Endothelial cell apoptosis in severe drug‐induced bullous eruptions

Background Toxic epidermal necrolysis (TEN) and Stevens–Johnson syndrome (SJS) are characterized by extensive keratinocyte apoptosis mediated by cytotoxic proteins. Similar features have been found in another severe dysimmune syndrome, allogeneic acute graft‐versus‐host disease, where endothelial cell apoptosis has been recently characterized. Objectives To determine whether endothelial cell apoptosis occurs in dermal vessels of TEN and SJS, and whether it is linked to expression of cytotoxic proteins. Methods Skin biopsies of eight patients with severe drug‐induced bullous eruptions (four TEN, four SJS), eight with drug‐induced urticaria and eight healthy controls were compared. Blood vessel damage was studied by electron microscopy and quantified by CD31 immunostaining. Apoptotic cells, characterized by electron microscopy, were quantified on terminal deoxyribonucleotidyl transferase‐mediated deoxyuridine triphosphate nick end labelling assay. Immunohistochemistry was also used to characterize and quantify inflammatory cells and granzyme B, tumour necrosis factor (TNF)‐α and Fas ligand (FasL) expression. Results Endothelial cell apoptosis was observed in all TEN and SJS cases: it occurred in 85% of the vessel sections. It occurred in one case of drug‐induced urticaria, in 5% of vessel sections, but not in healthy controls. Numbers of CD68+ macrophages and CD8+ T lymphocytes were significantly higher in TEN and SJS compared with both other groups; granzyme B and TNF‐α but not FasL were expressed. Conclusions Characterization of endothelial cell apoptosis in TEN and SJS is important to assess a factor worsening skin damage, with possible extension to other organs. It may also be useful for the development of novel therapeutic strategies.     

Pustular‐type drug‐induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms due to carbamazepine with systemic muscle involvement

Drug‐induced hypersensitivity syndrome (DIHS)/drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe reaction usually associated with maculopapular eruptions and systemic involvement. Here we report the first case, to our knowledge, of DIHS/DRESS due to carbamazepine with acute generalized pustular bacterid‐like (AGPB‐like) eruptions and skeletal muscle involvement. Reviewing our case and the published work, we discuss pustular‐type DIHS/DRESS which, in most cases, involves acute generalized exanthematous pustulosis (AGEP)‐like skin eruptions in response to carbamazepine. Pustular eruptions may appear in relatively few cases of DIHS/DRESS, in particular, when the causative drug is carbamazepine and, even in cases of intractable pustular bacterid‐like eruptions, a reaction to a drug should be suspected. Skeletal muscle involvement may be associated with DIHS/DRESS as one of its systemic manifestations.     

Patch testing is an effective method for the diagnosis of carbamazepine‐induced drug reaction,eosinophilia and systemic symptoms (DRESS) syndrome in an 8‐year‐old girl

Drug reaction, eosinophilia and systemic symptoms (DRESS) is an acute and life‐threatening disease, characterised by fever, rash and systemic symptoms, including lymphadenopathy, abnormal liver function, interstitial nephritis, pulmonary and cardiac infiltrates and haematological abnormalities with eosinophilia and atypical lymphocytes. The drugs mostly associated with DRESS are anticonvulsants, allopurinol, minocycline and sulfonamides. This syndrome is rarely seen in childhood even though a large number of children have anticonvulsant treatment. An 8‐year‐old girl was admitted with fever, lymphadenopathy and skin eruptions on her trunk. Her medical history was notable for epilepsy and carbamazepine treatment had been started 5 weeks previously. Laboratory studies showed a white cell count of 6200/µL (normal, 4100–11 200/µL) with 22% eosinophils and a γ‐glutamyl transpeptidase level of 296 U/L (normal, 0–23 U/L). Laboratory tests for infections and collagen diseases were in the normal range. Persistence of fever and maculopapular eruption with generalised desquamation and the appearance of cheilitis and facial angioedema suggested a hypersensitivity reaction to carbamazepine. The carbamazepine was replaced with levetiracetam. All clinical symptoms improved within a week with corticosteroids and antihistamine treatment. Six weeks after complete recovery an epicutaneous patch test with carbamazepine was performed and a carbamazepine‐induced positive skin reaction was observed at 48‐h. Carbamazepine‐induced DRESS syndrome is a rare entity in children. An epicutaneous patch test is a useful tool for identifying the inducing agent for the DRESS syndrome and for identifying a safe anticonvulsant drug.     

Viral exanthems in childhood – infectious (direct) exanthems. Part 2: Other viral exanthems

The group of the non‐classic infectious exanthems are mostly maculopapular or vesicular. The latter changes are typical for infections with varicella‐zoster virus and Coxsackie viruses. Congenital cytomegalovirus infections are characterized by petechiae and purpura, while the papular‐purpuric gloves and socks syndrome is usually associated with parvovirus B19. Aside from these, the non‐classic infectious exanthems diseases include nonspecific exanthems coupled with respiratory and enteric infections.     

Presence of the HLA‐A*3101 allele in a familial case of drug reaction with eosinophilia and systemic symptoms,secondary to carbamazepine

Anticonvulsants such as carbamazepine and phenytoin are associated with adverse skin reactions ranging from maculopapular exanthems to more severe reactions, including drug reaction with eosinophilia and systemic symptoms (DRESS), Stevens–Johnson syndrome and toxic epidermal necrolysis. In addition to their antiepileptic role, anticonvulsants are also used to treat pain syndromes including trigeminal neuralgia. Until recently, the associated skin reactions were thought to be unpredictable; however, the current literature suggests a genetic predisposition involving the human leucocyte antigen (HLA) in cutaneous reactions associated with carbamazepine usage. We present two familial cases of DRESS secondary to carbamazepine, in which an underlying genetic predisposition and allelic association were identified.     

Case of vitiligo universalis as a sequela of drug‐induced hypersensitivity syndrome

Drug‐induced hypersensitivity syndrome (DIHS) is a type of severe drug adverse reaction with high morbidity and mortality. DIHS patients have been reported to subsequently develop autoimmune disease, which may be followed by end‐organ decompensation. We report a 47‐year‐old woman who presented with fever, generalized maculopapular eruption, facial edema and eosinophilia with liver function impairment after taking celecoxib and sulfasalazine for 1 month. The patient was diagnosed with definite DIHS. The patient was treated with immunosuppressants including systemic corticosteroid for approximately 1.5 years due to recurrent episodes. Reactivation of human herpesvirus 6 and possible reactivation of cytomegalovirus were detected. Generalized hypopigmentation of the skin and leukotrichia were noted 4 months after the onset of DIHS. Histopathological examination confirmed the diagnosis of vitiligo. Some spontaneous repigmentation was noted 4 years after DIHS without specific treatment. Further immunoserology study showed elevated plasma C‐X‐C motif chemokine 10 level, which is related to vitiligo activity, in our patient. The occurrence of widespread vitiligo after DIHS is an extremely rare condition. This case provides an important reminder for physicians to monitor such severe complications after DIHS.     

Anticonvulsiva-Hypersensitivitäts-Syndrom auf Carbamazepin

Summary. In a 39-year-old woman an anticonvulsant therapy was initiated because of focal attacks in the left arm and face. The patient experienced generalized maculopapular skin rashes in response to each of four chemically similar anticonvulsant drugs: phenytoin, carbamazepine, primidone and clonazepam. During administration of carbamazepine the clinical features included fever, hepatitis and haemotological eosinophilia in addition to the skin rash (anticonvulsant hypersensitivity syndrome). The anticonvulsant hypersensitivity syndrome is defined as an idiosyncratic reaction caused by disturbed drug metabolism. Positive lymphocytetransformation tests with carbamazepine and phenytoin indicate an immunological mechanism underlying the rashes in our patient. Patch testing with the four anticonvulsant drugs gave positive results only with carbamazepine. Skin biopsy showed the histological features of a delayed-type allergy. The anticonvulsant therapy was continued with a chemically unrelated preparation, valproic acid; this drug is well tolerated and has proved appropriate for prevention of seizures. Eingegangen am 2. August 1993 / Angenommen am 27. Oktober 1993     

Characterization of skin‐resident T cells using a crawl‐out method and flow cytometry

A large fraction of the skin‐homing T‐cell population resides in the skin even under resting, non‐inflammatory conditions. Here, we used a crawl‐out culture method to retrieve T cells from human skin and characterized them using flow cytometric analysis. On average, 48000 viable, non‐proliferating cells were retrieved per biopsy. We found that human skin contains a larger fraction of IL‐17‐, IL‐4‐, IL‐10‐ and IL‐22‐positive T cells as compared with paired blood samples. Our research indicates that it is feasible to use the crawl‐out method in combination with flow cytometry to characterize T‐cell subpopulations in patient‐derived skin biopsies. This method enables further study of the skin immune system and could function as a valuable tool for evaluation of the effects of immunotherapy in skin diseases.     

A systematic review on treatment‐related mucocutaneous reactions in COVID‐19 patients

Most of drugs could have certain mucocutaneous reactions and COVID‐19 drugs are not an exception that we focused. We systematically reviewed databases until August 15, 2020 and among initial 851 articles, 30 articles entered this study (20 case reports, 4 cohorts, and 6 controlled clinical trials). The types of reactions included AGEP, morbiliform drug eruptions, vasculitis, DRESS syndrome, urticarial vasculitis, and so on. The treatments have been used before side effects occur, included: antimalarial, anti‐viral, antibiotics, tocilizumab, enoxaparin and and so on. In pandemic, we found 0.004% to 4.15% of definite drug‐induced mucocutaneous reactions. The interval between drug usage and the eruption varied about few hours to 1 month; tightly dependent to the type of drug and hydroxychloroqine seems to be the drug with highest mean interval. Antivirals, antimalarials, azithromycin, and tocilizumab are most responsive drugs for adverse drug reactions, but antivirals especially in combination with antimalarial drugs are in the first step. Types of skin reactions are usually morbilliform/exanthematous maculopapular rashes or urticarial eruptions, which mostly may manage by steroids during few days. In the setting of HCQ, specific reactions like AGEP should be considered. Lopinavir/ritonavir is the most prevalent used drug among antivirals with the highest skin adverse reaction; ribarivin and remdisivir also could induce cutaneous drug reactions but favipiravir has no or less adverse effects. Logically the rate of dermatologic adverse effects among anivirals may relate to their frequency of usage. Rarely, potentially life‐threatening reactions may occur. Better management strategies could achieve by knowing more about drug‐induced mucocutaneous presentations of COVID‐19.     

Dermal dendrocytes FXIIIA+ phagocytizing extruded mast cell granules in drug‐induced acute urticaria

Background Few authors have been attempting between mast cells and dermal dendrocytes interactions on urticaria. Objective To describe the extruded mast cell granules and dermal dendrocytes in drug‐induced acute urticaria. Methods Seven patients with drug‐induced acute urticaria were enrolled in the study. We token skin biopsies of urticaria lesion and perilesional skin. The 14 fragments collected were processed to immunogold electron microscopy using single stains to tryptase and FXIIIa, besides double immunogold labeling with both. Results Some sections demonstrated mast cells in degranulation process, both in anaphylactic and piecemeal degranulation types. After double immunogold staining, 10 nm (FXIIIa) and 15 nm (Tryptase) gold particles were present together over the granules in mast cells indicating that tryptase and FXIIIa are each localized within the granules of these cells. Interestingly, we found a strong evidence of than the exocytosed mast cell granules contents both FXIIIa and tryptase immunolabeled are phagocytized by dermal dendrocytes. Conclusions The current observations provide morphological evidence that the exocytosis‐phagocytosis mechanisms of mast cell granules represents one pathophysiological example of mast cells‐dermal dendrocytes interactions in urticaria.     

Using human hair follicle‐derived keratinocytes and melanocytes for constructing pigmented tissue‐engineered skin

Background: Traditional tissue‐engineered skin does not produce a satisfactory long‐term result because it lacks natural skin pigmentation and leads to discolored cosmetically unpleasing skin that only functions to cover the body of patients. Additionally, the cell sources for tissue‐engineered skin are generally derived from normal skin, which is often limited in patients with skin defects. Methods: In this study, hair follicle melanocytes and keratinocytes were isolated from human scalp. The melanocytes were co‐cultured with keratinocytes until the second passage and then purified. Purified melanocytes and keratinocytes were seeded onto the chitosan–gelatin membrane for 1 week to construct pigmented tissue‐engineered skin. The pigmented skin equivalent was used to resurface the skin defect in nude mice. Four weeks after grafting, skin biopsies were harvested to take hematoxylin and eosin staining and immunohistochemistry staining of Melan‐A and HLA‐ABC. Results: Large quantities of purified melanocytes can be obtained with co‐culture method. The hematoxylin and eosin staining of repaired skin biopsy demonstrated that the tissue‐engineered skin can repair skin defects successfully. Engineered skin contained pigmentation and stained positive for Melan‐A and HLA‐ABC, which confirmed the presence of melanocytes and its sources were of human origin. Conclusion: This study demonstrated the possibility of constructing pigmented tissue‐engineered skin with human hair follicle‐derived keratinocytes and melanocytes, which brings a promising method to make up for the deficiency of traditional tissue‐engineered skin and provides an alternative treatment for depigmentation diseases.     

Severe cutaneous adverse drug reactions

The clinical manifestations of drug eruptions can range from mild maculopapular exanthema to severe cutaneous adverse drug reactions (SCAR), including drug‐induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms, Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) which are rare but occasionally fatal. Some pathogens may induce skin reactions mimicking SCAR. There are several models to explain the interaction of human leukocyte antigen (HLA), drug and T‐cell receptor (TCR): (i) the “hapten/prohapten” theory; (ii) the “p‐i concept”; (iii) the “altered peptide repertoire”; and (iv) the “altered TCR repertoire”. The checkpoints of molecular mechanisms of SCAR include specific drug antigens interacting with the specific HLA loci (e.g. HLA‐B*15:02 for carbamazepine‐induced SJS/TEN and HLA‐B*58:01 for allopurinol‐induced SCAR), involvement of specific TCR, induction of T‐cell‐mediated responses (e.g. granulysin, Fas ligand, perforin/granzyme B and T‐helper 1/2‐associated cytokines) and cell death mechanism (e.g. miR‐18a‐5p‐induced apoptosis; annexin A1 and formyl peptide receptor 1‐induced necroptosis in keratinocytes). In addition to immune mechanism, metabolism has been found to play a role in the pathogenesis of SCAR, such as recent findings of strong association of CYP2C9*3 with phenytoin‐induced SCAR and impaired renal function with allopurinol SCAR. With a better understanding of the mechanisms, effective therapeutics and prevention for SCAR can be improved.     

Severe drug‐induced skin reactions: clinical pattern,diagnostics and therapy

The spectrum of severe drug‐induced skin reactions includes not only Stevens‐Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) but also generalized bullous fixed drug eruption (GBFDE), acute generalized exanthematous pustulosis (AGEP) and hypersensitivity syndrome (HSS), also called drug reaction with eosinophilia and systemic symptoms (DRESS). These reactions differ in clinical presentation as well as prognosis, causative agents and therapy. Therefore, the appropriate diagnostic measures should be undertaken rapidly, in order to prove the diagnosis. In addition to a thorough clinical examination, a skin biopsy should be taken and specific laboratory investigations should be done if AGEP or HSS/DRESS is suspected. Since these reactions are drug‐induced, the causative agent should be rapidly identified and withdrawn. Besides adequate supportive therapy, systemic immunomodulatory treatments may be considered. Despite intensive care management, the prognosis in SJS and TEN is often poor and influenced by the amount of skin detachment as well as the age of the patients and the pre‐existing underlying conditions. Severe sequelae may develop in survivors and affect especially mucosal sites. The prognosis of GBFDE is better but recurrent events may lead to more severe involvement. In HSS/DRESS sequelae have been also described as well as long lasting and recurrent courses, whereas AGEP usually heals without problems.     

Is drug allergy less prevalent than previously assumed? A 5‐year analysis

Background Rashes are a frequent conundrum in clinical practice as they may be reactive, drug induced or disease specific. Identification of the culprit drug is important as re‐exposure may be harmful or even life‐threatening and unnecessary avoidance of ‘innocent’ drugs leads to limitations of treatment options. Objective To objectify the cause of suspected cutaneous drug reactions in a large patient population. Method Over 5 years (2006–10), 612 patients with suspected cutaneous drug reactions were evaluated. Histology was assessed. About 200 patients were invited for complete work‐up with skin tests (prick/intracutaneous testing and scratch/patch as indicated) and, if necessary, lymphocyte transformation tests (LTT). In special cases, drug provocation tests were conducted. Results A total number of 141 cases with suspected drug reaction underwent full work‐up (age 6–86 years; 75% female, 25% male). In 107 cases (76%) a drug was identified whereas 34 (24%) were reactive rashes or had other causes. Mostly, cutaneous drug reactions were maculopapular rashes, urticaria/angio‐oedema; less frequently, acute generalized exanthematous pustulosis, drug reaction with eosinophilia and systemic symptoms, systemic drug‐related intertriginous and flexural exanthema, toxic epidermal necrolysis and fixed drug eruptions were present. Of all the cutaneous drug reactions investigated, 39·8% were caused by antibiotics, 21·2% by anti‐inflammatories, 7·6% by contrast media and 31·4% by others (oral antidiabetics, antimycotics, antipsychotics, antiepileptics and others). Conclusion Clinical assessment overestimates the role of drug allergies in cutaneous reactions. Assessment of suspected drug reactions can be greatly improved by thorough evaluation including dermatological and allergological work‐up with skin testing and assays such as LTT.     

Fas (CD95) and bcl-2 expression in active skin lesions of Behçet''s disease

Over‐expression of bcl‐2 in lymphocytes has an important role in some immunological and inflammatory diseases. Fas (CD95) is a cell surface molecule that mediates receptor‐triggered apoptosis in various cells including autoreactive T cells. In this study we investigated bcl‐2 and Fas (CD95) expression in dermal lymphocytes in active skin lesions of Behçet's disease (BD) and in skin biopsy samples with chronic, non‐specific inflammations. Tissue sections of 29 skin lesions of Behçet's disease and of 10 chronic non‐spesific inflammatory process cases from the archives of the Ondokuz May?s University's Pathology Department were immunohistochemically stained for bcl‐2 and Fas (CD95), and lymphocytes in the dermal infiltrate were evaluated for cytoplasmic staining. bcl‐2 staining was observed in the skin lesions of 22 cases (75.8%) of Behçet's disease. bcl‐2 staining was detected in two (20%) control skin biopsy samples with non‐specific chronic inflammation. Fas (CD95) positivity was not detected in lymphocytes in Behçet's disease‐related skin lesions. Fas (CD95) staining was observed in only three skin biopsy samples with non‐specific chronic inflammation. bcl‐2 and Fas (CD95) staining values in Behçet's and non‐specific inflammation groups were significantly different (P < 0.01); differences in the bcl‐2 staining values between Behçet's patients with mucocutaneous involvement only and mucocutaneous and other systemic involvements were not significant (P > 0.05). Expression of bcl‐2 and loss of Fas (CD95) expression in dermal lymphocytes may play a role in the development of skin lesions and may account for the chronic course with periodic exacerbations in BD.     

Chilblains‐like lesions and SARS‐CoV‐2 in children: An overview in therapeutic approach

SARS‐CoV‐2 (Severe Acute Respiratory Syndrome, Coronavirus, type 2) is the virus responsible for the global pandemic of Coronavirus disease 2019 (COVID‐19) that began in China in December 2019. The variability of nasal olfactory symptoms in pediatric patients is interlinked with possible warning signs, including respiratory, gastrointestinal, ocular, or dermatological symptoms. Skin findings in patients with COVID‐19 can range from petechiae to papulovesicular rashes to diffuse urticaria and can be confused with rashes of non‐COVID‐19 conditions. These lesions typically appear early during COVID‐19 and are thought to be secondary to viral replication or circulating cytokines. Herein, we discuss two pediatric cases, presenting with skin lesions, which tested positive for SARS‐CoV‐2, thus, briefly reviewing current literature for similar reports and related management. Although these lesions heal spontaneously in most cases, an adequate “targeted” therapeutic approach can shorten the time and the discomfort of the skin disease.     

Elevated transglutaminase‐2 expression in the epidermis of psoriatic skin and its role in the skin lesion development

Psoriasis, an inflammatory skin disease triggered by the immune system, presents keratinocyte hyperproliferation, differentiation and angiogenesis. The role of transglutaminase‐2 (TG2) in psoriasis has not been fully established yet. In this retrospective, non‐randomized and non‐blinded study, skin biopsies were collected from 37 psoriatic patients and immunohistochemical staining was performed. TG2 staining was positive in all 37 samples, among which 32 were strong and five weak. The localization of TG2 staining was present in the epidermis and spreading from basal layer to stratum granulosum in decreasing staining intensity. However, TG2 was also expressed in the basal layer in the non‐lesional site of psoriasis and the skin of healthy people. The presence of TG2 was not associated with disease duration, stage of disease and subtype of psoriasis. Overexpression of TG2 seems to be an important role in psoriatic development.     

Drug‐reaction eosinophilia and systemic symptoms and drug‐induced hypersensitivity syndrome

Drug reaction with eosinophilia and systemic symptoms (DRESS), also known as drug‐induced hypersensitivity syndrome (DIHS), is a rare, severe cutaneous adverse reaction characterised by fever, rash, lymphadenopathy, eosinophilia and/or other leukocyte abnormalities, and internal organ involvement and often has a relapsing–remitting course despite withdrawal of the drug. The drugs that are most implicated include aromatic anticonvulsants, allopurinol, sulphonamides, antiretrovirals (abacavir and nevirapine), and minocycline. The pathogenesis of DRESS/DIHS is far from clear but probably involves a combination of impaired pharmacokinetics and the accumulation of drug metabolites, the sequential reactivation of the herpesvirus family and genetic susceptibility conferred by the association with certain human leukocyte antigen (HLA) class I alleles. The strong association between abacavir and HLA‐B*5701 has enabled pharmacogenetics screening to be employed successfully to minimise the occurrence of hypersensitivity. A prolonged course of oral corticosteroids is required to treat DRESS/DIHS, given the relapsing–remitting nature of the condition with i.v. immunoglobulin and valgangciclovir reserved for refractory or life‐threatening cases.     

T‐lymphocyte‐induced,fas‐mediated apoptosis is associated with early keratinocyte differentiation

Please cite this paper as: T‐lymphocyte‐induced, fas‐mediated apoptosis is associated with early keratinocyte differentiation. Experimental Dermatology 2009. Abstract: The development of eczematous lesions is thought to be due in part to a breakdown in skin barrier function as a result of T lymphocytes (T cells) invading the skin causing epidermal keratinocyte apoptosis. In this study, we investigated the interaction of T cells and keratinocytes on apoptosis and terminal differentiation using an in vitro co‐culture system. Experiments were performed using the HaCaT keratinocyte cell line or normal human epidermal keratinocytes. Activated human peripheral blood‐derived T cells were found to induce Fas‐dependent keratinocyte apoptosis by up to sixfold. Increased Fas was associated with increased IFN‐γ. The T‐cell apoptotic signal was found to target preferentially keratinocytes in the very early stages of terminal differentiation, such as those with low levels of α6‐integrin expression, and result in subsequent increased caspase 3 activity. This observation was accompanied by a marked increase in keratinocyte ICAM‐1 expression and its ligand LFA‐1 on T cells. Our data suggest that T cells may initiate the onset of keratinocyte terminal differentiation making them more susceptible to Fas‐dependent cell death signals delivered by the T cells.