Targeting tumor necrosis factor alpha. New drugs used to modulate inflammatory diseases

Drug suspending during wound healing effectively weakens immunosuppression-related complications by preserving CD8+ T cell function

Immunosuppressive medications, which interfere with the activation and proliferation of T and B cells, increase the risk of wound healing complications. To address it, this study aimed to validate the feasibility of drug suspending during wound healing, whilst exploring the mechanisms exerted by T cells, which are important in the wound healing process. For this, a mouse skin wound model was set up. Tacrolimus (FK506) and fingolimod (FTY720) were both administered intraperitoneally prior to wounding to inhibit the T cell activation and migration, respectively. Flow-cytometric analysis subsequently revealed the functional T cell subtypes detected during the healing process. A CD8a antibody was also administered to deplete CD8+ T cells in vivo to verify their specific function. It was found that FK506 or FTY720 administration delayed the early phase of wound healing by reducing collagen production, which was also supported by the downregulation of col1a1, col3a1 and tgfb1. However, there was no significant difference in the total healing period. Both spleen- and skin-derived CD8+ T cells were proliferated and activated after injury without intervention, whereas CD4+ T cells showed no significant changes. Furthermore, selectively depleting CD8+ T cells retarded the healing process by downregulating collagen production-associated genes (col1a1, col3a1, tgfβ1 and en1) and proteins (collagen type 1 and 3). In addition, the CD8a antibody decreased the expression of genes lta, tnfa, il13 and il13ra, and protein interleukin-13Rα. In conclusion, suspending immunosuppressive drugs during wound healing was shown to be feasible through restraining the migration of activated T cells. CD8+ T cells represented the primary functional subtype positively associated with wound healing.

Systemic Monotherapy Treatments for Generalized Pustular Psoriasis: A Systematic Review

Generalized pustular psoriasis (GPP) is a rare but serious and difficult to treat cutaneous disease, with high morbidity and mortality rates. Despite the numerous treatment regimens available, the overall quality of evidence-based research is limited with a lack of an algorithmic approach available. In this review, we aim to evaluate the current level of evidence regarding the efficacy and safety/tolerability of systemic monotherapies available in the treatment of GPP. A comprehensive MEDLINE, EMBASE, and PubMed search of clinical studies examining systemic monotherapy treatment options for GPP was conducted. In total, 31 studies met eligibility criteria. Described treatment modalities included retinoids, cyclosporine, biologics, and dapsone. Despite the lack of high-quality evidence or a well-accepted treatment algorithm for GPP, systemic retinoids, cyclosporine, biologics, and dapsone are all possible first-line agents, with retinoids being one of the best-supported treatment options and biologics as an emerging therapeutic field with great potential requiring additional data. However, the final choice of treatment should be considered within the unique context of each patient.

Understanding the New Clinical Landscape for Psoriasis: A Comparative Review of Biologics

Background:

Encouraging results from clinical trials suggest that biologic therapies are effective treatments for psoriasis.

Objective:

The aim of our study was to evaluate the scientific evidence for the efficacy and safety of biologic drugs for psoriasis.

Methods:

The studies reviewed include data on the biologies alefacept, efalizumab, etanercept, and infliximab. This article reviews all data published in the dermatology literature listed in the MEDLINE database, as well as data presented as abstracts and posters at dermatology society meetings, including the annual meetings of the American Academy of Dermatology.

Results:

The majority of the studies used an improvement from baseline of 75% or more in the psoriasis area and severity index (PASI 75) as the primary measure of efficacy.

Conclusions:

Overall, biologics represent an important addition to the psoriatic therapies and have a great impact on the disease course and life quality of those afflicted with psoriasis.

A Review of the Use of Infliximab to Manage Cutaneous Dermatoses

Background:

Infliximab is a chimeric monoclonal antibody that binds specifically to human tumor necrosis factor-alpha (TNF-α), decreasing the effect of the cytokine in inflammatory diseases.

Objective:

The aim of this study was to review the efficacy and safety of infliximab in the treatment of dermatological diseases.

Methods:

A MEDLINE search (1966–January 2003), using the keyword “infliximab” was performed to find relevant articles pertaining to the use of infliximab in dermatology.

Results:

Infliximab has been used in the following dermatological diseases: psoriasis, Behçet's disease, graft versus host disease, hidradenitis suppurativa, panniculitis, pyoderma gangrenosum, SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) syndrome, sarcoidosis, subcorneal pustular dermatosis, Sweet's syndrome, toxic epidermal necrolysis, and Wegener's granulomatosis. There is a generally good safety profile for infliximab, which is similar to that when it is used to treat Crohn's disease and rheumatoid arthritis.

Conclusion:

Although not approved for use in dermatological diseases, there have been numerous reports of the efficacy of infliximab in cutaneous inflammatory diseases. The most promise lies in those diseases that have increased amounts of TNF-α in the cutaneous lesions, such as psoriasis.

Successful Treatment of von Zumbusch Pustular Psoriasis with Infliximab

Background:

Von Zumbusch pustular psoriasis is a severe, generalized form of psoriasis. Patients may also suffer from systemic complications, such as fever, arthropathy, congestive heart failure, and infections, which can ultimately prove fatal. Generalized pustular psoriasis can often be recalcitrant, making treatment difficult.

Objective:

The purpose of this study was to demonstrate the efficacy of infliximab in treating generalized pustular psoriasis.

Methods:

Four consecutively admitted patients with generalized pustular psoriasis were treated with infliximab 5 mg/kg intravenous infusion. ResultsAfter treatment with infliximab, white blood cell count, sedimentation rate, C-reactive protein, and vital signs normalized in all 4 patients within 24 h of the infusion. PASI scores on discharge had improved in all 4 patients.

Conclusion:

All 4 patients with generalized pustular psoriasis had rapid and positive responses to infliximab without any significant side effects. This experience adds support to the use of infliximab for generalized pustular psoriasis.

TNF-α increases the expression and activity of vitamin D receptor in keratinocytes: role of c-Jun N-terminal kinase

Several inflammatory mediators increase calcitriol production by epidermal keratinocytes. In turn calcitriol attenuates the keratinocyte inflammatory response. Since the effect of the in-situ generated calcitriol depends also on the sensitivity to the hormone we studied the effect of inflammatory cytokines on the response of HaCaT human keratinocytes to calcitriol by examining the expression and transcriptional activity of VDR. Treatment with TNF, but not with IL-1β or interferon γ, increased VDR protein level, while decreasing the level of its heterodimerization partner RXRα. This was associated with increased VDR mRNA levels. c-Jun N-terminal kinase, but not P38 MAPK or NFκB, was found to participate in the upregulation of VDR by TNF. The functional significance of the modulation of VDR and RXRα levels by TNF is manifested by increased induction of VDR target gene CYP24A1 by calcitriol. Calcitriol, in turn, inhibited the enhanced expression of VDR by TNF. In conclusion, the inflammatory cytokine TNF increases the response of keratinocytes to calcitriol through upregulation of its receptor VDR, which in turn is subject to negative feedback by the hormone accelerating the return of the keratinocyte vitamin D system to its basal activity. We surmise that the increased generation and sensitivity to calcitriol in keratinocytes play a role in the resolution of epidermal inflammation.

Folate receptor expression on murine and human adipose tissue macrophages

OBJECTIVE AND DESIGN

Adipose tissue macrophages (ATMs) have been implicated in a number of obesity-related diseases. Because the activated macrophages associated with many types of autoimmune and inflammatory diseases express a folate receptor (FR) that can be exploited for FR-targeted drug delivery, we examined the visceral adipose tissue of obese mice and humans to determine whether ATMs also express FR that are accessible by folate conjugates.

MATERIAL OR SUBJECTS

C57BL/6 or FATSO mice fed on either a low- or high-fat diet were used in murine studies. Human adipose tissue were obtained from healthy volunteers during adipose reduction surgery.

METHODS

Visceral adipose tissue was collected from both obese mice and humans, collagenase digested, and stained with folate-Oregon Green and antibodies for macrophage markers including F4/80, mannose receptor (CD206), CD11b, and CD11c. Cells were then examined for expression of the above markers by flow cytometry. Furthermore, the ability of folate conjugates to target the FR-expressing ATMs in obese mice was evaluated in vivo.

RESULTS

A subset of the ATMs harvested from obese mice were found to express FR. Subpopulations of ATMs also simultaneously express both pro- and anti-inflammatory markers, and FR is expressed on both subsets. We then demonstrate that FR-expressing ATMs can be targeted with folate-linked fluorescent dyes in vivo.

CONCLUSIONS

FR are expressed on multiple subsets of ATMs and these subsets can be targeted with folate-linked drugs, allowing for the possible development of FR-targeted therapies for obesity-related inflammatory diseases.

Biologics in dermatology: an integrated review

The advent of biologics in dermatologic treatment armentarium has added refreshing dimensions, for it is a major breakthrough. Several agents are now available for use. It is therefore imperative to succinctly comprehend their pharmacokinetics for their apt use. A concerted endeavor has been made to delve on this subject. The major groups of biologics have been covered and include: Drugs acting against TNF-α, Alefacept, Ustekinumab, Rituximab, IVIG and Omalizumab. The relevant pharmacokinetic characteristics have been detailed. Their respective label (approved) and off-label (unapproved) indications have been defined, highlighting their dosage protocol, availability and mode of administration. The evidence level of each indication has also been discussed to apprise the clinician of their current and prospective uses. Individual anti-TNF drugs are not identical in their actions and often one is superior to the other in a particular disease. Hence, the section on anti-TNF agents mentions the literature on each drug separately, and not as a group. The limitations for their use have also been clearly brought out.

Compound K inhibits MMP-1 expression through suppression of c-Src-dependent ERK activation in TNF-α-stimulated dermal fibroblast

Compound K (CK) is one of the major metabolites of ginsenosides exhibiting a variety of pharmacological properties such as anti-ageing, anti-oxidation and anti-inflammatory activities. However, the protective efficacy of CK in abnormal skin conditions with inflammatory responses was not examined. Here, we investigated the effects of CK on matrix metalloproteinase-1 (MMP-1) and type I procollagen production in tumor necrosis factor-α (TNF-α)-stimulated human skin fibroblasts HS68 cells and human skin equivalents. We found that CK suppressed MMP-1 secretion and increased the level of reduced type I procollagen secretion, caused by the inhibition of extracellular signal-regulated kinase (ERK) activation, but not p38 and c-Jun N-terminal kinase (JNK) activation in TNF-α-stimulated HS68 cells. Then, we focused on the involvement of the c-Src and epidermal growth factor receptor (EGFR) as upstream signalling molecules for ERK activation by TNF-α in HS68 cells. CK suppressed the phosphorylation of c-Src/EGFR by TNF-α, which led to the inactivation of downstream signalling molecules including AKT and MEK. In addition, CK suppressed AP-1 (c-jun and c-fos) phosphorylation as downstream transcription factors of active ERK for MMP-1 expression in TNFα-stimulated HS68 cells. These results showed novel mechanisms by which CK inhibits TNF-α-induced MMP-1 expression through the inactivation of c-Src/EGFR-dependent ERK/AP-1 signalling pathway, resulting in the inhibition of collagen degradation in human fibroblast cells. Therefore, CK may be a promising protective agent for the treatment of inflammatory skin conditions such as skin ageing and atopic dermatitis.

α-Dihydroxychalcone-glycoside (α-DHC) isolated from the heartwood of Pterocarpus marsupium inhibits LPS induced MAPK activation and up regulates HO-1 expression in murine RAW 264.7 macrophage

Three phenolic glycosides isolated from the heartwood of Pterocarpus marsupium showed significant free radical and superoxide ion scavenging activity and antioxidant potential that were comparable to, or several folds higher than those of standard antioxidants, trolox and ascorbic acid. The effective concentrations of these compounds were far below their cytotoxic levels. Compound 3, which was characterized to be α-dihydroxychalcone-glycoside (α-DHC), was the most potent one. Subsequent studies demonstrated that α-DHC effectively reduced nitric oxide and cytokine production by the LPS stimulated RAW 264.7 mouse macrophage cell line. The compound effectively attenuated the expression of inflammation-mediating enzymes COX-2 and iNOS at the mRNA as well as protein levels in a concentration dependent manner. It prevented phosphorylation of all the three MAPKs (JNK, ERK, p38) and eventually blocked the activation of downstream elements contributing to inflammation. Phosphorylation of IκB-α and subsequent translocation of NF-κB into the nucleus were restricted, while the expression of stress responsive gene HO-1 was up-regulated. α-DHC targeted Keap-1 by modifying its cysteine thiols, dissociating it from Nrf-2 and facilitating nuclear entry of the latter; and this in turn induced HO-1 expression. Thus α-DHC exerts its anti-inflammatory activity in a dual manner: by down regulating MAPKs and restricting nuclear stabilization of NF-κB at one end, and by disrupting Nrf-2-Keap-1 complex on the other. In conclusion, the anti-inflammatory potential together with its high therapeutic index envisages α-DHC as a prospective candidate molecule for the development of therapeutic strategy against inflammatory disorders.

miR-424 levels in hair shaft are increased in psoriatic patients

Objective diagnostic markers have not been in clinical use for psoriasis. In this study, we investigated the levels of miR-424 in hair roots and hair shafts in psoriatic patients, and evaluated the possibility that miR-424 can be a biomarker of the disease. A single hair root and five pieces of hair shafts (~5 cm in length) were obtained from the non-lesional occiput of each individual of 26 psoriatic patients. Control hair samples were collected from nine normal subjects. Samples from 10 atopic dermatitis patients were also included as the disease control. miR-424 levels were determined by quantitative real-time polymerase chain reaction. Hair shaft miR-424 levels were significantly upregulated only in patients with psoriasis compared with normal controls and those with atopic dermatitis. By receiver-operator curve analysis of hair shaft miR-424 to distinguish psoriatic patients from normal subjects, the area under the curve was 0.77. However, relative miR-424 levels were not correlated with disease activity markers including disease duration, body surface area and Psoriasis Area and Severity Index. Hair root miR-424 was not useful for evaluating both diagnosis and severity of the disease. Our results indicated hair shaft miR-424 levels may be useful as a diagnostic marker of psoriasis.

A case series of refractory cutaneous sarcoidosis successfully treated with infliximab

INTRODUCTION

Sarcoidosis is a systemic granulomatous disease of unknown cause. The management of sarcoidosis remains problematic. Systemic and topical corticosteroids are the mainstay of therapy but may cause unacceptable side effects. Biologic therapies, such as infliximab, have recently been proposed as another treatment option for cutaneous sarcoidosis.

CASE REPORT

The authors describe three patients who were diagnosed with cutaneous sarcoidosis with systemic involvement. All of the patients were refractory to conventional therapies but responded to infliximab therapy.

CONCLUSION

Infliximab is an alternative medication for refractory sarcoidosis that has a relatively benign side-effect profile. However, definite indications, dosage, interval, and duration of treatment for cutaneous sarcoidosis are not firmly established.

CCL20 Stimulates Proinflammatory Mediator Synthesis in Human Fibroblast-like Synoviocytes Through a MAP Kinase-dependent Process with Transcriptional and Posttranscriptional Control

Objective.

To compare levels of the chemokine CCL20 and its receptor CCR6 in donor, osteoarthritic (OA), and rheumatoid arthritis (RA) synovium; and to determine the molecular mechanism of cellular activation induced by chemokine/receptor ligation in human fibroblast-like synoviocytes (FLS).

Methods.

Synovia and isolated FLS from donor, OA, and RA joints were analyzed for CCL20 and CCR6 expression by RT-PCR and immunohistochemistry. The effect of CCL20 on cytokines and mediators of cartilage degradation was examined by PCR for mRNA expression levels and ELISA, and Western blotting for protein. CCL20-dependent transcriptional and posttranscriptional activation of target genes was monitored using reporter constructs and luciferase assays in transfected donor FLS.

Results.

CCL20 and CCR6 proteins were abundantly expressed in RA synovial lining cells compared to donor or OA synovia as judged by immunohistochemistry. RT-PCR of synovial extracts confirmed the predominance of CCL20/CCR6 mRNA expression in RA synovium. CCL20 mRNA expression was low in donor FLS, but increased dramatically after stimulation with recombinant human (rh) interleukin 1ß (IL-1ß). rhCCL20 increased mRNA and protein expression of COX-2, IL-1ß, tumor necrosis factor-α, IL-6, and the matrix-destructive metalloprotease MMP-3 in donor FLS cultures. High constitutive levels of IL-6 were released from RA synovia; CCL20-induced expression of IL-6 occurred through an NSAID/COXIB-sensitive process. CCL20-induced expression of COX-2 was mediated by a PLCP1/PKCα/MEK1/2/ERK1/2-dependent pathway involving both transcriptional and posttranscriptional mechanisms.

Conclusion.

CCL20/CCR6 may play an important role in the pathogenesis of RA by assembling the molecular and cellular components orchestrating synovitis.

Anti-tumor necrosis factor-α treatment with infliximab for disseminated granuloma annulare

Granuloma annulare (GA) is a chronic inflammatory disease of unknown etiology characterized by the development of plaques preferentially localized to the distal extremities. Spontaneous remission and relapses are quite common and the course of GA is not easy to predict. Moreover, most therapeutic regimens have been used anecdotally and with variable success. We report the case of a 62-year-old White female patient affected by disseminated GA unsuccessfully treated with psoralen plus UVA photochemotherapy, prednisone, and cyclosporine (ciclosporin) who responded to the anti-tumor necrosis factor-α monoclonal antibody infliximab administered intravenously at a dosage of 5 mg/kg at weeks 0, 2, and 6 and thereafter at monthly intervals for 10 additional months. Most of the GA lesions improved within 8 weeks and then slowly resolved within 10 months of treatment. We suggest that infliximab may be proposed as an additional therapeutic option in the treatment of recalcitrant forms of disseminated GA.

Cutaneous scarring: a clinical review

Cutaneous scarring can cause patients symptoms ranging from the psychological to physical pain. Although the process of normal scarring is well described the ultimate cause of pathological scarring remains unknown. Similarly, exactly how early gestation fetuses can heal scarlessly remains unsolved. These questions are crucial in the search for a preventative or curative antiscarring agent. Such a discovery would be of enormous medical and commercial importance, not least because it may have application in other tissues. In the clinical context the assessment of scars is becoming more sophisticated and new physical, medical and surgical therapies are being introduced. This review aims to summarise some of the recent developments in scarring research for non-specialists and specialists alike.

Inhibitory effect of eupatilin and jaceosidin isolated from Artemisia princeps on carrageenan-induced inflammation in mice

ETHNOPHARMACOLOGICAL RELEVANCE

Artemisia princeps Pampanini (family Asteraceae) is an herbal medicine widely used as a hepatoprotective, antioxidative, anti-inflammatory, and antibacterial agent in Korea, China, and Japan.

AIM OF THE STUDY

This study aimed to elucidate the anti-inflammatory effect of the main constituents, eupatilin and jaceosidin, isolated from Artemisia princeps.

MATERIALS AND METHODS

We used carrageenan-induced inflammation in an air pouch on the back of mice and carrageenan-induced hind paw edema in rats to determine the anti-inflammatory effects of eupatilin and jaceosidin. Inflammatory makers, such as expression of pro-inflammatory cytokines and cyclooxygenase (COX)-2, and activation of nuclear factor-kappa B (NF-kappaB), were measured by enzyme-linked immunosorbent assays and immunoblot analyses.

RESULTS

Eupatilin and jaceosidin blocked carrageenan-induced increase in leukocyte number and protein levels in air pouch exudates. Eupatilin and jaceosidin inhibited COX-2 expression and NF-kappaB activation, and markedly reduced TNF-alpha, IL-1beta, and prostaglandin E2 (PGE(2)) levels. They also inhibited hind paw edema induced by carrageenan. Eupatilin and jaceosidin had similar activity.

CONCLUSIONS

These findings suggest that eupatilin and jaceosidin may reduce inflammation by inhibiting NF-kappaB activation, and that Artemisia princeps inhibits inflammation because of these constituents.

A prospective clinical trial of open-label etanercept for the treatment of hidradenitis suppurativa

BACKGROUND

Medical therapies for hidradenitis suppurativa (HS) are often ineffective. Tumor necrosis factor-alpha inhibitors may be a potential treatment for patients with moderate to severe HS.

OBJECTIVES

We sought to evaluate the safety and efficacy of etanercept for patients with severe HS.

METHODS

We conducted a phase II clinical trial of etanercept (50 mg/wk subcutaneously) in patients with moderate to severe HS. Efficacy was measured using a Physician Global Assessment and several secondary physician- and patient-reported outcome measures. Responders were classified as those achieving at least a 50% reduction on the Physician Global Assessment score at week 12 compared with baseline.

RESULTS

Only 3 of the 15 patients who entered the study were classified as responders (response rate of 20%; 95% confidence interval: 4.3-48.1) based on the intention-to-treat analysis. Dermatology Life Quality Index scores improved slightly from a median of 19 to 15 (P = .02). Comparison of baseline with week-12 Physician Global Assessment scores, and secondary outcome measures of lesion counts and patient pain scores, failed to show statistically significant improvement. Etanercept was generally well tolerated; however, two patients discontinued the study as a result of skin infections at the site of hidradenitis lesions requiring oral antibiotics.

LIMITATIONS

Lack of a control group and a small number of participants are limitations.

CONCLUSIONS

Our study demonstrated minimal evidence of clinically significant efficacy of etanercept (50 mg/wk subcutaneously) in the treatment of hidradenitis. Future studies using higher doses of etanercept are indicated; however, patients need to be carefully monitored for infection and other adverse events. Randomized, controlled trials will be necessary to demonstrate the risk-to-benefit ratio of tumor necrosis factor-alpha inhibitors in the treatment of hidradenitis.

Anti-tumor necrosis factor-a for the treatment of steroid-refractory acute graft-versus-host disease

Allogeneic stem cell transplantation has been increasingly performed for a variety of hematologic diseases. Clinically significant acute graft-versus-host disease (GVHD) occurs in 9 to 50% of patients who receive allogeneic grafts, resulting in high morbidity and mortality. There is no standard therapy for patients with acute GVHD who do not respond to steroids. Studies have shown a possible benefit of anti-TNF-a (infliximab)for the treatment of acute GVHD. We report here on the outcomes of 10 recipients of related or unrelated stem cell transplants who received 10 mg/kg infliximab, iv, once weekly for a median of 3.5 doses (range: 1-6) for the treatment of severe acute GVHD and who were not responsive to standard therapy. All patients had acute GVHD grades II to IV (II = 2, III = 3, IV = 5). Overall, 9 patients responded and 1 patient had progressive disease. Among the responders, 3 had complete responses and 6 partial responses. All patients with cutaneous or gastrointestinal involvement responded, while only 2 of 6 patients with liver disease showed any response. None of the 10 patients had any kind of immediate toxicity. Four patients died, all of them with sepsis. Six patients are still alive after a median follow-up time of 544 days (92-600) after transplantation. Considering the severity of the cases and the bad prognosis associated with advanced acute GVHD, we find our results encouraging. Anti-TNF-a seems to be a useful agent for the treatment of acute GVHD.

Augmentation of UVB radiation-mediated early gene expression by the epidermal platelet-activating factor receptor

UVB radiation (UVB) is a known inducer of many biological changes in human skin, and triggers the production of glycerophosphocholines that act as platelet-activating factor (PAF) agonists. To gain a better insight into the role of the epidermal PAF receptor (PAF-R) in UVB-mediated gene expression, Affymetrix oligonucleotide microarrays were used to compare mRNA expression in the PAF-R-negative epithelial cell line KB-expressing PAF-Rs (KBP) with that in KB cells transduced with a vector control (KBM). Total RNA was isolated from KB cells 1 hour after treatment with a PAF-R agonist or UVB irradiation. Treatment of KBP with PAF agonist resulted in altered expression of 220 genes, including cytokines and growth factors. UVB irradiation of KB cells resulted in an increased expression of genes in both cell types. A panel of genes including cytokines CCL20 (MIP3alpha) and tumor necrosis factor-alpha (TNF-alpha) were upregulated selectively in KBP cells and are also selectively upregulated in response to PAF agonist. Consistent with these in vitro findings, UVB irradiation resulted in increased levels of epidermal CCL20 and TNF-alpha mRNA in wild-type over PAF-R-deficient mice in vivo. These studies provide evidence that the epidermal PAF-R can modulate UVB-mediated early gene expression.

Effect of etanercept on insulin secretion and insulin sensitivity in a randomized trial with psoriatic patients at risk for developing type 2 diabetes mellitus

Tumor necrosis factor-alpha (TNF-alpha) inhibitors have been used in the treatment of psoriasis, which is associated with the insulin resistance syndrome. The purpose of this study was to determine the effect of etanercept, a TNF-alpha inhibitor, on insulin secretion and insulin sensitivity in psoriatic patients with high risk factors to develop type 2 diabetes mellitus. Randomized double blind clinical trial with 2 weeks of follow-up. The allocation was done by simple randomization. The investigation was performed in 12 psoriatic patients with indication of systemic treatment and 2 or more risk factors for type 2 diabetes mellitus. Patients with infections, topical corticosteroids or salicylic acid ointments for 6 weeks before the study, diabetes, acromegaly, cancer and other systemic diseases were excluded. All subjects gave written informed consent to participate in the study and the protocol was approved by the hospital-based Ethical Committee. Etanercept was injected in a subcutaneous dose of 25 mg in 1 ml twice by week for 2 weeks or 1 ml of saline solution as placebo. Insulin secretion was estimated with the formula for the homeostasis model analysis beta-cell function index and insulin sensitivity was assessed using the euglycemic-hyperinsulinemic clamp technique. There was no significant difference in insulin secretion and insulin sensitivity with etanercept. Fasting serum insulin levels were decreased in the etanercept group (146 +/- 117-111 +/- 87 pmol/l, P = 0.04). Etanercept did not modify insulin secretion and insulin sensitivity in psoriatic patients with risk factors for type 2 diabetes mellitus.

Use of infliximab in pyoderma gangrenosum

A 57-year-old man, with a 2-year history of Crohn's disease, presented with a rapidly progressive abdominal ulcer. It was clinically and histologically consistent with pyoderma gangrenosum but it did not respond to either high-dose oral prednisolone or intravenous hydrocortisone. Infliximab resulted in an early, dramatic and sustained improvement. His bowel symptoms, which flared a few weeks prior to the onset of pyoderma gangrenosum, only partially improved. Despite six infliximab infusions, the inflammatory bowel disease is poorly controlled, whereas the pyoderma gangrenosum remains healed.

Treatment of inflammatory dermatoses by tumour necrosis factor antagonists

BACKGROUND

The treatment of inflammatory skin diseases is at present often empirical as causal therapeutic approaches, based on an incomplete knowledge of the immune pathogenesis, are mostly unavailable. The currently applied treatments can in fact lead to remission of the disease; however, under certain circumstances undesirable side-effects must be expected. On the basis of experience gained in cytokine modulation therapy of chronic inflammatory diseases such as rheumatoid arthritis and psoriasis, the application of TNF-alpha inhibitors represents a novel, more specific, and effective therapeutic option for distinct chronic inflammatory diseases.

PATIENTS AND METHODS

The current status of the therapeutic effect of TNF-alpha blockers is discussed based on our own observations and a review of the current literature. Also discussed are potential undesirable side-effects and possible contraindications of this therapy.

RESULTS AND CONCLUSIONS

Based on recent findings, the use of TNF-alpha blockers seems to be promising in the treatment of therapy-resistant inflammatory dermatoses. At present, guidelines for indications and contraindications of anti-TNF-alpha treatment of inflammatory skin disorders are rare. Such guidelines are necessary to improve the efficacy of anticytokine treatment and the reduction of side-effects.

Inhibition of chronic skin inflammation by topical anti-inflammatory flavonoid preparation, Ato Formula

Flavonoids are known as natural anti-inflammatory agents. In this investigation, an anti-inflammatory potential of new topical preparation (SK Ato Formula) containing flavonoid mixtures from Scutellaria baicalensis Georgi roots and Ginkgo biloba L. leaves with an extract of Gentiana scabra Bunge roots was evaluated in an animal model of chronic skin inflammation. Multiple 12-O-tetradecanoylphorbol-13-acetate treatments for 7 consecutive days on ICR mouse ear provoked a chronic type of skin inflammation: dermal edema, epidermal hyperplasia and infiltration of inflammatory cells. When topically applied in this model, this new formulation (5-20 microL/ear/treatment) reduced these responses. Furthermore, it inhibited prostaglandin E2 generation (17.1-33.3%) and suppressed the expression of proinflammatory genes, cyclooxygenase-2 and interleulin-1beta in the skin lesion. Although the potency of inhibition was lower than that of prednisolone, all these results suggest that Ato Formula may be beneficial for treating chronic skin inflammatory disorders such as atopic dermatitis.

Effects of anti-inflammatory biflavonoid, ginkgetin, on chronic skin inflammation

Ginkgetin, a biflavonoid from Ginkgo biloba leaves (Ginkgoaceae), was previously demonstrated to inhibit phospholipase A2 and to suppress proinflammatory gene expression such as cyclooxygenase-2 (COX-2) and inducible nitric oxide synthase. In this study, the effects of ginkgetin were examined on an animal model of chronic skin inflammation and proinflammatory gene expression. When topically applied to ICR mouse ear, ginkgetin (20-80 microg/ear/treatment) inhibited ear edema (22.8-30.5%) and prostaglandin E2 production (30.2-31.1%) induced by multiple treatment of 12-O-tetradecanoylphorbol-13-acetate (TPA) for 7 consecutive days. By histological comparison, ginkgetin was also found to reduce epidermal hyperplasia. The expression of proinflammatory gene, interleukin-1beta, was suppressed by ginkgetin. From the results, it is suggested that ginkgetin may be beneficial against chronic skin inflammatory disorders like atopic dermatitis.

Defining the transcriptome of accelerated and replicatively senescent keratinocytes reveals links to differentiation, interferon signaling, and Notch related pathways

Epidermal keratinocytes (KCs) undergo highly orchestrated morphological and molecular changes during transition from proliferative compartment into growth arrested early and late differentiation layers, prior to dying in outermost cornified layers of normal skin. Creation of stratum corneum is vital to barrier function protecting against infection. Transcriptional events in KCs regulating complex processes of differentiation and host defense required to maintain constant epidermal thickness and resistance to infection in either young or aged skin are largely unknown. Furthermore, as terminal differentiation is characterized by irreversible loss of replicative potential culminating in dead layers at the skin surface, this process may be viewed as a form of senescence. However, a complete transcriptional profile of senescent (SN) human KCs has not been previously defined to permit delineation of molecular boundaries involving differentiation and senescence. To fill this void, we utilized global transcriptional analysis of KCs maintained in vitro as either cultures of proliferating (PR) cells, early and late confluent (LC) (accelerated senescence) cultures, or KCs undergoing replicative senescence. Global gene expression profiling revealed early confluent (EC) KCs were somewhat similar to PR KCs, while prominent differences were evident when compared to LC KCs; which were also distinct from replicatively SN KCs. While confluent KCs have in common several genes regulating differentiation with replicatively SN KCs, the latter cells expressed elevated levels of genes involved in interferon signaling and inflammatory pathways. These results provide new insights into cell autonomous transcriptional-based programs operative within KCs contributing to replicative senescence, with partial sharing of genes involved in differentiation. In addition, regulation of KC senescence may involve participation of interferon signaling pathways derived from the important role of KCs in protecting skin from infection. Integrating all of the transcriptional data revealed a key role for Notch receptor mediated signaling in the confluency induced differentiation phenotype using this model system.

Etanerceptbehandlung bei rheumatoider Arthritis—monozentrische Langzeitbeobachtung über vier Jahre

The tumor necrosis factor blocking agent etanercept is effective in the treatment of chronic inflammatory diseases. Previously published studies provided no evidence for an elevated frequency of severe adverse events under therapy. The present work documents efficacy and safety of long-term treatment with etanercept up to four years in 29 patients with rheumatoid arthritis in single German study center. Follow-up examinations were conducted at monthly intervals. The response was assessed in an intention-to-treat analysis (last observation carried forward) according to the ACR and EULAR criteria. The evaluation is based on 95 patient years, the median observation period was 50 (4-52) months. After four years, 21 patients were still in the study. Reasons for study dropouts were inefficacy (n=3), severe adverse events (n=1), long distance to study center (n=2), scheduled surgery (n=1), and desire for pregnancy (n=1). Morning stiffness, the number of painful and swollen joints, C-reactive protein, erythrocyte sedimentation rate, and DAS28 significantly decreased within 6 months. At their most recent visit, 26 patients (90%) had achieved the ACR20, 17 patients (59%) the ACR50, and 6 patients (21%) the ACR70 criteria. Subject to the EULAR criteria, 14 patients (48%) responded well and another 12 patients (41%) moderately well. Severe adverse events occurred in the form of a sigma perforation with subsequent sepsis (week 17), suture insufficiency (twice) following rupture of an Achilles tendon (weeks 3 and 9), pneumonia (week 121), and breast cancer (week 197). In our patients, long-term treatment with etanercept continued to be effective and safe up to four years. Severe adverse events were rare and not more frequent than expected. For the detection of uncommon or late occurring severe adverse events under the treatment with biologic agents, documentation in central registers should be encouraged.

Rapid improvement of recalcitrant disseminated granuloma annulare upon treatment with the tumour necrosis factor-alpha inhibitor, infliximab

Granuloma annulare (GA) is a chronic inflammatory disorder of unknown aetiology, which is characterized clinically by erythematous plaques preferentially localized to the distal extremities, although disseminated variants exist. In light of the chronic relapsing nature of GA and lack of satisfactory treatment options, we initiated treatment with infliximab in a patient with chronic disseminated GA that was recalcitrant to standard treatment. The 59-year-old female patient with insulin-dependent diabetes had experienced GA lesions for more than 4 years despite various systemic and topical treatments. Systemic glucocorticoids were not a therapeutic option because of the preexisting unstable insulin-dependent diabetes. Infliximab was administered intravenously at 5 mg kg(-1) day(-1) at weeks 0, 2 and 6 and thereafter at a monthly interval for an additional 4 months. Most of the GA plaques resolved within 4-6 weeks, leaving postinflammatory brownish macules. Newly arising plaques disappeared within 2 weeks and new GA lesions were not observed during the entire observation period of more than 16 months. Infliximab may be an additional option in the treatment of recalcitrant forms of GA as well as in other chronic granulomatous skin disorders, such as sarcoidosis and necrobiosis lipoidica.

Novel Opportunities in the Treatment and Prevention of Scarring

Numerous treatments have been described for the treatment and prevention of scars, but the optimal management strategy is yet to be defined. In this article we present and evaluate new opportunities for the treatment and prevention of hypertrophic scars, keloids, and atrophic scars. Clinical, animal, and in vitro studies reporting novel techniques for the treatment and prevention of scarring were identified primarily from the MEDLINE/PubMed database. We found that a variety of new treatments exist with potential effectiveness for the treatment of hypertrophic scars and keloids, including interferon, imiquimod 5% cream, tacrolimus, botulinum toxin, 5-fluorouracil, bleomycin, and verapamil. For atrophic scars, different types of lasers represent modern treatment modalities with satisfactory results. Several agents have been reported to be effective in reducing scarring in vitro and in animal studies, representing potential opportunities for scarring management. We conclude that several novel modalities may be potential therapies for scarring.

Is there a role for tumor necrosis factor-alpha inhibitors and especially thalidomide in dermatology?

Because of the relative shortcomings and their side effects of the available anti-inflammatory drugs such as systemic nonsteroids, corticosteroids, and immunosuppressive drugs, and since tumor necrosis factor-a plays a major role in noninfectious inflammatory and autoimmune disorders, tumor necrosis factor-a inhibitory drugs and the available tumor necrosis factor-a inhibitory biologic modifying reagents are described. Among the drugs reviewed are pentoxifylline, thalidomide, etanercept, infliximab, and adalimumab. Their relative effectiveness and side effects are reported and recommendations are made.

Successful Treatment of Von Zumbusch Pustular Psoriasis with Infliximab

BACKGROUND

Von Zumbusch pustular psoriasis is a severe, generalized form of psoriasis. Patients may also suffer from systemic complications, such as fever, arthropathy, congestive heart failure, and infections, which can ultimately prove fatal. Generalized pustular psoriasis can often be recalcitrant, making treatment difficult.

OBJECTIVE

The purpose of this study was to demonstrate the efficacy of infliximab in treating generalized pustular psoriasis.

METHODS

Four consecutively admitted patients with generalized pustular psoriasis were treated with infliximab 5 mg/kg intravenous infusion.

RESULTS

After treatment with infliximab, white blood cell count, sedimentation rate, C-reactive protein, and vital signs normalized in all 4 patients within 24 h of the infusion. PASI scores on discharge had improved in all 4 patients.

CONCLUSION

All 4 patients with generalized pustular psoriasis had rapid and positive responses to infliximab without any significant side effects. This experience adds support to the use of infliximab for generalized pustular psoriasis.

Effects of thalidomide on reproductive function and early embryonic development in male and female New Zealand white rabbits

BACKGROUND

The present work was performed to determine the effect of thalidomide exposure on reproductive function and early embryonic development.

METHODS

Twenty-five female New Zealand White rabbits were orally gavaged with 0, 10, 50, or 100 mg/kg/day thalidomide 14 days prior to mating through to gestation day 7 for a total of 22 days. Treated females were Caesarean-sectioned approximately 29 days after the date of attempted mating. Following mating with treated females, male rabbits (25/dose) were gavaged with 0, 30, 150, or 500 mg/kg/day beginning 14 days prior to mating with a group of untreated females (25/dose). Doses were administered through mating until the day before sacrifice for a minimum of 56 days. Untreated females were Caesarean-sectioned 29 days after the last attempted mating. Comprehensive necropsy and histopathology of the reproductive system were performed.

RESULTS

Treated females had reduction in body weight gain during gestation. Mating and pregnancy parameters were unaffected by thalidomide. At 100 m/kg, litter averages for corpora lutea, implantations, litter sizes, does with viable fetuses and live fetuses decreased and the number of early resorptions, does with any resorptions, does with all conceptuses resorbed, and the percent resorbed conceptuses per litter increased. The number of early resorptions, the average number of early resorptions per litter, and the percent resorbed conceptuses per litter increased at 10 and 50 mg/kg. There were no thalidomide-related external fetal malformations. Mating and fertility in male rabbits were unaffected by thalidomide. There was an increased incidence of flaccid testes at 150 and 500 mg/kg and of bilateral small testes in all treated groups. At 500 mg/kg, there was degeneration of the germinal epithelium of the testicles with an increase in multinucleated giant cells in seminiferous tubule and a loss of round and elongating spermatids.

CONCLUSIONS

Thalidomide had no adverse effects on mating and fertility in male and female rabbits dosed up to 500 and 100 mg/kg/day, respectively, for 14 days prior to mating. After 56 day of dosing, histopathologic changes with no associated sperm abnormalities were observed in the testicles. Embryonic development NOAEL for treated females mated to untreated males was <10 mg/kg. Corresponding fertility NOAEL for treated males mated to untreated females was 500 mg/kg.

Adalimumab: efficacy and safety in psoriasis and rheumatoid arthritis

The next generation of targeted biologic therapies for psoriasis will either be directed against new protein targets or improve on the efficacy, safety, or convenience of medications available for an already validated area in the immune response. Adalimumab is a fully human monoclonal antibody directed against tumor necrosis factor-alpha, a central cytokine in the immune response in psoriasis that has already been shown to be an effective target for therapy. This medication is approved by the US Food and Drug Administration (USFDA) for the treatment of rheumatoid arthritis. Early phrase II studies with adalimumab have shown excellent efficacy for psoriasis with either weekly or every other week subcutaneous injection. Moreover, the safety and tolerability of adalimumab in large clinical studies of rheumatoid arthritis have shown good results. Thus, adalimumab shows significant promise for the therapy of psoriasis in the future.

Inhibition of tumor necrosis factor-alpha reduces atherosclerosis in apolipoprotein E knockout mice

OBJECTIVE

Inflammation plays an important role in atherosclerosis. One of the most potent pro-inflammatory cytokines is tumor necrosis factor-alpha (TNF-alpha), a cytokine identified to have a pathogenic role in chronic inflammatory diseases such as rheumatoid arthritis (RA). The aim of the study was to evaluate the importance of TNF-alpha in atherogenesis.

METHODS AND RESULTS

Mice deficient in both apolipoprotein E (apoE) and TNF-alpha were compared regarding their atherosclerotic burden. Mice were fed a Western-style diet (WD) or normal chow. Mice deficient in both apoE and TNF-alpha exhibited a 50% (P=0.035) reduction of relative lesion size after 10 weeks of WD. Bone marrow transplantation of apoE(o) mice with apoE(o)tnf-alpha(o) bone marrow resulted in a 83% (P=0.021) reduction after 25 weeks on WD. In apoE knockout mice treated with recombinant soluble TNF receptor I releasing pellets, there was a reduction in relative lesion size after 25 weeks of 75% (P=0.018).

CONCLUSIONS

These findings demonstrate that TNF-alpha is actively involved in the progression of atherosclerosis. Accordingly, TNF-alpha represents a possible target for prevention of atherosclerosis. This may be of particular importance in rheumatoid arthritis because these patients have an increased risk for cardiovascular disease.

Treatment of irritant and allergic contact dermatitis

The treatment of contact dermatitis lies principally in the avoidance of the offending agent. In certain circumstances, avoidance protocols are insurmountable, and therapy is rendered to assuage the inflammatory component and its consequent objective and subjective findings. However, the options thereafter vary, as some patients will require continuous symptomatic therapy despite avoidance of the purported offending agent. This manuscript will review established treatment options for contact dermatitis, such as corticosteroids and dietary manipulation, as well as discuss some promising new therapies from the last decade, such as the immunomodulatory and anti-inflammatory agents.

Changing paradigms in dermatology: tumor necrosis factor alpha (TNF-alpha) blockade in psoriasis and psoriatic arthritis

Psoriasis is an inflammatory T cell-mediated disease characterized by epidermal hyperplasia and parakeratosis, resulting in lesional areas of thick and scaling skin. Elevated levels of proinflammatory cytokines, including TNF-alpha, are found in psoriatic lesions. TNF-alpha has many effects in producing an inflammatory response such as stimulating production of pro-inflammatory molecules (eg, IL-1, IL-6, IL-8, NF-kappaB) and adhesion molecules (eg, ICAM-1, P-selectin, E-selectin). As such, TNF-alpha is a target for immunotherapy in the treatment of psoriasis and psoriatic arthritis. The role of TNF-alpha in the pathogenesis of psoriasis is reviewed, along with clinical trials demonstrating the efficacy of new anti-TNF-alpha immunobiologics in the treatment of psoriasis and psoriatic arthritis.