Tapinarof Is a Natural AhR Agonist that Resolves Skin Inflammation in Mice and Humans

The tryptophan derivative 6-formylindolo[3,2-b]carbazole, FICZ, a dynamic mediator of endogenous aryl hydrocarbon receptor signaling, balances cell growth and differentiation

The aryl hydrocarbon receptor (AHR) is not essential to survival, but does act as a key regulator of many normal physiological events. The role of this receptor in toxicological processes has been studied extensively, primarily employing the high-affinity ligand 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). However, regulation of physiological responses by endogenous AHR ligands remains to be elucidated. Here, we review developments in this field, with a focus on 6-formylindolo[3,2-b]carbazole (FICZ), the endogenous ligand with the highest affinity to the receptor reported to date. The binding of FICZ to different isoforms of the AHR seems to be evolutionarily well conserved and there is a feedback loop that controls AHR activity through metabolic degradation of FICZ via the highly inducible cytochrome P450 1A1. Several investigations provide strong evidence that FICZ plays a critical role in normal physiological processes and can ameliorate immune diseases with remarkable efficiency. Low levels of FICZ are pro-inflammatory, providing resistance to pathogenic bacteria, stimulating the anti-tumor functions, and promoting the differentiation of cancer cells by repressing genes in cancer stem cells. In contrast, at high concentrations FICZ behaves in a manner similar to TCDD, exhibiting toxicity toward fish and bird embryos, immune suppression, and activation of cancer progression. The findings are indicative of a dual role for endogenously activated AHR in barrier tissues, aiding clearance of infections and suppressing immunity to terminate a vicious cycle that might otherwise lead to disease. There is not much support for the AHR ligand-specific immune responses proposed, the differences between FICZ and TCDD in this context appear to be explained by the rapid metabolism of FICZ.

Staphylococcus epidermidis Activates Aryl Hydrocarbon Receptor Signaling in Human Keratinocytes: Implications for Cutaneous Defense

Bacterial challenge of keratinocytes with the abundant skin commensal Staphylococcus epidermidis induces distinct innate immune responses, but the underlying molecular mechanisms are still emerging. We report that the aryl hydrocarbon receptor (AhR) was activated in human primary keratinocytes infected with S. epidermidis, leading to induction of the AhR-responsive gene cytochrome P450 1A1 (CYP1A1). In addition, functional AhR was required for S. epidermidis-mediated induction of IL-1β expression in keratinocytes. AhR-dependent gene induction of IL-1β and CYP1A1 was mediated by factor(s) < 2 kDa secreted by S. epidermidis. Blockade of the AhR in a 3D organotypic skin equivalent infected with S. epidermidis attenuated the S. epidermidis-induced CYP1A1 and IL-1β expression. Moreover, S. epidermidis also induced expression of IL-1α and of the antimicrobial peptide human β-defensin-3 in an AhR-dependent manner in a 3D skin equivalent. An increased outgrowth of S. epidermidis on the surface of skin explants treated with a specific AhR inhibitor further indicate a pivotal role of the AhR in mediating an epidermal defense response. Taken together, our data expand the role of the AhR in innate immunity and support a previously unappreciated contribution for the AhR in cutaneous defense.

Testing biologics and intracellular signaling inhibitors on pediatric atopic dermatitis: a stairway to modern therapeutic approaches

INTRODUCTION

Atopic dermatitis (AD) is the most common cutaneous inflammatory disease in adults and children. In the last few years, the pathogenesis of AD has been profoundly revised, and this has led to the identification of novel druggable targets and the development of new agents targeting specific molecular pathways. Despite the high prevalence of AD in the pediatric population, the clinical development of new treatments, either topical or systemic, has been focused on the adult population in recent years; only a limited number of these new agents have been tested in pediatric cohorts.

AREAS COVERED

In this review, we describe the pathogenic model of pediatric AD which shows similarities and substantial differences when compared to adult AD. The identification of therapeutic targets is highlighted, and novel targeted therapies, both topical and systemic, are discussed.

EXPERT OPINION

The current therapeutic armamentarium for pediatric AD is very limited, and this represents a critical unmet need. The enhancement of clinical research on pediatric patients is necessary to facilitate an increase in the number of new targeted therapeutic options being available on the market.

Adult atopic dermatitis: new and emerging therapies

INTRODUCTION

Adult atopic dermatitis (AD) is very difficult to manage. Indeed, AD in adults is frequently refractory to topical treatment, especially with regards to the persistent form. Therefore, long-term treatment with oral immunosuppressive therapy is often required to control the burden of the disease, prevent flare-ups and achieve better patient quality of life outcomes. Areas covered: In the last decade the better understanding of AD pathogenesis has been used to improve treatment strategies with many emerging therapeutics options. Epidermal barrier impairment often plays the initial role in the initiation of the disease. Moreover, T helper 2 cytokines interleukin (IL)-4 and IL-13 and their downstream effects are prominent in AD, with pleiotropic effects on the innate and adaptive immune system. Targeting these cells, their products or receptors appears to be a reasonable therapeutic strategy. Expert commentary: In the next years, many therapeutic options for adult AD will be available. Clinical trials showed that JAK inhibitors, PDE-4 inhibitors and monoclonal antibodies against some IL (IL-4, IL 13, IL-17, IL-22, IL-31) seem to be the most promising drugs, but dermatologists will have to evaluate their effectiveness and safety in clinical practice.

Implications of tryptophan photoproduct FICZ in oxidative stress and terminal differentiation of keratinocytes

Ultraviolet B (UVB) irradiation activates aryl hydrocarbon receptor (AHR), generates reactive oxygen species (ROS) and mediates photocarcinogenesis and photoaging. 6-Formylindolo[3,2-b]carbazole (FICZ) is a tryptophan photoproduct generated by UVB exposure. FICZ exhibits similar biological effects to UVB, including AHR ligation and ROS production. FICZ also acts as a potent photosensitizer for UVA and the production of ROS is synergistically augmented in the simultaneous presence of FICZ and UVA. In contrast, FICZ upregulates the expression of terminal differentiation molecules such as filaggrin and loricrin via AHR. In parallel with this, the administration of FICZ inhibits skin inflammation in a murine psoriasis and dermatitis model. In this article, we summarize the harmful and beneficial aspects of FICZ in skin pathology.

A phase 2, randomized dose-finding study of tapinarof (GSK2894512 cream) for the treatment of atopic dermatitis

BACKGROUND

Safe and efficacious topical treatments are needed for atopic dermatitis (AD).

OBJECTIVE

We assessed the safety and efficacy of tapinarof cream (2 concentrations and 2 application frequencies) in patients with AD.

METHODS

A double-blind, vehicle-controlled, randomized, 6-arm trial (1:1:1:1:1:1) in patients age 12 to 65 years, with body surface area involvement of at least 5% to 35% and an Investigator's Global Assessment score of 3 or higher (moderate to severe) at baseline. Primary end points included an Investigator's Global Assessment score of clear or almost clear (0 or 1) and a minimum 2-grade improvement (treatment success) at week 12. Secondary analyses included a 75% or greater improvement in Eczema Area and Severity Index score, reduction of numeric rating scale (NRS) score for itch from baseline, and other prespecified end points.

RESULTS

The rates of treatment success with tapinarof cream at week 12 were 53% (a concentration of 1% twice daily), 46% (a concentration of 1% once daily), 37% (a concentration of 0.5% twice daily), 34% (0.5% once daily), 24% (vehicle twice daily), and 28% (vehicle once daily). The rate with a concentration of 1% twice daily (53%) was statistically significantly higher than the rate with vehicle twice daily (24%). Treatment success was maintained for 4 weeks after the end of tapinarof treatment. The rate of treatment-emergent adverse events was higher with tapinarof (93 of 165 [56%]) than with vehicle (34 of 82 [41%]), and the events were mild to moderate in intensity.

LIMITATIONS

Large confirmation trials are needed.

CONCLUSIONS

Tapinarof cream is efficacious and well tolerated in adolescent and adult patients with AD.

Upregulation of FLG, LOR, and IVL Expression by Rhodiola crenulata Root Extract via Aryl Hydrocarbon Receptor: Differential Involvement of OVOL1

Rhodiola species are antioxidative, salubrious plants that are known to inhibit oxidative stress induced by ultraviolet and γ-radiation in epidermal keratinocytes. As certain phytochemicals activate aryl hydrocarbon receptors (AHR) or OVO-like 1 (OVOL1) to upregulate the expression of epidermal barrier proteins such as filaggrin (FLG), loricrin (LOR), and involucrin (IVL), we investigated such regulation by Rhodiola crenulata root extract (RCE). We demonstrated that RCE induced FLG and LOR upregulation in an AHR-OVOL1-dependent fashion. However, RCE-mediated IVL upregulation was AHR-dependent but OVOL1-independent. Coordinated upregulation of skin barrier proteins by RCE via AHR may be beneficial in the management of barrier-disrupted inflammatory skin diseases such as atopic dermatitis.

Aryl hydrocarbon receptor (AhR) a possible target for the treatment of skin disease

Aryl hydrocarbon receptor (AhR) is a transcription factor expressed in all skin cells type. It responds to exogenous and endogenous chemicals by inducing/repressing the expression of several genes with toxic or protective effects in a wide range of species and tissues. In healthy skin, AhR signalling contributes to keratinocytes differentiation, skin barrier function, skin pigmentation, and mediates oxidative stress. In the last years, some studies have shown that AhR seems to be involved in the pathogenesis of some skin diseases, even if the currently available data are contradictory. Indeed, while the blocking the AhR signalling activity could prevent or treat skin cancer, the AhR activation seems to be advantageous for the treatment of inflammatory skin diseases. Therefore, for its multifaceted role in skin diseases, AhR seems to be an attractive therapeutic target. Indeed, recently some molecules have been identified for the prevention of skin cancer and the treatment of inflammatory skin diseases.

Murine models of psoriasis and their usefulness for drug discovery

INTRODUCTION

Psoriasis is an autoimmune skin disease characterized by red plaques with silver or white multilayered scales with a thickened acanthotic epidermis. Using mouse models of cutaneous inflammation, IL-23/Th17 was identified to have a potential key role in psoriasis. New treatments to slow this inflammatory skin disorder are urgently needed. To aid their discovery, a psoriasis animal model mimicking human psoriasis is urgently needed for their early preclinical evaluation. Areas covered: The authors review animal models of psoriasis and analyze the features and molecular mechanisms involved in these mouse models. The application of various mouse models of psoriasis for drug discovery and development has also been reviewed and the possible molecular targets in psoriasis for future anti-psoriatic drug design is discussed. Expert opinion: So far, it has been difficult to create an animal model that exactly simulates a human disease or condition. The xenotransplantation model is regarded as the closest to incorporating the complete genetic, phenotypic, and immunopathogenic processes of psoriasis. However, the imiquimod (IMQ)-induced model is the most prevalent among psoriatic mouse models due to its ease of use, convenience, and low cost. Further efforts to develop psoriasis-like skin models in mice are needed for the study and treatment of this complex disease.

Past, present and future of in vitro 3D reconstructed inflammatory skin models to study psoriasis

Psoriasis is a common chronic inflammatory skin disease with a significant socio-economic impact that can greatly affect the patients' quality of life. The prevailing dogma in the aetiology and pathophysiology of this complex disease is that skin cells, immune cells and environmental factors contribute to psoriatic skin inflammation. For a better understanding of the disease pathogenesis, models are required that mimic the disease and which can be used to develop therapeutics. Over the last decades, in vitro human reconstructed skin models have been widely used in dermatological research and have also been developed to mimic psoriatic skin. This viewpoint summarizes the most commonly used in vitro models and the latest accomplishments for the combination of the dermal and epidermal compartments with other cell types and factors that are important players in the psoriatic skin environment. We aim to critically list the most complete and best-validated models that include major psoriasis hallmarks with regard to gene and protein expression profile and epidermal morphology, but also discuss the shortcoming of the current models. This viewpoint intends to guide the development of in vitro 3D skin models that faithfully mimic all features of psoriatic skin. Such model will enable fundamental biological studies for a better understanding of the aetiology and pathophysiology of psoriasis and aid in novel therapeutic target identification and drug development studies.

Systemic Pharmacokinetics, Safety, and Preliminary Efficacy of Topical AhR Agonist Tapinarof: Results of a Phase 1 Study

Tapinarof cream is a novel topical nonsteroidal agent that represents a unique class of anti-inflammatory molecules targeting the aryl hydrocarbon receptor. Study 201851 was an open-label, 2-cohort sequential study that assessed the systemic pharmacokinetics, safety, and efficacy of tapinarof in adults with moderate to severe atopic dermatitis. A total of 11 participants were enrolled: 5 received 2% cream, and 6 received 1% cream. Tapinarof was systemically absorbed, and measurable amounts were detected in both cohorts. Generally, plasma exposure was greater with the 2% cream and decreased from day 1 to day 21. Median T_max ranged from 1 to 4 hours. Preliminary efficacy results were similar between the 1% and 2% concentrations, with the 1% cream showing better tolerability based on 3 subjects in the 2% cohort who discontinued treatment because of systemic AEs. The efficacy and safety of 1% tapinarof support results of previous positive studies that used a different formulation. However, conclusions in the present study are limited because of the open-label design and small number of participants. The 1% cream was selected as the concentration for use in future studies because of its lower AE incidence and efficacy comparable to the 2% cream.

Topical E6005/RVT-501, a novel phosphodiesterase 4 inhibitor, for the treatment of atopic dermatitis

INTRODUCTION

Local adverse effects of steroid use and the burning sensation of calcineurin inhibitors impair patients' adherence to treatment and decrease the treatment response in atopic dermatitis (AD). Steroid phobia appears to be a psychological problem in patients with AD. Topical non-steroidal remedies are in demand. Areas covered: This manuscript reviews the current literature on preclinical and clinical studies regarding topical E6005/RVT-501, a novel phosphodiesterase 4 inhibitor. We also discuss the mechanistic background of E6005/RVT-501 in the treatment of AD. Expert opinion: Topical E6005/RVT-501 improves skin eruption and pruritus of pediatric and adult AD patients without any serious side effects. It is useful for mild to moderate lesions of AD in pediatric and adult patients. Topical E6005/RVT-501 is non-steroidal agent but its potency is equal to that of mild rank topical steroid, therefore, it may fit the demand of patients with steroid phobia. Its steroid-sparing effects may also be investigated in future clinical trials and may minimize the dose and frequency of topical steroids.

Antioxidant Artemisia princeps Extract Enhances the Expression of Filaggrin and Loricrin via the AHR/OVOL1 Pathway

The Japanese mugwort, Artemisia princeps (yomogi in Japanese), has anti-inflammatory and antioxidant effects. Skin care products containing Artemisia princeps extract (APE) are known to improve dry skin symptoms in atopic dermatitis. Atopic dry skin is associated with a marked reduction of skin barrier proteins, such as filaggrin (FLG) and loricrin (LOR). Recently, aryl hydrocarbon receptor (AHR), and its downstream transcription factor OVO-like 1 (OVOL1), have been shown to regulate the gene expression of FLG and LOR. The focus of this paper is to evaluate the effects of APE on the AHR/OVOL1/FLG or LOR pathway since they have remained unknown to this point. We first demonstrated that non-cytotoxic concentrations of APE significantly upregulated antioxidant enzymes, NAD(P)H dehydrogenase quinone 1 and heme oxygenase 1, in human keratinocytes. Even at these low concentrations, APE induced nuclear translocation of AHR and significantly upregulated CYP1A1 (a specific target gene for AHR activation), FLG, and LOR expression. AHR knockdown downregulated OVOL1 expression. The APE-induced upregulation of FLG and LOR was canceled in keratinocytes with AHR or OVOL1 knockdown. In conclusion, antioxidant APE is a potent phytoextract that upregulates FLG and LOR expression in an AHR/OVOL1-dependent manner and this may underpin the barrier-repairing effects of APE in treating atopic dry skin.