Immunohistochemical analysis of transforming growth factor-beta3 expression in acquired reactive perforating collagenosis

Dupilumab improve acquired reactive perforating collagenosis characterized by type 2 inflammation

Background

Acquired reactive perforating collagenosis (ARPC) is a clinically challenging disease with an unclear pathogenesis.

Objective

To evaluate the efficacy and safety of dupilumab for the treatment of ARPC, and analyze the expression of type 2 inflammation-related molecules in ARPC lesions.

Methods

This retrospective cohort study included 20 patients with ARPC; 10 received dupilumab and 10 received conventional therapy. The efficacy and safety of dupilumab were evaluated at 12 weeks. Immunohistochemical and immunofluorescence analyses of T- and B-cell markers, and type 2 inflammation-related cytokines, were performed on skin samples from ARPC patients, atopic dermatitis (AD) patients, and healthy controls.

Results

Significantly more patients showed improvements in the Investigator Global Assessment score (100% vs. 0%; p < 0.0001) and itching (90%/8.33%, P =.001) in the dupilumab group compared to the conventional group at 12 weeks. There were no adverse effects in the dupilumab group. The ARPC lesions showed enhanced dermal infiltration of CD3+ T-cells, with a predominance of Th2 cells, similar to AD lesions. IL-4 and IL-13 were co-localized with GATA3 in ARPC lesions.

Conclusion

Dupilumab improved ARPC charaterized with type 2 inflammation.

Acquired perforating dermatosis: A clinicopathologic study, and the features of dermoscopy and reflective confocal microscopy of 37 cases

BACKGROUND

Acquired perforating dermatosis (APD) is a rare skin condition characterized by degenerated materials eliminated from the dermis. Several retrospective studies on APD have been reported; however, few data are available on Chinese APD and their features on dermoscopy and reflective confocal microscope (RCM) assays.

OBJECTIVE

The aim of this study was to retrospectively evaluate the clinical and histopathologic data of 37 acquired perforating dermatosis cases, and assess their features on dermoscopy and RCM.

METHODS

Thirty-seven APD patients were retrospectively enrolled in our study. We characterized the clinical histopathological features, concomitant diseases, treatment responses, and the dermoscopy and RCM findings.

RESULTS

Pruritus was the most common symptom, with the lower extremities as the most predilection sites (86.5%, n = 32; 91.9%, n = 34, respectively). Concomitant diseases were found in 34 patients (92.6%), among which diabetes mellitus was the most common, followed by thyroid nodules, allergic dermatosis, and chronic renal insufficiency. Dermoscopy and RCM assays were performed in 11 patients. The typical RCM images were hyperreflective cord-like structures from the epidermis to dermis. Dermoscopy features of fully developed lesions showed central ulceration with peripheral hairpin-like or loop-like capillaries with characteristic garland arrangements.

CONCLUSION

APD is an uncommon skin disorder associated with various systemic conditions in Chinese individuals. Thyroid disorders are an overlooked complication and may play an important role in the development of APD. The results of this study indicate that noninvasive dermoscopy and RCM examination are helpful in the rapid diagnosis and early intervention of APD.

Acquired perforating dermatoses show increased levels of cutaneous advanced glycation end-products

BACKGROUND

Acquired perforating dermatoses (APDs) are characterized by transepidermal elimination of skin materials. Altered glycation of dermal components may be involved in pathogenesis.

AIM

To assess whether patients affected by APDs have increased levels of cutaneous advanced glycation end-products (AGEs).

METHODS

A cross-sectional controlled study involving a total of 109 patients was conducted, enrolling 29 patients consecutively diagnosed with primary APDs [reactive perforating collagenosis (RPC), elastosis perforans serpiginosa (EPS), perforating folliculitis (PF) and Kyrle disease (KD)], 40 age- and sex-matched healthy controls (HCs) and 40 patients with mild atopic dermatitis (AD). The levels of cutaneous AGEs were measured using a validated fluorescence technique.

RESULTS

The median skin autofluorescence value in patients with APDs was significantly higher [2.7 arbitrary units (AU), interquartile range (IQR) 1.9-3.9 AU] compared with HCs (1.8 AU, IQR 1.6-2.3 AU; P < 0.001) and patients with AD (2.1 AU, IQR 1.9-2.3 AU; P = 0.01). Median values were 3.5 AU (IQR 2.7-4.6 AU) for RPC, 1.83.5 AU (1.4-2.4 AU) for EPS, 3.1 AU (2.4-4.4 AU) for PF and 2.6 AU (2.3-3.1 AU) for KD.

CONCLUSIONS

Our results may suggest a possible physiopathological role of AGEs in the transepidermal elimination mechanisms involved in certain APDs.

Pseudoperforation: an uncommon histologic phenomenon in prurigo misleading for the diagnosis of reactive perforating collagenosis

Prurigo is a common skin condition characterized by vigorous scratching. Although ulceration is not uncommon in prurigo, a perforating-like lesion was not previously reported. In this study we described series of cases of prurigo with perforating-like lesions and discussed its relation to acquired perforating dermatoses. The study included 32 cases, during the period from 2008 to 2013. Clinical data and histological features were recorded and analyzed. The study included 78.1% males and 21.9% females with a mean age of 39.3 ± 5.61 years. History of insect bite was evident in 28.1%, hepatitis C virus infection in 46.9%, and diabetes mellitus in 9.4% of patients. Histologically, well developed lesions showed full thickness epidermal degeneration overlay by a cup-shaped crater. The contents of the crater included collagen and elastic fibers, bacterial colonies, inflammatory cells and necrotic keratin. The dermis showed non-altered collagen, increased vascularity and mixed inflammatory infiltrate. We believe that this pseudoperforation process is a secondary response to vigorous scratching in prurigo patients and not a primary mechanism as occurred in perforating dermatoses. The absence of altered collagen, the presence of full thickness epidermal necrosis and concomitant elimination of elastic fibers are significant histologic clues for differentiation between both conditions.

Acquired Reactive Perforating Collagenosis in a Patient with Lung Fibrosis

Reactive perforating collagenosis (RPC) is a rare disorder characterized by the transepidermal elimination of altered collagen. The inherited form of RPC begins in early childhood, but acquired reactive perforating collagenosis (ARPC) begins in adult life. ARPC is associated with diabetes mellitus, renal disease, and malignancy. ARPC with lung fibrosis has not previously been reported in the literature, and the relationship between ARPC and lung fibrosis has not been studied. The etiological relationship between the two disorders appears to be uncertain. Although their association in this case could be due to chance, it may be due to the transforming growth factor beta abnormalities seen in both diseases. In this report, we describe a case of ARPC with lung fibrosis and propose an etiological association between the two diseases.

Acquired reactive perforating dermatosis

Acquired reactive perforating dermatosis is characterized by umbilicated erythematous papules and plaques with firmly adherent crusts. Histopathological examination shows a typical cup-shaped ulceration in the epidermis containing cellular debris and collagen. There is transepidermal elimination of degenerated material with basophilic collagen bundles. The etiology and pathogenesis of acquired reactive perforating dermatosis are unclear. Metabolic disorders and malignancies are associated with this dermatosis. Associated pruritus is regarded as a key pathogenic factor. Constant scratching may cause a repetitive trauma to the skin. This pathogenesis may involve a genetic predisposition. The trauma may lead to degeneration of the collagen bundles. Treatment of acquired reactive perforating dermatosis follows a multimodal approach. Apart from the treating any underlying disease, treatment of pruritus is a major goal. Systemic steroids and retinoids, as well as UVB phototherapy are well-established treatment options. Some patients may also benefit from oral allopurinol.

Transepidermal elimination in cutaneous leishmaniasis: a multiregional study

BACKGROUND

Transepidermal elimination has been documented in a myriad of infectious diseases; however, its occurrence in cutaneous leishmaniasis has not been evaluated.

METHODS

Skin biopsies (n = 212) with cutaneous leishmaniasis in Lebanon (n = 46), Syria (n = 53), Saudi Arabia (n = 45) and Pakistan (n = 68) were evaluated. Clinical data collected included age, gender, eruption type (papule, nodule, verrucous or scar), duration and anatomic location. Histopathologically, multiple parameters were recorded including Ridley's parasitic index and pattern, transepidermal elimination, interface changes, ulceration and necrosis. Transepidermal elimination was defined as the presence of amastigotes in the epidermis in all layers, limited to the basal layer or present in a perforating plug. All cases were confirmed by polymerase chain reaction (PCR) analysis followed by restriction fragment length polymorphism analysis for molecular subspeciation.

RESULTS

Leishmania tropica was identified in 88.2% and Leishmania major in 11.8% of all cases. Transepidermal elimination was observed in 28.3% of cases (29 perforating plug, 19 all layers and 12 basal layer) with a significant prevalence of L. major in this group (35 vs. 2%, p < 0.001). Cases with transepidermal elimination were associated with interface changes and higher parasitic index (p < 0.001) but not with an increased ulceration rate (p > 0.05). Multivariate analysis showed that transepidermal elimination was independently predicted by L. major [OR (95% confidence interval) = 80 (9-712); p < 0.001], parasitic index [OR = 3.4 (2.1-5.3); p < 0.001], interface changes [OR = 6.24 (2.2-17.8); p < 0.001] and necrosis [OR = 0.2 (0.1-0.8);p = 0.026].

CONCLUSIONS

We report the largest multiregional cutaneous leishmaniasis series with a 28.3% documented transepidermal elimination incidence of which 48% were perforating plug; a significant prevalence of L. major was also identified in the transepidermal elimination group. The association of transepidermal elimination with interface changes and a higher parasitic index, without an increased ulceration rate, may reflect a unique biologic alteration in the epidermis, serving to facilitate the extrusion of the parasites through the skin.

Perforating folliculitis in a patient with cystic fibrosis

We report a case of a young man with perforating folliculitis and cystic fibrosis with complications including chronic obstructive pulmonary disease, insulin dependent diabetes mellitus, and liver cirrhosis. We demonstrate increased TGF-β1 immunohistochemical staining in the perforating folliculitis lesions of our patient and discuss the possible associations between cystic fibrosis and perforating folliculitis.

Acquired reactive perforating collagenosis: current status

Acquired reactive perforating collagenosis is a unique perforating dermatosis, characterized clinically by umbilicated hyperkeratotic papules or nodules and histologically by a focal hyperkeratosis in direct contact with transepidermal perforating dermal collagen. Several inflammatory or malignant systemic diseases may coexist with acquired reactive perforating collagenosis. The possible biochemical or immunological mechanisms of the systemic diseases, potentially responsible for the development and appearance of acquired reactive perforating collagenosis, are still under investigation. Several topical treatments, ultraviolet B phototherapy and allopurinol p.o. administration may be effective.

Up-regulation of transforming growth factor-beta3 and extracellular matrix proteins in acquired reactive perforating collagenosis

BACKGROUND

Acquired reactive perforating collagenosis (ARPC) is an uncommon itchy dermatosis of unknown etiology.

OBJECTIVES

We aimed to study clinical features of ARPC and to characterize the expression profiles of proteins which are involved in extracellular matrix remodeling and wound repair.

METHODS

Seventeen patients with ARPC were included in the study. Immunohistochemical analyses were performed for CD34, factor VIIIa, vascular endothelial growth factor, matrix metalloproteinase-1 (MMP-1), tissue inhibitor of metalloproteinase-1 (TIMP-1), transforming growth factor-beta3 (TGF-beta3), Smad-3, and Smad-7.

RESULTS

Twelve patients (70.6%) had diabetes mellitus with disease duration of 14.6 +/- 13.1 years (mean +/- standard deviation). In all patients, chronic kidney disease was evident; two patients were receiving hemodialysis. Preexisting scabies infection was observed in 7 patients (41.2%). CD34 staining was significantly stronger in vessels of perilesional than those of lesional skin (P = .024). TGF-beta3, MMP-1, and TIMP-1 immunoreactivity was significantly stronger in lesional skin as compared with perilesional skin (P = .016, P = .0065, and P = .035, respectively). Although Smad-3 and Smad-7 immunoreactivity did not significantly differ in lesional and perilesional skin, there was a significant correlation between the protein expression of TGF-beta3 and Smad-3 (r = 0.56; P = .02), Smad-7 (r = 0.64; P = .006), and TIMP-1 (r = 0.56; P = .018) expression.

LIMITATIONS

We did not perform polymerase chain reaction studies on mRNA expression.

CONCLUSIONS

Our clinical data indicate that ARPC is etiopathogenetically linked to chronic kidney disease. Overexpression of TGF-beta3 and extracellular matrix proteins may represent antecedent tissue repair and therefore may be considered a significant event in the resolution of ARPC lesions.

Characteristics of acquired reactive perforating collagenosis

The status of the patient's associated disease can generally affect the onset or healing of acquired reactive perforating collagenosis (ARPC). We treated eight cases of ARPC and noted that the patients had similar findings. However, it was not clear why ARPC developed in the patients with these diseases. Nevertheless, several factors related to the diseases associated with ARPC could affect the degeneration of collagen fibers or the production of dermal products. Some patients had diseases that were characterized by fibrosis and an increased amount of reticular fibers. Factors related to tissue remodeling might act not only in diseases associated with ARPC but also in ARPC itself.

Acquired Perforating Dermatosis in a Patient with Poland Syndrome

Acquired perforating dermatosis (APD) is characterized by umbilicated 1- to 10-mm-measuring papulonodules with a central adherent oystershell-like keratotic plug, typically on the dorsa of the hands, forearms and over the knees. APD is associated with systemic diseases, especially diabetes mellitus and/or renal failure. Histologically the lesions show transepidermal elimination of altered dermal components into a cup-shaped epidermal depression. We present a 69-year-old man with coexisting APD and Poland syndrome (PS), an association not yet described. PS (OMIM 173800) is a rare congenital anomaly consisting of unilateral partial or total absence of the greater pectoralis muscle and ipsilateral symbrachydactyly. Most cases of PS are sporadic as it was in our case. Our patient had, in addition, an untreated diabetic condition, hyperuricaemia, dilated cardiomyopathy and a very recent pulmonary embolism. He responded to therapy with allopurinol.