1
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He Y, Wang W, Ma X, Duan Z, Wang B, Li M, Xu H. Discovery and Potential Functional Characterization of Long Noncoding RNAs Associated with Familial Acne Inversa with NCSTN Mutation. Dermatology 2023; 240:119-131. [PMID: 37490873 DOI: 10.1159/000531978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 07/06/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Long noncoding RNAs (lncRNAs) are associated with many dermatologic diseases. However, little is known about the regulatory function of lncRNAs in familial acne inversa (AI) patients with nicastrin (NCSTN) mutation. OBJECTIVES The aim of this study was to explore the regulatory function of lncRNAs in familial AI patients with NCSTN mutation. METHODS The expression profiles of lncRNAs and mRNAs in skin tissues from familial AI patients with NCSTN mutation and healthy individuals were analysed in this study via RNA sequencing (RNA-seq). RESULTS In total, 359 lncRNAs and 1,863 mRNAs were differentially expressed between the two groups. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses revealed that the dysregulated mRNAs targeted by lncRNAs were mainly associated with the immune regulation, Staphylococcus aureus infection and B cell receptor signalling pathways. The lncRNA-miRNA-mRNA coexpression network contained 265 network pairs comprising 55 dysregulated lncRNAs, 11 miRNAs, and 74 mRNAs. Conservation analysis of the differentially expressed lncRNAs between familial AI patients with NCSTN mutation and Ncstn keratinocyte-specific knockout (NcstnΔKC) mice identified 6 lncRNAs with sequence conservation; these lncRNAs may participate in apoptosis, proliferation, and skin barrier function. CONCLUSIONS These findings provide a direction for exploring the regulatory mechanisms underlying the progression of familial AI patients with NCSTN mutation.
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Affiliation(s)
- Yanyan He
- Institute of Dermatology, Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China,
| | - Wenzhu Wang
- Institute of Dermatology, Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China
| | - Xiao Ma
- Institute of Dermatology, Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China
| | - Zhimin Duan
- Institute of Dermatology, Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China
| | - Baoxi Wang
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Min Li
- Institute of Dermatology, Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China
- Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Haoxiang Xu
- Institute of Dermatology, Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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2
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Kashyap MP, Khan J, Sinha R, Jin L, Atigadda V, Deshane JS, Ahmed AR, Kilic A, Raman C, Mukhtar MS, Elmets CA, Athar M. Advances in molecular pathogenesis of hidradenitis suppurativa: Dysregulated keratins and ECM signaling. Semin Cell Dev Biol 2022; 128:120-129. [PMID: 35131152 PMCID: PMC9232849 DOI: 10.1016/j.semcdb.2022.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 01/12/2022] [Accepted: 01/14/2022] [Indexed: 12/12/2022]
Abstract
Hidradenitis suppurativa (HS) is characterized by deep-seated, highly inflamed, and painful lumps/abscesses, fistulae, and sinus tracts that grow extensively deep in the dermis and are highly immunogenic in nature. In about one-third of the HS patients there is strong evidence for the role of γ-secretase mutations along with dysregulated Notch signaling. However, the contribution of dysregulated Notch signaling in HS pathogenesis in relation to hair follicle alterations and hyper-activation of the immune system remains undefined. A genome-wide association study (GWAS), proteomic data and functional investigations of identified sequence variants in HS pathology are not fully revealing. The disease initiation or progression may involve bacterial infection besides intrinsic functional defects in keratinocytes, which may be key to further exacerbate immune cell infiltration and cytokine production in and around the lesional tissue. The absence of a suitable animal model that could fully recapitulate the pathogenesis of HS is a major impediment for proper understanding the underlying mechanisms and development of effective treatments. The presence of extracellular matrix (ECM) degradation products along with dysregulation in keratinocytes and, dermal fibroblasts ultimately affect immune regulation and are various components of HS pathogenesis. Bacterial infection further exacerbates the complexity of the disease progression. While anti-TNFα therapy shows partial efficacy, treatment to cure HS is absent. Multiple clinical trials targeting various cytokines, complement C5a and ECM products are in progress. This review provides state-of-the-art information on these aspects with a focus on dysregulated keratinocyte and immune cells; and role of ECM, and Keratin functions in this regard.
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Affiliation(s)
- Mahendra Pratap Kashyap
- UAB Research Center of Excellence in Arsenicals, Department of Dermatology, University of Alabama at Birmingham, Birmingham AL35294, USA
| | - Jasim Khan
- UAB Research Center of Excellence in Arsenicals, Department of Dermatology, University of Alabama at Birmingham, Birmingham AL35294, USA
| | - Rajesh Sinha
- UAB Research Center of Excellence in Arsenicals, Department of Dermatology, University of Alabama at Birmingham, Birmingham AL35294, USA
| | - Lin Jin
- UAB Research Center of Excellence in Arsenicals, Department of Dermatology, University of Alabama at Birmingham, Birmingham AL35294, USA
| | - Venkatram Atigadda
- UAB Research Center of Excellence in Arsenicals, Department of Dermatology, University of Alabama at Birmingham, Birmingham AL35294, USA
| | - Jessy S Deshane
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham AL35294, USA
| | - Ayesha R Ahmed
- Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA 99202, USA
| | - Ali Kilic
- Division of Plastic Surgery, University of Alabama at Birmingham, Birmingham AL35294, USA
| | - Chander Raman
- UAB Research Center of Excellence in Arsenicals, Department of Dermatology, University of Alabama at Birmingham, Birmingham AL35294, USA
| | - M Shahid Mukhtar
- Department of Biology, University of Alabama at Birmingham, Birmingham AL35294, USA
| | - Craig A Elmets
- UAB Research Center of Excellence in Arsenicals, Department of Dermatology, University of Alabama at Birmingham, Birmingham AL35294, USA
| | - Mohammad Athar
- UAB Research Center of Excellence in Arsenicals, Department of Dermatology, University of Alabama at Birmingham, Birmingham AL35294, USA.
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3
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Autoantibodies Present in Hidradenitis Suppurativa Correlate with Disease Severity and Promote the Release of Proinflammatory Cytokines in Macrophages. J Invest Dermatol 2022; 142:924-935. [PMID: 34606886 PMCID: PMC8860851 DOI: 10.1016/j.jid.2021.07.187] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/09/2021] [Accepted: 07/19/2021] [Indexed: 12/11/2022]
Abstract
Hidradenitis suppurativa (HS), also known as acne inversa, is a debilitating inflammatory skin disorder that is characterized by nodules that lead to the development of connected tunnels and scars as it progresses from Hurley stages I to III. HS has been associated with several autoimmune diseases, including inflammatory bowel disease and spondyloarthritis. We previously reported dysregulation of humoral immune responses in HS, characterized by elevated serum total IgG, B-cell activation, and antibodies recognizing citrullinated proteins. In this study, we characterized IgG autoreactivity in HS sera and lesional skin compared with those in normal healthy controls using an array-based high-throughput autoantibody screening. The Cy3-labeled anti-human assay showed the presence of autoantibodies against nuclear antigens, cytokines, cytoplasmic proteins, extracellular matrix proteins, neutrophil proteins, and citrullinated antigens. Most of these autoantibodies were significantly elevated in stages II‒III in HS sera and stage III in HS skin lesions compared with those of healthy controls. Furthermore, immune complexes containing both native and citrullinated versions of antigens can activate M1 and M2 macrophages to release proinflammatory cytokines such as TNF-α, IL-8, IL-6, and IL-12. Taken together, the identification of specific IgG autoantibodies that recognize circulating and tissue antigens in HS suggests an autoimmune mechanism and uncovers putative therapeutic targets.
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4
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Zouboulis VA, Zouboulis KC, Zouboulis CC. Hidradenitis Suppurativa and Comorbid Disorder Biomarkers, Druggable Genes, New Drugs and Drug Repurposing-A Molecular Meta-Analysis. Pharmaceutics 2021; 14:pharmaceutics14010044. [PMID: 35056940 PMCID: PMC8779519 DOI: 10.3390/pharmaceutics14010044] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/20/2021] [Accepted: 12/23/2021] [Indexed: 12/28/2022] Open
Abstract
Chronic inflammation and dysregulated epithelial differentiation, especially of hair follicle keratinocytes, have been suggested as the major pathogenetic pathways of hidradenitis suppurativa/acne inversa (HS). On the other hand, obesity and metabolic syndrome have additionally been considered as an important risk factor. With adalimumab, a drug has already been approved and numerous other compounds are in advanced-stage clinical studies. A systematic review was conducted to detect and corroborate HS pathogenetic mechanisms at the molecular level and identify HS molecular markers. The obtained data were used to confirm studied and off-label administered drugs and to identify additional compounds for drug repurposing. A robust, strongly associated group of HS biomarkers was detected. The triad of HS pathogenesis, namely upregulated inflammation, altered epithelial differentiation and dysregulated metabolism/hormone signaling was confirmed, the molecular association of HS with certain comorbid disorders, such as inflammatory bowel disease, arthritis, type I diabetes mellitus and lipids/atherosclerosis/adipogenesis was verified and common biomarkers were identified. The molecular suitability of compounds in clinical studies was confirmed and 31 potential HS repurposing drugs, among them 10 drugs already launched for other disorders, were detected. This systematic review provides evidence for the importance of molecular studies to advance the knowledge regarding pathogenesis, future treatment and biomarker-supported clinical course follow-up in HS.
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Affiliation(s)
- Viktor A. Zouboulis
- Faculty of Medicine, Universitaetsklinikum Hamburg-Eppendorf (UKE), 20251 Hamburg, Germany;
| | - Konstantin C. Zouboulis
- Department of Chemistry and Applied Biosciences, Swiss Federal Institute of Technology (ETH) Zurich, 8092 Zurich, Switzerland;
| | - Christos C. Zouboulis
- Departments of Dermatology, Venereology, Allergology and Immunology, Dessau Medical Center, Brandenburg Medical School Theodor Fontane and Faculty of Health Sciences Brandenburg, 06847 Dessau, Germany
- Correspondence: ; Tel.: +49-340-5014000
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5
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Stalder R, Brembilla N, Conrad C, Yawalkar N, Navarini A, Boehncke WH, Kaya G. IL-17E, iNOS and Arginase1 as new biomarkers in the identification of neutrophilic dermatoses. Clin Exp Dermatol 2021; 47:675-683. [PMID: 34669971 PMCID: PMC9300036 DOI: 10.1111/ced.14988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/06/2021] [Accepted: 10/17/2021] [Indexed: 11/28/2022]
Abstract
Background Neutrophilic dermatoses (ND) are a heterogeneous group of diseases, but can often have a relatively similar histological appearance. Aim To identify a combination of biomarkers allowing a better differentiation of ND types. Methods Biopsies were obtained from normal human skin (NS; n = 4), chronic plaque‐type psoriasis (PsO; n = 7), paradoxical psoriasis (PP; n = 8), generalized pustular psoriasis (GPP; n = 9), subcorneal pustular dermatosis of Sneddon–Wilkinson (SPD; n = 3), acute generalized exanthematous pustulosis (AGEP; n = 3), hidradenitis suppurativa (HS; n = 7), Sweet syndrome (SS; n = 8) and pyoderma gangrenosum (PG; n = 8). Samples were analysed by immunofluorescence using three biomarkers, interleukin (IL)‐17E, inducible nitric oxide synthase (iNOS) and arginase1, each one in combination with two cell markers, myeloperoxidase (MPO) and CD68, which allow the identification of neutrophils and macrophages, respectively. Results We found that SS is characterized by high expression of IL‐17E and iNOS in the epidermis, while PG exhibits low expression. The density of the neutrophil infiltrate helps to differentiate PP (high‐density infiltrate) from PsO (low‐density infiltrate). High expression of arginase1 in the granular layer of the epidermis is a hallmark of SPD. Finally, mature neutrophils and proinflammatory macrophages are readily detectable in PP, SPD and PG, whereas immature neutrophils and anti‐inflammatory macrophages are more frequent in GPP, AGEP, HS and SS. Conclusions The analysis of ND by immunofluorescence using IL‐17E, iNOS and arginase1 in combination with MPO and CD68 allows for characterization of differential expression patterns in the epidermis as well as the determination of the polarization status of the dermal neutrophils and macrophages. The appropriate markers may help in the differentiation of ND in clinical practice.
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Affiliation(s)
- R Stalder
- Department of Pathology and Immunology, University of Geneva, Geneva, Switzerland
| | - N Brembilla
- Department of Pathology and Immunology, University of Geneva, Geneva, Switzerland
| | - C Conrad
- Department of Dermatology, University Hospital CHUV, Lausanne, Switzerland
| | - N Yawalkar
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - A Navarini
- Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - W H Boehncke
- Department of Pathology and Immunology, University of Geneva, Geneva, Switzerland.,Division of Dermatology and Venereology, University Hospitals of Geneva, Geneva, Switzerland
| | - G Kaya
- Department of Pathology and Immunology, University of Geneva, Geneva, Switzerland.,Division of Dermatology and Venereology, University Hospitals of Geneva, Geneva, Switzerland.,Division of Clinical Pathology, University Hospitals of Geneva, Geneva, Switzerland
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6
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Nakai K. Multiple roles of macrophage in skin. J Dermatol Sci 2021; 104:2-10. [PMID: 34493430 DOI: 10.1016/j.jdermsci.2021.08.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/28/2021] [Accepted: 08/30/2021] [Indexed: 01/26/2023]
Abstract
More than 100 years have passed since Elie Metchnikoff discovered macrophage. Over the recent decade, attracting information about macrophage polarization have been reported. This is because many molecules have been identified as markers of macrophage polarization. Additionally, mechanistic insights have been demonstrated by experiments with various stimuli-induced macrophage polarization. Historically and simply, macrophages are divided into M1 (classically activated) and M2 (alternatively activated). However, some of them are not specific yet. Studies in the field of cardiology revealed the plasticity of macrophages and their subsets are divided into details: Mhem, MHb, Mox and M4 macrophages. M2 macrophages were further divided in M2a, M2b, M2c and M2d. There appears to be more phenotypes of macrophages. However, there still lack studies in dermatological field. This review summarizes the spectrum of macrophage activation and finding about various roles of macrophages in the dermatological field.
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Affiliation(s)
- Kozo Nakai
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan.
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7
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Johnston DGW, Kirby B, Tobin DJ. Hidradenitis suppurativa: A folliculotropic disease of innate immune barrier dysfunction? Exp Dermatol 2021; 30:1554-1568. [PMID: 34418166 DOI: 10.1111/exd.14451] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 08/18/2021] [Accepted: 08/20/2021] [Indexed: 12/11/2022]
Abstract
The innate immune system of human skin consists of a multi-layered barrier consisting of cells and soluble effector molecules charged with maintaining homeostasis and responding to insults and infections. It has become increasingly clear that these barrier layers become compromised in skin diseases, especially in disorders of an (auto)inflammatory nature. In the case of hidradenitis suppurativa, great strides have been made in recent years in characterizing the underlying breakdown in homeostatic innate immunity, including an increasing understanding of the central role of the hair follicle in this process. This breakdown appears to occur at multiple levels: the pilosebaceous unit, associated epithelium, the cutaneous microbiome, alteration of immune cell function and local molecular events such as complement activation. This review seeks to summarize, contextualize and analyse critically our current understanding of how these innate immune barriers become dysregulated in the early stage(s) of hidradenitis suppurativa, and to speculate on where potential hidradenitis suppurativa research could be most fruitful.
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Affiliation(s)
- Daniel G W Johnston
- The Charles Institute of Dermatology, School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Brian Kirby
- The Charles Institute of Dermatology, School of Medicine, University College Dublin, Dublin 4, Ireland.,Charles Department of Dermatology, St Vincent's University Hospital, Dublin, Ireland
| | - Desmond J Tobin
- The Charles Institute of Dermatology, School of Medicine, University College Dublin, Dublin 4, Ireland.,The Conway Institute, University College Dublin, Dublin 4, Ireland
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8
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Navrazhina K, Garcet S, Gonzalez J, Grand D, Frew JW, Krueger JG. In-Depth Analysis of the Hidradenitis Suppurativa Serum Proteome Identifies Distinct Inflammatory Subtypes. J Invest Dermatol 2021; 141:2197-2207. [PMID: 33766512 DOI: 10.1016/j.jid.2021.02.742] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 01/19/2021] [Accepted: 02/02/2021] [Indexed: 02/06/2023]
Abstract
Hidradenitis suppurativa is a chronic inflammatory dermatosis with presentations ranging from painful nodules and abscesses to draining tunnels. Using an unbiased proteomics approach, we assessed cardiovascular-, cardiometabolic-, and inflammation-related biomarkers in the serum of patients with moderate-to-severe hidradenitis suppurativa. The serum of patients with hidradenitis suppurativa clustered separately from that of healthy controls and had an upregulation of neutrophil-related markers (Cathepsin D, IL-17A, CXCL1). Patients with histologically diagnosed dermal tunnels had higher serum lipocalin-2 levels compared with those without tunnels. Consistent with this, patients with tunnels had a more neutrophilic-rich serum signature, marked by Cathepsin D, IL-17A, and IL-17D alterations. There was a significant serum‒skin correlation between proteins in the serum and the corresponding mRNA expression in skin biopsies, with healthy-appearing perilesional skin demonstrating a significant correlation with neutrophil-related proteins in the serum. CSF3 mRNA levels in lesional skin significantly correlated with neutrophil-related proteins in the serum, suggesting that CFS3 in the skin may be a driver of neutrophilic inflammation. Clinical significantly correlated with the levels of lipocalin-2 and IL-17A in the serum. Using an unbiased, large-scale proteomic approach, we demonstrate that hidradenitis suppurativa is a systemic neutrophilic dermatosis, with a specific molecular signature associated with the presence of dermal tunnels.
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Affiliation(s)
- Kristina Navrazhina
- Laboratory of Investigative Dermatology, The Rockefeller University, New York, New York, USA; Weill Cornell/Rockefeller/Sloan Kettering Tri-Institutional MD-PhD Program, New York, New York, USA
| | - Sandra Garcet
- Laboratory of Investigative Dermatology, The Rockefeller University, New York, New York, USA
| | - Juana Gonzalez
- Laboratory of Investigative Dermatology, The Rockefeller University, New York, New York, USA
| | - David Grand
- Laboratory of Investigative Dermatology, The Rockefeller University, New York, New York, USA
| | - John W Frew
- Laboratory of Investigative Dermatology, The Rockefeller University, New York, New York, USA
| | - James G Krueger
- Laboratory of Investigative Dermatology, The Rockefeller University, New York, New York, USA.
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9
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Lowe MM, Naik HB, Clancy S, Pauli M, Smith KM, Bi Y, Dunstan R, Gudjonsson JE, Paul M, Harris H, Kim E, Shin US, Ahn R, Liao W, Hansen SL, Rosenblum MD. Immunopathogenesis of hidradenitis suppurativa and response to anti-TNF-α therapy. JCI Insight 2020; 5:139932. [PMID: 32841223 PMCID: PMC7566733 DOI: 10.1172/jci.insight.139932] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/20/2020] [Indexed: 01/15/2023] Open
Abstract
Hidradenitis suppurativa (HS) is a highly prevalent, morbid inflammatory skin disease with limited treatment options. The major cell types and inflammatory pathways in skin of patients with HS are poorly understood, and which patients will respond to TNF-α blockade is currently unknown. We discovered that clinically and histologically healthy appearing skin (i.e., nonlesional skin) is dysfunctional in patients with HS with a relative loss of immune regulatory pathways. HS skin lesions were characterized by quantitative and qualitative dysfunction of type 2 conventional dendritic cells, relatively reduced regulatory T cells, an influx of memory B cells, and a plasma cell/plasmablast infiltrate predominantly in end-stage fibrotic skin. At the molecular level, there was a relative bias toward the IL-1 pathway and type 1 T cell responses when compared with both healthy skin and psoriatic patient skin. Anti-TNF-α therapy markedly attenuated B cell activation with minimal effect on other inflammatory pathways. Finally, we identified an immune activation signature in skin before anti-TNF-α treatment that correlated with subsequent lack of response to this modality. Our results reveal the fundamental immunopathogenesis of HS and provide a molecular foundation for future studies focused on stratifying patients based on likelihood of clinical response to TNF-α blockade.
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Affiliation(s)
- Margaret M. Lowe
- Department of Dermatology, University of California at San Francisco (UCSF), San Francisco, California, USA
| | - Haley B. Naik
- Department of Dermatology, University of California at San Francisco (UCSF), San Francisco, California, USA
| | - Sean Clancy
- Department of Dermatology, University of California at San Francisco (UCSF), San Francisco, California, USA
| | - Mariela Pauli
- Department of Dermatology, University of California at San Francisco (UCSF), San Francisco, California, USA
| | | | - Yingtao Bi
- AbbVie Cambridge Research Center, Cambridge, Massachusetts, USA
| | - Robert Dunstan
- AbbVie Bioresearch Center, Worcester, Massachusetts, USA
| | | | - Maia Paul
- Department of Dermatology, University of California at San Francisco (UCSF), San Francisco, California, USA
| | - Hobart Harris
- Department of Surgery, UCSF, San Francisco, California, USA
| | - Esther Kim
- Department of Surgery, UCSF, San Francisco, California, USA
| | - Uk Sok Shin
- Department of Surgery, UCSF, San Francisco, California, USA
| | - Richard Ahn
- Department of Dermatology, University of California at San Francisco (UCSF), San Francisco, California, USA
- Institute for Quantitative and Computational Biosciences, University of California at Los Angeles, Los Angeles, California, USA
| | - Wilson Liao
- Department of Dermatology, University of California at San Francisco (UCSF), San Francisco, California, USA
| | | | - Michael D. Rosenblum
- Department of Dermatology, University of California at San Francisco (UCSF), San Francisco, California, USA
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10
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Sanchez J, Le Jan S, Muller C, François C, Renard Y, Durlach A, Bernard P, Reguiai Z, Antonicelli F. Matrix remodelling and MMP expression/activation are associated with hidradenitis suppurativa skin inflammation. Exp Dermatol 2020; 28:593-600. [PMID: 30903721 DOI: 10.1111/exd.13919] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 01/29/2019] [Accepted: 03/01/2019] [Indexed: 12/28/2022]
Abstract
Hidradenitis suppurativa/acne inversa (HS) is a chronic, inflammatory, recurrent, debilitating skin disease of the hair follicle, associated with considerable tissue remodelling. Although abnormal cytokine expression was detected both in perilesional and in uninvolved skin, up to now there is no model allowing a better understanding of the implicit inflammatory mechanisms in HS. The aim of this study was to investigate the inflammatory response in HS skin by mean of an ex vivo model culture. To that purpose, nine skin biopsy specimens from patients suffering from HS and controls were cultured up to 4 days. Microscopy imaging investigations showed variations of collagen I and III organization, and an increase in elastin fibres fragmentation in HS skin after 4 days of culture. The HS matrix structure remodelling was associated with high level of MMP-2 and MMP-9 in HS lesional skin. After 4 days of culture, the MMP expression in HS perilesional skin reached the level observed in HS lesional skin. Concomitantly, an increase in IL-1β concentration was observed in all skin samples after 4 days of culture, although IL-1β concentrations remained significantly higher in HS lesional skin as compared with control skin. Meanwhile, neither IL-17 concentrations nor the inflammasome components NLRP3 and caspase-1 varied. Thus, our HS skin model culture showed that MMP-induced matrix alteration could participate in HS inflammation by releasing biological active peptides and inflammatory factors from the extracellular matrix (ECM), and open new opportunities to investigate the regulation of the inflammatory mechanism associated with HS.
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Affiliation(s)
- Julia Sanchez
- Department of Dermatology, Reims University Hospital, University of Champagne-Ardenne, Reims, France.,EA 7509 IRMAIC, UFR Medicine, University of Champagne-Ardenne, Reims, France
| | - Sébastien Le Jan
- EA 7509 IRMAIC, UFR Medicine, University of Champagne-Ardenne, Reims, France
| | - Céline Muller
- EA 7509 IRMAIC, UFR Medicine, University of Champagne-Ardenne, Reims, France
| | - Caroline François
- Department of Plastic, Esthetic and Reconstructive Surgery, Reims University Hospital, University of Champagne-Ardenne, Reims, France
| | - Yohan Renard
- Department of Digestive surgery, Reims University Hospital, University of Champagne-Ardenne, Reims, France
| | - Anne Durlach
- Department of Histopathology, Reims University Hospital, University of Champagne-Ardenne, Reims, France
| | - Philippe Bernard
- Department of Dermatology, Reims University Hospital, University of Champagne-Ardenne, Reims, France.,EA 7509 IRMAIC, UFR Medicine, University of Champagne-Ardenne, Reims, France
| | - Ziad Reguiai
- Department of Dermatology, Reims University Hospital, University of Champagne-Ardenne, Reims, France
| | - Frank Antonicelli
- EA 7509 IRMAIC, UFR Medicine, University of Champagne-Ardenne, Reims, France.,Department of Biological Sciences, Immunology, UFR Odontology, University of Reims Champagne-Ardenne, Reims, France
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11
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Nisar S, Roberson J, Carney B, Alkhalil A, Moffatt L, Shupp J. Further Histological and Cellular Characterization of Hidradenitis Suppurativa in 11 Patients. EPLASTY 2019; 19:e21. [PMID: 31885764 PMCID: PMC6916621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background: Hidradenitis suppurativa is a chronic inflammatory skin disease, with significant morbidity secondary to its recurrent painful and exudative lesions. Given limited research on the cytoarchitecture of hidradenitis suppurativa, this study describes the microscopic structure and cell surface markers present in hidradenitis suppurativa tissue to better understand the disease and identify potential therapeutic targets. Methods: Skin biopsies of hidradenitis suppurativa lesions from patients who underwent surgical excision (n = 11) were compared with grossly normal-appearing perilesional skin (n = 5) and normal skin biopsies from unaffected individuals (n = 4). Histopathology and epidermal thickness were assessed using hematoxylin and eosin and picrosirius red staining, and CD3, a T-cell marker, and CD31 (PECAM), a vascular endothelial cell marker, were assayed using immunofluorescence. Data were analyzed and compared using analysis of variance and Student's t test. Results: Histological examination showed that hidradenitis suppurativa samples had a significantly thicker epidermal layer than normal skin (335.23 ± 165.01 µm vs 57.24 ± 18.43 µm, P = .005), extending into and engulfing the dermis. The hidradenitis suppurativa dermis had extensive cellular infiltration and aggregation as well as disorganized collagen. Immunofluorescence analysis revealed that, at the dermal level, hidradenitis suppurativa lesions had a significantly greater quantity of CD3+ (324.29 ± 139.28 vs 14.93 ±16.32, P < .0001) and CD31+ (322.15 ± 155.46 vs 2.84 ± 5.56, P < .0001) cells/mm2 compared with normal skin samples. Conclusions: Hidradenitis suppurativa lesions have thicker epidermal layers, more dermal cellular infiltrate, and disorganized collagen fibers compared with normal skin. Furthermore, hidradenitis suppurativa dermis has a greater quantity of CD3+ and CD31+ cells than normal skin.
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Affiliation(s)
- Saira Nisar
- aFirefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC,bThe Burn Center, MedStar Washington Hospital Center, Washington, DC
| | - Jeffrey L. Roberson
- aFirefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC,cDepartment of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Bonnie C. Carney
- aFirefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC,dDepartment of Biochemistry and Molecular and Cellular Biology, Georgetown University School of Medicine, Washington, DC
| | - Abdulnaser Alkhalil
- aFirefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
| | - Lauren T. Moffatt
- aFirefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC,dDepartment of Biochemistry and Molecular and Cellular Biology, Georgetown University School of Medicine, Washington, DC
| | - Jeffrey W. Shupp
- aFirefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC,bThe Burn Center, MedStar Washington Hospital Center, Washington, DC,dDepartment of Biochemistry and Molecular and Cellular Biology, Georgetown University School of Medicine, Washington, DC,eDepartment of Surgery, MedStar Georgetown University Hospital, Washington, DC,Correspondence:
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12
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Byrd AS, Carmona-Rivera C, O’Neil LJ, Carlucci PM, Cisar C, Rosenberg AZ, Kerns ML, Caffrey JA, Milner SM, Sacks JM, Aliu O, Broderick KP, Reichner JS, Miller LS, Kang S, Robinson WH, Okoye GA, Kaplan MJ. Neutrophil extracellular traps, B cells, and type I interferons contribute to immune dysregulation in hidradenitis suppurativa. Sci Transl Med 2019; 11:11/508/eaav5908. [DOI: 10.1126/scitranslmed.aav5908] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 03/20/2019] [Accepted: 07/26/2019] [Indexed: 12/16/2022]
Abstract
Hidradenitis suppurativa (HS), also known as acne inversa, is an incapacitating skin disorder of unknown etiology manifested as abscess-like nodules and boils resulting in fistulas and tissue scarring as it progresses. Given that neutrophils are the predominant leukocyte infiltrate in HS lesions, the role of neutrophil extracellular traps (NETs) in the induction of local and systemic immune dysregulation in this disease was examined. Immunofluorescence microscopy was performed in HS lesions and detected the prominent presence of NETs. NET complexes correlated with disease severity, as measured by Hurley staging. Neutrophils from the peripheral blood of patients with HS peripheral also displayed enhanced spontaneous NET formation when compared to healthy control neutrophils. Sera from patients recognized antigens present in NETs and harbored increased antibodies reactive to citrullinated peptides. B cell dysregulation, as evidenced by elevated plasma cells and IgG, was observed in the circulation and skin from patients with HS. Peptidylarginine deiminases (PADs) 1 to 4, enzymes involved in citrullination, were differentially expressed in HS skin, when compared to controls, in association with enhanced tissue citrullination. NETs in HS skin coexisted with plasmacytoid dendritic cells, in association with a type I interferon (IFN) gene signature. Enhanced NET formation and immune responses to neutrophil and NET-related antigens may promote immune dysregulation and contribute to inflammation. This, along with evidence of up-regulation of the type I IFN pathway in HS skin, suggests that the innate immune system may play important pathogenic roles in this disease.
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Affiliation(s)
- Angel S. Byrd
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carmelo Carmona-Rivera
- Systemic Autoimmunity Branch, Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Liam J. O’Neil
- Systemic Autoimmunity Branch, Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Philip M. Carlucci
- Systemic Autoimmunity Branch, Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Cecilia Cisar
- VA Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Avi Z. Rosenberg
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michelle L. Kerns
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Julie A. Caffrey
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephen M. Milner
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Justin M. Sacks
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Oluseyi Aliu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kristen P. Broderick
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan S. Reichner
- Division of Surgical Research, Department of Surgery, Rhode Island Hospital, Providence, RI, USA
| | - Lloyd S. Miller
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sewon Kang
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William H. Robinson
- VA Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Ginette A. Okoye
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mariana J. Kaplan
- Systemic Autoimmunity Branch, Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
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13
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Byrd AS, Dina Y, Okoh UJ, Quartey QQ, Carmona-Rivera C, Williams DW, Kerns ML, Miller RJ, Petukhova L, Naik HB, Barnes LA, Shipman WD, Caffrey JA, Sacks JM, Milner SM, Aliu O, Broderick KP, Kim D, Liu H, Dillen CA, Ahn R, Frew JW, Kaplan MJ, Kang S, Garza LA, Miller LS, Alavi A, Lowes MA, Okoye GA. Specimen Collection for Translational Studies in Hidradenitis Suppurativa. Sci Rep 2019; 9:12207. [PMID: 31434914 PMCID: PMC6704132 DOI: 10.1038/s41598-019-48226-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 07/22/2019] [Indexed: 12/13/2022] Open
Abstract
Hidradenitis suppurativa (HS) is a chronic inflammatory disorder characterized by painful nodules, sinus tracts, and scars occurring predominantly in intertriginous regions. The prevalence of HS is currently 0.053-4%, with a predominance in African-American women and has been linked to low socioeconomic status. The majority of the reported literature is retrospective, population based, epidemiologic studies. In this regard, there is a need to establish a repository of biospecimens, which represent appropriate gender and racial demographics amongst HS patients. These efforts will diminish knowledge gaps in understanding the disease pathophysiology. Hence, we sought to outline a step-by-step protocol detailing how we established our HS biobank to facilitate the formation of other HS tissue banks. Equipping researchers with carefully detailed processes for collection of HS specimens would accelerate the accumulation of well-organized human biological material. Over time, the scientific community will have access to a broad range of HS tissue biospecimens, ultimately leading to more rigorous basic and translational research. Moreover, an improved understanding of the pathophysiology is necessary for the discovery of novel therapies for this debilitating disease. We aim to provide high impact translational research methodology for cutaneous biology research and foster multidisciplinary collaboration and advancement of our understanding of cutaneous diseases.
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Affiliation(s)
- A S Byrd
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA.
- Department of Dermatology, Howard University College of Medicine, Washington, DC, 20060, USA.
| | - Y Dina
- Meharry Medical College, Nashville, TN, 37208, USA
| | - U J Okoh
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Q Q Quartey
- University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - C Carmona-Rivera
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - D W Williams
- Department of Molecular and Comparative Pathobiology, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - M L Kerns
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - R J Miller
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - L Petukhova
- Departments of Dermatology and Epidemiology, Columbia University, New York, NY, 10032, USA
| | - H B Naik
- Program for Clinical Research, Department of Dermatology, University of California San Francisco, San Francisco, CA, 94143-0808, USA
| | - L A Barnes
- Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - W D Shipman
- Weill Cornell/Rockefeller/Sloan-Kettering Tri-Institutional MD-PhD Program, New York, NY, 10065, USA
| | - J A Caffrey
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - J M Sacks
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - S M Milner
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - O Aliu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - K P Broderick
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - D Kim
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - H Liu
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - C A Dillen
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - R Ahn
- Department of Microbiology, Immunology, and Molecular Genetics, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - J W Frew
- Department of Dermatology, Liverpool Hospital, Sydney, NSW, 2170, Australia
- Ingham Institute of Applied Medical Research, Liverpool, Sydney, NSW, 2170, Australia
- University of New South Wales, Sydney, NSW, 2033, Australia
| | - M J Kaplan
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - S Kang
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - L A Garza
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - L S Miller
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - A Alavi
- Department of Medicine (Dermatology), University of Toronto, Toronto, Ontario, M1C 1A4, Canada
- Division of Dermatology, Women's College Hospital, Toronto, ON, M5S 1B2, Canada
| | - M A Lowes
- The Rockefeller University, New York, NY, 10065, USA
| | - G A Okoye
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
- Department of Dermatology, Howard University College of Medicine, Washington, DC, 20060, USA
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14
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Shavit E, Alavi A, Bechara FG, Bennett RG, Bourcier M, Cibotti R, Daveluy S, Frew JW, Garg A, Hamzavi I, Hoffman LK, Hsaio J, Sciacca Kirby J, Lev-Tov H, Martinez E, Micheletti R, Naik HB, Nassif A, Nicholson C, Parks-Miller A, Patel Z, Piguet V, Ramesh M, Resnik B, Sayed C, Schultz G, Siddiqui A, Tan J, Wortsman X, Lowes MA. Proceeding report of the Second Symposium on Hidradenitis Suppurativa Advances (SHSA) 2017. Exp Dermatol 2019; 28:94-103. [PMID: 30484907 PMCID: PMC6600821 DOI: 10.1111/exd.13849] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 11/13/2018] [Accepted: 11/20/2018] [Indexed: 12/27/2022]
Abstract
The 2nd Annual Symposium on Hidradenitis Suppurativa Advances (SHSA) took place on 03-05 November 2017 in Detroit, Michigan, USA. This symposium was a joint meeting of the Hidradenitis Suppurativa Foundation (HSF Inc.) founded in the USA, and the Canadian Hidradenitis Suppurativa Foundation (CHSF). This was the second annual meeting of the SHSA with experts from different disciplines arriving from North America, Europe and Australia, in a joint aim to discuss most recent innovations, practical challenges and potential solutions to issues related in the management and care of Hidradenitis Suppurativa patients. The last session involved clinicians, patients and their families in an effort to educate them more about the disease.
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Affiliation(s)
- Eran Shavit
- Department of Medicine, Division of Dermatology, Women College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Afsaneh Alavi
- Department of Medicine, Division of Dermatology, Women College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Falk G. Bechara
- Department of Dermatology, Dermatologic Surgery Unit, Ruhr-University Bochum, Bochum, Germany
| | - Richard G. Bennett
- Department of Dermatology, University of California, Los Angeles, Los Angeles, California
| | - Marc Bourcier
- Dermatology Clinic, Sherbrooke University, Moncton, New Brunswick, Canada
| | - Ricardo Cibotti
- National Institute of Arthritis and Musculoskeletal and skin diseases, National Institute of Health, Bethesda, Maryland
| | - Steven Daveluy
- Department of Dermatology, Wayne State University, Dearborn, Michigan
| | - John W. Frew
- Department of Dermatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Amit Garg
- Department of Dermatology, Hofstra Northwell School of Medicine, New Hyde Park, New York
| | - Iltefat Hamzavi
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan
| | - Lauren K. Hoffman
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Jenny Hsaio
- Ronald Reagan UCLA Medical Center, Santa Monica, California
| | | | - Hadar Lev-Tov
- Department of Dermatology & Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida
| | | | - Robert Micheletti
- Departments of Dermatology and Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Haley B. Naik
- Department of Dermatology, UCSF School of Medicine, San Francisco, California
| | - Aude Nassif
- Institut Pasteur, Centre Medical, Paris, France
| | - Cynthia Nicholson
- Department of Dermatology, Wayne State University, Detroit, Michigan
| | - Angie Parks-Miller
- Department of Dermatology, Dermatologic Surgery Unit, Ruhr-University Bochum, Bochum, Germany
- Clinical Research Manager, Henry Ford Hospital, Detroit, Michigan
| | - Zarine Patel
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York
| | - Vincent Piguet
- Department of Medicine, Division of Dermatology, Women College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mayur Ramesh
- Department of Internal Medicine/Infectious Diseases, Henry Ford Hospital, Detroit, Michigan
| | - Barry Resnik
- Department of Dermatology & Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Christopher Sayed
- Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Gregory Schultz
- Institute of Wound Research, University of Florida, Gainesville, Florida
| | - Aamir Siddiqui
- Department of Plastic Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Jerry Tan
- Department of Medicine, University of Western Ontario, Windsor, Ontario, Canada
| | - Ximena Wortsman
- Department of Dermatology, Institute for Diagnostic Imaging and Research of the Skin and Soft Tissues, University of Chile, Santiago, Chile
- Department of Dermatology, Pontifical Catholic University, Santiago, Chile
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