Antinuclear antibodies in patients with atopic dermatitis and severe facial lesions

Antinuclear Autoantibodies in Health: Autoimmunity Is Not a Synonym of Autoimmune Disease

The incidence of autoimmune diseases is increasing. Antinuclear antibody (ANA) testing is a critical tool for their diagnosis. However, ANA prevalence in healthy persons has increased over the last decades, especially among young people. ANA in health occurs in low concentrations, with a prevalence up to 50% in some populations, which demands a cutoff revision. This review deals with the origin and probable physiological or compensatory function of ANA in health, according to the concept of immunological clearance, theory of autoimmune regulation of cell functions, and the concept of functional autoantibodies. Considering ANA titers ≤1:320 as a serological marker of autoimmune diseases seems inappropriate. The role of anti-DFS70/LEDGFp75 autoantibodies is highlighted as a possible anti-risk biomarker for autoimmune rheumatic disorders. ANA prevalence in health is different in various regions due to several underlying causes discussed in the review, all influencing additive combinations according to the concept of the mosaic of autoimmunity. Not only are titers, but also HEp-2 IFA) staining patterns, such as AC-2, important. Accepting autoantibodies as a kind of bioregulator, not only the upper, but also the lower borders of their normal range should be determined; not only their excess, but also a lack of them or "autoimmunodeficiency" could be the reason for disorders.

Atopic dermatitis and autoimmunity: the occurrence of autoantibodies and their association with disease severity

Atopic dermatitis (AD) is a widespread condition that appears to be increasing in prevalence and severity worldwide, yet the underlying mechanisms are not well understood. Recent research has identified various similarities between AD and autoimmune conditions, as well as indicating that there may be an association between AD and autoimmunity. This systematic review evaluates the association between AD and autoimmunity, as well as between severity of disease in AD and autoimmunity, with an emphasis on the associations with autoantibodies. MEDLINE (1946 to December 2017) and Embase (1974 to December 2017) databases were searched. Further relevant articles were retrieved from reference lists. Only studies measuring direct indicators of autoimmunity, in humans, were included. Qualitative analysis was carried out for all studies. In addition, quantitative analysis was used to evaluate prevalence of IgE autoantibodies and anti-nuclear antibodies (ANAs) in AD patients and control subjects. The Mantel-Haenszel method was used with a random-effects model. 28 studies assessed the occurrence of autoantibodies in AD patients and 16 studies were used to evaluate association between disease severity and autoantibodies. Pooled analysis from 14 studies, involving 986 AD patients and 441 control subjects, showed that IgE autoantibodies were significantly more prevalent in patients with AD (P < 0.00001) than control subjects. Similar analysis was carried out for ANAs, with eight studies that involved 1045 AD patients and 1273 control subjects. ANAs were significantly more prevalent in patients with AD (P = 0.003). This quantitative analysis supported an association between AD and IgE autoantibodies, as well as between AD and ANAs. There was insufficient data to make similar conclusions for other indicators of autoimmunity. The weight of evidence also suggests an association between IgE autoantibodies and disease severity. There was insufficient evidence to make this link for other indicators of autoimmunity.

Humoral and Cellular Autoreactivity to Epidermal Proteins in Atopic Dermatitis

Atopic dermatitis (AD), a chronic relapsing inflammatory disease of the skin, is an important public health concern affecting 10-20 % of children worldwide. The etiology and pathogenesis of AD involve the interplay of genetic and environmental factors, including abnormalities in skin integrity and a skewed immune system usually driven by a Th2 phenotype in childhood with a switch to Th1 in the chronic phase of disease. Children and adults with AD commonly have elevated IgE levels directed to multiple different antigens, including aeroallergens, food allergens, and microbial proteins. IgE targeting self-antigens from epidermal proteins have been detected in up to 91 % of patients, particularly in severe persistent AD. It has been suggested that the occurrence of autoreactivity develops in early childhood. However, it is not clear yet if autoreactive IgEs in patients with AD are pathogenic or just an epiphenomenon. The fact that these autoantibodies are associated with severity and are not present in other allergic or skin diseases favors the pathogenicity of IgE-mediated autoreactivity in AD. In this review, we evaluate the pathogenesis of AD and the emerging role of autoreactivity to various keratinocyte antigens involving both the humoral and cellular components of the immune system.

Effects of oral vitamin E on treatment of atopic dermatitis: A randomized controlled trial

BACKGROUND

The pathogenesis of atopic dermatitis (AD) remains to be determined; recently a possible change in the immune system with production of immunoglobulins is proposed. As vitamin E is a potent antioxidant, with the ability to decrease the serum levels of immunoglobulin E (IgE) in atopic patients, we aimed to evaluate the effect of oral vitamin E on treatment of AD.

MATERIALS AND METHODS

This randomized, double-blind, placebo-controlled trial comprised seventy participants with mild-to-moderate AD, based on the Hanifin and Rajka diagnostic criteria. The patients were randomly selected from teaching skin clinics in Isfahan, Iran. They were randomly assigned to two groups of equal number, receiving vitamin E (400 IU/day) and placebo for four 4 months. Each month, the extent, severity, and subjective symptoms including itch and sleeplessness were measured by SCORAD index. Three months after the end of intervention, the recurrence rate was assessed.

RESULTS

The improvement in all symptoms, except sleeplessness, was significantly higher in the group receiving vitamin E than in controls (-1.5 vs. 0.218 in itching, -10.85 vs. -3.54 in extent of lesion, and -11.12 vs. -3.89 in SCORAD index, respectively, P < 0.05). Three months after the end of intervention, the recurrence rate of AD was evaluated. Recurrence rate between all 42 individuals, who remained in the study, was 18.6%. Recurrence ratio of the group receiving vitamin E compared to the placebo group was 1.17, without significant differences between the two groups (P > 0.05).

CONCLUSION

This study suggests that vitamin E can improve the symptoms and the quality of life in patients with AD. As vitamin E has no side effects with a dosage of 400 IU/day, it can be recommended for the treatment of AD.

Antinuclear antibodies in atopic dermatitis: a cross-sectional study on 346 children

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease that can be classified into an extrinsic or intrinsic type. A high percentage of patients, especially adults with the extrinsic type of AD, have been reported to show antibodies to antinuclear proteins (ANA). We aimed to study the prevalence of ANA in children with AD and to evaluate clinical differences between patients with ANA-positive and ANA-negative AD.

METHODS

A total 346 serum samples from children with active AD (mean age 5.8 years) and 117 hospital controls without known skin, inflammatory, or immune-mediated disease (mean age 7.9 years) were tested for IgG ANA with indirect immunofluorescence on HEp-2 cells, total serum IgE levels, and IgE type antibodies to food allergen panels.

RESULTS

In total, 47 patients with AD (13.6%) and 15 subjects in the control group (12.8%) were ANA positive at screening dilution 1:10 (P > 0.05). In patients with AD, ANA was found already at the age of 2 years, significantly more often in females (P < 0.005) and at slightly higher titers (up to 1:160). No differences were found in ANA positivity regarding the severity of AD or sensitization to food allergens.

CONCLUSION

No significant differences were observed between AD and the control group, or between different subtypes of AD in ANA prevalence. In both groups, ANA frequency increased with age, but in patients with AD, ANA had a tendency to appear earlier. Therefore, active AD during the early years of life could dispose selected patients towards earlier development of systemic autoreactivity and stress the need for regular follow-up of patients with ANA-positive AD.

Does "autoreactivity" play a role in atopic dermatitis?

The role of autoimmunity in atopic dermatitis (AD) is unclear. We sought to critically examine the occurrence, correlation with severity, and possible causative role of autoreactivity in patients with AD. Our systematic review of studies identified from MEDLINE included 31 experiments that described autoreactivity in patients with AD. We defined autoreactivity as in vitro or in vivo evidence of immune response to autologous human, generic human, or recombinant human proteins or other tissue/cellular components. Autoreactivity prevalence in patients with AD ranged from 23% to 91% in 14 studies involving 2644 participants, although it did not appear to vary with age, sex, or disease duration. In contrast to studies of AD, IgE autoreactivity was not found in healthy subjects or in those with allergic rhinoconjunctivitis, psoriasis, systemic lupus erythematosus, or other inflammatory diseases (8 studies of 816 participants). Two reports found a positive correlation between autoreactivity and AD severity. We suggest that autoreactivity might be playing a causative role in AD based on the magnitude and specificity of the associations found; plausible mechanisms through IgE autoantibodies, IgG autoantibodies, and T(H)1 autoreactivity; and experimental elicitation of eczematous lesions after provocation. Whether autoantibodies contribute to AD chronicity now needs to be examined in longitudinal studies.

Vitamin E and immunity

Vitamin E is the most important chain-breaking, lipid-soluble antioxidant present in body tissues of all cells and is considered the first line of defense against lipid peroxidation and it is important for normal function of the immune cells. However, vitamin E deficiency is rare in well-nourished healthy subjects and is not a problem, even among people living on relatively poor diets, both T- and B-cell functions are impaired by vitamin E deficiency. While immune cells are particularly enriched in vitamin E because of their high polyunsaturated fatty acid content, this point puts them at especially high risk for oxidative damage. Besides its immunomodulatory effects, vitamin E also plays an important role in carcinogenesis with its antioxidant properties against cancer, and ischemic heart disease with limiting the progression of atherosclerosis. Supplementation of vitamin E significantly enhances both cell mediated and humoral immune functions in humans, especially in the elderly and animals.

Clinical features of antinuclear antibody-positive patients with atopic dermatitis

Twenty to thirty percent of patients with atopic dermatitis (AD) are positive for antinuclear antibodies (ANAs). In this study we investigated the prevalence of ANA in 100 patients with AD and examined the difference between ANA-positive (ANA+) and ANA-negative (ANA(-)) patients with AD. ANAs were identified with indirect immunofluorescence on Hep-2 cells. Nineteen patients (19%) with AD were found to be positive for ANAs at titers ranging from 1 : 40 to 1 : 640. The rate of ANA positivity in male patients (20.4%) was higher than that in female patients (17.6%). The rate of ANA positivity differed significantly between patients with AD and healthy control subjects (p=0.0001, odds ratio: 2.8). There was also a relationship between ANA+ AD and photosensitivity in male subjects (p=0.0346). The ANA+ patients with AD showed higher levels of cedar pollen-specific IgE than did ANA(-) patients (p=0.0232). In ANA+ patients disease severity was correlated with basophil counts (r=0.513, p=0.0344) and serum LDH levels (r=0.741, p=0.0056). The results indicate that patients with AD who are positive for ANA are a subpopulation of patients with AD.

LEDGF/DFS70, a major autoantigen of atopic dermatitis, is a component of keratohyalin granules

Lens epithelium-derived growth factor/dense fine speckles 70 kDa protein (LEDGF/DFS70) is a transcriptional cofactor, a transcriptional activator, survival factor, and HIV-1 transporter. It is also a major autoantigen in patients with atopic dermatitis (AD), because autoantibodies to this protein are found in approximately 30% of AD patients. To better understand the role of autoantibodies and autoantigens in the pathogenesis of AD, we examined the distribution of LEDGF/DFS70 in the epidermis of normal human skin by light and electron microscopic immunocytochemistry. Increased amounts of LEDGF/DFS70 were located in the nuclei of cells in the basal layer, whereas the cytoplasm of cells in the granular layer stained for LEDGF/DFS70 by light microscopy. Using immunoelectron microscopy, we observed the accumulation of LEDGF/DFS70 in keratohyalin granules (KGs) in the cytoplasm of cells in the granular layer. In addition, Ig heavy chain-binding protein/glucose-regulated protein, 78-kDa (Bip/GRP78), a stress sensing protein in the endoplasmic reticulum, colocalized with LEDGF/DFS70 in the KGs. These results suggest that LEDGF/DFS70 is predominantly located in the nucleus of the basal epidermal cells and translocates into the cytoplasm during differentiation. Once in the cytoplasm, LEDGF/DFS70 accumulates in the KGs in the granular layer. Finally, LEDGF/DFS70, a "nuclear" autoantigen in AD, may play a functional role in the KGs.

Evaluation of dietary intake of vitamin E in the treatment of atopic dermatitis: a study of the clinical course and evaluation of the immunoglobulin E serum levels

BACKGROUND

Vitamin E (VE) is a potent antioxidant that can improve the immune macrophage-mediated response, decrease the production and/or release of prostaglandins in humans, and decrease the serum levels of immunoglobulin E (IgE) in atopic subjects.

AIM

To compare the effects of placebo (PL) and VE intake (400 IU/day) on subjective symptoms and serum IgE levels in 96 subjects with atopic dermatitis.

MATERIALS AND METHODS

A single-blind clinical analysis was performed on 96 subjects randomly divided into two groups. Fifty subjects were given orally 400 IU (268 mg) of VE of natural origin, once a day for 8 months, and 46 took PL for the same period. Complete blood count, serum IgE levels, radioallergosorbent test (RAST) score, antinuclear antibodies (ANA), and biochemical analysis were obtained at the time of enrollment and every 15 days during the 8 months of the study. To evaluate VE therapy, a questionnaire was sent to each subject for completion at the end of the study.

RESULTS

The results were as follows: (A) four subjects treated with VE worsened, compared to 36 in the PL group; (B) six subjects in the VE group and five in the PL group showed no change; (C) slight improvement was observed in 10 subjects in the VE group and four in the PL group; (D) 23 of the 50 subjects treated with VE showed great improvement, compared to only one in the PL group; and (E) there was almost complete remission of atopic dermatitis in seven of the 50 subjects in the VE group, but none in the PL group. Females showed less progression of atopic dermatitis than males in both groups and a higher percentage of almost complete remission (five females and two males). The range of serum IgE levels varied markedly from 1005 to 490 IU/mL in the VE group and from 1239 to 812 IU/mL in the PL group over 8 months. Subjects with great improvement and near remission of atopic dermatitis in the VE group demonstrated a decrease of 62% in serum IgE levels based on initial conditions, while, in subjects taking PL, the difference was approximately 34.4%. No complications were observed in either group. A remarkable improvement in facial erythema, lichenification, and the presence of apparently normal skin was reported. Eczematous lesions healed mostly as a result of decreased pruritus.

CONCLUSIONS

The correlation between VE intake, IgE levels, and the clinical manifestations of atopy indicates that VE could be an excellent therapeutic tool for atopic dermatitis.

Investigation of antinuclear antibodies in canine atopic dermatitis

Serum samples from 40 atopic dogs and 20 healthy dogs were assayed for antinuclear antibodies (ANA) using a human epithelial cell line (HEp-2) and standard indirect immunofluorescent methods. Samples from the atopic dogs were grouped according to the presence (n = 28) or absence (n = 12) of facial lesions at any moment during the follow-up period. Positive ANA titres were found in 10 of the 40 atopic dogs analysed (25%) whereas samples from the control group were negative. Eight atopic dogs with facial lesions had a positive titre (28.57%) in contrast with atopic dogs without facial lesions where two positive samples (16.67%) were found; however, the differences were statistically not significant. Endpoint titres were low (1/40), only two samples yielded a 1/80 positive titre and one sample had a 1/320 titre, all of them from the facial lesions group. Response to immunotherapy was classified as positive only in four of the 10 ANA-positive patients (40%) compared with a response rate of 73% (22 of 30) in the ANA-negative atopic dogs. However, a Fisher's exact test showed a two-sided P-value of 0.122 which was considered statistically not significant. The overall response rate to immunotherapy for all atopic dogs was 65% (26 of 40). In conclusion, the prevalence of ANA is higher in atopic than in healthy dogs, especially if facial lesions are present. Although a clinically significant pathogenic contribution is not probable, this higher prevalence should be taken into account in the differential diagnosis of canine autoimmune dermatitis.

Autoantibodies in atopic dermatitis

Recent progress in the autoimmune aspects of atopic dermatitis has clarified that patients with atopic dermatitis develop IgE-class autoantibodies mainly against intracellular proteins. The cloning of cDNAs encoding autoallergens with human expression cDNA libraries and serum IgE from atopic dermatitis patients has unraveled the molecular characteristics of IgE-binding autoantigens. Some patients with atopic dermatitis also have IgG-class autoantibodies, especially anti-nuclear antibodies. One of the nuclear autoantigens was identified as DFS70/transcription coactivator p75. In addition, p80-coilin in nuclear coiled bodies is also targetted. Several lines of evidence suggest that a subset of atopic dermatitis may be associated with an autoimmune response.

Autoantibodies to DFS 70 kd/transcription coactivator p75 in atopic dermatitis and other conditions

BACKGROUND

Sera of patients with atopic dermatitis (AD) were found to have autoantibodies that reacted with tissue culture cell substrates in immunohistochemistry to display a characteristic pattern of nuclear distribution of dense fine speckles. The sera also recognized a 70-kd protein on Western immunoblots, and the antigen was termed dense fine speckles 70 kd (DSF70).

OBJECTIVE

Because spontaneously occurring autoantibodies could be immune responses to proteins that might be participating in the disease process, it was of interest to identify the antigens driving the autoimmune antibody response.

METHODS

A serum containing high-titer antibodies to DFS70 was used to immunoscreen a complementary (c)DNA expression library to isolate cDNA encoding the antigen. After the cDNA was isolated, this was used to express recombinant protein to determine the prevalence of antibody in AD and other conditions.

RESULTS

Thirty percent of patients with AD were found to have antibody to recombinant DFS70 in Western immunoblots. Sixteen percent of patients with asthma and 9% of patients with interstitial cystitis had antibodies of the same specificities. The cDNA encoding DFS70 was identical to a transcription coactivator called p75, which had been shown to be required for RNA polymerase II-dependent transcription. Another important finding was that IgE antibodies to DFS70 were also present in AD sera.

CONCLUSION

It is suggested that a common basis for the presence of autoantibodies to DFS70 might be related to AD in asthma, interstitial cystitis, and other conditions. A possible role of this antigen-antibody system in pathogenesis remains to be demonstrated, but it appears to be a marker for a subset of patients with AD.

Anti-elongation factor-1alpha autoantibody in adult atopic dermatitis patients

Adult atopic dermatitis (AD) patients develop severe facial lesions, which sometimes distribute in sun-exposed areas similar to the rash of systemic lupus erythematosus. To declare autoimmunity in the pathogenesis of AD, we investigated serum antinuclear antibody (ANA) in 256 adult AD patients and identified its ligands. A high titer of ANA was found in 31.3% of AD patients and 75% of the ANA showed a homogenous pattern. Sixty-five percent of ANA(+) sera reacted to a 52 kDa protein (p52) in HeLa cell immunoblots. By screening the HeLa cell cDNA expression library with anti-p52 sera, a clearly positive clone was isolated. The sequence of this cDNA was identical to human elongation factor (hEF)-1alpha. The eluate of IgG bound to hEF-1alpha-glutathione S-transferase (GST) fusion protein recognized a band at 52 kDa in a HeLa cell immunoblot, and stained Hep-2 cell nuclei and cytoplasma as reported in hEF-1alpha distribution. The anti-p52 AD sera recognized the hEF-1alpha-GST fusion protein. The anti-hEF-1alpha antibody-positive AD patients were characterized by higher facial involvement and lower white blood cell counts compared with antibody-negative patients. The present results suggest the possible involvement of autoimmunity in the pathogenesis of adult AD.

Clinical features and IgG subclass distribution of anti-p80 coilin antibodies

We examined the clinical features of patients presenting antinuclear autoantibodies against p80-coilin and the IgG subclass distribution of anti- p80-coilin antibodies. Sera from 365 Japanese patients were analysed. Immunoblotting and indirect immunofluorescence microscopy techniques were used with a polyclonal rabbit antiserum against p80-coilin. Eleven patients with anti-p80-coilin antibodies were found. All the patients were female and nine were in their twenties. None could be diagnosed with differentiated rheumatic disease except for one case of systemic scleroderma and another of Sjögren's syndrome. Most patients had general fatigue, arthralgia, headaches, dysmenorrhea, lymph node swelling and/or low grade fever such as chronic fatigue syndrome (CFS), and showed low complement. One patient fulfilled the criteria for CFS. All were younger females than those often diagnosed with rheumatic disease in previous reports. Patients' sera had a predominant distribution of subclass IgG(1)anti-p80-coilin antibodies and five sera had concomitant subclass IgG(2). Two rheumatic disease patients had a relatively high titer of IgG(2)anti-p80-coilin antibodies. The IgG(2)subclass of anti-p80-coilin antibodies may be a specific marker for systemic autoimmune disease.

Head and neck dermatitis: the role of Malassezia furfur, topical steroid use and environmental factors in its causation

The aetiology of head and neck dermatitis (HND), one subgroup of postpubertal atopic dermatitis (AD), is still unclear. The aim of this study was to evaluate the influence on HND of common environmental factors, long-term topical steroid use, and the role of Malassezia furfur infection. Relevant information was obtained from 100 patients with HND attending our dermatology clinic by means of both physical examinations and questionnaires. Corticosteroid-induced vasoconstriction was estimated by visual scoring of laser-Doppler flowmetry. and the following immunological studies were performed: skin prick test, measurement of total IgE, eosinophil cationic protein, and specific IgE antibodies to several fungal antigens including those of M. furfur. The questionnaire revealed that sweating (81%), heat (71%), dryness (70%), psychic stress (67%), and sun exposure (50%) were responsible for aggravation of skin lesions. The vascular response to topical steroid was reduced in HND patients as compared with that of normal healthy controls (P < 0.05). Fifty-four of 80 patients with HND (68%) had anti M. furfur-specific IgE antibodies and 36 of 80 patients (45%) showed positive skin prick tests for M. furfur. The clinical severity and serum total IgE of HND patients were higher in patients with positive response to anti-M. furfur-specific IgE antibodies than in patients with negative response (P < 0.05). These results suggest that HND can be aggravated not only by M. furfur but also by environmental factors such as sweating, heat, dryness, psychic stress and sun exposure. Furthermore, long-term use of topical steroid might be associated with the development of diffuse erythematous lesions with telangiectasia on the head and neck areas.