Neuropeptides in the skin of patients with atopic dermatitis

There is increasing evidence that neuropeptides may be involved in the pathogenesis of atopic dermatitis (AD). This study examines whether neuropeptide distribution in the skin of patients with AD differs from normal controls. The distribution and density of several neuropeptides were examined in lesional and non-lesional skin of AD patients (n = 5) and in normal controls (n = 4) using indirect immunofluorescence and image analysis. Cholinergic innervation was studied using cholinesterase histochemistry. Staining with the general neuronal marker protein gene product 9 x 5 showed a subepidermal network of nerves with fibres penetrating the epidermis, and nerves around blood vessels, sweat glands and hair follicles. Image analysis of nerves around sweat glands showed a significantly higher nerve density in non-lesional compared with both normal controls and lesional skin (P < 0.05); lesional compared with control skin showed no significant difference. In the epidermis the density of nerves was not significantly greater in non-lesional compared with lesional skin and controls. Calcitonin gene-related peptide immunoreactivity was similar in all subjects except in three of the AD patients, where more nerves appeared to penetrate the epidermis. Substance P immunoreactivity in the papillary dermis was seen in all AD patients but no controls. Vasoactive intestinal polypeptide and neuropeptide Y staining were similar in all groups. Acetylcholinesterase-positive nerves were found around sweat glands in all subjects, the staining being greatest in non-lesional and least in lesional skin. Occasional nerves were seen in the papillary dermis in lesional skin of two out of the four patients. We have demonstrated quantitative differences in nerve growth in clinically normal skin of AD patients, and altered cutaneous neuropeptide expression in these patients which may contribute to the pathogenesis of AD. The cause of atopic dermatitis (AD) has not been fully established but it is believed that there is a complex interaction between genetic susceptibility, precipitating environmental factors and disordered immune responsiveness. There is increasing evidence that neuropeptides may be involved in the pathogenesis of AD. Exacerbations of the disease can be provoked by stress, scratching and sweating which may be the result of neurogenic inflammation. One of the first features of an exacerbation is flushing of the affected skin and pruritus. Several neuropeptides that have been identified in human skin are potent inducers of vasodilation and may induce pruritus. Substance P (SP), calcitonin gene-related peptide (CGRP) and vasoactive intestinal polypeptide (VIP) all cause vasodilation when injected intradermally, and SP and CGRP have been shown to be mediators of the weal and flare reaction. Spantide, a competitive antagonist of SP, has been shown to inhibit immediate and delayed-type hypersensitivity reactions. Part of these responses may be due to release of histamine and indeed elevated concentrations of histamine have been found in vivo in the skin and plasma of patients with AD. In this study the distribution and density of several neuropeptides were examined in lesional and nonlesional skin of AD patients and in normal controls using indirect immunofluorescence and image analysis. Cholinergic innervation was studied using cholinesterase histochemistry. Because many afferent fibres do not express CGRP or SP, the general neuronal marker protein gene product (PGP 9 x 5) was used to assess the overall nerve supply to the skin.

Differentiation and CD23 expression of peripheral blood monocytes in patients with atopic dermatitis

In this study we investigate the expression of the low affinity immunoglobulin E (IgE) receptor (Fc epsilon RII) on plastic-adherent leucocytes from patients with atopic dermatitis (AD). Peripheral blood mononuclear cells were obtained from patients with AD, normal controls (and in one study from a group of atopic asthmatic patients). Monocytes were separated by 2-h adherence to plastic. These cells were then cultured for up to 7 days. Cells were harvested at time 0 (after adherence), and after 5 and 7 days culture, and cytospins were prepared. The proportion of cells expressing the phenotype of antigen presenting cells (monoclonal antibodies (mAb) RFD1+), and mature phagocytes (mAb RFD7+) together with CD23, were evaluated using combination staining with immunoperoxidase and alkaline phosphatase anti-alkaline phosphatase methods. It was found that a significantly larger proportion of circulating adherent cells in AD patients expressed the RFD1 antigen, and that increases in the proportion of these adherent cells expressing RFD1 or RFD7 occurred faster as cells matured in culture, when compared with cells obtained from normal controls. By day 7, however, equivalent proportions of RFD1+ and RFD7+ cells were present in AD and control cultures. None the less, expression of the CD23 molecule was consistently present on a larger proportion of both RFD1+ and RFD7+ cells from AD patients compared with controls. The raised proportion of circulating RFD1+ cells found in AD was not present in samples from atopic asthmatics, while the raised expression of CD23 on these cells occurred in samples from both these groups. These data support the suggestion that abnormalities in peripheral blood adherent cell phenotype, maturation, and CD23 expression, occur in AD patients. Some of these observations may be related to atopy in general rather than being specific for this skin disease.

Efficacy of traditional Chinese herbal therapy in vitro. A model system for atopic eczema: inhibition of CD23 expression on blood monocytes

Recently, there has been growing interest in the use of traditional Chinese herbal therapy (TCHT) decoctions for the treatment of atopic eczema (AE). The mode of action of this treatment is still unknown, and in order to investigate this we have analysed the effect of an extract of these herbs (TCHTE) on interleukin 4 (IL-4)-induced CD23 expression on peripheral blood monocytes from non-atopic subjects. We found that TCHTE inhibited CD23 expression up to 60% (P < 0.001), whereas the placebo extract had no significant effect on CD23 expression. This inhibition was dose-dependent, and TCHTE was effective at a concentration of 250 micrograms/ml (P = 0.001). If TCHTE or placebo was added after IL-4, the action of TCHTE could still be seen at 12 h. This inhibition was not due to cell death, as peripheral blood mononuclear cells (PBMCs) cultured with TCHTE or placebo at a concentration used in these experiments had a similar viability to control cultures. Down-regulation of the low affinity receptors for IgE on antigen-presenting cells in patients with AE may contribute to the benefit observed following treatment with TCHT.

Follow-up of adult patients with atopic eczema treated with Chinese herbal therapy for 1 year

Adult patients with severe atopic eczema who had completed a double-blind placebo-controlled crossover trial of a specific formulation of Chinese herbal therapy were offered continued therapy for 1 year. Of 31 patients who completed the original placebo-controlled study and after a washout period and 2 months of further treatment, 17 continued treatment (group 1), 11 chose not to continue treatment (group 2), one was lost to follow-up and two patients originally in group 1 decided to stop treatment and became pregnant. At the end of the year, 12 of the patients in group 1 had greater than 90% reduction and the remaining five had greater than 60% reduction in clinical scores compared with baseline values. Clinical scores of patients in group 2 gradually deteriorated so that by the end of the year the difference between groups 1 and 2 was highly significant (P = 0.005 and P = 0.002 for erythema and surface damage, respectively). At the end of the year no patient in group 1 felt able to discontinue treatment permanently, but eight patients were on an alternate-day regimen by 6 months and remained on this regimen until the end of the year, and seven were able to control their eczema with a 1 in every 3 day treatment by the end of the year. The remaining two patients continued on daily treatments. Toxicology screening revealed no abnormalities in either full blood counts or biochemical parameters in any patient on continued treatment. Improvement in disease was not associated with any significant change in serum IgE level or peripheral blood lymphocyte subsets.(ABSTRACT TRUNCATED AT 250 WORDS)

Fibroblastic rheumatism

The first British case of fibroblastic rheumatism is reported. Treatment with apha-interferon in combination with a reducing course of steroids resulted in some regression of the cutaneous nodules, and initial improvement in the skin fibrosis and digital contractures.

Chronic rash associated with congenital rubella

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Stelazine-induced pigmentation

A case of a West Indian patient is reported who developed abnormal blue-grey pigmentation on exposed areas of skin following treatment with low dose stelazine. Oculocutaneous melanosis is a well-recognized side-effect of prolonged phenothiazine treatment. In this condition the areas of skin exposed to sunlight develop a violaceous, blue-grey or slate-grey colour in more severe cases. These characteristic changes are rarely seen now. We describe the case of a patient who developed pigmentation while taking a low dose of stelazine for 5 years.

Systemic lupus erythematosus in association with ulcerative colitis: related autoimmune diseases

We report a patient who developed urticaria, angio-oedema and polyarthropathy secondary to the hypocomplementaemic urticarial vasculitis syndrome, a year prior to the onset of ulcerative colitis. Ten years later, primary sclerosing cholangitis and the antiphospholipid syndrome developed concomitantly. We believe this patient represents only the second reported case of idiopathic systemic lupus erythematosus (SLE) occurring in association with ulcerative colitis.

Cyclical psoriatic arthritis responding to anti-oestrogen therapy

We report a patient with severe psoriatic arthritis in whom the severity of both the arthritis and psoriasis fluctuated with the menstrual cycle. These features failed to improve with standard therapy, but there was a prompt response to treatment which suppressed oestrogen secretion. Such treatment should be considered in patients with disabling cyclical changes in psoriatic arthritis.

Risk of cancer in relatives of patients with cutaneous melanoma

BACKGROUND

Cutaneous malignant melanoma (CMM) is a recognized feature of the Lynch type II cancer-family syndrome and the Li-Fraumeni's syndrome. A significant contribution of these syndromes to the total burden of CMM would be reflected in an increased risk of nonmelanoma cancers in first degree relatives.

METHODS

Pedigrees were taken from 85 patients with CMM using a family history questionnaire. The relative risk of death from all cancers and individual cancers in first degree relatives was calculated.

RESULTS

Of the 85 questionnaires, those of 79 patients were completed and of adequate quality for analysis. The first degree relatives of CMM patients showed no increased risk of cancer death, the relative risk of cancer death being 1.0. Six patients (7.6%) had first degree relatives with CMM. One patient had a family history compatible with the dominant transmission of a predisposition to cancer.

CONCLUSIONS

It is important to establish whether an increased cancer risk is present in relatives of patients with malignancies so that screening programs may be offered. This study provides little evidence to support seeing relatives for noncutaneous malignancies in the absence of a dominant family history of predisposition to cancers. The increased frequency of CMM in relatives suggests that relatives of CMM patients should be counseled on protection from the sun and examination of the skin for melanoma.

Generalized morphoea secondary to porphyria cutanea tarda

We report a patient with generalized morphoea secondary to porphyria cutanea tarda, who responded to treatment with cyclosporin. The differences between the sclerodermatous skin changes seen in porphyria cutanea tarda and generalized morphoea are discussed.

Bullous pemphigoid in infancy--a case report including new immunoblotting observations

A 1-year-old boy developed bullous pemphigoid. Immunoblotting, which has not been previously reported in childhood pemphigoid, showed the serum reacted to a 190 kDa band only. Bullous pemphigoid is rare in infancy and childhood with only 40 cases previously reported. A brief review of the literature is given and treatment of childhood bullous pemphigoid is discussed.

Neutrophilic eccrine hidradenitis with an unusual presentation

Neutrophilic eccrine hidradenitis (NEH) is an eruption most commonly seen in patients undergoing chemotherapy, and is characterized histologically by a neutrophilic infiltrate around the eccrine coils, with associated necrosis of the sweat coils. The rash usually affects the trunk and extremities, and the morphology of the lesions is very variable. We describe a patient with neutrophilic eccrine hidradenitis who presented with symmetrical, erythematous, swollen ears, a manifestation of NEH which has not been previously reported.

Pellagra secondary to 5-fluorouracil

The development of pellagra in a patient treated with 5-fluorouracil for malignant disease is reported. The aetiology of pellagra in this patient is discussed, and the reasons for possible under-diagnosis of pellagra in association with malignant disease considered. We report a patient who presented with the typical skin changes of pellagra. The rash, and an associated acute deterioration in cerebral function, were exacerbated by treatment with 5-fluorouracil. The importance of considering nicotinic-acid deficiency in patients with malignant disease has not been emphasized in the literature.