[Mycophenolate mofetil: a new immunosuppressive drug in dermatology and its possible uses]

Mycophenolate mofetil represents a new immunosuppressive drug. Several case reports have shown that mycophenolate mofetil has a good therapeutic effect in patients with psoriasis and autoimmune dermatoses. Mycophenolate mofetil is a morpholine ester of mycophenolic acid which was shown in the 1970s to be effective in patients with severe psoriasis. Mycophenolate mofetil has an increased bioavailability as compared to mycophenolic acid and thereby an improved therapeutic window. Currently, mycophenolate mofetil is indicated for the prevention of organ rejection in transplant patients. The mode of action and the pharmacology of mycophenolate mofetil are reviewed and the current clinical experience with this immunosuppressive drug for dermatological disorders is summarized.

Establishment and characterization of an immortalized human sebaceous gland cell line (SZ95)

Human facial sebaceous gland cells were transfected with a PBR-322-based plasmid containing the coding region for the Simian virus-40 large T antigen. The resulting proliferating cell cultures have been passaged over 50 times to date, have been cloned, and show no signs of senescence after 4&DF;1 2 y in vitro, whereas normal human sebocytes can only be grown for three to six passages. The immortalized transfected cells, termed SZ95, expressed the Simian virus-40 large T antigen and presented an hyper-diploid-aneuploid karyotype with a modal chromosome number of 64.5. The SZ95 cell line exhibited epithelial, polymorphous characteristics with different cell sizes of up to 3.25-fold during proliferation and 6-fold at confluence, showing numerous cytoplasmic lipid droplets. The cells showed large cytoplasm profiles with abundant organelles, including vacuoles and myelin figures which indicated lipid synthesis. Lack of or only few desmosomal areas were observed. SZ95 cells expressed molecules typically associated with human sebocytes, such as keratins 7, 13, and 19, and several proteins of the polymorphous epithelial mucin family. Functional studies revealed synthesis of the sebaceous lipids squalene and wax esters as well as of triglycerides and free fatty acids, even after 25-40 passages; active lipid secretion; population doubling times of 52.4 +/- 1.6 h; reduced growth but maintenance of lipid synthesis under serum-free conditions; and retrieval of cell proliferation after addition of 5alpha-dihydrotestosterone. Retinoids significantly inhibited proliferation of certain SZ95 cell clones in the expected magnitude 13-cis-retinoic acid > all-trans-retinoic acid > > acitretin. Thus SZ95 is an immortalized human sebaceous gland cell line that shows the morphologic, phenotypic and functional characteristics of normal human sebocytes.

Treatment of psoriasis with retinoids: present status

Oral retinoids such as etretinate/acitretin are well established for the treatment of severe generalized psoriasis. They are particularly useful for the management of pustular and erythrodermic variants and plaque-type psoriasis because they act synergistically with many other topical antipsoriatic agents (corticosteroids, anthralin, tar, and phototherapies). Oral regimens are dose-dependent, and, if carefully administered, are manageable and tolerable. Long-term toxicity is rare; however, teratogenicity restricts the use of oral retinoids and requires close monitoring in females. In recent years, a topical agent, tazarotene, has been developed and added to the armamentarium of psoriasis therapy.

Unilateral angiolymphoid hyperplasia with eosinophilia involving the left arm and hand

A case report of recurrent angiolymphoid hyperplasia with eosinophilia (ALHE) in an otherwise healthy 20-year-old female with manifestation of the disease limited to the left arm and hand is presented together with brief evaluation of the literature as well as the features distinguishing ALHE and Kimura's disease. Immunohistochemical investigations support the hypothesis that ALHE represents a reactive inflammatory lesion rather than a benign vascular neoplasm. A viral cause of ALHE (e.g., HHV8 or Epstein-Barr virus (EBV)) could not be demonstrated. The recurrent nature of the disease is shown by this case, which also demonstrates the need for frequent medical and surgical management.

[Shower PUVA: a new possibility for topical PUVA therapy. Phototoxicity in relation to shower time, water temperature and skin type]

During the past few years, bath PUVA has become established as an effective treatment for various dermatoses and especially for psoriasis. Using 3,4,5 trimethylpsoralen (TMP) in combination with subsequent UVA irradiation, a shower PUVA has been developed as an alternative in local PUVA therapy. This involves moistening the patient's skin - with the exception of the head and neck area - in a shower using water containing psoralen (TMP concentration 0,27 mg/l). The advantages of shower PUVA method are that time, space and cost savings are possible and that only a slight amount of physical exertion is required by the patient standing in the shower compared to immersing the whole body during bath PUVA therapy. The efficacy and practicability of shower PUVA were evaluated using the minimal phototoxic dose (MPD) for healthy volunteers assessing water temperature (33-38 degrees C), shower time (5-10 min), and UVA dose (0,06-1,0 J/cm(2)). Additionally, the time course of TMP-induced photosensitivity was observed over a period of 4 hours after the shower. Using a TMP concentration of 0,27 mg/l, the MPD for skin type I-II lay between 0,125-0,375 J/cm(2) and for skin type III-IV between 0,375-1,0 J/cm(2). Photosensitivity was induced by shower PUVA within 5-10 minutes shower time and at 33-38 degrees C water temperature. MPD exhibited an inverse correlation to temperature but no differences were apparent for shower times between 5 and 10 minutes. Photosensitivity completely disappeared within 2 hours. Minimal phototoxic doses using TMP in shower PUVA are comparable with classical bath PUVA when taking skin type into account. These results support the therapeutic use of shower PUVA using TMP.

Beyond inflammation: tolerance, immunotherapy and more

Inflammatory skin diseases such as allergic contact dermatitis, atopic dermatitis, and psoriasis are together the most frequent dermatoses and are of great medical and economic significance. Despite impressive progress in recent years, the immune pathogenesis of these diseases is not yet fully understood. In particular, it remains an open question which anti-inflammatory mechanisms can be activated to prevent development of such abnormal immune reactions in the still healthy organism, and how these anti-inflammatory processes may be enhanced and instrumentalized for treatment of these disease states.

[Hepatitis C virus-associated dermatoses: a review]

Acute infection with hepatitis C virus (HCV) is often clinically inapparent, but may affect several organ systems in its chronic course. In dermatology, common diseases such as lichen planus, cryoglobulinemic vasculitis and porphyria cutanea tarda have been described in association with HCV infection. A number of other dermatologic disorders, e.g., psoriasis, chronic urticaria, chronic pruritus, pseudo-kaposi sarcoma, necrolytic migratory erythema and Behçet disease, have been associated in case reports with HCV-induced liver disease. In this study we summarize the recent literature reports, present three patients observed by our group and update the topic.

Long-term extracorporeal photoimmunotherapy for treatment of chronic cutaneous graft-versus-host disease: observations in four patients

BACKGROUND

Chronic cutaneous graft-versus-host disease (GvHD) can arise as a late complication after allogeneic bone marrow transplantation. Patients with extensive disease to date require intensive early and long-term immunosuppression; however, treatment is often insufficient. Since the beneficial effects of phototherapy for chronic cutaneous GvHD are well known, extracorporeal photoimmunotherapy (ECP) was also tried with some success for a few single patients with this disease.

OBJECTIVE

The long-term effect of ECP was evaluated in 4 patients with therapy-resistant severe chronic cutaneous GvHD after allogeneic bone marrow transplantation.

METHODS

Four patients were treated with monthly sessions of ECP over a period of 16-40 months. Disease severity was assessed by a semiquantitative score adapted from the literature including extent of skin area involved, rigidity of the skin, involvement of joints and immunosuppressive drug consumption.

RESULTS

In all patients, a favorable response was observed after 6-12 treatment cycles. One patient had a complete response, 2 patients had a partial response, and 1 patient had a minor response after treatment. In 2 patients, immunosuppressive medication started before initiating ECP could be reduced or completely withdrawn under ECP. Peripheral blood lymphocyte immunophenotyping revealed reduction of CD3+ CD4+ T cells in 3 patients and of elevated CD3+ CD8+ and CD57+ CD8+ T cell subsets in 2 patients.

CONCLUSION

ECP is effective in treating severe chronic cutaneous GvHD. ECP possibly exerts its effects by reducing the number of CD8+ suppressor/cytotoxic T cells, the presumptive effector cells of GvHD. ECP is well tolerated with essentially no side effects and allows reducing the dosage of immunosuppressive agents.

Twenty-eight cases of juvenile-onset Adamantiades-Behçet disease in Germany

BACKGROUND AND OBJECTIVE

Adamantiades-Behçet disease is a rare entity at a juvenile age. We aimed to enlighten epidemiological and clinical characteristics of juvenile-onset disease in Germany.

METHODS

Data from the German Registry were used to compare clinical and epidemiological features of patients with juvenile-onset (</=16 years) and adult-onset (>16 years) disease diagnosed according to the criteria of the International Study Group.

RESULTS

Twenty-eight (17%) of 168 patients of the German Registry exhibited the onset of the disease and 8 (5%) of them the complete symptom complex at a juvenile age. Juvenile-onset disease was characterized by an increase in familial cases (25 vs. 8% in patients with adult-onset; p = 0.047). The frequency of diagnostic signs was similar between the two study groups. In juvenile-onset disease, delayed development of the complete symptom complex (median value 35 months vs. 12 months after onset; p = 0.014) and lower prevalence of severe complications (9 vs. 29%; p = 0.042) were detected.

CONCLUSIONS

The major clinical features of juvenile-onset and adult-onset disease in Germany are comparable, but in juvenile-onset disease, the course is delayed and patients experience less severe complications. In addition, there is a higher rate of familial occurrence of the disease in patients with juvenile-onset.

Increased expression of tenascin C by keloids in vivo and in vitro

Tenascin C, undulin, collagen XIV and fibronectin are extracellular matrix glycoproteins with a partial DNA sequence homology. During embryogenesis, tenascin C is abundant in mesenchymal tissues but its distribution in human adult tissue is severely restricted. The levels of tenascin C expression are enhanced with skin inflammation, wound healing and hyperproliferative skin diseases and return to normal in normal scar tissue after wound contraction is completed. Undulin/collagen XIV is associated with collagen fibrils and fibronectin is present throughout the dermis in adult skin but it is produced by keloidal fibroblasts in an increased amount. In this study we investigated by immunohistochemistry the expression of the three extracellular matrix proteins in keloids and normal skin as well as in keloidal and normal fibroblasts in vitro. In keloids, increased tenascin C expression was observed especially in the reticular dermis associated with collagen fibrils sharply demarcating the limit of the lesion. In normal tissue, tenascin C was only expressed beneath the basal lamina and dermal-epidermal junction. Corresponding to the in vivo findings, tenascin C expression was increased in keloidal fibroblasts compared with normal fibroblasts in vitro (P < 0.003), whereas undulin/collagen XIV and fibronectin expression in keloids and keloidal fibroblasts was similar to that in normal tissue and normal fibroblasts, respectively. Therefore, tenascin C is a marker associated with keloids and we suggest that keloidal fibroblasts, once stimulated, continue to produce tenascin C independently from circulating factors.

Follicular mycosis fungoides

We describe a patient with follicular mycosis fungoides (MF), a rare folliculotropic variant of cutaneous T-cell lymphoma (CTCL). Follicular involvement in CTCL usually presents clinically as alopecia mucinosa associated histologically with follicular mucinosis. Follicular MF differs from alopecia mucinosa/follicular mucinosis associated with MF with regard to its clinical presentation, histology and, presumably, prognosis. Our patient presented with the characteristic findings of follicular MF, i.e. infiltrated plaques showing numerous enlarged, comedo-like follicular infundibula; histology was dominated by exclusive folliculotropism of atypical lymphocytes sometimes forming follicular Pautrier's microabscesses, and by lack of epidermotropism and follicular mucinosis. Despite photochemotherapy and treatment with oral retinoids and interferon alpha, the patient's follicular MF rapidly developed into a progressive CTCL with large tumorous lesions, but responded to electron beam therapy. The course of our patient's disease confirms the notion that follicular MF may be associated with a worse prognosis than classical MF. However, electron beam irradiation induced remission of follicular MF that was maintained by a combination therapy consisting of extracorporeal photopheresis and interferon alfa.

Downregulation of endothelin B receptor in human melanoma cell lines parallel to differentiation genes

Normal human melanocytes have been shown to respond to the signal peptide endothelin by increased proliferation and melanin formation. Contradictory findings, however, have been reported about which of the two endothelin receptors (EDNRA or EDNRB) is expressed in normal melanocytes and melanoma cells. Moreover it was not clear whether malignant cells differ from their normal precursors in this respect. Screening a melanocyte cDNA library for genes downregulated in melanomas identified clones specific for EDNRB. Northern blots proved that the corresponding mRNA is generally expressed in cultures of human cutaneous melanocytes and congenital melanocytic nevus cells. In 16 of 17 melanoma cell lines, however, the expression of EDNRB mRNA was strongly downregulated. EDNRA was only weakly expressed and detectable by northern blotting in 12 of 17 cultures of benign melanocytic cells and four of 17 melanoma cell lines. Nested reverse transcriptase-polymerase chain reaction proved several melanoma cell lines to be completely negative for EDNRA expression. Gene deletion as the cause of missing endothelin receptor expression was ruled out by genomic Southern blots. Receptor binding assays confirmed RNA data revealing 1.6 x 105 endothelin-1 binding sites per cell for a melanocyte culture and between 8.7 x 104 and 400 sites per cell for melanoma cell lines. Expression of pigmentation genes coding for tyrosinase, TRP-1 and TRP-2 correlated positively with that of EDNRB but negatively with EDNRA expression. EDNRB but not EDNRA expression is therefore typical for melanocytic cells, and downregulation of EDNRB seems to be an important characteristic of melanoma cells possibly related to malignancy or apoptosis.

Clonal T-cell receptor gamma-chain gene rearrangement by PCR-based GeneScan analysis in advanced cutaneous T-cell lymphoma: a critical evaluation

Detection of clonal T-cell receptor gamma (TCRgamma)-chain gene rearrangement is a promising approach to distinguish between cutaneous T-cell lymphomas (CTCLs) and reactive T-cell infiltrates. Despite the improved sensitivity by using the polymerase chain reaction (PCR) rather than Southern blot analysis, monoclonality could be demonstrated in only 53-90 per cent of CTCL biopsies in recent studies. In the present study, formalin-fixed, paraffin-embedded specimens of 21 selected patients with clear-cut advanced-stage CTCL were analysed using a semi-nested TCRgamma PCR with newly developed consensus primer pairs. Detection of PCR products was done by GeneScan analysis (GSA); this technique is advantageous due to its sensitivity and accuracy in the detection and size determination of PCR products and it is easier to interpret than direct read-outs from TGGE or DGGE gels. In serial dilution experiments, TCRgamma-PCR-GSA allowed the detection of clonal, rearranged T-cells with a high in vitro sensitivity against a polyclonal background (1-6 per cent). Despite the selection of clear-cut, advanced-stage CTCL cases, however, dominant clonal TCRgamma-chain gene rearrangement was found in only 16 of the 21 patients analysed, indicating an overall clinical sensitivity of 76 per cent. Specificity was evaluated using biopsy specimens from 21 control patients suffering from long-standing psoriasis (n=13) and eczema (n=8). Surprisingly, GeneScan profiles showing apparently single dominant peaks were detected in 14 per cent of these skin lesions, but these profiles turned out to be pseudo-monoclonal by repeated determinations. In conclusion, TCRgamma-PCR-GSA does not suffice reliably to exclude malignancy, due to its limited clinical sensitivity, but with precautions taken to detect pseudo-monoclonality and to secure specificity, TCRgamma-PCR-GSA is a valuable instrument in the diagnosis of CTCL.

Basal cell carcinoma possibly originates from the outer root sheath and/or the bulge region of the vellus hair follicle

In the present study, the immunophenotype of basal cell carcinoma was analysed in comparison with human vellus hair follicular keratinocytes. We also established the lectin binding profile of basal cell carcinoma and human vellus hair follicles (VHF), using several lectins with different sugar specificities. Our findings showed an almost identical immunohistochemical profile for basal cell carcinoma and the suprabulbar region of the outer root sheath of VHF, whereas other follicular compartments such as the bulbar, the isthmus or the supraseboglandular regions did not correlate. In particular, homogeneous and constant expression of the basal differentiation markers CK 5 and CK 14 were found in both specimen, with no expression of the simple epithelium type keratin CK 8 and the suprabasal differentiation markers CK 1 and CK 10. CK 19 showed variable expression in basal cell carcinoma, with constant expression in the outer root sheath and the follicular bulge regions, but was always absent in interfollicular epidermal keratinocytes. In addition, the lectin binding profiles of basal cell carcinoma and the outer root sheath in the suprabulbar region of human VHF were comparable, with the presence of binding sites for PNA, Con A and WGA. These findings provide evidence for a histochemical relationship between basal cell carcinoma and the follicular epithelium of VHF which is closer than that with the epidermis, and suggest its possible origin from or possibly its differentiation pattern towards the cells of the outer root sheath and/or the follicular bulge region of the VHF.

[Kaposiform HHV-8 negative acroangiodermatitis in chronic venous insufficiency]

A 76-year-old female patient developed severe manifestations of a kaposi-like acroangiodermatitis (so-called Mali's disease) due to chronic venous insufficiency of the lower extremities. The patient presented with large areas of confluent, violaceous or brown-black papules on both lower legs. Histologically, proliferation of thick-walled capillaries was seen in the upper dermis consisting of fully differentiated endothelial cells, as shown by immunohistochemistry. In contrast to true Kaposi's sarcoma, human-herpes-virus-8 DNA could not be detected by polymerase-chain-reaction in this condition. We review the diagnostic criteria used to distinguish between acroangiodermatitis, also called pseudo-Kaposi's sarcoma, and the true Kaposi's sarcoma.

Occupational contact dermatitis due to 2-chloracetophenone tear gas

2-Chloracetophenone (CN) is widely used as tear gas by police and civilians for self-defence. It may affect the eyes, respiratory system and skin, sometimes causing serious injuries. Both irritative and allergic contact dermatitis have been described. We report three police officers who experienced accidental escape of CN from their professional tear gas canisters. All of them showed localized dermatitis at the site of contact to CN, while widespread lesions appeared after 4 days in one case. Patch tests with the original involved tear gas dissolved in acetone (at 0.1-0.0001%) indicated an allergic reaction in two patients and an irritative reaction in the third. Occupational contact dermatitis due to CN seems to occur among police officers more often than is generally known. Infrequently, extensive health problems may be caused by CN when lesions spread over the integument. Therefore, an improvement of safety measures in occupational CN gas use is needed, especially aiming at avoidance of accidental leakage of canisters.

[Acquired reactive perforating dermatosis. Successful treatment with allopurinol in 2 cases]

Perforating disorders represent a heterogenous group of dermatoses characterized by transepithelial elimination of dermal structures. Primary perforating disorders should be distinguished from secondary perforating disorders in which perforation with transepithelial elimination is a rare component of a variety of dermatoses. The primary perforating disorders are hyperkeratosis follicularis et parafollicularis in cutem penetrans (Kyrle's disease), elastosis perforans serpiginosa and perforating folliculitis. Acquired reactive perforating dermatosis (also known as acquired reactive perforating collagenosis) together with the hereditary variant of the reactive perforating collagenosis represent further examples of the primary perforating disorders. We report on 84 year old and 96 year old female patients with an acquired perforating dermatosis. Both of the patients additionally showed diabetes and hyperuricemia. Oral administration of allopurinol (100 mg daily) led to a healing of the disseminated skin lesions in 1-2 weeks. After a follow-up period of 6 months, both patients were in complete remission. On one hand, these results prove again the existence and the severity of this disease, and on the other hand suggest an immunomodulating or differentiation-promoting action in addition to the uricostatic effect of allopurinol.