Profiles of Foxp3+ regulatory T cells in eczematous dermatitis, psoriasis vulgaris and mycosis fungoides

Regulatory T cells and immunodeficiency in mycosis fungoides and Sézary syndrome

Cutaneous T-cell lymphoma (CTCL) is the term for diseases characterized by primary accumulation of malignant T cells in the skin. Patients with the two predominant clinical forms of CTCL called mycosis fungoides (MF) and Sézary syndrome (SS) characteristically develop severe immunodeficiency during disease progression and consequently patients with advanced disease frequently die of infections and not from the tumor burden. For decades, it has been suspected that the malignant T cells actively drive the evolving immunodeficiency to avoid antitumor immunity, yet, the underlying mechanisms remain unclear. The identification of a subset of highly immunosuppressive regulatory T cells (Tregs) triggered a variety of studies investigating if MF and SS are malignant proliferations of Tregs but seemingly discordant findings have been reported. Here, we review the literature to clarify the role of Tregs in MF and SS and discuss the potential mechanisms driving the immunodeficiency.

Regulatory T cells in cutaneous immune responses

Regulatory T cells (Treg) are a subset of T cells with strong immunosuppressive activity. In the skin, it has recently been revealed that Treg play important roles not only in the maintenance of skin homeostasis but also in the regulation of the immune responses, such as contact hypersensitivity and atopic dermatitis. Furthermore, the skin plays important roles in the induction of Treg in the periphery. In this review, we will provide an overview of the mechanism of Treg-mediated immunosuppression and discuss the role of Treg in the skin.

Resting but not CpG stimulated keratinocytes suppress autologous T-helper cell proliferation--importance of PGE2 and T regulatory function

In the last decade, keratinocytes have increasingly been recognized to actively participate in the skin immune response. However, their influence on infiltrating lymphocytes - abundantly found in e.g. atopic and psoriatic inflammation - is still controversial. In this study, we aimed to investigate the influence of keratinocytes on T-cell proliferation by use of an autologous co-culture model. Because the skin has an important function with regard to detecting invading pathogens, we also investigated the influence of pathogen-associated molecular pattern on keratinocyte - T-cell interaction. We observed a clear inhibition of T-cell proliferation by co-cultured keratinocytes. This effect was found to be mediated by PGE2, as T-cell proliferation was recovered in the presence of the PGE2 inhibitor indometacin. Furthermore, presence of keratinocytes led to enhanced expression of the T regulatory cell-specific transcription factor Foxp3 in the CD4+CD25+ T-cell population which also showed regulatory function. Interestingly, the presence of the TLR9 ligand CpG was able to prevent the inhibition of T-cell proliferation. This was paralleled by a reduced PGE2 production by keratinocytes and a down-regulated T regulatory cell function. Our results indicate that the inhibitory capacity of keratinocytes in the skin is strongly influenced by the surrounding micromillieu.

Pathogenesis of Mycosis fungoides

Mycosis fungoides is the most common type of primary cutaneous lymphomas. The phenotype of the tumor cell corresponds to an effector/memory-type of helper T cell which, given its repertoire of homing receptors, is specialized for recirculation through the skin. In recent years genetic analyses have uncovered various chromosomal aberrations in the tumour cells of mycosis fungoides. Their relevance to the pathogenesis and clinical appearance are discussed in the following.

Long-term reduction in local inflammation by a lipid raft molecule in atopic dermatitis

BACKGROUND

The complex pathogenesis of atopic dermatitis (AD) is guided by cell surface receptor-mediated signal transduction regulated in lipid rafts. Miltefosine is a raft-modulating molecule targeting cell membranes. With this controlled clinical study, the clinical and immunomodulatory efficacy of miltefosine was investigated in patients with AD in comparison with a topical corticosteroid treatment.

METHODS

Sixteen patients with AD were treated topically with miltefosine and hydrocortisone localized on representative AD target lesions for 3 weeks. To assess the clinical efficacy, the three item severity (TIS) score was evaluated before, during and after treatment as well as after 4-week-follow-up period. To study the anti-inflammatory effect of miltefosine on the cellular T cell pattern, skin biopsies were analysed before and after treatment.

RESULTS

The TIS score dropped in both groups significantly after treatment. A carry-over effect was exclusively seen for miltefosine after discontinuing the treatment. These findings were substantiated by thermographic imaging with a significant decrease in the maximum temperature (T(max)) after miltefosine application (P = 0.034, DeltaT(max) = 1.7 degrees C [2.1-3.9]). Immunohistochemically, a reduction in lesional CD4(+)-infiltrating T cells was observed in both treatments. Moreover, increased FoxP3(+) cells were present in the skin after miltefosine treatment (before 5.4% [1.9-9.8], after 6.2% [3.5-9.5]).

CONCLUSION

We demonstrate that miltefosine is locally active in patients with AD and led to a sustained clinical improvement in local skin inflammation. Moreover, the increased frequency of FoxP3(+) cells in the skin of patients with AD suggests its immunomodulatory properties.

T regulatory cells and plasmocytoid dentritic cells in hansen disease: a new insight into pathogenesis?

Leprosy is characterized by spectrum of histologically different granulomatous skin lesions that reflects the patient's immune response to Mycobacterium leprae. Presence, frequency, and distribution of both CD4+ CD25+ FoxP3+ T regulatory cells (T-regs) and CD123+ plasmacytoid dendritic cells in leprosy have never been investigated. We performed a retrospective immunohistochemical study on 20 cases of leprosy [tuberculoid tuberculoid (TT): 1 patient; borderline tuberculoid (BT): 3 patients; borderline lepromatous (BL): 5 patients; lepromatous lepromatous (LL): 5 patients; borderline borderline in reversal reaction (BB-RR): 1 patient; BT-RR: 2 patients; and erythema nodosum leprosum (ENL): 3 patients]. FoxP3-positive cells were present in 95% of the cases with an average density of 2.9% of the infiltrate. Their distribution was not related to granulomatous structures or special locations. There was no statistical difference of FoxP3 expression between TT, BT, BL, and LL, whereas a statistical significant increment (P = 0.042) was observed in patients affected by reversal leprosy reactions (BT-RR and BB-RR) compared with patients affected by ENL and patients with nonreactional disease forms (BL, LL, BT, TT). CD123 expression was not observed in any of the biopsy specimens evaluated; with the exception of 2 cases of ENL, in which a focal positivity for CD123 was observed. Our results show that plasmacytoid dendritic cells are not involved in the immune response against M. leprae while T-regs are present in leprosy skin lesions. These data raise the question if T-regs have a pathogenetic role in HD as previously demonstrated in Leishmania major and Mycobacterium tuberculosis.

Role of immune-regulatory cells in skin pathology

The skin harbors a complex and unique immune system that protects against various pathologies, such as infection and cancer. Although many of the mechanisms of immune activation in the skin have been investigated, it is likewise important to uncover the immune-regulatory components that limit effective immunity or prevent autoimmunity. Several cell populations are involved in this immune-regulatory function, including CD4+ T cells that coexpress the transcription factor Foxp3, known as Tregs, and cells with immune-regulatory function known as myeloid-derived suppressor cells (MDSCs). This review focuses on the role that immune-regulatory cells, such as MDSCs and Tregs, play in cutaneous pathology, such as malignancy, psoriasis, dermatitis, burn wounds, and transplantation. Although their depletion may serve to augment immunity, expansion of these cells may be used to suppress excessive immune reactions. These cells are attractive, therapeutic targets for various conditions and thus, deserve further exploration.

Foxp3+ regulatory T cells and related cytokines differentially expressed in plaque vs. guttate psoriasis vulgaris

BACKGROUND

Differences in the number of Foxp3+ regulatory T cells (Tregs) in lesional skin and peripheral blood and their functioning in plaque vs. guttate psoriasis have not been reported.

OBJECTIVES

To investigate whether there is a differential expression of Foxp3+ Tregs and a differential regulation of inflammatory cytokines in plaque vs. guttate psoriasis vulgaris.

METHODS

The number and the percentage of Foxp3+ cells in different phases of skin lesions of patients with plaque and guttate psoriasis vulgaris were assessed by immunohistochemical staining. The expression of Foxp3 and interleukin (IL)-17 protein in CD4 populations was measured by flow cytometry. Inflammatory cytokine production by transforming growth factor-beta1-induced Foxp3+ Tregs was assessed in an in vitro study. The cytokines in supernatant and serum were determined by enzyme-linked immunosorbent assay.

RESULTS

The percentage of Foxp3+ CD3+ cells in the papillary layer was higher than in the reticular layer of dermis and in epidermis (P < 0.05). The numbers of Foxp3+ Tregs in skin lesions and peripheral blood were higher in plaque than in guttate psoriasis, whereas the percentage of IL-17+ CD4+ cells was higher in guttate than in plaque psoriasis (P < 0.05). The numbers of Foxp3+ cells were positively correlated with the Psoriasis Severity Index score of skin lesions (P < 0.0001), and the percentages of Foxp3+ CD4+ cells in peripheral blood were positively correlated with the Psoriasis Area and Severity Index score of patients (P < 0.05). The inhibitory functions of Tregs to IL-17 and IL-6 in guttate psoriasis and to tumour necrosis factor-alpha in plaque psoriasis were deficient.

CONCLUSIONS

Differential expression and regulatory functioning for inflammatory cytokine production by Foxp3+ Tregs may imply a different immunopathogenesis for plaque and guttate psoriasis.

Expansion of FOXP3-positive CD4+CD25+ T cells associated with disease activity in atopic dermatitis

BACKGROUND

FOXP3-positive CD4+CD25+ T cells are known to have an immunoregulatory function by means of preventing T-cell reactivity to both self- and non-self-antigens. However, the role of these cells in the pathogenesis of allergic diseases is not clear.

OBJECTIVE

To evaluate the quantity and quality of circulating FOXP3-positive T cells in patients with atopic dermatitis (AD).

METHODS

Peripheral blood mononuclear cells were isolated from 35 AD patients (mean [SD] age, 27.1 [7.5] years) and 36 controls (mean [SD] age, 27.5 [10.0] years). Cellular FOXP3 expression was analyzed using flow cytometry. Characteristics of FOXP3-positive T cells were evaluated with respect to cytokine production capability and suppressive function.

RESULTS

Frequencies of circulating FOXP3+CD25+ cells in the CD4+ T-cell population of AD patients were significantly higher than those in controls (mean [SD], 7.4% [4.6%] vs 4.5% [1.3%]; P = .002) and correlated with their Scoring Atopic Dermatitis (SCORAD) scores (r = 0.74, P = .008) and peripheral blood eosinophil counts (r = 0.72, P < .001). In the patients whose samples were analyzed at intervals of 1 to 2 months, frequencies of FOXP3-positive T cells were decreased as their skin lesions improved, regardless of medicines used. FOXP3-positive CD4+ T cells from patients, as well as those from controls, showed little capability to synthesize interferon gamma and interleukin 4. No differences were found in suppression abilities of CD4+CD25+ T cells between AD patients and controls.

CONCLUSIONS

Our data suggest that dynamic fluctuation in numbers of circulating FOXP3-positive regulatory T cells might contribute to the pathogenesis of AD.

Paucity of intraepidermal FoxP3-positive T cells in cutaneous T-cell lymphoma in contrast with spongiotic and lichenoid dermatitis

BACKGROUND

FoxP3 is the most specific available marker for regulatory T cells (Tregs). Tumor-associated FoxP3-positive Tregs have been identified in various neoplasms, including cutaneous T-cell lymphoma (CTCL). FoxP3 expression in CTCL varies across groups; few studies have compared CTCL with inflammatory conditions.

METHODS

Lesional skin biopsies from 20 patients with CTCL [13 mycosis fungoides (MF); 7 Sézary syndrome (SS)] and 22 with inflammatory dermatoses (11 spongiotic; 11 lichenoid or interface) were examined for FoxP3 expression by immunohistochemistry. Epidermal FoxP3-positive lymphocytes were counted as a percentage of the total epidermal CD3-positive T-cell population.

RESULTS

FoxP3-positive T cells composed the minority of infiltrate in all major categories. Lower numbers of epidermal FoxP3-positive T cells were observed in CTCL, particularly MF, than in inflammatory dermatoses (P < .001). CTCL neoplastic T cells did not express FoxP3.

CONCLUSION

FoxP3-positive T cells are less frequently encountered in MF than in inflammatory dermatoses. FoxP3-positive T cells occur in higher proportions in the dermis than in the epidermis and probably correlate with coexisting inflammatory components. CTCL neoplastic cells do not typically express a Treg phenotype and are associated with low numbers of FoxP3-positive Tregs in the infiltrate. FoxP3 expression by immunohistochemistry may aid histologic evaluation of these conditions.