE SYNTHESIS IN LYMPHOCYTES

Summary.— Deficient folate activity was diagnosed in all of 7 patients treated for psoriasis with methotrexate (Mtx) by applying a new method (Ellegaard and Esmann, 1972a) of assaying folate activity which utilizes the folate-dependent incorporation of ¹⁴C-formate into serine of lymphocytes during incubation under standardized conditions. The arithmetical mean of this folate activity was 4–8%± 0.6 (SEM) of added ¹⁴C-activity per 10⁹ lymphocytes per 4 hours, as compared to 9.2%± 0.4 in 24 normals. The ¹⁴C-formate incorporation into RNA was severely depressed in each case. Mtx added to lymphocytes in vitro had no effect on the folate activity.
In addition, the new observation was made that patients under treatment with Mtx develop decreasing serum concentrations of B₁₂, possibly due to an impaired B₁₂-absorption.     

Detection of Epstein-Barr virus in cutaneous and lymph nodal anaplastic large cell lymphomas (Ki-l+)

Summary Epstein-Barr virus (EBV) is a gamma DNA herpes virus which is thought to play a part in the pathogenesis of some non-Hodgkin's lymphomas in individuals with or without immunodeficiency. We investigated 16 lymph nodal and 12 cutaneous anaplastic large cell lymphomas (ALCLs) (Ki-1 ⁺), all of which were in patients without immunodeficiency, for the presence of EBV genomes. The highly sensitive polymerase chain reaction (PCR) technique was employed for detection of viral DNA in extracts from formalin-fixed, paraffin-embedded tissue sections. In addition, we performed radioactive and non-radioactive in situ hybridization (ISH) for localization of EBV at the single cell level. EBV-DNA was demonstrated by PCR in five cases of nodal ALCLs (31 %). All cutaneous ALCLs were negative. EBV-encoded small nuclear RNAs (EBERs) could be identified by ISH in the tumour cells of one of the five EBV-DNA-positive patients. Our results further support the concept that EBV may be involved in the development of a proportion of nodal ALCLs, hut not in cutaneous ALCLs.     

Mycobacterium tuberculosis responsible for cutaneous disease after percutaneal inoculation of solutions: a case report

Tuberculosis continues to be a public health problem, especially in developing countries. It is responsible for 3 million deaths annually. ¹ Cutaneous infection is distributed worldwide, with an increased incidence in temple environments. ² In the USA, cutaneous tuberculosis comprises 0.14% of reported tuberculosis cases. ³ Here we report a case of cutaneous tuberculosis in a woman undergoing neural therapy. The therapy included periumbilical injections of procainamide and a substance called 'machura', which formed part of an "antihomotoxic" homeopathic treatment whose composition is unknown.     

Numerical aberrations of chromosome 7 detected in 15 μm paraffin-embedded tissue sections of primary cutaneous melanomas by fluorescence in situ hybridization and confocal laser scanning microscopy

Fluorescence in situ hybridization (FISH) to sections of formalin-fixed paraffin-embedded archival tissues allows the detection of gene or chromosome copy number changes in interphase cell nuclei within the histological context and thus may be of particular interest in tumor pathology. In this report, we describe the application of FISH to thick (15 μn) paraffin sections of 7 primary cutaneous malignant melanomas. A chromosome 7-specific centromeric DNA probe was used to detect numerical aberrations of chromosome 7. By optical sectioning using confocal laser scanning microscopy (CLSM) only complete, uncut interphase cell nuclei were scored. The mean percentage (±SEM) of melanoma cell nuclei with three hybridization spots was (20.7±2.8)%; (6.8±1.0)% of nuclei showed one spot and (5.0±1.2) % four or more spots. The frequency distribution of spot numbers among melanoma cell nuclei and normal keratinocyte nuclei was significantly different (χ²= 176.8, df= 5, p<0.001). Trisomy 7 was detected in all 7 cases analyzed, mostly associated with monosomy 7 or polysomy 7. The approach used in our study and the data obtained could be useful for further studies designed to investigate a possible involvement of chromosome 7 in melanocytic tumor progression.     

CD30+ lymphoproliferative disorders: histopathology, differential diagnosis, new variants, and simulators

Summary:  CD30⁺ lymphoproliferative disorders of the skin (CD30⁺ LPD) represent a well-defined spectrum of primary cutaneous T-cell lymphomas which have been recognized as distinct entities in recent lymphoma classifications. Lymphomatoid papulosis and anaplastic large-cell lymphoma share the expression of CD30 antigen as a common phenotypic hallmark but differ in regard to their clinical and histologic features as well as their biologic behavior. This article summarizes the histologic features of CD30⁺ LPD and presents recently identified new clinicopathologic variants of CD30⁺ LPD. There is an increasing number of reactive inflammatory disorders and neoplastic diseases which are composed of or contain a significant number of CD30⁺ cells and mimic LyP or anaplastic large cell lymphoma clinically or histologically. Differential diagnostic considerations focus on other lymphoproliferative processes with CD30⁺ tumor cells as well as non-lymphoid neoplasms and inflammatory simulators. The term CD30⁺ pseudolymphoma is proposed to designate inflammatory processes with CD30⁺ T cells. The final diagnosis of CD30⁺ LPD is based on a synthesis of clinical, histologic, phenotypic, and molecular genetic findings.     

TNF-α, RANTES, and MCP-1 are major chemoattractants of murine Langerhans cells to the regional lymph nodes

We have previously reported that lymph node cells generated chemotactic factors for Langerhans cells (LCs) in the induction phase of contact dermatitis. In order to clarify the chemotactic factors involved in migration to the regional lymph nodes, we investigated the migratory activity of murine LCs toward several cytokines and chemokines in vitro . One-day cultured LC-enriched epidermal cells were added to the upper compartment of a modified Boyden chamber and cytokines were added to the lower compartment. We counted dendritic cells migrated to the lower chamber as LCs under phase contrast microscopy. About 99% of migrated dendritic cells were positively reacted with anti-Ia^d and NLDC145 antibodies and considered to be LCs. We could detect LC migration more accurately by this direct examination than by counting the migrated cells in the filter membrane of a Boyden chamber. In our system, migration of murine epidermal LCs was stimulated by TNF-β, RANTES and MCP-1, but not by GM-CSF, IL-1β, IL-4, and IL-6. TNF-α induced LC migration at concentrations from 4X10³ U/ml to 5X10⁴ U/ml. RANTES at concentrations from 10 to 100 ng/ml and MCP-1 a concentration of 100 ng/ml induced LC migration in a dose-dependent manner. These data confirmed that TNF-α, RANTES, and MCP-1 induced LC migration from epidermis during contact sensitization.     

Acne fulminans and erythema nodosum during isotretinoin therapy responding to dapsone

Acne vulgaris is very common, 85% of teenagers being affected at any one time. In most cases, the disease is mild and patients do not present to the dermatologist. Most are instead treated with over-the-counter products and conventional treatment such as peeling agents or topical and systemic antibiotics. Isotretinoin has revolutionized the treatment of severe acne unresponsive to oral antibiotics. Explosive and very severe acne such as pyoderma faciale, acne conglobata and acne fulminans are rare, the features that distinguish acne fulminans from the other conditions being systemic upset with fever, joint pain, malaise and leucocytosis,^1–3 while there have been two reports of the condition associated with erythema nodosum.^4,5 The recommended treatment for acne fulminans is a combination of oral steroids and systemic antibiotics, isotretinoin probably not being the treatment of choice.⁶ We now report a patient who developed acne fulminans and erythema nodosum within 3 weeks of starting isotretinoin and then responded to dapsone without oral steroids.     

Multiple superficial basal cell carcinomas (basalomatosis) following cobalt irradiation

Summary Basalomalosis is an uncommon skin condition characterized by the occurrence of multiple basal cell carcinomas. Many cases reported in the literature have been attribuled to arsenic treatment in psoriasis patients. We report a patient with basalomatosis caused by cobalt-60 (⁶⁰Co) irradiation. A 55-year-old farmer developed 43 basal cell carcinomas 20 years after treatment of an immuno-blastoma with ⁶⁰Co irradiation. All the tumours were located within the radiation fields. Other possible causes of basalomatosis, such as arsenic intoxication and basal cell naevus syndrome, were excluded. The patient's multiple superficial basal cell carcinomas probably represent a late adverse effect of the ⁶⁰ irradiation.