Cytokines and anticytokines in psoriasis

Associations between cardiovascular risk factors and psoriasis in Iran

Background

Psoriasis is a common chronic inflammatory skin disease. There is overwhelming evidence on the higher risk of cardiovascular diseases in patients with psoriasis as a result of hyperlipidemia, which is more common in these patients.

Objectives

The aim of this study was to elucidate the association between the cardiovascular risk factors and psoriasis.

Methods

In a cross-sectional study, 55 patients with psoriasis and 55 matched (sex and age) controls were entered the study at the Department of Dermatology between March 2011 and March 2013. Blood samples were obtained following 14 hours fasting status and serum levels of triglyceride, cholesterol, high-density lipoprotein, and low-density lipoprotein were determined using standard laboratory methods, and other variables such as sex, age, smoking, alcohol consumption, and the type of disease were recorded.

Results

Our findings showed that levels of triglyceride, low-density lipoprotein, and smoking were significantly higher in psoriatic patients when compared with controls, whereas the level of high-density lipoprotein and cholesterol was not significantly different between two groups. Body mass index of psoriatic patients was not significantly higher than controls. Patients with psoriasis also had an increased prevalence of hypertension.

Conclusion

Our findings further verify lipid abnormalities in psoriatic patients. Psoriasis is associated with higher rate of hypertension, which may be resulted in increasing the risk of cardiovascular diseases in these patients. Thus, serum lipid profile and blood pressure in all patients with psoriasis, regardless of disease severity, deserve consideration to be checked.

Influence of psoriasis on circulatory system function assessed in echocardiography

Psoriasis vulgaris is a chronic disease with a multifactorial pathogenesis. It affects about 2–4 % of the population all over the world. In course of psoriatic arthritis, joints’ damages are observed. In patients with psoriasis vulgaris and psoriatic arthritis, there is increased morbidity and mortality caused by cardiovascular diseases observed. The aim of the study is to analyze the echocardiography of patients with psoriasis vulgaris and psoriatic arthritis on the basis of the literature available in PubMed database. Abnormalities found in echocardiography of patients with psoriasis include valvular defects (40.7 % of the patients), left ventricle diastolic dysfunction (27.8 %), and left ventricle hypertrophy (11.1 %). Left ventricle’s systolic disorders, increased aorta stiffness index and increased pulmonary artery blood pressure were also observed in this group of patients.

Leukocyte-derived koebnerisin (S100A15) and psoriasin (S100A7) are systemic mediators of inflammation in psoriasis

BACKGROUND

Psoriasis is a systemic immune-mediated chronic inflammatory disease. In the skin, the antimicrobial proteins koebnerisin (S100A15) and psoriasin (S100A7) are overexpressed in the epidermis of psoriatic lesions and mediate inflammation as chemoattractants for immune cells. Their role for systemic inflammation in circulating leukocytes is unknown.

OBJECTIVE

The aim of the study was to identify circulating leukocyte populations as a source of koebnerisin and psoriasin. Further, immune-stimulatory effects of these S100A proteins on circulating leukocytes were evaluated and their role as therapeutic response markers in patients with psoriasis was analyzed upon UVB treatment.

METHODS

The expression and production of koebnerisin and psoriasin by leukocytes were assessed by quantitative real-time PCR (qRT-PCR) and immunoblotting. The S100A protein mediated regulation of proinflammatory cytokines by peripheral blood mononuclear cells (PBMCs) was measured with qRT-PCR and cytometric bead assay.

RESULTS

We identified circulating leukocytes as novel sources of koebnerisin (S100A15) and psoriasin (S100A7). Circulating leukocytes (PBMCs) of patients with psoriasis produced increased levels of koebnerisin and psoriasin compared to healthy individuals. Both S100A proteins further acted as 'alarmins' on PBMC to induce proinflammatory cytokines implicated in the pathogenesis of psoriasis, such as IL-1β, TNF-α, IL-6 and IL-8. Koebnerisin levels were suppressed in PBMC of psoriatic patients when effectively treated with narrow-band UVB.

CONCLUSIONS

Data suggest that koebnerisin and psoriasin are systemic pro-inflammatory mediators and koebnerisin acts as a therapeutic response marker in psoriasis.

Mean platelet volume is elevated in patients with psoriasis vulgaris

PURPOSE

This retrospective study was done to investigate the mean platelet volume (MPV) level in patients with psoriasis vulgaris and its relationship with disease severity.

MATERIALS AND METHODS

We undertook a cross-sectional study on 176 patients and 101 healthy controls to examine the association between MPV and psoriasis. Various clinical and laboratory parameters were analyzed and compared.

RESULTS

Platelet distribution width and MPV were significantly higher in patients with psoriasis than controls. In addition, there was positive correlation between Psoriasis Area Severity Index (PASI) and MPV. When psoriasis patients were grouped into mild psoriasis (PASI<10) and moderate to severe psoriasis (PASI≥10), the MPV of the latter group was significantly elevated. Nevertheless, patients with higher MPV level (MPV≥10.4 fL) did not show higher PASI than lower MPV level (MPV<10.4 fL). MPV levels significantly decreased after improvements of psoriasis with various treatments. The variations of MPV and PASI also showed significant correlation.

CONCLUSION

We have shown that MPV is increased in psoriasis patients and correlates with disease severity. Therefore, MPV levels may be considered as a marker of disease severity of psoriasis.

Non-alcoholic fatty liver disease and psoriasis: So far, so near

Psoriasis is a chronic inflammatory immune-mediated skin diseases which is frequently associated to comorbidities. Non-alcoholic fatty liver disease (NAFLD) is defined as an excessive accumulation of triglycerides in hepatocytes and includes a wide spectrum of liver conditions ranging from relatively benign steatosis to non-alcoholic steatohepatitis with fatty infiltration and lobular inflammation and to cirrhosis and end-stage liver disease. Actually, psoriasis is considered a systemic diseases associated to comorbidities, as metabolic syndrome and NAFLD is seen the hepatic manifestation of the metabolic syndrome. The possible link between psoriasis, obesity and metabolic syndrome, which are known risk factors for NAFLD has been recently documented focusing in the crucial role of the adipose tissue in the development of the inflammatory background sharing by the above entities. According to recent data, patients with psoriasis show a greater prevalence of NAFLD and metabolic syndrome than the general population. Moreover, patients with NAFLD and psoriasis are at higher risk of severe liver fibrosis than those with NAFLD and without psoriasis. The link between these pathological conditions appears to be a chronic low-grade inflammatory status. The aim of this review is to focus on the multiple aspects linking NAFLD and psoriasis, only apparently far diseases.

Red blood cell distribution width is increased in patients with psoriasis vulgaris: A retrospective study on 261 patients

Circulating inflammatory cytokines and markers are increased in patients with psoriasis. Recent studies have shown that a higher red blood cell distribution width (RDW) is associated with disease activity in various disorders. Our objective was to investigate whether RDW is increased in psoriasis patients, and to evaluate its possible association with disease severity. We conducted a retrospective study of psoriasis patients seen in a university hospital in South Korea. Information about demographics, hematological parameters and disease severity were collected. Statistical analysis was performed using Student's t-test, multivariable logistic regression, Fisher's exact test and Spearman's rank correlation coefficient analysis as appropriate. A total of 261 psoriasis patients and 102 healthy controls were included in our study. The mean RDW value was significantly increased in psoriasis patients compared with healthy control (P = 0.037). Compared with mild psoriasis patients (Psoriasis Area and Severity Index [PASI], <7), moderate to severe patients (PASI, ≥7) showed significantly higher RDW values (P = 0.044). However, RDW did not show significant correlation with PASI (P = 0.358). When patients were divided into two groups according to their RDW value (<14.6% and ≥14.6%), the mean value of PASI was not significantly different (P = 0.219). Patients with psoriasis showed increased RDW values compared with healthy controls. It was also higher in the moderate and severe disease group than the mild group. Though this is only a pilot study, it is possible that RDW value can reflect the inflammatory status of psoriasis patients.

Psoriasis and dyslipidemia

INTRODUCTION

Psoriasis is a chronic skin ailment, which can be connected with other ailments including dyslipidemia.

EXAMINEES AND METHODS

Research included 70 patients affected by psoriasis. Both genders, above 18 years of age. Average age of the respondents was 47.14 (SD= ±15.41), which consisted of 36 men (51.43%) and 34 women (48.57%). The average duration of psoriasis was 15.52 (SD= ±12.54) years.

RESULTS

Frequency of dyslipidemia on those affected by psoriasis was 62.85%. Most often it was hypertriglyceridemia (39%) and hypertriglyceridemia with a lowered value of HDL (36%), average age of those affected by psoriasis with dyslipidemia was 48.76 years (SD= ±14.72), and the average duration of the basic disease was 16.15 years (SD= ±12.63), the average values of the PASI score were 16.65. Increase in values of PASI score and dyslipidemia were statistically significantly connected (r=0.41; p=0.0001).

CONCLUSION

Psoriasis is connected with dyslipidemia.

Hepcidin expression in psoriasis patients

Background:

Iron is an essential nutrient for mammals. Accelerated loss of nutrients through hyperproliferation and desquamation from the skin in psoriasis is known. Hepcidin is an important and recently discovered regulator of iron homeostasis.

Aims and Objectives:

The present study was undertaken to investigate the hepcidin expression in psoriasis patients.

Materials and Methods:

We examined peripheral blood cell counts, serum Fe, ferritin, interleukin-6 (IL-6) and hepcidin levels using respectively automated hematology analyzer, Iron assay on the AEROSET system, chemiluminescent microparticle immunoassay with automated analyzer, and enzyme-linked immunosorbent assay.

Results:

The independent comparison of Fe, ferritin, IL-6 and hepcidin levels in psoriasis patients and control group (healthy volunteers) revealed lower Fe and higher IL-6, hepcidin levels in psoriasis patients. No significant difference was seen in the ferritin level between the psoriasis and the control group.

Conclusions:

We think that studies on hepcidin expression in psoriatic plaques will contribute to our understanding the role of iron and hepcidin in the pathogenesis of psoriasis.

Serum levels of LL-37 and inflammatory cytokines in plaque and guttate psoriasis

Psoriasis is a chronic inflammatory skin disease. It is assumed that the plaque phenotype of psoriasis is associated with T helper (Th) 1 immune response activation, while the guttate phenotype is associated with the Th17 immune response. Previous investigations of differences in the serum levels of cytokines relative to the clinical psoriatic phenotype have yielded conflicting results. This study compared the levels of circulating inflammatory cytokines and LL-37 relative to the morphological phenotype in patients with psoriasis. Seventy-four age-matched patients with psoriasis (32 with guttate psoriasis and 42 with plaque psoriasis) and 12 healthy controls were included. A multiplex cytokine assay and enzyme-linked immunosorbent assay were used to measure levels of Th1- and Th17-derived cytokines and LL-37, respectively. Circulating levels of interferon- (IFN)-γ, interleukin- (IL)-1RA, IL-2, and IL-23, and LL-37 were significantly higher in patients with psoriasis than in healthy controls. However, the serum levels of inflammatory cytokines (IL-7, IL-22, and IL-23) and LL-37 did not differ significantly between the guttate and plaque phenotypes of psoriasis. There was a positive correlation between serum inflammatory cytokine levels and the Psoriasis Area and Severity Index score. The findings of this study suggest that the serum levels of inflammatory cytokines reflect the disease activity rather than determine the morphological phenotype.

Brodalumab: an evidence-based review of its potential in the treatment of moderate-to-severe psoriasis

Advances in knowledge regarding the pathogenesis of psoriasis have allowed the development of a new class of agents known as biologic drugs. Data confirm that T helper (Th)17 and interleukin (IL)-17 signaling has a crucial role in the pathogenesis of the disease. High levels of IL-17 and Th17-related cytokines have been reported in psoriasis, leading to the suggestion of agents targeting IL-17 as a potential therapeutic strategy in psoriasis. Brodalumab is a human monoclonal antibody that targets IL-17 receptor A, blocking the effects of IL-17A, IL-17F, and IL-17E. Data from Phase I and Phase II clinical trials indicate that brodalumab has a favorable safety and tolerability profile, with strong clinical activity, suggesting that it is a potential tool for use in the treatment of moderate-to-severe psoriasis.

Biological products for the treatment of psoriasis: therapeutic targets, pharmacodynamics and disease-drug-drug interaction implications

Psoriasis is a chronic inflammatory skin disease condition that involves altered expression of a broad spectrum of proinflammatory cytokines which are associated with activation of T cells and proliferation of keratinocytes. Currently approved biological products for psoriasis treatment fall into two main classes: cytokine modulators and biologics targeting T cells. In psoriatic patients, elevated levels of proinflammatory cytokines are observed. Elevated proinflammatory cytokines can suppress some cytochrome P450 (CYP) enzymes, and the treatment of psoriasis with biological products can reduce proinflammatory cytokine levels. Therefore, the exposure of CYP substrate drugs is anticipated to be affected by the psoriasis disease resulting in a higher exposure than in healthy state (named disease-drug interaction) as well as by the biological treatments due to disease improvements resulting in a decrease in exposure (named disease-drug-drug interaction, disease-DDI). However, the quantitative impact on CYP substrate exposure due to disease or due to treatment with biological products remains to be evaluated. The objective of the current review is to provide an overview of the therapeutic targets and cytokine-related pharmacodynamic effects of biological products in psoriasis treatment with a particular focus on their implications for disease-DDI. The clinical study design considerations for psoriasis disease-DDI evaluation are also discussed.

Rationale and early clinical data on IL-17 blockade in psoriasis

Psoriasis vulgaris is a chronic, immune-mediated, inflammatory disease that affects between 2 and 3% of the US population. Often severely physically and emotionally debilitating, psoriasis has driven investigators to strive to better characterize its complex immune pathogenesis. Some of the most promising and exciting advances have occurred in the last decade with recognition of the IL-23/Th17 pathway in disease initiation, progression and maintenance. Biologic therapies targeting various points in the pathway have met with success, prompting the study of the safety and efficacy of IL-17 blockade for moderate-to-severe plaque psoriasis. This article will review the rationale and early clinical data on IL-17 blockade in psoriasis.

Markers of systemic inflammation in psoriasis: a systematic review and meta-analysis

Studies investigating systemic inflammation in psoriasis use different serum markers and report discrepant results. We set out to determine whether systemic inflammation is elevated in patients with psoriasis compared with healthy controls, and to measure the extent of this elevation, by summarizing available data on serum inflammatory markers. PubMed, Embase and Web of Science were searched from inception to March 2011. We included studies comparing the serum inflammatory markers interleukin (IL)-1β, IL-6, IL-10, C-reactive protein (CRP), intracellular adhesion molecule (ICAM)-1, E-selectin and tumour necrosis factor (TNF)-α in patients with psoriasis and healthy controls. Differences in serum marker levels between patients and controls were pooled as standardized mean differences (SMDs; Cohen's d) using a random-effects model. Seventy-eight studies were eligible. Of the 7852 individuals included, 3085 had (severe plaque) psoriasis. The pooled SMDs were higher in patients with psoriasis than in healthy controls for IL-6 [d = 1·32, 95% confidence interval (CI) 0·83-1·81], CRP (d = 1·83, 95% CI 0·76-2·90), TNF-α (d = 1·32, 95% CI 0·86-1·79), E-selectin (d = 1·78, 95% CI 1·32-2·25) and ICAM-1 (d = 1·77, 95% CI 1·15-2·39). The SMD between cases and controls for IL-1β and IL-10 was not significant. Age had a significant effect on the SMD for IL-6 and TNF-α. For IL-6 the effect size was higher for plaque psoriasis studies (d = 1·98). The effect size was not influenced by the Psoriasis Area and Severity Index, measurement method or quality assessment. The pooled analyses suggest modest but significantly elevated levels of the proinflammatory cytokines in the serum of patients with psoriasis with predominantly severe disease. To what extent this modest increment is clinically relevant could be investigated in a synthesis of all studies measuring inflammation before and after antipsoriatic therapy.

Association of disease severity with IL-1 levels in methotrexate-treated psoriasis patients

Interleukin-1 plays a key role in inflammation and keratinocyte activation. It is an important mediator in the initiation and maintenance of psoriatic plaques and may represent an attractive therapeutic target. The aim of this study is to evaluate the effect of Methotrexate (MTX) on IL-1 α and IL-1 β levels in both plasma and skin biopsy of patients with psoriasis and to investigate their association with clinical disease activity. Forty-five control subjects and 58 patients with psoriasis were recruited for this study. The patients were treated with 7.5 mg of MTX per week for 12 weeks. Folic acid was given at 5 mg once daily except on the day of MTX for 12 weeks. Blood samples and lesional skin biopsy were taken. Disease severity was assessed by Psoriasis Area Severity Index (PASI) score. IL-1 levels in plasma and skin biopsy were analysed using ELISA. PASI score declined significantly (P < 0.001) from day 0 to 12 weeks of MTX treatment. IL-1 α level in plasma and skin biopsy was reduced at day 0 sample and elevated significantly (P < 0.001) after MTX treatment. IL-1β level in plasma and skin biopsy was higher at day 0 sample and reduced significantly (P < 0.001) after MTX treatment. IL-1α levels and PASI score showed inverse correlation score before and after treatment with MTX. Whereas IL-1β levels showed positive correlation before and after treatment with MTX. Decreasing IL-1β levels by MTXs in psoriasis may block the Th17 differentiation. This shows the therapeutic effect of MTX in controlling the immunopathogenesis of psoriasis.

Effects of zinc on interleukins and antioxidant enzyme values in psoriasis-induced mice

The effects of zinc chloride (ZnCl2), disodium zinc ethylenediamine tetraacetate (Zn-EDTA), and zinc gluconate (Zn-GLU) on the antioxidant enzyme activities and levels of interleukins (ILs) in psoriasis-induced mice were studied. One hundred twenty female mice were randomly divided into six groups with 20 mice in each group: the control, positive control (PC), methotrexate (MTX), ZnCl2, Zn-EDTA, and Zn-GLU groups. All animals except the control group were given diethylstilbestrol for three consecutive days. After successfully inducing psoriasis, the control and PC groups were given normal saline (i.g.) daily while the remaining groups were given MTX, ZnCl2, Zn-EDTA, and Zn-GLU, respectively. The results revealed that the zinc supplementation could significantly (p < 0.05) inhibit mitosis in the mouse vaginal epithelium as methotrexate did and the inhibiting efficacy had nothing to do with the zinc forms. After ZnCl2, Zn-EDTA, and Zn-GLU supplementation, the levels of liver superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), and catalase (CAT) activities increased and the concentration of malondialdehyde (MDA) decreased significantly (p < 0.05) compared to the PC group. The levels of SOD, CAT activity, and MDA level between each zinc supplementation group and MTX group were insignificant (p > 0.05). The zinc treatments also caused a significant (p < 0.05) decrease in the raised IL-2 level of animal serum. The results obtained in the present work indicate the potential for zinc as a complementary pharmaceutical intervention for the treatment of topical psoriasis.

Serum levels of selected Th17 and Th22 cytokines in psoriatic patients

INTRODUCTION

Psoriasis is a T cell-mediated inflammatory disease in which pathogenesis T helper (Th) lymphocytes (Th1, Th17, and Th22) play an important role. The aim of the study was to assess the serum levels of some cytokines involved in the Th17 and Th22 responses in psoriatic patients.

MATERIAL AND METHODS

The study comprised 60 psoriatic patients and 30 healthy controls. In the serum collected from psoriatic patients and healthy controls, the concentrations of IL-6, IL-12, IL-17, IL-20, IL-22, and IL-23 were examined with ELISA kits. Severity of psoriatic skin lesions was assessed by means of PASI, BSA, and PGA scores.

RESULTS

IL-6, IL-20, and IL-22 concentrations were significantly higher in psoriatic patients in comparison with the control group. The positive correlations between the concentrations of IL-22 and IL-20 and severity of psoriasis assessed with PASI and BSA scores as well as IL-17 and PASI score were found. There was also a positive correlation between IL-23 and IL-17 concentrations.

CONCLUSIONS

Results of the conducted studies suggest that Th22 response may contribute to the skin and systemic inflammatory disease in psoriasis. It seems that early identification of soluble biomarkers and initiation of well-matched treatment may prevent exacerbation and progression of psoriasis.

NF-κB and STAT3 inhibition as a therapeutic strategy in psoriasis: in vitro and in vivo effects of BTH

Benzo[b]thiophen-2-yl-3-bromo-5-hydroxy-5H-furan-2-one (BTH) is a simple and interesting synthetic derivative of petrosaspongiolide M, a natural compound isolated from a sea sponge with demonstrated potent anti-inflammatory activity through inhibition of the NF-κB signaling pathway. In the present study, we report the in vitro and in vivo pharmacological effect of BTH on some parameters related to the innate and adaptive response in the pathogenesis of psoriasis. BTH inhibited the release of some of the key psoriatic cytokines such as tumor necrosis factor α, IL-8, IL-6, and CCL27 through the downregulation of NF-κB in normal human keratinocytes. Moreover, it impaired signal transducers and activators of transcription 3 (STAT3) phosphorylation and translocation to the nucleus, which resulted in decreased keratinocyte proliferation. These results were confirmed in vivo in two murine models of psoriasis: the epidermal hyperplasia induced by 12-O-tetradecanoylphorbol-13-acetate and the imiquimod-induced skin inflammation model. In both cases, topical administration of BTH prevented skin infiltration and hyperplasia through suppression of NF-κB and STAT3 phosphorylation. Our results confirm the pivotal role of both transcriptional factors in skin inflammation, as occurs in psoriasis, and highlight the potential of small molecules as therapeutic agents for the treatment of this skin disease, with BTH being a potential candidate for future drug research.

Risk of cardiovascular disorders in psoriasis patients: current and future

Psoriasis is an inflammatory autoimmune disease that affects the skin. Recently, psoriasis and its consequential lifestyle and dietary habits have been associated with increased risks for cardiovascular diseases. This article discusses the connection between cardiovascular disorders and psoriasis and the effects of available treatment options on cardiovascular risk. A PubMed search revealed 11 articles that were analyzed for information regarding this association, its effects, and potential courses of treatment. Both the presence and severity of psoriasis increases the risk for cardiovascular disorders and co-morbidities. Forty percent of psoriasis patients met metabolic syndrome criteria as compared with 23 % of non-psoriasis control subjects. Rate ratios for atrial fibrillation are correlated with the severity of psoriasis; patients with severe and mild psoriasis produced rate ratios of 1.63 and 1.31, respectively. Studies also show an increase in the risks for myocardial infarction, atherosclerosis, ischemic stroke, and other cardiovascular disorders. The exact mechanisms behind this affiliation are still uncertain; however, the psychological and physiological effects of psoriasis and the overlapping pathogenesis behind atherosclerosis and psoriasis may play a role. Since the risk for cardiovascular disorders increases with the presence and severity of psoriasis, psoriasis treatment should not only address the disease and its symptoms, but also its co-morbidities. Recent National Psoriasis Foundation (NPF) guidelines have provided recommendations for psoriasis patient care. Histories of co-morbidities, screenings for potential diseases, increased exercise, decreased alcohol consumption, and smoking cessation should be implemented. Unfortunately, while there are data for the increased risk for cardiovascular diseases within psoriasis patients, there are presently no data stating that increasing cardiovascular screening rates in patients produces a significant difference.

Comparative transcriptomic analyses of atopic dermatitis and psoriasis reveal shared neutrophilic inflammation

BACKGROUND

Atopic dermatitis (AD) and psoriasis are common inflammatory diseases canonically described as involving distinct T(H) polarization and granulocytic infiltration. Acute AD lesions are associated with T(H)2 and eosinophilic inflammation, whereas psoriatic lesions are associated with T(H)1/T(H)17 and neutrophilic inflammation. Despite intensive investigation, these pathways remain incompletely understood in vivo in human subjects.

OBJECTIVE

Using AD and psoriatic lesional skin as exemplar T(H)2 and T(H)1/T(H)17 diseased tissue, we sought to clarify common and unique molecular and pathophysiologic features in inflamed skin with different types of inflammatory polarization.

METHODS

We conducted gene expression microarray analyses to identify distinct and commonly dysregulated expression in AD (based on Hanifin and Rajka criteria) and psoriatic lesions. We defined gene sets (GSs) as comprising genes encoding cytokines, chemokines, and growth factors that were uniquely or jointly dysregulated in patients with AD and those with psoriasis and calculated aggregate GS expression scores for lesional skin of patients with these dermatoses and healthy control skin.

RESULTS

The atopic dermatitis gene set (AD-GS) score correlated with systemic and local measures of allergic inflammation, including serum IgE levels, blood eosinophil counts, and tissue eosinophil counts. Unexpectedly, genes encoding neutrophil chemoattractants among the common GS were highly expressed in AD lesional skin. Hematoxylin and eosin and immunohistochemical analyses showed the numbers of neutrophils in AD lesional skin were comparable with those in psoriatic lesional skin, and both were correlated with the extent of expression of neutrophil chemoattractant genes.

CONCLUSION

These data are evidence that neutrophilic inflammation is a feature of lesional AD pathology comorbid with allergic inflammation.

Comparative study of systemic inflammatory responses in psoriasis vulgaris and mild to moderate allergic contact dermatitis

BACKGROUND

Psoriasis vulgaris (PV) is associated with low-grade systemic inflammation.

OBJECTIVE

Cytokines' and growth factors' serum patterns in patients with PV, allergic contact dermatitis (ACD) and healthy subjects were investigated to describe and compare systemic inflammatory responses in these diseases.

METHODS

A total of 12 inflammation-sensitive biomarkers were analyzed simultaneously by means of the Evidence Investigator™ biochip technology.

RESULTS

In PV, proinflammatory tumor necrosis factor (TNF)-α, interferon (IFN)-γ, interleukins (IL)-1β, -2, -6, -8, and monocyte chemoattractant protein (MCP)-1 were elevated. In ACD, 2 markers, TNF-α and MCP-1, were increased, and regulatory cytokine IL-10 was decreased. Proinflammatory IL-2 had the strongest correlations with other pro- as well as anti-inflammatory cytokines in PV and ACD, whilst IL-6 correlated positively with the Psoriasis Area and Severity Index. Growth factors' levels correlated with MCP-1, but only in PV.

CONCLUSION

Although psoriasis induces a more variegated proinflammatory systemic response, ACD is likewise associated with a systemic increase in inflammatory mediators.

The roles of cells and cytokines in the pathogenesis of psoriasis

Psoriasis is considered an immune chronic disease in which T cells are accepted as important. Nowadays, it is believed that psoriasis is most likely a T helper (Th)1/Th17 induced inflammatory disease. However, some other cells, such as endothelial cells, dendritic cells, monocytic cells, neutrophils, keratinocytes, and several cytokines, appear to have, at different stages of the disease, an important role in its pathogenesis. For instance, the response to psoriasis therapy is dependent not only on the inactivation of Th1 and Th17 immune responses but also on the inactivation of dendritic cell products. Moreover, interleukin (IL)-23 deregulation appears to be an independent factor in the pathogenesis of psoriasis. Indeed, currently, the IL-23/Th17 axis is believed to be crucial in psoriasis pathogenesis, and its inhibition appears to be important for therapeutic achievement. This review presents the roles and interactions of cells and cytokines that are related to psoriasis pathogenesis.

Serum interleukin-6 levels in response to methotrexate treatment in psoriatic patients

BACKGROUND

Psoriasis is a chronic autoimmune hyperproliferative skin disease. In psoriasis, the cutaneous and systemic overexpression of various proinflammatory cytokines, such as interleukin-6 (IL-6) has been demonstrated. Methotrexate (MTX) has been used in the treatment of psoriasis. The aim of this study is to assess the effect of MTX on serum IL-6 levels and also to find the association between PASI score and IL-6 levels in psoriatic patients during MTX therapy.

METHODS

We recruited 20 control subjects and 22 Psoriasis vulgaris patients for this study. The patients were treated with 7.5mg of methotrexate per week for 12 weeks. Folic acid was given at 5mg once daily except on the day of MTX for 12 weeks. There were 2 dropouts, because of increased liver enzyme levels. Blood samples were collected at three intervals (i.e., Day 0, 6 weeks, 12 weeks) from psoriatic patients and only once from control subjects. PASI score, biochemical and hematological parameters were assessed. Serum IL-6 level was analyzed by using ELISA.

RESULTS

Biochemical and hematological parameters showed no significant changes. Serum IL-6 level and PASI score declined significantly (p<0.001) from Day 0 to 12 weeks of MTX treatment and also showed positive correlation before (r=0.992; p<0.000) and after (r=0.987; p<0.000) treatment with MTX. Out of 4 clinical indices of PASI, only 2 indices namely Infiltration (I) and Desquamation (D) showed positive correlation with IL-6 before and after MTX treatment.

CONCLUSION

The treatment response with MTX in psoriatic patients can be seen both at clinical and molecular levels.

Psoriasis, a model of dermatologic psychosomatic disease: psychiatric implications and treatments

Psoriasis is a common dermatologic disorder with psychiatric comorbidity that often goes undetected and untreated. Psoriasis has higher associations with psychiatric illness than do other dermatologic conditions. We conducted a comprehensive qualitative review of all published medical literature on psoriasis and psychiatric comorbidities since 2005. We found that psoriasis patients suffer psychiatric and psychosocial morbidity that is not commensurate with the extent of cutaneous lesions. Biologic therapies and nonpharmacologic psychosocial interventions show promise in treating comorbid psychiatric illness. The main limitations of this review are the low quality of published studies and the infrequent use of basic science endpoints in reporting treatment outcomes. The literature examining the psychiatric comorbidity of psoriasis is expanding but remains of variable quality. Stronger studies will be necessary to more accurately estimate comorbidities and help identify and comprehensively treat suffering patients.

Extended DNFB-induced contact hypersensitivity models display characteristics of chronic inflammatory dermatoses

Despite recent developments, there is a high medical need for new treatment options for chronic inflammatory dermatoses like allergic contact dermatitis (ACD) and psoriasis. Particularly, more predictive skin inflammation models are required to facilitate the process of drug discovery. Murine contact hypersensitivity (CHS) models adequately reflect ACD and are also used to characterize therapeutic approaches for psoriasis. Using the hapten 2,4-dinitrofluorobenzene (DNFB), we established new subacute and subchronic DNFB-induced CHS models in C57BL/6 mice, which more closely reflect the characteristics of chronic T-cell-dependent inflammatory dermatoses as pronounced keratinocyte proliferation, strong hypervascularization, immune cell infiltration and overexpression of T cell and inflammatory cytokines. For the subacute DNFB model, we demonstrated anti-inflammatory activity of the glucocorticoid, prednisolone, as well as of neutralization of TNFα, IL-12/IL-23 or IL-18. In the subchronic DNFB-induced CHS model, deficiency for MyD88 and IL-12/IL-35 p35 chain but not IL-12/IL-23 p40 chain led to decreased skin inflammation. Furthermore, as exemplified by the dose-dependently effective therapeutic prednisolone treatment, the subchronic model allows the continuous therapy of a pre-established stable contact dermatitis. Altogether, prolonged DNFB-induced mouse CHS models closely reflect ACD sensitive to glucocorticoids as standard therapy, reveal a more chronic skin inflammation and are responsive to cytokine antagonization.

The effect of systemic psoriasis therapies on the incidence of myocardial infarction: a cohort study

BACKGROUND

Psoriasis confers an independent risk of cardiovascular disease that is likely to be related to systemic inflammation. Anti-inflammatory treatment could theoretically reduce the risk of cardiovascular disease, and initial data suggest that treatment may reduce the incidence of cardiovascular risk factors.

OBJECTIVES

To determine the impact of anti-inflammatory therapy on the risk of acute myocardial infarction (MI) in patients with moderate-to-severe psoriasis.

METHODS

Cohort study using administrative and pharmacy claims data from a large U.S. insurer comparing patients with psoriasis aged ≥ 18 years receiving systemic immunomodulatory therapies (methotrexate, ciclosporin, alefacept, efalizumab, adalimumab, etancercept and infliximab) with a control group treated with ultraviolet B phototherapy that has limited systemic anti-inflammatory effects. The risk of acute MI was calculated using a proportional hazards model while controlling for sex, age, hypertension, hyperlipidaemia, diabetes and depression. Significant interaction terms were included in the final model.

RESULTS

The study group included 25,554 patients with psoriasis receiving systemic treatment or phototherapy. There was a trend towards an increased risk of MI in the systemic treatment group but not a significant difference in overall MI risk [hazard ratio (HR) 1·33, 95% confidence interval (CI) 0·90-1·96]. Additionally, there was a significant interaction with age: in patients under 50 years the HR for MI if receiving systemic therapy was 0·65 (95% CI 0·32-1·34), and in patients aged 50-70 years it was 1·37 (95% CI 0·79-2·38).

CONCLUSIONS

Overall, there does not appear to be a reduced risk of MI in patients with psoriasis receiving systemic therapy compared with a group undergoing phototherapy. The risk of MI may vary by age.

Dopamine agonists upregulate IL-6 and IL-8 production in human keratinocytes

AIM

Catecholamines regulate functions of the nervous, neuroendocrine and immune systems. Dopamine may modulate the activity of keratinocytes, which play a role in secreting cytokines and chemokines. The aim of this study was to evaluate the effect of dopaminergic agonists on the production of IL-6 and IL-8 by a non-tumoral human keratinocyte cell line (HaCaT).

METHODS

Cells were stimulated with dopamine and the D(2) dopamine receptor agonist cabergoline. Levels of IL-6 and IL-8 in culture supernatants were then determined. Cell proliferation was also assessed. Assays were carried out in the presence or absence of the dopaminergic and β-adrenergic receptor antagonists (sulpiride and propranolol, respectively) and ascorbic acid.

RESULTS

Dopamine stimulated the production of IL-6 and IL-8 in a concentration-dependent manner. The effects observed on the secretion of IL-6 were more potent than those corresponding to IL-8 and were reduced by ascorbic acid. The dopamine-induced IL-6 secretion was partially reduced by sulpiride and abrogated by propranolol. The latter drug was able to block the effect of dopamine on the secretion of IL-8. The cabergoline-induced IL-6 release was reduced by sulpiride. Cell viability was not affected by any of the drugs.

CONCLUSIONS

Dopaminergic agonists can stimulate keratinocytes to produce IL-6 and IL-8 which are related to inflammatory cutaneous processes. These effects are mediated by dopaminergic and β-adrenergic receptors and by receptor-independent oxidative mechanisms.

Smoking and pathogenesis of psoriasis: a review of oxidative, inflammatory and genetic mechanisms

Recent studies suggest that cigarette smoking may trigger the development of psoriasis through oxidative, inflammatory and genetic mechanisms. Smoking initiates formation of free radicals that stimulate cell signalling pathways active in psoriasis including mitogen-activated protein kinase (MAPK), nuclear factor-κB (NF-κB) and Janus kinase/signal transducers and activators of transcription (JAK-STAT). Smoking damages the skin by increasing formation of reactive oxygen species and decreasing the gene expression of antioxidants. Nicotine also stimulates innate immune cells integral to the pathogenesis of psoriasis including dendritic cells, macrophages and keratinocytes. These cells release cytokines that activate T lymphocytes and perpetuate a cycle of chronic inflammation. Smoking also enhances expression of genes known to confer an increased risk of psoriasis, including HLA-Cw6, HLA-DQA1*0201 and CYP1A1. Improved understanding of the possible link between smoking and psoriasis pathogenesis may provide further insight into mechanisms underlying smoking, psoriasis and risk of subsequent cardiovascular disease.

NK cells and psoriasis

Psoriasis is a chronic condition of the skin characterised by distinctive scaly plaques. The immune system is now thought to play a major role in the development and pathogenesis of psoriasis with immune cells and cytokines influencing keratinocyte function. Keratinocytes in turn, can activate and recruit immune cells leading to a positive feedback loop in disease. Natural Killer (NK) cells are lymphocytes that are best known for killing virally infected and cancer cells. However, evidence is emerging to support a role for NK cells in psoriasis. NK cells are found in the inflammatory infiltrate in psoriatic skin lesions. They can produce a range of inflammatory cytokines, many of which are important in the pathogenesis of psoriasis. Recent genetic studies have identified a range of potential molecules relating to NK cell biology that are known to be important in psoriasis. This paper will discuss the evidence, both cellular and genetic, for NK cell involvement in psoriasis.

Mechanism of the biological effect of the tumor necrosis factor-аlpha at psoriasis

Among different cytokines, tumor necrosis factor-аlpha (tumor necrosis factor α, TNF-α) plays a special role in psoriatic immunopathogenesis. Data on this cytokine collected for the recent decades made it possible to create a number of biological drugs blocking TNF-α, which are successfully applied in clinical practice for treating medium to severe psoriasis and psoriatic arthritis. This review presents general information about the cytokine structure and its receptor apparatus, regulation mechanisms of TNF-α synthesis and ways of signal transmission as the basis needed to implement the biological effects of cytokine in the development of psoriatic skin affections.

Gene expression profiling in psoriatic scalp hair follicles: clobetasol propionate shampoo 0.05% normalizes psoriasis disease markers

BACKGROUND

Clobetasol propionate shampoo is effective and safe in treatment of scalp psoriasis (SP). Gene expression profiling of psoriatic skin biopsies led to the identification of numerous disease-related genes. However, it remained unknown whether the gene expression profile of hair follicles of SP patients was also affected.

OBJECTIVES

To determine whether psoriasis-related genes are differentially regulated in the hair follicles of SP patients and whether the modulation of these genes can be correlated with clinical severity scores.

METHODS

A single arm, open study was conducted in three centres. SP patients received daily treatment with clobetasol propionate shampoo. At Baseline, Weeks 2 and 4, investigators assessed clinical severity parameters and collected scalp hair follicles in anagen phase. Total RNA extracted from hair follicles was used to determine the expression level of 44 genes, which were reported previously to be upregulated in the skin of psoriasis patients.

RESULTS

RNA of good quality and sufficient quantity was obtained from hair follicles of psoriasis patients and healthy volunteers (HV). The expression level of 10 inflammation-related genes was significantly increased in psoriatic hair follicles. The patient's exploratory transcriptomic score, defined as the mean fold modulation of these 10 genes compared with HV, correlated with clinical severity scores. Clobetasol propionate shampoo was effective in decreasing both the exploratory transcriptomics and the clinical severity scores.

CONCLUSION

Hair follicles of SP patients are affected by the inflammatory process. The change in the expression level of inflammation-related genes correlates with the severity of the disease.

Neutrophil elastase promotes proliferation of HaCaT cell line and transwell psoriasis organ culture model

BACKGROUND

Neutrophil elastase (NE) plays an important role in psoriasis. In this study we observed the effect of NE on the proliferation of HaCaT cells and transwell psoriasis organ culture model and investigated the mechanism.

METHODS

HaCaT cells were treated with various concentrations NE (0, 0.1, 1, 10, 100 IU/l). In addition, the cells were co-stimulated with 10 IU/l NE and 1 g/l sivelestat. Then, HaCaT cells proliferation and DNA synthesis were determined using methyl thiazolyl tetrazolium (MTT) and tritiated thymidine (3H-TdR) assay respectively. Cell cycle distribution was measured using fluorescence activated cell sorting (FACS). Subsequently, we established cultured transwell psoriasis organ model in vitro. Then, the cultured transwell psoriasis organ model was treated with 10 IU/l NE. Immunohistochemistry was employed to detect the expression levels of Ki67 and p53 in the cultured transwell psoriasis organ model.

RESULTS

MTT and 3H-TdR incorporation assay suggested NE could remarkably promote the proliferation and DNA synthesis of HaCaT cell in a dose-dependent manner. After NE treatment (10 IU/l) for 24 h, the cell fraction of HaCaT cell in G2 + S phase was increased significantly, whereas the cell fraction in G1 phase was reduced remarkably. Immunohistochemistry results revealed enhanced expression of both Ki67 and p53 genes in cultured transwell psoriasis organ model after NE treatment.

CONCLUSIONS

NE significantly promotes the proliferation of HaCaT cell. Meanwhile, it also up-regulates the expression levels of Ki67 and p53 in psoriasis lesion tissue, which plays an important role in the pathogenesis of psoriasis lesion.

Elevation of serum epidermal growth factor and interleukin 1 receptor antagonist in active psoriasis vulgaris

BACKGROUND

Psoriatic plaques present a complex expression profile, including high levels of cytokines, chemokines and growth factors. Circulating cytokines have been suggested to reflect the activation status of the inflammatory process.

OBJECTIVES

To analyse 20 cytokines, chemokines and growth factors in 14 patients with psoriasis vulgaris at the start and during the course of ultraviolet B treatment.

METHODS

A multiplex cytokine assay was used.

RESULTS

We identified increased serum levels of epidermal growth factor (EGF) (mean 323 vs. 36·6 pg mL⁻¹, P = 0·0001), interleukin (IL)-1 receptor antagonist (mean 39·1 vs. 14·6 pg mL⁻¹, P = 0·02) and tumour necrosis factor-α (mean 7·5 vs. 4·5 pg mL⁻¹, P = 0·04) at baseline in patients with psoriasis compared with matched controls. None of these cytokines was correlated to the severity of the disease (Psoriasis Area and Severity Index) or decreased with phototherapy, suggesting that sources other than lesional skin contribute to the production of these cytokines. Using cluster analysis, we observed coordinate upregulation of EGF, IL-6, macrophage inflammatory protein-1ß and vascular endothelial growth factor.

CONCLUSIONS

The sustained high expression of inflammatory circulating cytokines is a potential mechanism linking psoriasis with its extracutaneous comorbidities.

Role of endothelial chemokines and their receptors during inflammation

Chemokines are a large group of small cytokines known for their chemotactic ability to regulate the recruitment of leukocytes to sites of inflammation. This occurs through the binding of chemokines to their receptors located on the leukocyte that results in cellular changes such as actin rearrangement and cell shape, which allow for the migration of the leukocyte. In addition to regulating leukocyte function, it is now becoming apparent that other nonhematopoetic cells, such as smooth muscle cells and endothelial cells, can also be regulated by chemokines. Studies within the past 10 years has demonstrated the presence of various chemokine receptors on endothelial cells as well as the ability of chemokines to activate these receptors resulting in various cellular responses including migration, proliferation, and cellular activation. The purpose of this review is to highlight the research that has been done to date demonstrating the important role for chemokines in regulating endothelial function during various inflammatory conditions associated with angiogenesis, homeostasis, and leukocyte transmigration. This review will focus specifically on the role of the endothelium in mediating chemokine effects associated with wound healing, atherosclerosis, and autoimmune diseases, conditions where leukocyte recruitment and angiogenesis play a major role. Recent progress in the development and implementation of therapeutics agents against these small molecules, or their receptors, will also be addressed.

Interleukin (IL)-22, IL-17, IL-23, IL-8, vascular endothelial growth factor and tumour necrosis factor-α levels in patients with psoriasis before, during and after psoralen-ultraviolet A and narrowband ultraviolet B therapy

BACKGROUND

Several cross-sectional studies have shown that different cytokines and growth factors are enhanced in psoriasis.

OBJECTIVES

We aimed to understand the role/relation of interleukin (IL)-22, IL-17, IL-23, IL-8, vascular endothelial growth factor (VEGF) and tumour necrosis factor (TNF)-α in psoriasis vulgaris, addressing their levels and changes before, during and after psoralen-ultraviolet A (PUVA) and narrowband ultraviolet B (NB-UVB) treatment.

METHODS

A cross-sectional and a longitudinal study (n = 34) - before (T0) and at 3 (T3), 6 (T6) and 12 (T12) weeks of NB-UVB and PUVA therapy - were performed; 17 patients started NB-UVB and 17 PUVA, and IL-22, IL-17, IL-23, IL-8, TNF-α and VEGF levels were evaluated.

RESULTS

At T0, compared with controls (n = 20), all the parameters were significantly higher in patients, except for TNF-α. Both NB-UVB and PUVA treatment gave, at T3, a significant decrease in TNF-α and IL-23; IL-22 and IL-17 decreased significantly at T6; all parameters and Psoriasis Area and Severity Index decreased significantly at T12. However, in both groups, at T12, VEGF was still significantly higher than control.

CONCLUSIONS

Psoriasis seems to be a complex disease in which the cytokine network is disturbed, namely in levels of IL-22, IL-17, IL-23, IL-8, TNF-α and VEGF. NB-UVB and PUVA follow-up studies suggested that the reduction in the IL-23/Th17 axis might be important in the pathogenic mechanisms of psoriasis. Further follow-up studies of patients with psoriasis treated with these and other therapies could be very helpful for the understanding of the disturbance in the cytokine network in psoriasis and indirectly in its pathogenesis.

Tranilast could has potential therapeutic value in the treatment of psoriasis

Psoriasis is a common chronic skin disease characterized by recurrent erythromatous skin plaques that exhibit epidermal hyperplasia, variable inflammatory cell infiltrate, and abnormalities of the dermal vascularization. The involvement of angiogenic growth factors such as vascular endothelial growth factor (VEGF), matrix metalloproteinases (MMPs) and inflammatory cytokines such as IFNγ, IL-1, IL-2, TNFα, TGFα and β, IL-6, IL-8, amphiregulin and monocyte chemoattractant protein 1 (MCP-1) have been known to play pathogenic roles in traumatic psoriatic skin. However, anti-angiogenic and anti-inflammatory cytokines regimens might favorably affect the psoriasis disease process. Tranilast is an anti-allergic drug now emerging as anti-angiogenesis and anti-inflammatory effects. In vitro and in vivo experiments have also been strongly showed that tranilast would treat skin psoriasis by inhibition of involving factors. Herein, we hypothesize that local administration of tranilast may be potentially clinically useful in psoriasis.

The use of cytokine array to examine cytokine profiles of two human cell lines exposed to indoor dust

Human cytokine array was used to investigate the cytokine profile of U937 and KERTr after exposure to indoor dust or dust extracts. The release of MCP-1 was increased while release of IL-8 and IL-1β on U937 were decreased after exposure to indoor dust. The releases of RANTES, IL-8 and VEGF from KERTr after exposure to dust extract were increased. The results of IL-8 ELISA assay were consistent with the cytokine array. Real-time RT-PCR was performed to analyze relative changes in gene expression. The MCP-1 mRNA levels were increased after U937 exposure to 18 indoor dust samples, whereas, IL-8 and IL-1β mRNA level showed both up-regulation and down-regulation. The dose-related increase and decrease response was observed on MCP-1 and IL-8, respectively. Most indoor dust extracts increased RANTES, IL-8 and VEGF mRNA levels on KERTr. The dose-dependent response was observed on RANTES and IL-8. A significant correlation (r=0.48, p<0.05) was obtained between the total PAHs concentration in dust extracts and the induction of RANTES mRNA.

A patient with psoriasis and vitiligo treated with etanercept

Psoriasis is a chronic, immune-mediated, inflammatory dermatosis whose aetiopathogenesis remains unclear, although tumour necrosis factor alpha (TNFalpha) appears to play a crucial role. The biological potential of TNFalpha inhibitors, such as etanercept, which reduce the inflammatory cascade, has radically changed the therapeutic management of patients with psoriasis and other immunomediated inflammatory diseases, associated with TNFalpha. The pathogenesis of the selective destruction of melanocytes in vitiligo is not fully understood, although there is growing evidence that several T helper type 1 cytokines, particularly TNFalpha, may be involved in the depigmentation process. A patient is described who presented with both psoriasis and vitiligo, and was treated with etanercept. After 24 weeks of therapy, the patient's psoriasis had improved markedly and the patient noted a mild improvement of vitiligo, with a reduction in macules and repigmentation in the scapular region.

Activation of blood coagulation in autoimmune skin disorders

The immune system and blood coagulation are simultaneously activated in several inflammatory systemic disorders, such as lupus erythematosus, rheumatoid arthritis and inflammatory bowel diseases. Proinflammatory cytokines, such as IL-6 and TNF-alpha, induce the expression of tissue factor, the main initiator of blood coagulation. Activated proteases of coagulation in turn act on protease-activated receptors, inducing the expression of various proinflammatory cytokines. This cross-talk between inflammation and coagulation amplifies and maintains the activation of both systems. This review focuses on three skin disorders: chronic urticaria (CU), which is considered autoimmune in approximately 50% of cases, bullous pemphigoid (BP), which is the prototype of autoimmune blistering disease, and psoriasis, which is an immune-mediated dermatitis. In CU, the activation of coagulation, which is due to the involvement of eosinophils and tissue factor pathways with the generation of thrombin, has local implications by increasing dermal vascular permeability. Preliminary data indicate that anticoagulant treatment with heparin and warfarin may be effective in reducing the symptoms of this disorder. In BP, the activation of coagulation seems to have both local and systemic implications. Locally, eosinophils and thrombin participate in bulla formation and tissue damage; systemically, the activation of coagulation may explain the increased thrombotic risk observed in these patients. In psoriasis, the activation of coagulation seems to be mainly systemic, potentially contributing to the increased cardiovascular risk associated with this disease.

Inflammatory mediators in gastroesophageal reflux disease: impact on esophageal motility, fibrosis, and carcinogenesis

Gastroesophageal reflux disease (GERD) is one of the most common problems in clinical practice today. It is widely believed that functional and structural abnormalities of the gastroesophageal junction as well as an abnormal exposure to gastroduodenal contents are the main contributors to its pathogenesis. Novel findings of the inflammatory process in GERD suggest a far more complex process involving multifaceted inflammatory mechanisms. This review summarizes knowledge about the expression of inflammatory mediators in GERD and their potential cellular sources and provides an integrated concept of disease pathogenesis. In addition we evaluate the contribution of inflammatory mediators to well-known complications of GERD, namely motility abnormalities, fibrosis, and carcinogenesis. Novel findings regarding the pathophysiology of esophageal inflammation should enhance our understanding of GERD and its complications and provide new treatment insights.