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Lin J, Bu F, Wu D, Jiang P, He Q, Yang D, Zhu X, Wang Y, Xiang X. Physiologically Based Pharmacokinetic Modeling and Clinical Extrapolation for Topical Application of Pilocarpine on Eyelids: A Comprehensive Study. J Pharm Sci 2024:S0022-3549(24)00222-3. [PMID: 38857643 DOI: 10.1016/j.xphs.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 05/31/2024] [Accepted: 06/02/2024] [Indexed: 06/12/2024]
Abstract
Exploiting a convenient and highly bioavailable ocular drug delivery approach is currently one of the hotspots in the pharmaceutical industry. Eyelid topical application is seen to be a valuable strategy in the treatment of chronic ocular diseases. To further elucidate the feasibility of eyelid topical administration as an alternative route for ocular drug delivery, pharmacokinetic and pharmacodynamic studies of pilocarpine were conducted in rabbits. Besides, a novel physiologically based pharmacokinetic (PBPK) model describing eyelid transdermal absorption and ocular disposition was developed in rabbits. The PBPK model of rabbits was extrapolated to human by integrating the drug-specific permeability parameters and human physiological parameters to predict ocular pharmacokinetic in human. After eyelid topical application of pilocarpine, the concentration of pilocarpine in iris peaked at 2 h with the value of 18,724 ng/g and the concentration in aqueous humor peaked at 1 h with the value of 1,363 ng/mL. Significant miotic effect were observed from 0.5 h to 4.5 h after eyelid topical application of pilocarpine in rabbits, while that were observed from 0.5 h to 3.5 h after eyedrop instillation. The proposed eyelid PBPK model was capable of reasonably predicting ocular exposure of pilocarpine after application on the eyelid skin and based on the PBPK model, the human ocular concentration was predicted to be 10-fold lower than that in rabbits. And it was suggested that drugs applied on the eyelid skin could transfer into the eyeball through corneal pathway and scleral pathway. This work could provide pharmacokinetic and pharmacodynamic data for the development of eyelid drug delivery, as well as the reference for clinical applications.
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Affiliation(s)
- Jiaying Lin
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai 201203, China
| | - Fengjiao Bu
- Department of Pharmacy, Eye and ENT Hospital, Fudan University, Shanghai 200031, China
| | - Dan Wu
- Department of Facial Plastic and Reconstructive Surgery, Eye and ENT Hospital of Fudan University, Shanghai 200031, China
| | - Pin Jiang
- Shanghai Medicilon Inc., Shanghai 201299, China
| | - Qingfeng He
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai 201203, China
| | - Dongsheng Yang
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai 201203, China
| | - Xiao Zhu
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai 201203, China
| | - Yixue Wang
- Pediatric Intensive Care Unit, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai 201102, China.
| | - Xiaoqiang Xiang
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai 201203, China.
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Foulad DP, Cirillo N, Grando SA. The Role of Non-Neuronal Acetylcholine in the Autoimmune Blistering Disease Pemphigus Vulgaris. BIOLOGY 2023; 12:biology12030354. [PMID: 36979046 PMCID: PMC10045443 DOI: 10.3390/biology12030354] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 01/25/2023] [Accepted: 02/22/2023] [Indexed: 02/25/2023]
Abstract
The importance of acetylcholine (ACh) in keratinocyte adhesion and acantholysis has been investigated over the last three decades, particularly in the pathophysiology of autoimmune blistering dermatoses. Pemphigus vulgaris (PV) is an autoimmune blistering skin disease where autoantibody-mediated suprabasilar intraepidermal splitting causes flaccid blisters and non-healing erosions of the oral mucosa and sometimes also of the skin. Historically, acantholysis in PV was thought to be driven by anti-desmoglein (Dsg) antibodies. Herein, we describe the role of autoantibodies against keratinocyte muscarinic and nicotinic acetylcholine receptors, as well as the annexin-like molecule pemphaxin that also binds ACh, in the immunopathogenesis of PV. The identification of targets in this disease is important, as they may lead to novel diagnostic and therapeutic options in the future for this potentially deadly disease.
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Affiliation(s)
- Delila Pouldar Foulad
- Division of Dermatology, University of California, Los Angeles, CA 90095, USA
- Correspondence: ; Tel.: +1-310-825-6911; Fax: +1-310-794-7005
| | - Nicola Cirillo
- Melbourne Dental School, University of Melbourne, Carlton, VI 3053, Australia
| | - Sergei A. Grando
- Department of Dermatology, University of California, Irvine, CA 92697, USA
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De D, Bishnoi A, Shilpa, Kamboj P, Arora AK, Pal A, Mahajan R, Handa S. Effectiveness of topical pilocarpine in refractory oral lesions of pemphigus vulgaris: Results from an open-label, prospective, pilot study. Dermatol Ther 2022; 35:e15449. [PMID: 35289044 DOI: 10.1111/dth.15449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 12/19/2021] [Accepted: 03/13/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The literature suggests a beneficial role of cholinomimetic agents in the treatment of pemphigus. In the present open-label, prospective pilot study, we assessed the effectiveness of topical pilocarpine 2% eye-drops in the treatment of recalcitrant oral lesions of pemphigus. METHODS Twenty patients with recalcitrant oral lesions of pemphigus were recruited and instructed to apply pilocarpine 2% eye-drops twice daily on the resistant oral lesions for 180 days. The systemic immunosuppression at the time of inclusion in the present study was continued at the same dose throughout the study duration. The photographs of the lesions were obtained at baseline and an interval of 30 days. The area representing the erosion was measured on clinical photographs using the imageJ software (National Institute of Health). Visual analogue scale and oral health impact profile-14 questionnaire were used to assess the degree of subjective improvement. Anti-desmoglein 1 and 3, and anti-acetylcholine M3 receptor antibodies were measured both in serum and saliva; at baseline and at the completion of the study. RESULTS Twenty patients were recruited in this pilot study. Mean total duration of illness was 3.4±1.3 years. The mean area of the erosions decreased significantly from 142.01±130.05 mm2 to 44.38±67.78 mm2 at study completion at 180 days (p 0.002, paired t-test). Repeated measures ANOVA demonstrated a significant trend in the reduction of the mean area of the erosions from baseline to day 180 (p 0.002). Mean VAS decreased significantly from 7.2±1.0 at baseline to 5.1±1.9 at day 180 (paired t-test, p 0.001). Mean OHIP-14 decreased significantly from 10.1±2.7 at baseline to 8.4±2.9 at day 180. No significant difference was observed between pre- and post-treatment levels of anti-desmoglein 1, anti-desmoglein 3, and anti-acetylcholine M3 receptor antibodies, in both serum and saliva. LIMITATIONS The depth component in the erosions could not be measured. An orabase formulation could be used in future studies to facilitate retention of the medication at the site of application. CONCLUSION Topical pilocarpine holds potential for the treatment of recalcitrant oral lesions of pemphigus vulgaris. It probably brings about re-epithelialization without imparting any immunomodulatory activity. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Dipankar De
- Department of Dermatology, Venereology and Leprology
| | | | - Shilpa
- Department of Dermatology, Venereology and Leprology
| | - Parul Kamboj
- Department of Dermatology, Venereology and Leprology
| | | | - Arnab Pal
- Department of Biochemistry, Postgraduate Institute of Medical Education and Research; Chandigarh, 160012, India
| | - Rahul Mahajan
- Department of Dermatology, Venereology and Leprology
| | - Sanjeev Handa
- Department of Dermatology, Venereology and Leprology
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Toosi R, Teymourzadeh A, Mahmoudi H, Balighi K, Daneshpazhooh M. Correlation of anti-γ/ε nicotinic acetylcholine receptor antibody levels with anti-desmoglein 1,3 antibody levels and disease severity in pemphigus vulgaris. Clin Exp Dermatol 2021; 46:1230-1235. [PMID: 33713456 DOI: 10.1111/ced.14645] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 01/29/2021] [Accepted: 03/08/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND A role for nondesmoglein antigens in the pathogenesis of pemphigus vulgaris (PV) has been suggested in several studies. Acetylcholine receptors (AchR), are one of the most important groups of these antigens. However, the exact role of both antimuscarinic (m) and nicotinic (n) AchR antibodies (Abs) is still controversial. AIM To evaluate anti-desmoglein (Dsg)1, Dsg 3 and anti-γ/ε nAchR Abs values in patients with PV before and 3 months after rituximab (RTX) treatment, and to assess their correlation with disease severity. METHODS In total, 75 patients with PV (26 men, 49 women) who were planned to receive RTX were enrolled. Disease activity was assessed by using the Pemphigus Disease Area Index (PDAI). Using ELISA, anti-Dsg1,3 and anti-γ/ε nAchR Abs were determined at baseline and 3 months after RTX treatment. RESULTS At baseline, 53.33% patients had positive values for anti-Dsg1, 89.33% for anti-Dsg3 and 13.33% for anti-γ/ε nAchR Abs. All patients with positive anti-γ/ε nAchR Abs had the mucocutaneous phenotype. PDAI, anti-Dsg1,3 and anti-γ/ε nAchR values were dramatically decreased 3 months after RTX infusion (P < 0.001). There was a significant positive correlation between disease activity and anti-γ/ε nAchR values at baseline (P = 0.04), whereas no significant correlation was observed between anti-Dsg1,3 and anti-γ/ε nAchR values at baseline and 3 months after RTX infusion. CONCLUSION The reduction in anti-γ/ε nAchR Abs with clinical improvement in this study may suggest a synergic role for anti-γ/ε nAchR Abs with anti-Dsg1,3 Abs, or it could be an epiphenomenon.
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Affiliation(s)
- R Toosi
- Autoimmune Bullous Diseases Research Center, Department of Dermatology, Tehran University of Medical Sciences, Tehran, Iran
| | - A Teymourzadeh
- Autoimmune Bullous Diseases Research Center, Department of Dermatology, Tehran University of Medical Sciences, Tehran, Iran
| | - H Mahmoudi
- Autoimmune Bullous Diseases Research Center, Department of Dermatology, Tehran University of Medical Sciences, Tehran, Iran
| | - K Balighi
- Autoimmune Bullous Diseases Research Center, Department of Dermatology, Tehran University of Medical Sciences, Tehran, Iran
| | - M Daneshpazhooh
- Autoimmune Bullous Diseases Research Center, Department of Dermatology, Tehran University of Medical Sciences, Tehran, Iran
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Soeberdt M, Kilic A, Abels C. Current and emerging treatments targeting the neuroendocrine system for disorders of the skin and its appendages. Exp Dermatol 2020; 29:801-813. [DOI: 10.1111/exd.14145] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/09/2020] [Accepted: 06/25/2020] [Indexed: 12/17/2022]
Affiliation(s)
| | - Ana Kilic
- Dr. August Wolff GmbH & Co. KG Arzneimittel Bielefeld Germany
| | - Christoph Abels
- Dr. August Wolff GmbH & Co. KG Arzneimittel Bielefeld Germany
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Comparison between the efficacy of intralesional rituximab versus intralesional triamcinolone in the treatment refractory Pemphigus Vulgaris lesions: A randomized clinical trial. Int Immunopharmacol 2019; 73:94-97. [DOI: 10.1016/j.intimp.2019.04.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 04/14/2019] [Accepted: 04/15/2019] [Indexed: 12/13/2022]
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Kridin K, Comaneshter D, Batat E, Cohen AD. Pemphigus and smoking - insights from a big data analysis. J Eur Acad Dermatol Venereol 2018; 32:e384-e386. [PMID: 29704278 DOI: 10.1111/jdv.15014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- K Kridin
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel
| | - D Comaneshter
- Department of Quality Measurements and Research, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
| | - E Batat
- Department of Quality Measurements and Research, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
| | - A D Cohen
- Department of Quality Measurements and Research, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel.,Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Lai O, Recke A, Zillikens D, Kasperkiewicz M. Influence of cigarette smoking on pemphigus - a systematic review and pooled analysis of the literature. J Eur Acad Dermatol Venereol 2018; 32:1256-1262. [DOI: 10.1111/jdv.14886] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 01/26/2018] [Indexed: 01/21/2023]
Affiliation(s)
- O. Lai
- Department of Dermatology; University of Illinois at Chicago; Chicago IL USA
| | - A. Recke
- Department of Dermatology; University of Lübeck; Lübeck Germany
| | - D. Zillikens
- Department of Dermatology; University of Lübeck; Lübeck Germany
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Harman K, Brown D, Exton L, Groves R, Hampton P, Mohd Mustapa M, Setterfield J, Yesudian P, McHenry P, Gibbon K, Buckley D, Leslie T, Mallon E, Wakelin S, Ungureanu S, Hunasehally R, Cork M, Johnston G, Natkunarajah J, Worsnop F, Chiang N, Duarte Williamson C, Donnelly J, Saunders C, Brain A. British Association of Dermatologists’ guidelines for the management of pemphigus vulgaris 2017. Br J Dermatol 2017; 177:1170-1201. [DOI: 10.1111/bjd.15930] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2017] [Indexed: 12/11/2022]
Affiliation(s)
- K.E. Harman
- University Hospitals Leicester Leicester Royal Infirmary Infirmary Square Leicester LE1 5WW U.K
| | - D. Brown
- St John's Institute of Dermatology Guy's and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital Westminster Bridge Road London SE1 7EH U.K
| | - L.S. Exton
- British Association of Dermatologists Willan House, 4 Fitzroy Square London W1T 5HQ U.K
| | - R.W. Groves
- St. John's Institute of Dermatology King's College London Guy's Campus, Great Maze Pond London SE1 9RT U.K
| | - P.J. Hampton
- Royal Victoria Infirmary Queen Victoria Road Newcastle upon Tyne Tyne and Wear NE1 4LP U.K
| | - M.F. Mohd Mustapa
- British Association of Dermatologists Willan House, 4 Fitzroy Square London W1T 5HQ U.K
| | - J.F. Setterfield
- St. John's Institute of Dermatology King's College London Guy's Campus, Great Maze Pond London SE1 9RT U.K
- Mucosal & Salivary Biology Division King's College London Dental Institute Guy's Campus, Great Maze Pond London SE1 9RT U.K
| | - P.D. Yesudian
- Wrexham Maelor Hospital Croesnewydd Road Wrexham LL13 7TD U.K
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Chernyavsky AI, Galitovskiy V, Grando SA. Molecular mechanisms of synergy of corneal muscarinic and nicotinic acetylcholine receptors in upregulation of E-cadherin expression. Int Immunopharmacol 2015; 29:15-20. [DOI: 10.1016/j.intimp.2015.04.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 03/31/2015] [Accepted: 04/17/2015] [Indexed: 12/20/2022]
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Chernyavsky AI, Marchenko S, Phillips C, Grando SA. Auto/paracrine nicotinergic peptides participate in cutaneous stress response to wounding. DERMATO-ENDOCRINOLOGY 2013; 4:324-30. [PMID: 23467535 PMCID: PMC3583894 DOI: 10.4161/derm.22594] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Restoration of epidermal barrier (epithelialization), is a major component of cutaneous response to stress imposed by wounding. Learning physiologic regulation of epithelialization may lead to novel treatments of chronic wounds. The non-canonical ligands of nicotinic acetylcholine receptors SLURP (secreted mammalian Ly-6/urokinase-type plasminogen activator receptor-related proteins)-1 and -2 are produced by keratinocytes (KCs) and inflammatory cells to augment physiologic responses to non-neuronal acetylcholine, suggesting that they can affect wound epithelialization and inflammation. In this study, recombinant (r)SLURP-1 and -2 exhibited dose dependent effects on migration of cultured KCs, and monoclonal antibodies inactivating auto/paracrine SLURPs in mouse skin delayed wound epithelialization. While effects of rSLURPs on migration were opposite, with rSLURP-1 inhibiting and rSLURP-2 stimulating migration of KCs, each anti-SLURP antibody produced a negative effect on epithelialization in vivo, suggesting their more extensive than regulation of keratinocyte migration involvement in wound repair. Since inflammation plays an important role in stress response to wounding, we measured inflammation biomarkers in wounds treated with anti-SLURP antibodies. Both anti-SLURP-1 and -2 antibodies, or their mixture, caused significant elevation of wound myeloperoxidase, IL-1β, IL-6 and TNFα. Taken together, results of this study demonstrated that SLURP-1 slows crawling locomotion of KCs, and exhibits a strong anti-inflammatory activity in wound tissue. In contrast, SLURP-2 facilitates lateral migration of KCs, but shows a lesser anti-inflammatory capacity. Thus, combined biologic activities of both SLURPs may be required for normal stress response to skin wounding, which favors clinical trial of rSLURP-1 and -2 in wounds that fail to heal.
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Affiliation(s)
- Alex I Chernyavsky
- Departments of Dermatology and Biochemistry; University of California; Irvine, CA USA
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Grando SA. Muscarinic receptor agonists and antagonists: effects on keratinocyte functions. Handb Exp Pharmacol 2012:429-50. [PMID: 22222709 DOI: 10.1007/978-3-642-23274-9_18] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The stratified epithelium enveloping the skin and lining the surfaces of oral and vaginal mucosa is comprised by keratinocytes that synthesize, secrete, degrade, and respond to acetylcholine via muscarinic and nicotinic receptors. The two pathways may compete or synergize with one another, so that net biologic effect represents the biologic sum of the effects of distinct acetylcholine receptors expressed by a keratinocyte at a particular stage of its development. Keratinocytes express a unique combination of muscarinic receptor subtypes at each stage of their development. Experimental results indicate that muscarinic receptors expressed in human keratinocytes regulate their viability, proliferation, migration, adhesion, and terminal differentiation, hair follicle cycling, and secretion of humectants, cytokines, and growth factors. Learning the muscarinic pharmacology of keratinocyte development and functions has salient clinical implications for patients with nonhealing wounds, mucocutaneous cancers, and various autoimmune and inflammatory diseases. Successful therapy of pemphigus lesions with topical pilocarpine and disappearance of psoriatic lesions due to systemic atropine therapy illustrate that such therapeutic approach is feasible.
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Affiliation(s)
- Sergei A Grando
- Departments of Dermatology and Biological Chemistry, University of California, 134 Sprague Hall, Irvine, CA 92697, USA.
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Abstract
The goal of contemporary research in pemphigus vulgaris and pemphigus foliaceus is to achieve and maintain clinical remission without corticosteroids. Recent advances of knowledge on pemphigus autoimmunity scrutinize old dogmas, resolve controversies, and open novel perspectives for treatment. Elucidation of intimate mechanisms of keratinocyte detachment and death in pemphigus has challenged the monopathogenic explanation of disease immunopathology. Over 50 organ-specific and non-organ-specific antigens can be targeted by pemphigus autoimmunity, including desmosomal cadherins and other adhesion molecules, PERP cholinergic and other cell membrane (CM) receptors, and mitochondrial proteins. The initial insult is sustained by the autoantibodies to the cell membrane receptor antigens triggering the intracellular signaling by Src, epidermal growth factor receptor kinase, protein kinases A and C, phospholipase C, mTOR, p38 MAPK, JNK, other tyrosine kinases, and calmodulin that cause basal cell shrinkage and ripping desmosomes off the CM. Autoantibodies synergize with effectors of apoptotic and oncotic pathways, serine proteases, and inflammatory cytokines to overcome the natural resistance and activate the cell death program in keratinocytes. The process of keratinocyte shrinkage/detachment and death via apoptosis/oncosis has been termed apoptolysis to emphasize that it is triggered by the same signal effectors and mediated by the same cell death enzymes. The natural course of pemphigus has improved due to a substantial progress in developing of the steroid-sparing therapies combining the immunosuppressive and direct anti-acantholytic effects. Further elucidation of the molecular mechanisms mediating immune dysregulation and apoptolysis in pemphigus should improve our understanding of disease pathogenesis and facilitate development of steroid-free treatment of patients.
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Affiliation(s)
- Sergei A Grando
- Department of Dermatology, University of California, Irvine, CA 92697, USA.
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Kalantari-Dehaghi M, Molina DM, Farhadieh M, John Morrow W, Liang X, Felgner PL, Grando SA. New targets of pemphigus vulgaris antibodies identified by protein array technology. Exp Dermatol 2011; 20:154-6. [DOI: 10.1111/j.1600-0625.2010.01193.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
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.
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Affiliation(s)
- Sergei A Grando
- Department of Dermatology, University of California-Davis, Sacramento, CA 95816, USA.
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Abstract
The pathogenesis of pemphigus vulgaris (PV) is a highly controversial, "hot" topic that has received considerable enrichment in recent years by both clinical and basic researchers. On the one hand, the classical view of desmogleins (Dsg) as main targets of this autoimmune disease is supported by the characterization of pathogenic anti-Dsg3 antibodies from both patients and animal models. On the other hand, fundamental doubt has been raised towards this monopathogenic view by several independent factors: (1) pemphigus lesions can be induced in Dsg3-knockout (KO) mice; (2) pemphigus sera contain multiple autoantibodies against different adhesion molecules and also cholinergic receptors; (3) experimental inhibition of PV IgG induced acantholysis can be obtained by interference with different signaling cascades regulating both calcium homeostasis and apoptosis; and (4) cholinergic agonists exhibit anti-acantholytic activity both in vitro and in vivo. The field is open for controlled clinical trials and further basic research to unfold the true story of the pemphigus enigma and provide the basis for a better treatment of pemphigus patients.
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Affiliation(s)
- Hjalmar Kurzen
- Department of Dermatology, University Medical Center Mannheim, University of Heidelberg, Heidelberg, Germany.
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Martin LK, Werth V, Villanueva E, Segall J, Murrell DF. Interventions for pemphigus vulgaris and pemphigus foliaceus. Cochrane Database Syst Rev 2009:CD006263. [PMID: 19160272 DOI: 10.1002/14651858.cd006263.pub2] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND A range of interventions have been described for treatment of pemphigus, however the optimal therapeutic strategy has not been established. OBJECTIVES To assess the efficacy and safety of all interventions used in the management of pemphigus vulgaris and pemphigus foliaceus. SEARCH STRATEGY We searched the Cochrane Skin Group Specialised Register (October 2008), The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2008), MEDLINE (2003 to October 2008), EMBASE (2005 to October 2008), LILACS (1981 to October 2008), Ongoing Trials Registers, reference lists of articles, conference proceedings from international pemphigus meetings and contacted experts in the field. SELECTION CRITERIA Randomised controlled trials of any intervention in pemphigus vulgaris or pemphigus foliaceus. DATA COLLECTION AND ANALYSIS Two authors independently assessed quality and extracted data from studies. All investigators were contacted for further information. Adverse events were identified from included studies. MAIN RESULTS Eleven studies with a total of 404 participants (337 pemphigus vulgaris, 27 pemphigus foliaceus and 40 not specified ) were identified. The quality of included studies was not high, the majority of studies did not report allocation concealment, and power was limited by very small sample sizes. Interventions assessed included prednisolone dose regimen, pulsed dexamethasone, azathioprine, cyclophosphamide, cyclosporine, dapsone, mycophenolate, plasma exchange, topical epidermal growth factor and traditional Chinese medicine. Ten studies included participants with newly diagnosed or newly active recurrent disease, and one trial included participants in maintenance phase.There was sufficient data for 4 meta-analyses, each pooling results of two studies only. For the majority of interventions, results were inconclusive. We found some interventions to be superior for certain outcomes, although we were unable to conclude which treatments are superior overall. Mycophenolate was more effective in achieving disease control than azathioprine (1 study; n=40; RR 0.72; 95% CI 0.52 to 0.99, NNT 3.7). There was evidence of a steroid-sparing benefit of azathioprine (1 study; n=57; MWD -3919 mg prednisolone; 95% CI -6712 to -1126) and cyclophosphamide (1 study; n=54; MWD -3355 mg prednisolone; 95% CI -6144 to -566) compared to glucocorticoids alone. Topical epidermal growth factor decreased time to control (1 study; n=20; HR 2.35; 95% CI 1.62 to 3.41). AUTHORS' CONCLUSIONS There is inadequate information available at present to ascertain the optimal therapy for pemphigus vulgaris or pemphigus foliaceus. Further research is required, especially to assess the optimal glucocorticoid dose, the role of adjuvant immunosuppressive medications, and long-term adverse events to improve harm:benefit analyses.
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Affiliation(s)
- Linda K Martin
- Department of Dermatology , St George Hospital, Gray St, Kogarah, Sydney, NSW, Australia, 2217
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Abstract
UNLABELLED Pemphigus vulgaris is an autoimmune disease that commonly presents with painful persistent erosions and ulcers. OBJECTIVE The current literature has focused on managing and maintaining remittance of this life-threatening disease. However, remission is not instantaneous and chronic pain is common. In this manuscript, we review the current peer reviewed works that elaborate specifically on pain management in pemphigus patients. METHODS A medline search was preformed and included any case report, review, clinical trial, or other publication that covered the subject matter. RESULTS From the review of literature, it is clear that pain is an important and underemphasized part of the literature on pemphigus. The majority of pain management in these patients is based on clinical experience rather than randomized blinded clinical studies. DISCUSSION Large scale blinded randomized studies are lacking in this field, and would be of great benefit to academia and the patient population. Current large-scale studies of pemphigus would also be strongly enhanced by inclusion and reporting pain scale assessments.
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Abstract
Desmosomes are patch-like intercellular adhering junctions ("maculae adherentes"), which, in concert with the related adherens junctions, provide the mechanical strength to intercellular adhesion. Therefore, it is not surprising that desmosomes are abundant in tissues subjected to significant mechanical stress such as stratified epithelia and myocardium. Desmosomal adhesion is based on the Ca(2+)-dependent, homo- and heterophilic transinteraction of cadherin-type adhesion molecules. Desmosomal cadherins are anchored to the intermediate filament cytoskeleton by adaptor proteins of the armadillo and plakin families. Desmosomes are dynamic structures subjected to regulation and are therefore targets of signalling pathways, which control their molecular composition and adhesive properties. Moreover, evidence is emerging that desmosomal components themselves take part in outside-in signalling under physiologic and pathologic conditions. Disturbed desmosomal adhesion contributes to the pathogenesis of a number of diseases such as pemphigus, which is caused by autoantibodies against desmosomal cadherins. Beside pemphigus, desmosome-associated diseases are caused by other mechanisms such as genetic defects or bacterial toxins. Because most of these diseases affect the skin, desmosomes are interesting not only for cell biologists who are inspired by their complex structure and molecular composition, but also for clinical physicians who are confronted with patients suffering from severe blistering skin diseases such as pemphigus. To develop disease-specific therapeutic approaches, more insights into the molecular composition and regulation of desmosomes are required.
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Affiliation(s)
- Jens Waschke
- Institute of Anatomy and Cell Biology, University of Würzburg, Koellikerstr. 6, 97070, Würzburg, Germany.
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Valikhani M, Kavusi S, Chams-Davatchi C, Hallaji Z, Esmaili N, Ghandi N, Farahani F, Lajevardi V. Impact of smoking on pemphigus. Int J Dermatol 2008; 47:567-70. [DOI: 10.1111/j.1365-4632.2008.03645.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Chernyavsky AI, Arredondo J, Piser T, Karlsson E, Grando SA. Differential coupling of M1 muscarinic and alpha7 nicotinic receptors to inhibition of pemphigus acantholysis. J Biol Chem 2007; 283:3401-3408. [PMID: 18073210 DOI: 10.1074/jbc.m704956200] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The mechanisms mediating and regulating assembly and disassembly of intercellular junctions is a subject of intensive research. The IgG autoantibodies produced in patients with the immunoblistering skin disease pemphigus vulgaris (PV) can induce keratinocyte (KC) dyshesion (acantholysis) via mechanisms that involve signaling kinases targeting intercellular adhesion molecules, thus providing a useful model to study the physiologic regulation of KC cohesion. Previous studies showed that activation of Src and protein kinase C are the earliest events in the PV IgG-induced intracellular phosphorylation cascades and that cholinergic agonists are effective for treating patients with pemphigus. In this study, we sought to elucidate the molecular mechanisms allowing cholinergic agonists to inhibit PV IgG-induced acantholysis and phosphorylation of KC adhesion molecules. The extent of acantholysis in KC monolayers correlated closely with the degree of PV IgG-induced phosphorylation of p120- and beta-catenins, with classic isoforms of protein kinase C mediating serine phosphorylation of beta-catenin and Src-tyrosine phosphorylation of p120-catenin. The M(1) muscarinic agonist pilocarpine blocked phosphorylation of both catenins, which could be abolised by the M(1) antagonist MT7. The alpha7 nicotinic agonist AR-R17779 inhibited phosphorylation of P120-cateinin. The alpha7 antagonist methyllycaconitine abolished the effect of AR-R17779. Okadaic acid abrogated protective effects of agonists on phosphorylation of beta-catenin, and pervanadate, on that of p120-catenin. Stimulation of KCs with pilocarpine significantly (p < 0.05) elevated both serine/threonine and tyrosine phosphatase activities in KCs. AR-R17779 both stimulated tyrosine phosphatase and decreased PV IgG-induced Src activity. Methyllycaconitine released Src activity in intact KCs and caused acantholysis. Thus, downstream signaling from M(1) abolished PV IgG-dependent catenin phosphorylation due to activation of both serine/threonine and tyrosine phosphatases, whereas alpha7 action involved both activation of tyrosine phosphatase and inhibition of Src. These findings identified novel paradigm of regulation of signaling kinases associated with cholinergic receptors and provided mechanistic explanation of therapeutic activity of cholinomimetics in PV patients.
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Affiliation(s)
- Alex I Chernyavsky
- Department of Dermatology, University of California, Irvine, California 92697
| | - Juan Arredondo
- Department of Dermatology, University of California, Irvine, California 92697
| | - Timothy Piser
- AstraZeneca Pharmaceuticals, Wilmington, Delaware 19850
| | - Evert Karlsson
- Karolinska Institute, Lindsbergsgatan 11A, Uppsala 752 40, Sweden
| | - Sergei A Grando
- Department of Dermatology, University of California, Irvine, California 92697.
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Abstract
Pemphigus is a group of rare autoimmune mucocutaneous bullous diseases with potential significant morbidity and mortality. The two main subtypes are pemphigus vulgaris (PV) and pemphigus foliaceus (PF). Systemic corticosteroid use and other advances in management have dramatically decreased the mortality rate for pemphigus. At present, the primary cause of morbidity and mortality is complications from treatment. Thus, the goal of pemphigus management is to induce and maintain remission with the lowest possible doses of medication and with the fewest side effects. Although our scientific knowledge of pemphigus is advancing and our treatment options are expanding, there are still very few randomized, controlled studies to evaluate the true effectiveness of the available therapies. Here we review the available treatment options and novel therapies for pemphigus and the supporting data.
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Affiliation(s)
- Sarah E Dick
- Department of Dermatology, Philadelphia VA Medical Center, University of Pennsylvania, Philadelphia, PA, USA
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Grando SA. Viewpoint 6. Exp Dermatol 2006. [DOI: 10.1111/j.1600-0625.2006.00499_10.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Paus R, Amagai M, Ahmed AR, Kitajima Y, Bystryn JC, Milner Y, Gniadecki R, Hertl M, Pincelli C, Fridkis-Hareli M, Aoyama Y, Frušić-Zlotkin M, Müller E, David M, Mimouni D, Vind-Kezunovic D, Michel B, Mahoney M, Grando S. Are desmoglein autoantibodies essential for the immunopathogenesis of pemphigus vulgaris, or just ‘witnesses of disease'? Exp Dermatol 2006. [DOI: 10.1111/j.1600-0625.2006.00499.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Grando SA, Pittelkow MR, Schallreuter KU. Adrenergic and Cholinergic Control in the Biology of Epidermis: Physiological and Clinical Significance. J Invest Dermatol 2006; 126:1948-65. [PMID: 16912692 DOI: 10.1038/sj.jid.5700151] [Citation(s) in RCA: 200] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The presence of an autocrine adrenergic and cholinergic intra/intercellular signal transduction network in the human epidermis contributes significantly to homeostatic and compensatory responses regulating vital functions in keratinocytes and melanocytes. The ligands produced control autocrine and paracrine loops to initiate responses through cognate receptors expressed within the same or adjacent cells. The epidermal adrenergic signal controls calcium homeostasis, cell growth, differentiation, motility, and pigmentation via the beta2 and alpha1 adrenoceptors. The cholinergic system is highly complex comprising both nicotinic and muscarinic receptors with multiple subtypes and this system plays an important role in keratinocyte cell cycle progression, differentiation, directional migration, adhesion, and apoptotic secretion. Moreover, lymphocytes also express adrenergic and cholinergic receptors. Both types of signal transduction receptors are coupled to classical intracellular second messenger pathways, including cAMP-, cGMP-, and calcium-mediated downstream responses. To date, it has been recognized that several dermatoses such as psoriasis, atopic dermatitis, Mal de Meleda, vitiligo, palmoplantar pustulosis, and pemphigus may be mediated, in part, by the non-neuronal adrenergic/cholinergic systems. A detailed understanding of the physiology and pathophysiology of the adrenergic/cholinergic network in the skin could offer the development of specific drugs for novel treatment modalities.
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Affiliation(s)
- Sergei A Grando
- Department of Dermatology, University of California, Davis, 95817, USA.
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Abstract
The non-neuronal cholinergic system of human epidermis includes the keratinocyte (KC) acetylcholine (ACh) axis composed of the enzymes mediating ACh synthesis and degradation, and two classes of ACh receptors, the nicotinic and muscarinic ACh receptors, mediating biological effects of the cutaneous cytotransmitter ACh. Regulation of KC cell-cell and cell-matrix adhesion is one of the important biological functions of cutaneous ACh. The downstream targets of ACh effects mediated by distinct ACh receptor subtypes include both the intercellular adhesion molecules, such as classical and desmosomal cadherins, and integrins mediating KC adhesion to a substrate. The signaling pathways include activation or inhibition of kinase cascades resulting in either up- or down-regulation of the expression of cell adhesion molecules or changes in their phosphorylation status, or both. The components of the KC ACh axis are involved in cutaneous blistering in patients with autoimmune pemphigus, junctional and dystrophic forms of epidermolysis bullosa, thermal burns, and mustard-induced vesication. Recent progress with the development of antiacantholytic therapies of patients with pemphigus using cholinomimetics indicates that cholinergic drugs may be a promising approach for other cutaneous blistering disorders.
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Affiliation(s)
- Sergei A Grando
- Department of Dermatology, University of California at Davis, Sacramento, CA 95817, USA.
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