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Krueger JG, Pagotto A, Haftel S, Gradl B. Targeted review of IL36RN mutations in patients with generalised pustular psoriasis. SKIN HEALTH AND DISEASE 2024; 4:e343. [PMID: 38577038 PMCID: PMC10988704 DOI: 10.1002/ski2.343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 01/08/2024] [Accepted: 01/18/2024] [Indexed: 04/06/2024]
Abstract
Background Generalised pustular psoriasis (GPP) is a rare and chronic skin disease historically treated with therapies that were originally intended to treat plaque psoriasis (PsO). However, GPP and plaque PsO have distinct pathogeneses and clinical courses. Objectives This study aimed to further characterise the unique genetic background of GPP by summarising evidence on the frequency and type of IL36RN gene mutation, a gene that normally suppresses proinflammatory responses, in patients with GPP compared to patients with GPP and plaque PsO, and patients with plaque PsO only. Methods and Results A targeted literature review was conducted to identify studies reporting IL36RN mutations and/or HLA-Cw6 allele frequency in patients with GPP. Meta-analyses showed a significantly higher rate of IL36RN mutations in the GPP-only population compared to the GPP + plaque PsO population (OR 3.51; 95% CI 2.29, 5.38). Monoallelic mutations of IL36RN were found in up to 33.3%, and biallelic mutations in up to 73.2% of patients with GPP (GPP-only and GPP + plaque PsO), in contrast with mono- and biallelic frequencies of only 0%-11.9% and 0%, respectively, in patients with plaque PsO only. Mean age-of-onset ranged from 5.9 to 48.9 years old, with most studies reporting a GPP age-of-onset between 20 and 40 years old. Twenty-one mutations were identified in the biallelic state and three in monoallelic. The most reported mutations were c.115 + 6T > C (p. Arg10ArgfsX1) (18 studies); c.227 C > T (p.Pro76Leu) (10 studies); and c.338 C > T (p.Ser113Leu) (8 studies). Mutations varied depending on geography and ethnicity, with the most frequently reported mutation predominantly reported in East Asian studies and international studies that included Asian patients. Rates of HLA-Cw6, the risk allele most strongly associated with plaque PsO, were 0%-28.6% for patients with GPP, similar to rates in the general population (10.5%-20%). Conclusion Considering the differences between GPP and plaque PsO in aetiology and disease symptoms, effective, GPP-specific treatment options are needed, and recent research suggests that blockade of IL-36 signalling may be an effective target for treatment of GPP.
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Affiliation(s)
- James G. Krueger
- Laboratory for Investigative DermatologyThe Rockefeller UniversityNew YorkNew YorkUSA
| | | | | | - Birgit Gradl
- Boehringer Ingelheim International GmbHIngelheim am RheinGermany
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Martin P, Goldstein JD, Mermoud L, Diaz-Barreiro A, Palmer G. IL-1 Family Antagonists in Mouse and Human Skin Inflammation. Front Immunol 2021; 12:652846. [PMID: 33796114 PMCID: PMC8009184 DOI: 10.3389/fimmu.2021.652846] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/22/2021] [Indexed: 12/23/2022] Open
Abstract
Interleukin (IL)-1 family cytokines initiate inflammatory responses, and shape innate and adaptive immunity. They play important roles in host defense, but excessive immune activation can also lead to the development of chronic inflammatory diseases. Dysregulated IL-1 family signaling is observed in a variety of skin disorders. In particular, IL-1 family cytokines have been linked to the pathogenesis of psoriasis and atopic dermatitis. The biological activity of pro-inflammatory IL-1 family agonists is controlled by the natural receptor antagonists IL-1Ra and IL-36Ra, as well as by the regulatory cytokines IL-37 and IL-38. These four anti-inflammatory IL-1 family members are constitutively and highly expressed at steady state in the epidermis, where keratinocytes are a major producing cell type. In this review, we provide an overview of the current knowledge concerning their regulatory roles in skin biology and inflammation and their therapeutic potential in human inflammatory skin diseases. We further highlight some common misunderstandings and less well-known observations, which persist in the field despite recent extensive interest for these cytokines.
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Affiliation(s)
- Praxedis Martin
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jérémie D. Goldstein
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Loïc Mermoud
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Alejandro Diaz-Barreiro
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Gaby Palmer
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Uppala R, Tsoi LC, Harms PW, Wang B, Billi AC, Maverakis E, Michelle Kahlenberg J, Ward NL, Gudjonsson JE. "Autoinflammatory psoriasis"-genetics and biology of pustular psoriasis. Cell Mol Immunol 2020; 18:307-317. [PMID: 32814870 DOI: 10.1038/s41423-020-0519-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/20/2020] [Indexed: 02/08/2023] Open
Abstract
Psoriasis is a chronic inflammatory skin condition that has a fairly wide range of clinical presentations. Plaque psoriasis, which is the most common manifestation of psoriasis, is located on one end of the spectrum, dominated by adaptive immune responses, whereas the rarer pustular psoriasis lies on the opposite end, dominated by innate and autoinflammatory immune responses. In recent years, genetic studies have identified six genetic variants that predispose to pustular psoriasis, and these have highlighted the role of IL-36 cytokines as central to pustular psoriasis pathogenesis. In this review, we discuss the presentation and clinical subtypes of pustular psoriasis, contribution of genetic predisposing variants, critical role of the IL-36 family of cytokines in disease pathophysiology, and treatment perspectives for pustular psoriasis. We further outline the application of appropriate mouse models for the study of pustular psoriasis and address the outstanding questions and issues related to our understanding of the mechanisms involved in pustular psoriasis.
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Affiliation(s)
- Ranjitha Uppala
- Graduate Program in Immunology, University of Michigan, Ann Arbor, MI, USA.,Department of Dermatology, University of Michigan, Ann Arbor, MI, USA
| | - Lam C Tsoi
- Department of Dermatology, University of Michigan, Ann Arbor, MI, USA
| | - Paul W Harms
- Department of Dermatology, University of Michigan, Ann Arbor, MI, USA.,Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Bo Wang
- Department of Dermatology, University of Michigan, Ann Arbor, MI, USA
| | - Allison C Billi
- Department of Dermatology, University of Michigan, Ann Arbor, MI, USA
| | - Emanual Maverakis
- Department of Dermatology, University of California, Davis, Sacramento, CA, USA
| | - J Michelle Kahlenberg
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,A. Alfred Taubman Medical Research Institute, Ann Arbor, MI, USA
| | - Nicole L Ward
- Departments of Nutrition and Dermatology, Case Western Reserve University, Cleveland, OH, USA
| | - Johann E Gudjonsson
- Department of Dermatology, University of Michigan, Ann Arbor, MI, USA. .,A. Alfred Taubman Medical Research Institute, Ann Arbor, MI, USA.
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4
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Li Z, Yang Q, Wang S. Genetic polymorphism of IL36RN in Han patients with generalized pustular psoriasis in Sichuan region of China: A case-control study. Medicine (Baltimore) 2018; 97:e11741. [PMID: 30075588 PMCID: PMC6081173 DOI: 10.1097/md.0000000000011741] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The aim of this study was to detect IL36RN variant types and frequency in Han patients with generalized pustular psoriasis (GPP) in Sichuan region of China, reveal the difference of variant frequency between GPP alone and GPP + PV (psoriasis vulgaris), and preliminarily clarify the pathogenesis of GPP in this region.Genomic DNA was extracted and subjected to polymerase chain reaction (PCR) for the amplification of the entire encoding and splice sites of the IL36RN gene followed by bidirectional sequencing. Differences in frequencies of IL36RN variants between groups were analyzed by SPSS Statistics 17.0 software. Meanwhile, the IL36RN variant frequency between GPP alone and GPP + PV was compared.The total IL36RN variant frequency was 60.47% in Han GPP patients from Sichuan region of China. Three variant types (c.115 + 6T > C, c.140A > G, c.227C > T) were identified, among which c.115 + 6T > C exhibited the highest frequency (55.81%). All the 3 variants' frequency of GPP alone group had statistical significance when compared with PV patients and normal controls (P < .05). The IL36RN variant frequency of GPP alone group was statistically higher than that of GPP + PV group (79.17% vs 36.84%, P < .05).IL36RN may be the major disease-causing gene in GPP patients in Han population in Sichuan region of China. c.115 + 6T > C is a possible hot-spot mutation within the IL36RN gene. In contrast to GPP + PV, IL36RN mutations possibly play a more important role in the development of GPP alone.
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Psoriasis in Skin of Color: Insights into the Epidemiology, Clinical Presentation, Genetics, Quality-of-Life Impact, and Treatment of Psoriasis in Non-White Racial/Ethnic Groups. Am J Clin Dermatol 2018; 19:405-423. [PMID: 29209945 DOI: 10.1007/s40257-017-0332-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Psoriasis is a chronic inflammatory skin condition affecting diverse racial/ethnic groups throughout the world. Large population-based studies suggest that psoriasis occurs most often in individuals of European ancestry, followed by black and Hispanic individuals, although the true prevalence of psoriasis in non-white individuals is likely underestimated. Despite similarities in psoriasis between ethnic groups, there are notable differences in the presentation, quality-of-life impact, and treatment of psoriasis with important implications for the management of non-white individuals. Overall, heterogeneity in psoriasis susceptibility alleles, in combination with cultural and socioeconomic factors, may explain these differences. In this article, we review the epidemiology, clinical presentation, genetic polymorphisms, quality-of-life impact, and treatment nuances of psoriasis in patients with skin of color.
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Ganesan R, Raymond EL, Mennerich D, Woska JR, Caviness G, Grimaldi C, Ahlberg J, Perez R, Roberts S, Yang D, Jerath K, Truncali K, Frego L, Sepulveda E, Gupta P, Brown SE, Howell MD, Canada KA, Kroe-Barrett R, Fine JS, Singh S, Mbow ML. Generation and functional characterization of anti-human and anti-mouse IL-36R antagonist monoclonal antibodies. MAbs 2017; 9:1143-1154. [PMID: 28726542 PMCID: PMC5627585 DOI: 10.1080/19420862.2017.1353853] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Deficiency of interleukin (IL)-36 receptor antagonist (DITRA) syndrome is a rare autosomal recessive disease caused by mutations in IL36RN. IL-36R is a cell surface receptor and a member of the IL1R family that is involved in inflammatory responses triggered in skin and other epithelial tissues. Accumulating evidence suggests that IL-36R signaling may play a role in the pathogenesis of psoriasis. Therapeutic intervention of IL-36R signaling offers an innovative treatment paradigm for targeting epithelial cell-mediated inflammatory diseases such as the life-threatening psoriasis variant called generalized pustular psoriasis (GPP). We report the discovery and characterization of MAB92, a potent, high affinity anti-human IL-36 receptor antagonistic antibody that blocks human IL-36 ligand (α, β and γ)-mediated signaling. In vitro treatment with MAB92 directly inhibits human IL-36R-mediated signaling and inflammatory cytokine production in primary human keratinocytes and dermal fibroblasts. MAB92 shows exquisite species specificity toward human IL-36R and does not cross react to murine IL-36R. To enable in vivo pharmacology studies, we developed a mouse cross-reactive antibody, MAB04, which exhibits overlapping binding and pharmacological activity as MAB92. Epitope mapping indicates that MAB92 and MAB04 bind primarily to domain-2 of the human and mouse IL-36R proteins, respectively. Treatment with MAB04 abrogates imiquimod and IL-36-mediated skin inflammation in the mouse, further supporting an important role for IL-36R signaling in epithelial cell-mediated inflammation.
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Affiliation(s)
- Rajkumar Ganesan
- a Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT ., USA
| | - Ernest L Raymond
- a Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT ., USA
| | - Detlev Mennerich
- a Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT ., USA
| | - Joseph R Woska
- a Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT ., USA
| | - Gary Caviness
- a Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT ., USA
| | | | - Jennifer Ahlberg
- a Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT ., USA
| | - Rocio Perez
- a Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT ., USA
| | - Simon Roberts
- a Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT ., USA
| | - Danlin Yang
- a Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT ., USA
| | - Kavita Jerath
- a Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT ., USA
| | | | - Lee Frego
- a Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT ., USA
| | - Eliud Sepulveda
- a Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT ., USA
| | - Priyanka Gupta
- a Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT ., USA
| | - Su-Ellen Brown
- a Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT ., USA
| | - Michael D Howell
- a Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT ., USA
| | - Keith A Canada
- a Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT ., USA
| | | | - Jay S Fine
- a Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT ., USA
| | - Sanjaya Singh
- a Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT ., USA
| | - M Lamine Mbow
- a Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT ., USA
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Wang TS, Chiu HY, Hong JB, Chan CC, Lin SJ, Tsai TF. Correlation of IL36RN mutation with different clinical features of pustular psoriasis in Chinese patients. Arch Dermatol Res 2015; 308:55-63. [PMID: 26589685 DOI: 10.1007/s00403-015-1611-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 10/18/2015] [Accepted: 11/05/2015] [Indexed: 11/25/2022]
Abstract
Different studies have reported various values for the percentage of patients with IL36RN mutations, and it has also been reported that the sites of these mutations differ among different ethnicities. The current study was a cross-sectional study conducted to investigate the risk factors predicting IL36RN mutation in Chinese patients with different clinical features of pustular psoriasis. 57 Han Chinese patients, including 32 with generalized pustular psoriasis, 14 with palmoplantar pustulosis, 9 with plaque-type psoriasis with pustules, and 2 with erythrodermic psoriasis, were enrolled between March 2013 and July 2014. Blood samples were collected, genomic DNA was extracted from leukocytes, and polymerase chain reaction (PCR)-based Sanger sequencing was used to analyze the coding exons and flanking introns of the IL36RN gene. The patients with generalized pustular psoriasis exhibited the highest IL36RN mutation rate (75 %) among the aforementioned patient types, with the subgroup consisting of those patients who had features of acrodermatitis continua of Hallopeau exhibiting the highest c.115+6T>C mutation rate (93.8 %). In addition, early onset, ever generalized pustular psoriasis (more than two attacks), ever acrodermatitis continua of Hallopeau, inverse psoriasis, and a family history of pustular psoriasis were associated with IL36RN mutation. The c.115+6T>C mutation was the most common and the most important variant in all subtypes of pustular psoriasis with IL36RN mutations among our sample of Chinese patients.
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Affiliation(s)
- Ting-Shun Wang
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, #7, Chung-Shan South Road, Taipei, Taiwan
- Division of Dermatology, National Taiwan University Hospital, Yun-Lin Branch, Dou-Liou, Taiwan
| | - Hsien-Yi Chiu
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, #7, Chung-Shan South Road, Taipei, Taiwan
- Division of Dermatology, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan
- Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei, Taiwan
| | - Jin-Bong Hong
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, #7, Chung-Shan South Road, Taipei, Taiwan
| | - Chih-Chieh Chan
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, #7, Chung-Shan South Road, Taipei, Taiwan
| | - Sung-Jan Lin
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, #7, Chung-Shan South Road, Taipei, Taiwan
- Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei, Taiwan
| | - Tsen-Fang Tsai
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, #7, Chung-Shan South Road, Taipei, Taiwan.
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Hussain S, Berki DM, Choon SE, Burden AD, Allen MH, Arostegui JI, Chaves A, Duckworth M, Irvine AD, Mockenhaupt M, Navarini AA, Seyger MMB, Soler-Palacin P, Prins C, Valeyrie-Allanore L, Vicente MA, Trembath RC, Smith CH, Barker JN, Capon F. IL36RN mutations define a severe autoinflammatory phenotype of generalized pustular psoriasis. J Allergy Clin Immunol 2014; 135:1067-1070.e9. [PMID: 25458002 DOI: 10.1016/j.jaci.2014.09.043] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 09/19/2014] [Accepted: 09/24/2014] [Indexed: 12/21/2022]
Affiliation(s)
- Safia Hussain
- Division of Genetics and Molecular Medicine, King's College London, London, United Kingdom
| | - Dorottya M Berki
- Division of Genetics and Molecular Medicine, King's College London, London, United Kingdom
| | - Siew-Eng Choon
- Department of Dermatology, Hospital Sultanah Aminah, Johor Bahru, Malaysia
| | - A David Burden
- Department of Dermatology, University of Glasgow, Glasgow, United Kingdom
| | - Michael H Allen
- Division of Genetics and Molecular Medicine, King's College London, London, United Kingdom
| | | | - Antonio Chaves
- Department of Dermatology, Hospital Infanta Cristina, Badajoz, Spain
| | - Michael Duckworth
- Division of Genetics and Molecular Medicine, King's College London, London, United Kingdom
| | - Alan D Irvine
- Paediatric Dermatology, Our Lady's Children's Hospital, Dublin, Ireland; Clinical Medicine, Trinity College Dublin, Dublin, Ireland
| | - Maja Mockenhaupt
- Department of Dermatology, Dokumentationszentrum Schwerer Hautreaktionen (dZh), Universitäts-Hautklinik, Freiburg, Germany
| | - Alexander A Navarini
- Division of Genetics and Molecular Medicine, King's College London, London, United Kingdom; Department of Dermatology, Zurich University Hospital, Zurich, Switzerland
| | - Marieke M B Seyger
- Department of Dermatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Pere Soler-Palacin
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Christa Prins
- Dermatology Service, Geneva University Hospital, Geneva, Switzerland
| | | | | | - Richard C Trembath
- Queen Mary University of London, Barts and The London School of Medicine and Dentistry, London, United Kingdom
| | - Catherine H Smith
- Division of Genetics and Molecular Medicine, King's College London, London, United Kingdom
| | - Jonathan N Barker
- Division of Genetics and Molecular Medicine, King's College London, London, United Kingdom.
| | - Francesca Capon
- Division of Genetics and Molecular Medicine, King's College London, London, United Kingdom.
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Sugiura K, Takemoto A, Yamaguchi M, Takahashi H, Shoda Y, Mitsuma T, Tsuda K, Nishida E, Togawa Y, Nakajima K, Sakakibara A, Kawachi S, Shimizu M, Ito Y, Takeichi T, Kono M, Ogawa Y, Muro Y, Ishida-Yamamoto A, Sano S, Matsue H, Morita A, Mizutani H, Iizuka H, Muto M, Akiyama M. The Majority of Generalized Pustular Psoriasis without Psoriasis Vulgaris Is Caused by Deficiency of Interleukin-36 Receptor Antagonist. J Invest Dermatol 2013; 133:2514-2521. [DOI: 10.1038/jid.2013.230] [Citation(s) in RCA: 189] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 04/22/2013] [Accepted: 04/26/2013] [Indexed: 11/09/2022]
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Li M, Han J, Lu Z, Li H, Zhu K, Cheng R, Jiao Q, Zhang C, Zhu C, Zhuang Y, Wang Y, Shi J, Guo Y, Wu R, Yao Z. Prevalent and Rare Mutations in IL-36RN Gene in Chinese Patients with Generalized Pustular Psoriasis and Psoriasis Vulgaris. J Invest Dermatol 2013; 133:2637-2639. [DOI: 10.1038/jid.2013.267] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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