The pathogenic role of pemphigus antibodies and proteinase in epidermal acantholysis

The human skin organ culture model as an optimal complementary tool for murine pemphigus models

Pemphigus is a severe autoimmune bullous disease of the skin and/or mucous membranes caused by autoantibodies that mainly target the adhesion proteins desmoglein (Dsg) 3 and/or Dsg1. Clinically, pemphigus is characterized by flaccid blistering, leading to severe water and electrolyte loss. Before the introduction of corticosteroid treatment, the disease turned out to be fatal in many cases. Despite recent therapeutic improvements, treatment of pemphigus patients is centred on prolonged systemic immunosuppression and remains challenging. Current drug development for pemphigus has a strong focus on disease-causing B cells and autoantibodies and, more recently, also on modulating autoantibody-induced tissue pathology and keratinocyte signalling. This drug development requires reliable pre-clinical model systems replicating the pathogenesis of the human disease. Among those are neonatal and adult mouse models based on the transfer of Dsg3, Dsg1/3 or Dsg1-specific autoantibodies. To reduce the number of animal experiments, we recently established a standardized human skin organ culture (HSOC) model for pemphigus. This model reproduces the clinical phenotype of autoantibody-induced tissue pathology in pemphigus vulgaris. For induction of blistering, a recombinant single-chain variable fragment (scFv) targeting both Dsg1 and 3 is injected into pieces of human skin (obtained from plastic surgeries). Further characterization of the HSOC model demonstrated that key morphologic, molecular and immunologic features of pemphigus are being replicated. Thus, the pemphigus HSOC model is an excellent alternative to pemphigus animal model systems that are based on the transfer of (auto)antibodies.

Mechanism-based therapeutic targets of pemphigus vulgaris: A scoping review of pathogenic molecular pathways

Pemphigus vulgaris (PV) is a potentially fatal autoimmune blistering disease characterised by cell-cell detachment or acantholysis. The mechanisms which follow antibody (Ab) binding and culminate in acantholytic changes and skin/mucosal blistering have not been fully clarified. Current treatment strategies are not specific to PV pathophysiology and although life-saving, harbour considerable side effects. We aimed to systematically assess the molecules amenable to targeted treatments that follow Ab binding and are associated with PV acantholysis. The resulting scoping review was conducted under PRISMA-ScR guidelines with clear inclusion and exclusion criteria and focused specifically on kinases, caspases, proteases, hydrolytic enzymes and other molecules of interest postulated to take part in the pathophysiology of PV. The review process resulted in the identification of 882 articles, of which 56 were eligible for qualitative synthesis. From the included articles, the majority (n = 42) used PV-IgG as the pathogenic agent, mainly via in vitro (n = 16) and in vivo (n = 10) models. Twenty-five molecules were found to play a pathogenic role in PV, including uPA, ADAM10, EGFR, Src, PKC, cdk2, ERK, PLC, calmodulin, NOS, p38MAPK and caspase-3. Selective inhibition of these molecules resulted in varying degrees of reduction in acantholysis and blistering. The pathogenic molecules identified in this review represent potential candidates for clinical translation.

Anti-α-2-macroglobulin-like-1 autoantibodies are detected frequently and may be pathogenic in paraneoplastic pemphigus

Paraneoplastic pemphigus (PNP) shows autoantibodies mainly to plakin and desmosomal cadherin family proteins. We have recently identified alpha-2-macroglobulin-like-1 (A2ML1), a broad range protease inhibitor, as a unique PNP antigen. In this study, we tested a large number of PNP sera by various methods. Forty (69.0%) of 58 PNP sera recognized A2ML1 recombinant protein expressed in COS7 cells by immunofluorescence (IF) and/or immunoprecipitation (IP)/immunoblotting (IB). IP/IB showed higher sensitivity than IF. In addition, 22 (37.9%) PNP sera reacted with A2ML1 by IB of cultured normal human keratinocytes (NHKs) under non-reducing conditions. Statistical analyses using various clinical and immunological data showed that the presence of anti-A2ML1 autoantibodies was associated with early disease onset and absence of ocular lesions. Next, to investigate the pathogenic role of anti-A2ML1 antibody, we performed additional functional studies. Addition of anti-A2ML1 polyclonal antibody to culture media decreased NHK cell adhesion examined by dissociation assay, and increased plasmin activity detected by casein zymography, suggesting that anti-A2ML1 antibody may decrease NHK cell adhesion through plasmin activation by inhibition of A2ML1. This study demonstrates that autoantibodies to A2ML1 are frequently and specifically detected and may have a pathogenic role in PNP.

Pemphigus herpetiformis in childhood

Pemphigus herpetiformis (PH) is a rare pemphigus variant. The clinical features of this form of pemphigus resembles dermatitis herpetiformis, however, histological examination and immunofluorescence yield findings diagnostic for pemphigus. A 5-year-old female patient with clinical features suggestive of dermatitis herpetiformis is reported. Histopathological exam showed skin with subcorneous blisters, epidermal spongiosis containing predominantly neutrophils, few eosinophils and rare acantholytic cells. Direct immunofluorescence showed intercellular deposits of IgG and C3. The skin lesions responded poorly to dapsone associated with systemic corticosteroid therapy. A complete remission of bullous lesions was obtained with azathioprine and immunosuppressive doses of systemic corticosteroids (prednisone). A case of PH in childhood is reported here, emphasizing the rarity and young age of onset.

Experimental human cell and tissue models of pemphigus

Pemphigus is a chronic mucocutaneous autoimmune bullous disease that is characterized by loss of cell-cell contact in skin and/or mucous membranes. Past research has successfully identified desmosomes as immunological targets and has demonstrated that acantholysis is initiated through direct binding of IgG. The exact mechanisms of acantholysis, however, are still missing. Experimental model systems have contributed considerably to today's knowledge and are still a favourite tool of research. In this paper we will describe to what extent human cell and tissue models represent the in vivo situation, for example, organ cultures of human skin, keratinocyte cultures, and human skin grafted on mice and, furthermore, how suitable they are to study the pathogenesis of pemphigus. Organ cultures closely mimic the architecture of the epidermis but are less suitable to answer posed biochemical questions. Cultured keratinocyte monolayers are convenient in this respect, but their desmosomal make-up in terms of adhesion molecules does not exactly reflect the in vivo situation. Reconstituted skin is a relatively new model that approaches organ culture. In models of human skin grafted on mice, acantholysis can be studied in actual human skin but now with all the advantages of an animal model.

Pemphigus in the XXI Century: New life to an old story

In this new century of pemphigus research, the search for novel treatments is switching from a monospecific approach, focused on immunosuppression, to a polyspecific approach that includes drugs acting on novel pathophysiologic pathways. Current research argues that acantholysis in pemphigus occurs as an active process resulting from intracellular signaling triggered as a result of IgG binding to the keratinocyte membrane antigens in a receptor-ligand fashion. Recent progress regarding the pathophysiology of pemphigus acantholysis led to, or was accompanied by, breakthrough discoveries of safer treatments. Both the identification of cell-surface receptors to acetylcholine among the nondesmoglein (Dsg) targets for pemphigus antibodies, and the elucidation of the cholinergic control of keratinocyte cell adhesion provide an explanation for the therapeutic efficacy of cholinomimetics in patients with pemphigus. In patients' skin, Fas-L, TNFalpha, and, probably, IL-1alpha act as autocrine/paracrine co-factors for anti-keratinocyte IgG. Thus, it appears that an array of interconnected signaling cascades is responsible for acantholysis and cell death in pemphigus. Future studies should define the signaling pathways mediating acantholysis that occur in individual pemphigus patients and identify the membrane proteins (receptors) triggering signaling along a specific pathway upon their ligation by autoantibodies. It will be important to determine which pathway 1) leads directly to a loss of cell-cell adhesion (primary pathway), 2) which is being activated due to cell shrinkage/detachment (secondary pathway), 3) which contributes to utilization of altered proteins and organelles (scavenging pathway), and 4) which represents the cell defense (protective pathway). To dissect out the signaling pathways originating from binding of pemphigus IgG to non-Dsg targets on the keratinocyte plasma membrane experiments should be performed in cultures of murine keratinocytes grown from the Dsg3-/- mice or human keratinocytes with the knocked-down expression of the Dsg1 and/or Dsg3 gene by the RNA interference.

Phosphatidylinositol-specific-phospholipase C cleaves urokinase plasminogen activator receptor from the cell surface and leads to inhibition of pemphigus-IgG-induced acantholysis in DJM-1 cells, a squamous cell carcinoma line

We showed previously that pemphigus IgG enhanced both the activity of urokinase plasminogen activator (uPA) in cultured cells and the expression of its receptor (uPAR) on uPA-binding keratinocytes. In the present study, to clarify whether uPAR and uPA-activated plasmin are actually involved in the blistering process after pemphigus IgG binding to the cell surface, we examined the effects of the following on uPAR expression and on cell-cell detachment in DJM-1 cells, a squamous cell carcinoma line: (i) phosphatidylinositol-specific phospholipase C (PI-PLC) - which releases uPAR from the membrane surface into the culture medium by cleaving the glycosylphosphatidylinositol anchor thus inhibiting uPAR activity, and (ii) uPA inhibitors (tranexamic acid, aprotinin, p-aminobenzonic acid and dexamethasone). Preincubation with PI-PLC decreased dramatically the pemphigus IgG-induced uPAR expression in a dose-dependent manner, and inhibited pemphigus IgG-induced cell-cell detachment at 10 microg/mL. On the other hand, tranexamic acid (15 mM) inhibited pemphigus IgG-induced cell-cell detachment without reduction of uPAR expression, although aprotinin, p-aminobenzonic acid and dexamethasone failed to alter either of these parameters. Although uPAR expression on the pemphigus IgG-bound cell surface and uPA activation may contribute significantly to the pathogenesis of acantholysis in pemphigus, the mechanisms are complicated and should be defined further.

The use of plasmapheresis and immunosuppression in the treatment of pemphigus vulgaris

BACKGROUND

Pemphigus vulgaris is an autoimmune blistering disease for which the mainstay of treatment is systemic corticosteroids and immunosuppressants. This therapy had reduced the mortality of pemphigus; however, it is associated with significant morbidity.

OBJECTIVE

The objective of this study was to assess the group's experience with plasmapheresis in the treatment of pemphigus vulgaris and report on its utility.

METHODS

Seven patients with severe or resistant pemphigus vulgaris underwent a series of 5 plasma exchanges over an average of 8 days. Immunosuppressive drugs were administered immediately after plasmapheresis to prevent the "rebound" flare of disease that can occur after plasmapheresis.

RESULTS

Remission was induced in 4 patients, partial remission was induced in 2 patients, and 1 patient continues to have active disease.

CONCLUSION

This study suggests that plasmapheresis is a useful intervention in patients with pemphigus vulgaris who are not responding to standard therapy or who require unacceptably high doses of steroids or immunosuppressants.

Assembly pathway of desmoglein 3 to desmosomes and its perturbation by pemphigus vulgaris-IgG in cultured keratinocytes, as revealed by time-lapsed labeling immunoelectron microscopy

To determine the assembly pathway of desmoglein 3 (Dsg3) into desmosomes and the subsequent effects of pemphigus vulgaris immunoglobulin G (PV-IgG) on such, we employed a time-lapsed labeling for FITC/Rhodamine (Rod) double-stained immunofluorescence and 5-nm/10-nm gold double-stained immunoelectron microscopy by using PV-IgG, which was confirmed to react specifically Dsg3. Cells from a human squamous cell carcinoma cell line (DJM-1) were first treated briefly with PV-IgG (3 min), then incubated in either anti-human IgG-FITC or 5-nm gold antibody-containing medium (5 min), followed by a 60-minute chase in normal medium without antibodies. The same cells were reincubated with PV-IgG medium for 3 minutes, followed by either anti-human IgG-Rod or 10-nm gold antibodies for 5 minutes. Using this method, FITC and 5-nm gold particles show the fate of Dsg3-PV-IgG complexes during the following 60-minute chase. IgG-Rod or 10-nm gold particles, which are bound during the last 5 minutes of the chase, show Dsg3 molecules newly expressed on the cell surface during the 60-minute-chase period. Initially, Dsg3 formed two types of small clusters on the nondesmosomal plasma membrane, ie, either half-desmosome-like clusters with keratin intermediate filament (KIF) attachment or simple clusters without KIF attachment. The PV-IgG binding to Dsg3 caused the internalization of the simple clusters into endosomes, but not the half-desmosome-like clusters. After the 60-minute-chase period, both types of cell surface Dsg3 clusters were labeled with only 10-nm gold, suggesting that new Dsg3 molecules were being delivered to the cell surface. Desmosomes were labeled with both 5-nm gold and 10-nm gold, whereas the half-desmosome-like clusters were labeled with only 10-nm gold, suggesting that the desmosomes themselves were not split. These results suggest that Dsg3 first forms simple clusters, followed by KIF-attachment, and then becomes integrated into desmosomes, and that PV-IgG-induced internalization of the nondesmosomal simple clusters of Dsg3 may represent the primary effects of PV-IgG on keratinocytes.

Pemphigus and bullous pemphigoid

Pemphigus and bullous pemphigoid are distinct autoimmune blistering diseases that are characterised by the presence of autoantibodies directed against specific adhesion molecules of the skin and mucous membranes. The comparison and contrast of molecular mechanism of blister formation of these two diseases provide a rational diagnostic and therapeutic approach to affected patients.

The new pemphigus variants

Pemphigus describes a group of autoimmune diseases characterized by blisters and erosions of the skin and mucous membranes, acantholysis by histology, and autoantibodies directed against epidermal cell surface components. Since the early 1970s, the following new clinical variants of pemphigus have been reported: pemphigus herpetiformis, IgA pemphigus, and paraneoplastic pemphigus. In recent years, significant data have been obtained from laboratory investigation on these rare and atypical variants, especially regarding their specific target antigens. We review these variants, their clinical presentations, histologic findings, immunopathology, target antigens, theories of pathogenesis, treatment modalities, and clinical courses.

Pemphigus vulgaris-IgG causes a rapid depletion of desmoglein 3 (Dsg3) from the Triton X-100 soluble pools, leading to the formation of Dsg3-depleted desmosomes in a human squamous carcinoma cell line, DJM-1 cells

In this study, we examined desmoglein (Dsg) 3 and other desmosomal molecules after pemphigus vulgaris (PV)-immunoglobulin G (IgG) binding to the Dsg3 on the cell surface in DJM-1 cells, a human squamous cell carcinoma cell line. After cells were incubated with PV-IgG for various time periods (0, 5, 10, 20, 30, 60 min, or 30 h), cells were fractionated into phosphate-buffered saline soluble (cytosol), phosphate-buffered saline insoluble-Triton X-100 soluble (membrane), and Triton X-100 insoluble (cytoskeleton) fractions, and subjected to immunoblotting and immunofluorescence microscopy using antibodies against Dsgl, Dsg3, plakoglobin, desmoplakin 1, and cytokeratins. Immunoblot analysis with PV-IgG revealed that Dsg3 was already dramatically depleted from the membrane fraction 20 min after PV-IgG treatment, whereas no reduction of Dsg3 was detected in the cytoskeleton fraction as examined by immunoblotting. A 30 h incubation with PV-IgG, however, caused a marked disappearance of Dsg3, but not other desmosomal molecules, from cytoskeleton fractions. Furthermore, double-staining immunofluorescence microscopy revealed that Dsg3 was depleted from the desmosomes whereas Dsg1, desmoplakin 1, plakoglobin, and keratin filaments were bound to desmosomes. These results provide a novel interpretation for a better understanding of mechanisms for blistering in PV; i.e., a possibility that PV-IgG generates the formation of aberrant desmosomes, which are lacking in Dsg3, but not other desmosomal constituents.

Functional involvement of urokinase-type plasminogen activator receptor in pemphigus acantholysis

Urokinase-type plasminogen activator (uPA) has been well documented in the development of pemphigus acantholysis. The function of its receptor (uPA-R) in pemphigus acantholysis has only recently attracted attention. Increased expression of uPA-R has been demonstrated in pemphigus vulgaris. In this study, we have further explored the functional involvement of uPA-R in pemphigus acantholysis. Our results show that uPA-R expression is significantly increased in acantholytic foci of pemphigus vulgaris and pemphigus foliaceus but not in bullous pemphigoid or normal skin specimens; the expression of uPA-R in cultured human keratinocytes is subjected to regulation by pemphigus vulgaris IgG but not by pemphigoid IgG or normal human IgG; furthermore, anti-uPA-R monoclonal antibody effectively inhibits pemphigus vulgaris IgG induced acantholysis in skin organ cultures. These data suggest that uPA-R may play an important role in the pathogenesis of pemphigus acantholysis.

Pemphigus IgG induces expression of urokinase plasminogen activator receptor on the cell surface of cultured keratinocytes

We previously found that the binding of pemphigus IgG to desmogleins caused marked activation of phospholipase C, a transient increase in inositol 1,4,5-trisphosphate production, and a concomitant increase in the intracellular calcium concentration in DJM-1 cells, a squamous cell carcinoma line. The binding of pemphigus IgG to cell membranes increased the activity of urokinase plasminogen activator in culture medium and induced subsequent cell-cell detachment in DJM-1 cells. Because urokinase plasminogen activator activates the conversion of plasminogen to plasmin by binding to urokinase plasminogen activator receptor evading inhibitors in serum, it is likely that plasmin is generated only in microenvironments adjacent to urokinase plasminogen activator receptor on the cell surface. It is not known whether pemphigus IgG causes acantholysis by inducing urokinase plasminogen activator receptor expression on the cell surface and secreting urokinase plasminogen activator in inhibitor-rich environments. We examined the effects of pemphigus IgG on urokinase plasminogen activator receptor expression in DJM-1 cells and normal keratinocytes by immunoblot analysis and immunofluorescence microscopy using antibodies to urokinase plasminogen activator receptor. IgG were obtained from serum samples from eight patients with bullous pemphigoid, five patients with pemphigus vulgaris, seven patients with pemphigus foliaceus, and eight normal subjects. Pemphigus vulgaris and pemphigus foliaceus IgG significantly increased the urokinase plasminogen activator receptor expression on the surface of DJM-1 cells and normal keratinocytes after 3- and 7-d incubation compared with normal IgG. These results suggest that enhanced urokinase plasminogen activator activity and urokinase plasminogen activator receptor expression activates plasmin in the limited cell surface of pemphigus IgG-bound keratinocytes and may contribute to the pathogenesis of differential acantholysis in pemphigus vulgaris and pemphigus foliaceus.

Three-dimensional cultures of keratinocytes and an application to in vitro-amyloid production of cutaneous amyloidosis

Some three-dimensional culture models of the skin were reviewed including our systems using a collagen dermal substitute and a matrix dermal substitute. No obvious junctional structures, such as hemidesmosomes and the lamina densa, were formed between the basal keratinocytes and the dermal substitutes, when the cytoplasmic membrane of the basal keratinocytes directly faced the collagenous materials. On the other hand, when the cytoplasmic membrane of the basal keratinocytes faced the preformed basement membrane, the type IV collagen film, or the extracellular matrix gel, an organized interaction occurred between the basal keratinocytes and the dermal substitute through hemidesmosomes and a rudimentary lamina densa. Keratinocyte differentiation in the suprabasal layers seemed to be closely related to such a basal cell differentiation. Our preliminary examination of the experimental amyloid production by the epidermal sheet from the lesional skin of patients with primary localized cutaneous amyloidosis suggested that the basal cells in the transplanted lesional epidermis produced amyloid fibrils in our in vitro culture model. This is another use of the three-dimensional culture models of the skin in addition to the application of the systems to wound treatment.

Plasmapheresis for the treatment of pemphigus vulgaris and bullous pemphigoid

Forty-two cases of pemphigus vulgaris (PV) and bullous pemphigoid (BP) were treated with plasmapheresis by one of 3 techniques: centrifugation, double filtration plasmapheresis (DFPP), or a combination of the two. Each plasmapheresis resulted in a rapid reduction in the autoantibody titer and an improvement in clinical symptoms, thereby allowing a lower dose of corticosteroid to be administered and remission to be achieved. These findings suggest that plasmapheresis is an effective treatment for PV and BP patients who have been unresponsive to conventional therapy, for those for whom conventional drugs are contraindicated due to complications, and for those who show severe clinical manifestations.

Pemphigus IgG activates and translocates protein kinase C from the cytosol to the particulate/cytoskeleton fractions in human keratinocytes

We have demonstrated previously that pemphigus vulgaris (PV)-IgG induces activation of phospholipase C (PLC), production of inositol 1,4,5-trisphosphate, and a rapid transient increase in [Ca2+]i in cultured human keratinocytes, leading to secretion of plasminogen activator and cell-cell detachment in cell culture. In the current study, to examine the involvement of protein kinase C (PKC) in the mechanism of blister formation in PV, we studied the PV-IgG-induced translocation of PKC isozymes from the cytosol to the particulate/cytoskeleton (p/c) fractions and the activation of PKC in human keratinocytes. Cells cultured in Eagle's minimum essential medium were incubated with PV-IgGs for 30 s, 1 min, 5 min, or 30 min. PV-IgG binding to the cell surface antigen (desmoglein III) induced translocation of PKC-alpha from the cytosol to the p/c fractions within 30 s, with a peak at 1 min that lasted at least 30 min. PKC-delta also was translocated within 1 min and reached a peak at 5 min but was reduced to basal levels at 30 min. Alternatively, PKC-eta translocation to the p/c fraction was induced slowly, taking more than 5 min, and was reduced to approximately half-maximum at 30 min, whereas PKC-zeta translocation reached a maximum at 30 s, rapidly returning to baseline by 5 min after PV-IgG stimulation. The total PKC activity in the p/c fraction also was increased after PV-IgG exposure, peaked at 1 min, and was sustained for at least 30 min. These findings suggest that a unique activation profile of PKC isomers may be involved in mediating the intracellular signaling events induced by PV-IgG binding to desmoglein III in cultured human keratinocytes.

Proteinase inhibitors and pemphigus vulgaris. An in vitro and in vivo study

The aim of this study was to determine the inhibitory effect of clinically usable proteinase inhibitors p-aminomethylbenzoic acid (PAMBA), and aprotinin on acantholysis in skin organ culture and in clinical trials with pemphigus patients. PAMBA added to the culture medium at a concentration of 1 mg/ml fully prevented the acantholysis, while Contrykal at 10 ATrE/ml reduced acantholysis. Subsequently, we treated 12 patients (groups 1) with PAMBA 100-200 mg daily for 7 to 26 days in combination with a moderate dose of corticosteroid (mean dose 36.1 mg prednisolone equivalent) or immunosuppressive drugs. A second group of 12 patients (group 2) were treated with a high dose of corticosteroid (mean 94.2 mg prednisolone equivalent) and immunosuppressive drugs. Evaluation was performed before treatment, after 3 weeks and on discharge using a clinical scoring system. The inclusion of PAMBA in the treatment protocol of group 1 resulted in active disease being brought under control with lower corticosteroid doses. As a result, fewer side effects were observed in group 1 than in group 2. In our opinion, protease inhibitors may be useful as adjuvant drugs in the combination therapy of pemphigus.

Bullous skin diseases

Fundamental advances in the fields of molecular biology and immunology have facilitated investigation of the autoimmune blistering disorders. Recently, the use of human autoantibodies has helped to identify biologically important adhesion molecules of the skin, and the pathogenic mechanisms involved in bullous skin diseases are now being precisely defined.

Pharmacologic evidence for involvement of phospholipase C in pemphigus IgG-induced inositol 1,4,5-trisphosphate generation, intracellular calcium increase, and plasminogen activator secretion in DJM-1 cells, a squamous cell carcinoma line

The precise mechanism for acantholysis after pemphigus IgG binds to the cell surface is as yet unknown, although involvement of proteinases such as plasminogen activator (PA) has been suggested. We previously reported that pemphigus IgG, but not normal nor bullous pemphigoid IgGs, caused a transient increase in intracellular calcium ([Ca++]i) and inositol 1,4,5-trisphosphate (IP3) concentration in cultured DJM-1 cells (a squamous cell carcinoma line). To clarify whether phospholipase C is involved in this process after the antibody binds to the cell surface, we examined the effects of a specific phospholipase C inhibitor (U73122) on the pemphigus IgG-induced increase in [Ca++]i, IP3, PA secretion, and cell-cell detachment in DJM-1 cells. [Ca+2]i and IP3 contents were determined with or without 30-min pre-incubation with U73122 or an inactive analogue (U73343) with fura-2 acetoxymethylester and a specific IP3 binding protein, respectively. PA activity in the culture medium was measured after various incubation periods with pemphigus IgG by two-step amidolytic assay. The detachment of cell-cell contacts was examined by detecting the retraction of keratin filament bundle from cell-cell contact points to the perinuclear region by immunofluorescence microscopy using anti-keratin antibody. Pemphigus IgG immediately increased [Ca++]i and IP3 content. PA activity in the culture medium has also been increased at 24 h after pemphigus IgG was added in association with cell-cell detachment. However, pre-incubation with U73122 (1-10 microM), but not with U73343 (10 microM), dramatically reduced the pemphigus IgG-induced increases in [Ca++]i, IP3, and PA activity and inhibited the pemphigus IgG-induced cell-cell detachment. Both U73122 and U73343 caused no effects on cell viability and IgG binding to the cell surface. These results suggest that phospholipase C plays an important role in transmembrane signaling leading to cell-cell detachment exerted by pemphigus IgG binding to the cell surface.

Pemphigus IgG, but not bullous pemphigoid IgG, causes a transient increase in intracellular calcium and inositol 1,4,5-triphosphate in DJM-1 cells, a squamous cell carcinoma line

It is still unclear what kinds of mechanisms are involved in blister formation after antibodies bind to the antigens in pemphigus and bullous pemphigoid. The effects of IgGs from pemphigus vulgaris, pemphigus foliaceus, and bullous pemphigoid sera on intracellular calcium concentration ([Ca++]i) and inositol 1,4,5-trisphosphate were examined in a human squamous cell carcinoma cell line (DJM-1 cells) and in cultured human keratinocytes to clarify whether signal transduction via calcium is involved. IgGs were purified with protein A affinity column from the sera of five pemphigus vulgaris patients, three pemphigus foliaceus patients, eight bullous pemphigoid patients, and 14 normal volunteers. Keratinocytes were cultured in Eagle's minimum essential medium containing 1.8 mM Ca++ and loaded with fura-2/AM, followed by addition of the IgGs. Subsequently, [Ca++]i was determined by measuring the fluorescence ratio (F340/F360) with videomicroscopy. Pemphigus IgGs (seven of eight cases) induced a rapid and transient increase in [Ca++]i in both the cells, whereas a [Ca++]i increase was caused by very few IgGs from bullous pemphigoid (one of eight cases) and normal sera (two of 14 cases). The pemphigus IgG-induced transient [Ca++]i increase was not affected by chelating extracellular Ca++ with ethyleneglycol-bis(beta-aminoethyl ether)-N,N,N',N'-tetracetic acid. In addition, monoclonal antibodies acid. In addition, monoclonal antibodies against 180-kD and 230-kD antigens did not exert this change. Pemphigus IgGs that caused a [Ca++]i increase induced rapid and transient production of inositol 1,4,5-trisphosphate, peaking at 20 seconds. These findings suggest that IgG from pemphigus induces Ca++ mobilization by inositol 1,4,5-trisphosphate from internal stores, and that mechanisms of antibody-transmitted signaling in pemphigus may differ from those in bullous pemphigoid.

Transient acantholytic dermatosis induced by recombinant human interleukin 4

BACKGROUND

Interleukin 4 is one of many cytokines under investigation about its possible role in the pathogenesis and treatment of disease. Transient acantholytic dermatosis is of uncertain origin. It has not previously been linked to drug ingestion and is generally not believed to have an immunologic basis.

OBJECTIVE

Our purpose was to describe the clinical characteristics and histologic features of a cutaneous eruption caused by interleukin 4.

METHODS

Three patients in whom an eruption developed after they received intravenous recombinant human interleukin 4 were examined and biopsy specimens were evaluated.

RESULTS

These patients had a pruritic papulovesicular eruption that was consistent, both clinically and histologically, with transient acantholytic dermatosis. None of the other conditions believed to precipitate transient acantholytic dermatosis was present in our patients.

CONCLUSIONS

This is the first report of a cutaneous side effect of interleukin 4. This may be antibody-mediated or related to increased production of tissue-type plasminogen activator.

Production of staphylococcal impetigo-like lesion on human skin explants in culture

We produced a highly reproducible experimental impetigo-like lesion in normal human skin explants in culture. The three Staphylococcus aureus strains we used were an isolate from a human impetigo (E strain), an isolate from a human furunculosis (N strain) and ATCC 29213 strain. E strain was a protein A positive, coagulase type V, producer of exfoliative toxin (ET) and beta-toxin. N strain was a coagulase type IV, ET non-producer and alpha-toxin positive. ATCC 29213 was a coagulase type II, ET non-producer, and alpha-, beta-, and delta-toxin positive. Normal human skin samples were obtained from 8 adult skin surgery patients. One specimen was obtained from human oral mucosa. Small pieces of the samples were slightly abraded on the epidermal surface and cultured on lens paper rafts floating in Eagle's Minimum Essential Medium in an atmosphere of 5% CO2 and 95% air. Fifty microliters of the respective bacterial suspensions were applied to the epidermal surfaces of the explants. The inoculated surfaces were then occluded under sterile plastic plaster. Histologically, the formation of intraepidermal blisters at the granular layer level with acantholytic cells was observed in all 8 of the skin specimens at 10 h after inoculation with E strain. The specimen from an oral mucous membrane did not produce similar changes with any of the three S. aureus strains. Neither N or ATCC strains developed bullae in the epidermis at 6, 10 or 18 h after inoculation. Immunofluorescent examination revealed that the inner surfaces of blisters in the epidermis were lined with anti-ETA antibody. Under the electron microscope, the blisters of the specimens which had been inoculated with strain E contained only a few S. aureus cells. These results suggest that blister formation at the granular layer level with acantholytic cells is mediated by ET action at the granular layer level and occurs without invasion of lymphocytes or neutrophils, or the involvement of any serum components. Therefore, under appropriate conditions, impetigo could develop even in adults.

Oral presentation of pemphigus vulgaris and its response to systemic steroid therapy

This article reviews our experience during a 20-year period with patients with oral lesions of pemphigus vulgaris. Of the 30 patients, 20 were women and 10 were men, with an age range of 24 to 68 years. The soft palate was involved in 80% of cases at initial presentation. Direct immunofluorescence studies were positive for IgG in the intercellular region in all cases where lesional tissue was histologically studied. Systemic steroid therapy alone controlled the disease in 24 patients, one patient was given no treatment, and the remaining five required additional treatment with either azathioprine, cyclophosphamide, or gold. Steroid therapy was continued in the long-term at a reduced dose, but side effects such as diabetes mellitus, hypertension, and duodenal ulcers were observed. Long-term steroid therapy is therefore the treatment of choice for the oral lesions of pemphigus vulgaris, but in some cases alternative treatment options may be required.

Different effects of pemphigus antibody and plasmin on the distribution of keratin intermediate filaments and desmoplakins between cultured oral and epidermal keratinocytes

In order to clarify the molecular mechanism of blister formation in oral mucosa in pemphigus vulgaris (PV) comparing with that in epidermis, we analyzed the effects of PV serum on the distribution of keratin intermediate filaments (KIFs) and desmoplakins in oral as well as epidermal cultured keratinocytes by immunofluorescence microscopy using anti-keratin and anti-desmoplakin I/II monoclonal antibodies. After incubation with PV serum for 96 h at 37 degrees C, clusters of anti-keratin positive dots were formed around the nucleus in some of the keratinocytes from normal gingiva and soft palate but not in keratinocytes from tongue and skin, and desmoplakins also changed their distribution from linear arrangement at cell-cell contacts to clusters of dots around the nucleus in gingiva but not in epidermal keratinocytes. The dotted structures similar to those induced by pemphigus serum were formed also by incubation with human plasmin in gingival keratinocytes. However, no dot-formation of keratins was induced in these cells after incubation with trypsin. Furthermore, in epidermal keratinocytes, no keratin-dot formation was observed even after incubation with plasmin or trypsin. These results suggest that the dotted structures of KIFs caused by PV serum and plasmin might be a feature characteristic for the response of oral keratinocytes to PV serum and that there are some distinct differences in susceptibility to, and mode of, bulla formation between oral epithelium and epidermis.

Expression of extracellular and intracellular bullous pemphigoid antigens at the dermal-epibolic junction in organ culture of human skin

Recent papers have reported that there are at least two distinct binding sites of bullous pemphigoid (BP) antibodies; one is the extracellular (lamina lucida) BP antigen (E-BPA) and the other is the intracellular (basal cell cytomembrane-hemidesmosome-cytoskeleton) BP antigen (I-BPA). In attempting to characterize the properties of these two BP antigens (BPA), we have investigated the expression of E-BPA and I-BPA as well as other basement membrane zone (BMZ) components such as type IV collagen, laminin, and epidermolysis bullosa acquisita (EBA) antigen at the dermal-epibolic junction as a model system for BMZ neogenesis. I-BPA was found along the dermal-epidermal junction and throughout the whole length of the dermal-epibolic junction. However, E-BPA and other BMZ components were found along the dermal-epidermal junction and along only the most proximal portion of the dermal-epibolic junction. These results suggest 1) that emergence of E-BPA varies from that of I-BPA in such a model system of BMZ neogenesis, and 2) that the emerged E-BPA may attach to the newly formed basement membrane complex.

Vesiculobullous mucocutaneous disease: pemphigus vulgaris

Pemphigus vulgaris is a potentially fatal autoimmune mucocutaneous disease in which oral lesions may be the initial and predominant manifestation. The disease is characterized by acantholysis in the immediately suprabasal layers of the stratified squamous epithelium, giving rise to blisters which readily rupture leaving erosions which show little tendency to heal. Immunogenetic studies indicate a marked genetic susceptibility to the disease, with the immune response-associated HLA-DR4 and DRw6 alleles being especially important. The trigger for autoantibody formation is unknown. The antigen in pemphigus vulgaris is probably a 130-140 kD cell adhesion molecule located in the cell membrane of basal and immediately suprabasal keratinocytes. Antibody binding to this antigen is likely to interfere with normal intercellular adhesion, leading to desmosomal detachment. Propagation of acantholysis and cell damage are attributable to complement activation, with deposition of the membrane attack complex on the keratinocyte cell membrane, and proteolysis due to increased plasminogen activator production. Steroid therapy is the treatment of choice, but significant mortality is still associated with the disease.

Ultrastructural studies of acantholysis induced in vivo by passive transfer of IgG from endemic pemphigus foliaceus (Fogo Selvagem)

Intraperitoneal (IP) injections of IgG from patients with Endemic Pemphigus Foliaceus [Fogo Selvagem (FS)] cause acantholysis in BALB/c mice (JID. 85:538, 1985). The dynamic ultrastructural changes of FS IgG-induced acantholysis in mice are the subject of this study. FS IgG was injected IP into neonatal BALB/c mice. Skin and serum was studied at 0, 1, 3, 6, 12, 18, and 24 h post injection by immunofluorescence (IF), electron microscopy (EM), and immuno-EM. Binding of FS IgG in the intercellular spaces (ICS) of the basal cell layer was seen by IF within 1 h and was strongest at 12 h. IgG binding affected the spinous and granular cell layer by 12 h, then faded and remain localized only in the basal cell layer at 24 h. By immuno-EM, IgG binding was diffuse along the keratinocyte surface. Edema of the ICS in the basal cell layer was present at 1 h by EM. At 12 h, there was microvillous formation with intact desmosomes at the tip of the projections. Splitting of desmosomes (forming half desmosomes) and acantholysis primarily affecting the granular cell layer were most prominent between 12 and 24 h. The plaques of the half desmosomes gradually disappeared and tonofilaments retracted into the cytoplasm. Detaching keratinocytes showed vacuolization, swollen mitochondria, and internalization of intact desmosomes and half desmosomes (remnants of split desmosomes). This investigation shows that the ultrastructural changes observed in the epidermis of patients with FS can be duplicated in experimental animals by IP injection of FS IgG. Further, FS IgG may have direct effects on the assembly/disassembly of desmosomes.

Proteinase inhibitors block formation of pemphigus acantholysis in experimental models of neonatal mice and skin explants: effects of synthetic and plasma proteinase inhibitors on pemphigus acantholysis

In organ culture experiments, the induction of pemphigus acantholysis is known to be blocked by the addition of serine proteinase inhibitors. Recently, nontoxic synthesized low molecular weight proteinase inhibitors have been clinically available for the treatment of disseminated intravascular coagulation and pancreatitis. To determine if these drugs are useful aids to treat patients with pemphigus, we examined the effect of omega-guanidino ester analogues, i.e., 1) gabexate mesilate, 2) camostat mesilate, and 3) nafamostat mesilate, on experimental pemphigus acantholysis in both organ culture and neonatal BALB/c mice. Furthermore, the effect of plasma natural proteinase inhibitors (alpha-1-proteinase inhibitor) isolated from human plasma was similarly examined. Results revealed that synthesized low molecular weight inhibitors (drugs) were able to inhibit the induction of acantholysis in organ culture system, but had little or no effect on lesion formation in the neonatal mouse system. By contrast, alpha-1-proteinase inhibitor could completely inhibit acantholysis formation in mice. These findings implied a possible new therapeutic approach using proteinase inhibitors for patients with pemphigus.

Binding modes of IgG from pemphigus autoimmune sera onto guinea pig keratinocytes and the fate of bound IgGs

Pemphigus is an intraepidermal autoimmune blistering disease of humans caused by circulating IgGs. We have investigated the binding mode and the fate of bound antibodies from Pemphigus sera (P-IgG) on guinea pig keratinocytes in suspension in order to find clues to the loss of cell adhesion in vivo (acantholysis). Flow cytometry, following indirect immunofluorescent labeling of the keratinocytes, and dead cells' staining with ethidium bromide, demonstrated the specific surface binding of P-IgG onto living keratinocytes only. This was shown with several Pemphigus sera or purified P-IgG. This technique, used with various Pemphigus sera, showed that the specific binding is increased when the serum titer is higher, and "Km" values for P-IgG were roughly and inversely correlated to the titers. Upon saturation the same average number of Pemphigus IgG sites per cell were found for the sera of different patients. Analysis of the specific binding of [125I]-P-IgG onto Percoll-separated (living) keratinocytes showed the existence of two classes of sites: 2 x 10(6) sites/cell high-affinity sites (Kd = 1.5 x 10(-6) M total IgG) and 25 x 10(6) sites/cell low-affinity sites (Kd = 6 x 10(-5) M total IgG). Cell sorting and flow cytometry of individual cells allowed us to correlate the light-scattering signal, the RNA content, the size and morphology, and the P-IgG binding to the cells. The results indicated that P-IgG binding is homogeneous within the living keratinocytes and increases with cell size (cell maturity). Cell-sorter analysis of cells with membrane-bound P-IgG, coupled to direct determination of P-IgG released in the medium, revealed the fate of bound P-IgG: 40-60% of the P-IgGs were released in the medium within 30 minutes at 37 degrees C. This was accompanied and followed by a much slower, metabolic energy-dependent, internalization process of the membrane-bound P-IgG. The internalization has been confirmed by electron microscopy of bound P-IgG labeled with protein A-gold. Internalized IgGs were seen in the cells in coated membranous vesicles and other endocytic compartments. Similar behavior was also observed with two other membrane ligands: i.e., concanavalin A and multispecific rabbit "antisurface" antibodies.

Pemphigus

The term pemphigus refers to a group of autoimmune intraepidermal blistering diseases of the skin and mucous membranes. Several clinical variants of pemphigus are recognized. The major histologic feature of all variants is acantholysis, the disruption of normal cell-to-cell adhesion, which leads to intraepidermal blister formation. Most patients with pemphigus demonstrate IgG autoantibodies directed against an antigen located on the surface of keratinocytes. Although the stimulus for autoantibody production is unknown, several mechanisms have been proposed to explain the pathogenesis of acantholysis. One popular model proposes that pemphigus antibodies induce acantholysis through local stimulation of the plasminogen-plasmin system. Another model proposes that pemphigus antibodies fix complement and thereby alter cell membrane integrity to produce acantholysis. Prior to the availability of corticosteroids, pemphigus vulgaris was commonly fatal. Treatment with glucocorticosteroids has drastically improved the prognosis. Immunosuppressive agents and plasmapheresis have been used successfully in some patients with severe disease.

Experimental suprabasal bulla formation in organ cultured human skin with low calcium medium

The effect of calcium ions on human epidermis was studied using an organ culture system. Acantholysis-like suprabasal cleft formation was constantly observed within 12 hours, when normal human skin explants were cultured in medium with less than 0.1 mM of calcium ions. This change resembled that induced by pemphigus serum observed with light or electron microscopy. This effect was greatly enhanced by the presence of fetal calf serum and was reversed when normal calcium concentrations were added back. Pemphigus antigen was not reduced in the explants. This change was inhibited by alpha 2-macroglobulin, a proteinase inhibitor with a wide spectrum. Biochemical study did not show apparent change of glycoproteins in epidermal cells. Therefore, it is most likely that this phenomenon is induced by some proteinase(s) which is(are) released from epidermal cells in the presence of fetal calf serum and activated at very low calcium ion concentration. Furthermore, this system is considered to be more useful than the cell culture system to study the effect of calcium ions in organized epidermis.

Involvement of urokinase-type plasminogen activator in acantholysis induced by pemphigus IgG

Pemphigus IgG induces acantholysis in skin organ culture without the involvement of complement. Urokinase-type plasminogen activator, a proteolytic enzyme, has been implicated in the development of acantholysis. To test this hypothesis, we prepared a rabbit anti-urokinase antibody, which inhibited the plasminogen activator activity in normal human epidermis and in cultured keratinocytes. When added to skin organ cultures along with pemphigus IgG, anti-urokinase IgG completely prevented the development of acantholysis. Normal or preimmune rabbit IgG had no effect on pemphigus IgG-induced acantholysis. Plasminogen activator converts the zymogen plasminogen to its active form plasmin, a broad specificity serine proteinase. When high concentrations of plasminogen alone were added to skin organ culture, acantholysis of the pemphigus foliaceous type was induced. Anti-urokinase antibody also inhibited plasminogen-induced acantholysis. These results strongly support a pivotal role for plasminogen activator in the development of acantholysis.

Effects of pemphigus antibody on the regeneration of cell-cell contact in keratinocyte cultures grown in low to normal Ca++ concentration

Pemphigus is an autoimmune blistering disease of epidermal cells in which autoantibodies to the surface develop. The present study was performed to determine whether the binding of pemphigus antibodies to the surface of keratinocytes can inhibit the regeneration of cell-cell contact induced by altering from low to normal Ca++ concentration medium. Human keratinocytes (a cell line of squamous cell carcinoma, DJM-1 cell) were grown in low Ca++ medium for 4 days, then the cells were incubated in normal Ca++ medium containing 10% pemphigus (4 patients with pemphigus vulgaris and 4 patients with pemphigus foliaceus) or normal serum (treated at 56 degrees C, for 30 min) for various incubation periods (2, 6, 12, 24 h). The cells were fixed and stained with antikeratin antibody by the indirect immunofluorescence method so that the detachment of cell-cell contact was able to be clearly visualized by observing the cytoskeletal arrays of keratin filaments. The cells grown in normal Ca++ medium showed detachments of cell-cell contact 24-36 h after addition of any one of the pemphigus sera used in this study. The cells grown in low Ca++ medium formed no cell-cell contacts and expressed no pemphigus antigens. However, re-formation of cell-cell contacts and reexpression of the antigens were confirmed by immunofluorescence microscopy 30 min after the addition of Ca++ to the medium. The addition of any pemphigus vulgaris and foliaceus sera with Ca++ did not inhibit the regeneration of cell-cell contact and exerted no effects on the contact during the subsequent 12 h. However, after 24 h, these cells again lost the contact. These results indicate that pemphigus antibody and antigen reaction on the cell surface did not directly inhibit the Ca++-induced re-formation of cell-cell contact.

Chronic balanitis owing to pemphigus vegetans

Pemphigus is an autoimmune bullous dermatosis in which intercellular antibodies are associated with loss of intercellular cohesion. Pemphigus vegetans, a rare variant of pemphigus, is manifested by vegetating plaques, usually in intertriginous areas of patients who probably have an increased resistance to the disease. We report a case of chronic balanitis owing to pemphigus vegetans, and discuss proposed pathogenic mechanisms and treatment.

Blister fluid from epidermolysis bullosa letalis induces dermal-epidermal separation in vitro

Normal human skin was cultured with blister fluid (BF) from 2 patients with epidermolysis bullosa letalis (EB letalis). After 12-24 h incubation, initial separation was observed at the dermal-epidermal junction. Complete separation was seen after 48-72 h incubation. Epidermal and dermal structures themselves were well preserved up to 72 h. Electron microscopy revealed that the separation took place through the lamina lucida. These findings corresponded to in vivo histologic pictures of the skin lesions. The activity in BF was lost by lowering (pH 4) or elevating (pH 9) pH of the media or by prolonged autoclaving (5h). Boiling and dialization did not affect the activity of BF. Certain protease inhibitors, such as alpha 2-macroglobulin, aprotinin (trasylol), soybean trypsin inhibitor, phenylmethylsulfonylfluoride, or 50% fetal bovine serum, inhibited or depressed the separation, while triamcinolone acetonide, n-ethylmaleimide, or EDTA did not. Patient's serum (case 2) and normal human sera partially inhibited cleft formation. It was proposed that in EB letalis some factors in BF, probably protease(s), play an important role in the induction and/or spread of blister.

Human pemphigus autoantibodies are pathogenic to squamous epithelium

In 1957, Witbesky et al. put forward several criteria that ideally should be fulfilled in order to prove the pathogenic role of an autoantibody in a putative autoimmune disease. There can now be very little doubt of the autoimmune nature of this disease and of the primary role of autoantibodies in its pathogenesis. The evidence that supports the concept that pemphigus autoantibodies are of primary pathogenic importance in the disease is as follows: IgG class autoantibodies can be found both circulating in the serum and bound to the epithelial cell surfaces in and around lesions in patients with pemphigus. These autoantibodies, purified from the serum of pemphigus patients, can induce acantholytic lesions typical of pemphigus both in experimental animals (neonatal mice) and in human and murine epidermal cell cultures. These autoantibodies react with a specific antigen of the epidermal cell. This purified antigen has been used to immunize rabbits and the resulting antibodies are capable of inducing pemphigus-like lesions in neonatal mice.

Effects of pemphigus antibody on the organization of microtubules and keratin-intermediate filaments in cultured human keratinocytes

It has been suggested that pemphigus antibodies (PA) react with the surface molecules on keratinocytes, and induce the production and release of proteases resulting in acantholysis. If this is the case, the immunoreactions on the cell surface may send signals to the interior of the cell across the membrane. The present study was carried out to determine whether or not cytoskeletons [microtubules (MT) and keratin-intermediate filaments (KIF)] respond to PA-immunoreactions in cultured human keratinocytes, by indirect immunofluorescence microscopy using anti-keratin and anti-alpha-tubulin antibodies. During incubation for 30 min to 72 h in a PA-containing medium with a normal concentration of Ca2+ (1.2 mM), no changes in MT or KIF organization were detected. Alterations in the organization of these filaments were observed 96 h after addition of PA. When cells grown in a normal medium for 5-7 days were transferred to a medium containing PA and a low level of Ca2+ (0.07-0.14 mM) the reorganization of KIFs and MTs occurred after 1 h incubation. However, no reorganization of the cytoskeletons was detected in the absence of cell detachment. These observations suggest that the pemphigus antibody-induced reorganization of MTs and KIFs does not precede acantholysis and is probably secondary to it, but is not a direct transmembrane response. The present study also showed that immunofluorescence microscopy of KIFs may be one of the most sensitive methods for detecting early cell-to-cell dissociation in cultured keratinocytes.

Morphological studies on cellular detachment induced by antibody reactions directed against membrane associated antigens. An ultrastructural study

The skin explant model was used to determine the effect of antibody reactions against membrane associated antigens on normal human keratinocytes. Addition of specific allo-antibodies against HLA class I antigens induced characteristic changes in the cells on the outermost region of the explant-outgrowth. A disorganization of the filopodia of these cells occurred and the edges of the cellular border were lifted from the substratum. These signs of detachment were also found when pemphigus serum was added. In both experimental conditions the detachment of the cells was complement independent. After removing the antiserum a recovery took place, but the cells once lifted from the substratum remained recognizable as a ridge of cells. No changes were observed when the explants were incubated with antibodies against HLA class II antigens. Incubation with specific antibodies against HLA class I antigens not present on the explant had also no effect. We propose that antibody reactions against various membrane associated antigens can induce within a few hours characteristic changes of the cellular margins.

Origin and properties of the blister formation factor in blister fluids from recessive dystrophic epidermolysis bullosa

The origin and properties of the blister formation factor in recessive dystrophic epidermolysis bullosa (RDEB) blister fluids were investigated. Organ cultures of normal human skin incubated with RDEB dermis extract or with RDEB fibroblast culture medium (FCM) produced a clear subepidermal blister with histology similar to that of a RDEB blister in vivo. The injection of RDEB dermis extract into guinea-pig skin also induced dermal-epidermal separation with similar histology to the skin lesions of RDEB patients. The blister forming activity of RDEB FCM which induces the subepidermal blister was inactivated by heat (60 degrees C for 30 min), trypsin digestion and by treating with EDTA, EGTA, alpha 2-macroglobulin, diisopropyl fluorophosphate and N-ethylmaleimide, but was not affected by dialysis. These results suggest that the RDEB fibroblast produces a blister formation factor(s), and that blister formation may be caused by a combination of a metallo-protease, serine protease and SH protease.