Human immunodeficiency virus-associated vitiligo: expression of autoimmunity with immunodeficiency?

Melanin: a unifying theory of disease as exemplified by Parkinson's, Alzheimer's, and Lewy body dementia

Melanin, a ubiquitous dark pigment, plays important roles in the immune system, including scavenging reactive oxygen species formed in response to ultraviolet radiation absorption, absorbing metals, thermal regulation, drug uptake, innate immune system functions, redox, and energy transduction. Many tissue types, including brain, heart, arteries, ovaries, and others, contain melanin. Almost all cells contain precursors to melanin. A growing number of diseases in which there is a loss of melanin and/or neuromelanin are increasingly thought to have infectious etiologies, for example, Alzheimer's disease (AD), Parkinson's disease (PD), Lewy Body Dementia (LBD), and vitiligo. AD, PD, LBD, and vitiligo have been linked with herpesvirus, which enters melanosomes and causes apoptosis, and with gut dysbiosis and inflammation. Herpesvirus is also linked with gut dysbiosis and inflammation. We theorize that under normal healthy states, melanin retains some of the energy it absorbs from electromagnetic radiation, which is then used to fuel cells, and energy from ATP is used to compliment that energy supply. We further theorize that loss of melanin reduces the energy supply of cells, which in the case of AD, PD, and LBD results in an inability to sustain immune system defenses and remove the plaques associated with the disease, which appear to be part of the immune system's attempt to eradicate the pathogens seen in these neurodegenerative diseases. In addition, in an attempt to explain why removing these plaques does not result in improvements in cognition and mood and why cognitions and moods in these individuals have ebbs and flows, we postulate that it is not the plaques that cause the cognitive symptoms but, rather, inflammation in the brain resulting from the immune system's response to pathogens. Our theory that energy retained in melanin fuels cells in an inverse relationship with ATP is supported by studies showing alterations in ATP production in relationship to melanin levels in melanomas, vitiligo, and healthy cells. Therefore, alteration of melanin levels may be at the core of many diseases. We propose regulating melanin levels may offer new avenues for treatment development.

Melanogenesis Connection with Innate Immunity and Toll-Like Receptors

The epidermis is located in the outermost layer of the living body and is the place where external stimuli such as ultraviolet rays and microorganisms first come into contact. Melanocytes and melanin play a wide range of roles such as adsorption of metals, thermoregulation, and protection from foreign enemies by camouflage. Pigmentary disorders are observed in diseases associated with immunodeficiency such as Griscelli syndrome, indicating molecular sharing between immune systems and the machineries of pigment formation. Melanocytes express functional toll-like receptors (TLRs), and innate immune stimulation via TLRs affects melanin synthesis and melanosome transport to modulate skin pigmentation. TLR2 enhances melanogenetic gene expression to augment melanogenesis. In contrast, TLR3 increases melanosome transport to transfer to keratinocytes through Rab27A, the responsible molecule of Griscelli syndrome. TLR4 and TLR9 enhance tyrosinase expression and melanogenesis through p38 MAPK (mitogen-activated protein kinase) and NFκB signaling pathway, respectively. TLR7 suppresses microphthalmia-associated transcription factor (MITF), and MITF reduction leads to melanocyte apoptosis. Accumulating knowledge of the TLRs function of melanocytes has enlightened the link between melanogenesis and innate immune system.

Quality of Life, Burden of Disease, Co-morbidities, and Systemic Effects in Vitiligo Patients

Vitiligo is a complex, systemic disease associated with many autoimmune and autoinflammatory conditions. Additionally, the cutaneous changes of vitiligo have significant effects on quality of life and self-esteem. Further efforts are needed to increase our understanding of vitiligo comorbidities as well as to increase awareness of the psychological effects of vitiligo.

Differential responses of normal human melanocytes to intra- and extracellular dsRNA

Viral factor has been implicated in the etiopathogenesis of vitiligo. To elucidate the effects of viral double-stranded RNA (dsRNA) on melanocytes and to explore the underlying mechanisms, primary cultured normal human melanocytes were treated with synthetic viral dsRNA analog poly(I:C). The results demonstrated that poly(I:C)-triggered apoptosis when transfected into melanocytes, while extracellular poly(I:C) did not have that effect. Intracellular poly(I:C)-induced melanocyte death was decreased by RIG-I or MDA5 siRNA, but not by TLR3 siRNA. Both intracellular and extracellular poly(I:C) induced the expression of IFNB, TNF, IL6, and IL8. However, extracellular poly(I:C) demonstrated a much weaker induction capacity of cytokine genes than intracellular poly(I:C). Further analysis revealed that phosphorylation of TBK1, IRF3, IRF7, and TAK1 was differentially induced by intra- or extracellular poly(I:C). NFκB inhibitor Bay 11-7082 decreased the induction of all the cytokines by poly(I:C), suggesting the ubiquitous role of NFκB in the process. Poly(I:C) treatment also induced the phosphorylation of p38 and JNK in melanocytes. Both JNK and p38 inhibitors showed suppression on the cytokine induction by intra- or extracellular poly(I:C). However, only the JNK inhibitor decreased the intracellular poly(I:C)-induced melanocyte death. Taken together, this study provides the possible mechanism of viral factor in the pathogenesis of vitiligo.

AIDS and HIV infections: uncommon presentations

Infection with HIV or AIDS has a great impact on skin diseases, not only by affecting the immune system and thereby host defense against bacterial, viral, or mycotic infection, but also by changing tumor immune response and autoimmune reactivity. In the present review, emphasis will be made on infectious diseases, including sexually transmitted disease, inflammatory skin disease, and neoplasias. Knowledge of changing disease pattern with HIV/AIDS may help the clinical dermatologist and venerologist to identify dermatoses and act in the most appropriate manner to support the patient.

Thiersch grafting in recurrent herpes-induced lip depigmentation

Recurrent herpes induced lip-depigmentation is an uncommon condition observed rarely in patients suffering from recurrent herpes labialis. Patients usually belong the age group between 20 and 40 who have had herpes labialis for 4--12 years. These patients do not respond to available methods of treatment such as psoralens and phototherapy because there is reactivation of the virus. Ten cases of recurrent herpes-induced lip depigmentation (HILD) were successfully treated with a combination therapy of acyclovir 400 mg twice a day for one year with Thiersch grafting six months after starting therapy.

Vitiligo in association with human immunodeficiency virus infection

Autoimmune disorders such as vitiligo have been previously reported in patients with human immunodeficiency virus (HIV) infection. We describe a case of vitiligo in association with HIV where a rising CD4 lymphocyte count due to highly active antiretroviral therapy (HAART) closely correlated with changes in the skin. This effect, to our knowledge, has not been previously observed.

Vitiligo: a manifestation of apoptosis?

Vitiligo is a common cutaneous disorder that has significant biological and social consequences for those affected. It is characterized by a loss of melanocytes from the epidermis, which results in the absence of melanin, i.e. depigmentation. There are numerous hypotheses about the etiology of vitiligo, but no data to definitively prove one theory over another. It is likely that there are numerous causes for the loss of these melanocytes. One way to approach the identification of the etiology is to determine the mechanism by which the melanocytes are destroyed. The two known mechanisms for the destruction of cells are necrosis and apoptosis. One purpose of this paper is to review the extant data that might suggest which of the two mechanisms is operative against melanocytes in patients with vitiligo. The histological data, and some laboratory data, support apoptosis, rather than necrosis, as the mechanism for removal of melanocytes. Apoptosis can be induced by a variety of factors, including immune cytokines, some environmental chemicals (for example substituted hydroquinones such as monobenzone) or other molecular mechanisms. Current therapies, such as corticosteroids and ultraviolet light, do affect apoptosis in a variety of ways. Confirmation of apoptosis as a mechanism, and identification of how apoptosis is initiated to produce vitiligo, can serve as a basis for devising medications that might stop the progression of the disorder. The problem of vitiligo would be essentially solved if there was a medication that is well tolerated in children, adults and pregnant women, and that would halt the progression of the depigmentation. The study of apoptosis, mechanisms of its induction, and the ways to block apoptosis, is one possible way to find both the causes of depigmentation and medications to prevent its progression.

Idiopathic CD4+T-cell lymphocytopenia associated with vitiligo

The syndrome of idiopathic CD4+ T lymphocytopenia (ICTL) is defined as the persistent depletion of peripheral blood CD4+ T lymphocytes below 300 cells/mm(3) or less than 20% of the total lymphocytes in the absence of either HIV infection or other known causes of immunodeficiency. To date no known viral origin has been identified. ICTL has a variable clinical course ranging from patients with minimal symptoms to those who have died from opportunistic infections. We report a case of a 32-year-old white man with a long history of vitiligo that is associated with ICTL. He also had incidental psoriasis. The correlation between ICTL and autoimmune vitiligo suggests an aberration in the immune surveillance that leads to an abnormal response of CD4+ T lymphocytes in the host.

PUVA therapy is preferable to UVB phototherapy in the management of HIV-associated dermatoses

Both methoxsalen plus UVA (PUVA) therapy and UVB phototherapy are commonly used in the management of human immunodeficiency virus-associated dermatoses but UVB phototherapy appears to be the preferred treatment. There are several considerations, in particular therapeutic efficacy and therapeutic profile, which suggest that PUVA therapy might be more effective. This needs to be established in clinical trials.

Cytomegalovirus DNA identified in skin biopsy specimens of patients with vitiligo

BACKGROUND

Viral infections have been implicated in the pathogenesis of a variety of autoimmune diseases.

OBJECTIVE

This investigation was undertaken to determine the presence or absence of viral genomes in the depigmented and uninvolved skin of patients with vitiligo.

METHODS

A polymerase chain reaction assay was used to detect viral genomes in paraffin-embedded skin biopsy specimens. Twenty-nine patients with vitiligo and 22 control subjects were included. Biopsy specimens were screened in a blinded fashion for a panel of DNA and RNA viruses including herpes simplex, varicella-zoster, cytomegalovirus (CMV), Epstein-Barr, HIV, and human T-cell lymphotropic virus.

RESULTS

CMV DNA was identified in 38% of the patients studied. Twenty-one percent had indeterminate results. Results in all control subjects were negative. Polymerase chain reaction screening for identification of other viral genomes was negative. Although not statistically significant, data trends suggested a correlation between the presence of CMV DNA in biopsy specimens and active vitiligo of relatively brief duration. In addition, CMV-positive patients had a statistically significant increased frequency of other concurrent autoimmune diseases.

CONCLUSION

CMV DNA in the depigmented and uninvolved skin of some patients with vitiligo and its absence in control subjects suggest that vitiligo may indeed be triggered by a viral infection in select patients.

Human immunodeficiency virus and the skin: selected controversies

Acquired immunodeficiency syndrome was first recognized as a new disease in 1981 because of the unusual association of Kaposi's sarcoma and Pneumocystis carinii pneumonia in young men. The skin remains one of the most important clinical markers for acquired immunodeficiency syndrome, now recognized as the end stage of infection with the human immunodeficiency virus (HIV). Indeed, an urticarial viral exanthem appearing during seroconversion may allow early identification of newly infected individuals who might benefit from administration of antiviral therapy during plasma viremia. The "asymptomatic HIV infection" is often accompanied by multiple skin complaints, which commonly include xerosis, pruritus, psoriasis/seborrheic dermatitis, and pruritic papular eruptions, the cause of which remains controversial. Psoriasis and Kaposi's sarcoma lesions share features including angiogenesis, dermal dendrocytes infected with HIV, and epidermal hyperproliferation, and are manifested by mice transgenic for HIV provirus or Tat-ltr. Changes in the immune system including T-cell function, antigen response, and shifting cytokine expression as well as a propensity for autoimmune reactions must underlie the skin immunodysfunction occurring in the setting of HIV infection. One of the most unsettling controversies suggested by in vitro data is that ultraviolet light, an effective therapy for HIV-related skin disorders, may actually activate the virus.

Blue vitiligo

The progression of vitiligo and postinflammatory hyperpigmentation simultaneously in a patient with AIDS led to the appearance of a blue color on much of the patient's skin. The blue coloration subsequently resolved with follicular repigmentation typical of resolving vitiligo. We believe this is the first reported case of "blue vitiligo."

Clinical and laboratory evaluation of AIDS trichopathy

BACKGROUND

The present study reports the incidence of trichocutaneous disorders studied in 500 patients infected with HIV 1 in a large university-based setting. Correlation of these findings with immunologic function at the time of diagnosis is presented. Unusual presentations and therapeutic interventions are discussed. Prognosis as related to various trichocutaneous disorders is elaborated.

METHODS

All patients in this study were HIV 1 positive by Western blot assay. T-cell subsets were evaluated by monoclonal antibodies against T-cell surface markers. Hair disorders were analyzed by means of light hair pull test, hair mount, polarizing microscopy, trichogram, scalp biopsy, and cultures for bacteria, fungi, and mycobacteria as indicated. Trichologic manifestations were classified based upon immunologic correlation of absolute level of helper T cells/mm3.

RESULTS

The majority of hair disorders in the study population occurred with helper T cell numbers of less than 150/mm3. Papulosquamous problems including seborrheic dermatitis and psoriasis were most commonly noted followed by disorders of cell growth cycle regulation and trichokeratinization, i.e., telogen effluvium and loose anagen syndrome.

CONCLUSIONS

Multiple trichocutaneous disorders occur in the setting of retroviral infection. Most of these disorders occur in the setting of progressive immunoincompetence. The awareness of the disorders described here will aid the clinician in both the recognition and management of pilar aberrations in the appropriate clinical setting.

Oral lesions of iatrogenic and undefined etiology and neurologic disorders associated with HIV infection

A review of a miscellaneous group of oral mucosal disorders in the setting of infection with the human immunodeficiency virus is presented. Included is a discussion of oral lesions of iatrogenic and undefined etiology and neurologic disorders. Mechanisms of pathogenesis, including possible common pathways and relationships to underlying immunosuppression, are emphasized.

Mucocutaneous disease in pediatric human immunodeficiency virus infection

Children with HIV infection may develop a wide variety of infectious and inflammatory diseases of the skin. These disorders are often more severe and more difficult to treat than in the healthy child. In some cases, disorders of the skin or mucous membranes may provide an early clue to the presence of pediatric HIV infection.

Cutaneous manifestations of acquired immunodeficiency syndrome in children

Cutaneous disorders are among the most common manifestations of HIV infection in both children and adults. Because of the obvious visibility of the integument, these lesions are often the presenting manifestation of HIV-related disease. The cutaneous afflictions are frequently related to the sequelae of impaired immunity and include opportunistic infections and neoplasms as well as dramatic exacerbations and/or the development of rapidly progressive and severe manifestations in pre-existing, normally benign dermatoses. In many cases of AIDS, iatrogenic cutaneous disorders associated with toxic or allergic drug reactions are seen. With the increasing incidence of pediatric HIV infection and with therapeutic prolongation of survival, certain cutaneous manifestations (especially drug reactions) are likely to become more common. Kaposi sarcoma and other neoplasms may be recognized with increased frequency in HIV-infected children. New or previously unrecognized cutaneous manifestations of pediatric AIDS are likely to emerge. Familiarity with the various dermatologic presentations of pediatric AIDS can result in the earlier diagnosis and treatment of the disease and, hopefully, the prolongation of the patient's life.

Alopecia totalis and vitiligo in common variable immunodeficiency

Three cases of severe and irreversible alopecia occurring in patients with common variable immunodeficiency are described. In all three cases, hair loss developed after the diagnosis of immune deficiency; one of the patients also had extensive vitiligo. A fourth patient had vitiligo in the absence of alopecia. No change in the alopecia or vitiligo was noted in any patient as a result of immunoglobulin replacement therapy.

Detection of a human intracisternal A-type retroviral particle antigenically related to HIV

Sjögren's syndrome is an autoimmune disease that is characterized by dryness of the mouth and eyes. The loss of salivary and lacrimal gland function is accompanied by lymphocytic infiltration. Because similar symptoms and glandular pathology are observed in certain persons infected with human immunodeficiency virus (HIV), a search was initiated for a possible retroviral etiology in this syndrome. A human intracisternal A-type retroviral particle that is antigenically related to HIV was detected in lymphoblastoid cells exposed to homogenates of salivary tissue from patients with Sjögren's syndrome. Comparison of this retroviral particle to HIV indicates that they are distinguishable by several ultrastructural, physical, and enzymatic criteria.

Immunology of AIDS Related to Psoriasis

The association of severe psoriasis with HIV infection, which dysregulates and destroys the human immune system, supports the hypothesis that psoriasis is an immunologically mediated disease. Psoriasis and Kaposi's sarcoma share angiogenesis as basic early findings and could both be caused by differential cytokine expression or responsiveness. AIDS and research models including transgenic mice offer new models in which to study the role of the immune system and specific gene products in the pathogenesis of psoriasis and other skin diseases.

Leukocytoclastic vasculitis in a patient infected with human immunodeficiency virus

We describe a 9-year-old girl with asymptomatic human immunodeficiency virus infection and cutaneous leukocytoclastic vasculitis.

Clinical features of human immunodeficiency virus-associated disseminated herpes zoster virus infection--a review of the literature

Some similarities and several differences in the epidemiological, morphological, therapeutic, and prognostic features of HIV-associated disseminated HZV infection and disseminated HZV infection occurring in HIV-seronegative immunosuppressed patients exist. The severity of the cutaneous disseminated HZV infection, the potential for significant HZV-related morbidity, and the poor prognosis associated with this infection in HIV-seropositive patients, warrants prompt therapeutic intervention. The emergence of acyclovir-resistant HZV infection emphasizes the importance of continued investigation of alternative therapies for individuals with coincident HIV infection.

Disseminated herpes zoster in patients with human immunodeficiency virus infection

Herpes zoster virus infections occur in persons with decreased cellular immunity. A 45-year-old man is described who presented with disseminated herpes zoster as the initial manifestation of his human immunodeficiency virus infection. Disseminated herpes zoster virus infections have been reported in human immunodeficiency virus-seropositive patients. Similar to disseminated herpes zoster virus infections that occur in immunosuppressed patients seronegative for human immunodeficiency virus, an increased morbidity and responsiveness to acyclovir is observed. In contrast, the morphology of the skin lesions and the clinical course have been more severe, and the mortality has been increased. Visceral involvement has not been described.