Hyaluronan in inflammatory joint disease

Lactic Acid-Induced Colloidal Microrheology of Synovial Fluids

The presence of colloidal scaffolds composed of proteins and hyaluronic acid engenders unique viscous and elastic properties to the synovial fluid (SF). While the elastic resistance of SF due to the presence of such nanoscale structures provides the load-bearing capacity, the viscous nature enables fluidity of the joints during the movements to minimize the wear and tear of the adjacent muscle, cartilage, or bone tissues. It is well-known that the hypoxic conditions at the bone joints often increase the lactic acid (LA) concentration due to the occurrence of excess anaerobic respiration during either hyperactivity or arthritic conditions. The present study uncovers that in such a scenario, beyond a critical loading of LA, the colloidal nanoscaffolds of SF break down to precipitate higher molecular weight (MW) proteins and hyaluronic acid (HA). Subsequently, the viscosity and elasticity of SF reduce drastically to manifest a fluid that has reduced load bearing and wear and tear resistance capacity. Interestingly, the study also suggests that a heathy SF is a viscoelastic fluid with a mild Hookean elasticity and non-Newtonian fluidity, which eventually transforms into a viscous watery liquid in the presence of a higher loading of LA. We employ this knowledge to biosynthesize an artificial SF that emulates the characteristics of the real one. Remarkably, the spatiotemporal microscopic images uncover that even for the artificial SF, a dynamic cross-linking of the high MW proteins and HA takes place before precipitating out of the same from the artificial SF matrix, emulating the real one. Control experiments suggest that this phenomenon is absent in the case when LA is mixed with either pure HA or proteins. The experiments unfold the specific role of LA in the destruction of colloidal nanoscaffolds of synovia, which is an extremely important requirement for the biosynthesis and translation of artificial synovial fluid.

[Biomechanics of diabetic vitreopapillary traction syndrome]

Diabetic vitreopapillary traction syndrome (VPT) is a variant of diabetic retinopathy (DR) that can lead to vision loss in advanced stages. This review reports on the biomechanics of the vitreous in the pathogenesis of proliferative DR, in particular diabetic VPT. The article analyzes and summarizes literature data, presents the views of different authors on this problem, and provides the results of Russian and foreign scientific research on this pathology. It is concluded that further research in this area can lead to a significant improvement in the results of therapy, timely diagnosis, and preservation of vision in patients with DR.

Hyaluronan as a Prominent Biomolecule with Numerous Applications in Medicine

Hyaluronan (HA) is a natural glycosaminoglycan present in many tissues of all vertebrates. HA has various biological functions, which are dependent on its molar mass. High-molar-mass HA has anti-angiogenic, immunosuppressive and anti-inflammatory properties, while low-molar-mass HA has opposite effects. HA has also antioxidative properties, however on the other hand it can be readily degraded by reactive oxygen species. For many years it has been used in treatment of osteoarthritis, cosmetics and in ophthalmology. In the last years there has been a growing interest of HA to also be applied in other fields of medicine such as skin wound healing, tissue engineering, dentistry and gene delivery. In this review we summarize information on modes of HA administration, properties and effects of HA in various fields of medicine including recent progress in the investigation of HA.

A 3D "In Vitro" Model to Study Hyaluronan Effect in Nasal Epithelial Cell Line Exposed to Double-Stranded RNA Poly(I:C)

Environmental agents, including viral and bacterial infectious agents, are involved in the alteration of physicochemical and biological parameters in the nasal epithelium. Hyaluronan (HA) has an important role in the regulation of tissue healing properties. High molecular weight HA (HMW-HA) shows greater anti-inflammatory responses than medium molecular weight HA (MMW-HA) and low molecular weight HA (LMW-HA). We investigated the effect of HMW-HA, MMW-HA and LMW-HA on the regulation of physicochemical and biological parameters in an “in vitro” model that might mimic viral infections of the nasal epithelium. Human nasal epithelial cell line RPMI2650 was stimulated with double-stranded RNA (dsRNA) Poly(I:C) for 5 days in air-liquid-interface (ALI) culture (3D model of airway tissue). dsRNA Poly(I:C) treatment significantly decreased transepithelial electrical resistance (TEER) in the stratified nasal epithelium of RPMI2650 and increased pH values, rheological parameters (elastic G’ and viscous G’’), and Muc5AC and Muc5B production in the apical wash of ALI culture of RPMI2650 in comparison to untreated cells. RPMI2650 treated with dsRNA Poly(I:C) in the presence of HMW-HA showed lower pH values, Muc5AC and Muc5B production, and rheological parameters, as well as increased TEER values in ALI culture, compared to cells treated with Poly(I:C) alone or pretreated with LMW-HA and MMW-HA. Our 3D “in vitro” model of epithelium suggests that HMW-HA might be a coadjuvant in the pharmacological treatment of viral infections, allowing for the control of some physicochemical and biological properties affecting the epithelial barrier of the nose during infection.

Filling Procedures for Lip and Perioral Rejuvenation: A Systematic Review

The ideal perioral and lip rejuvenation technique provides the longest period of efficacy, lowest complication rate, and best esthetic results. Genetics, intrinsic aging, sun exposure, and repetitive muscle twitching of the orbicularis oris produce angular, radial, and vertical lines of the perioral lines and, for this reason, the needs of patients in the treatment of this anatomical area can range from simple lip enhancement to a broader and more comprehensive treatment with simultaneous correction of perioral wrinkles. A myriad of materials have been described for rejuvenation of this area. At present, the most popular and commonly used lip enhancers are dermal fillers, but there is still no agreement on what the best material for filling soft tissue of the face and in particular of the perioral region is. This systematic review will focus on the various dermal fillers, of different materials approved by the US Food and Drug Administration (FDA) namely poly-L-lactic acid, calcium hydroxylapatite, and hyaluronic acid and also different grafts, for perioral rejuvenation, with the goal of determining the optimal approach. A systematic search for English studies involving perioral rejuvenation was performed using these databases: PubMed, Google Scholar, and Ovid, using a combined keyword search or medical subject headings. At the end of our study selection process, 17 relevant publications were included. For each study, year of publication, type of material used for filling, number of patients, subject of study assessment, and efficacy of the filler procedure for lip rejuvenation were analyzed.

Can viscosupplementation be used in the hip? An Italian perspective

Viscosupplementation is the intra-articular administration of preparations containing hyaluronic acid or hyaluronate intended to restore the normal biological properties of hyaluronic acid normally found in synovial fluid. Infiltration of hyaluronic acid in the arthritic hip is a more recent technique than viscosupplementation of the knee due to the greater technical difficulty of infiltration to the hip, which requires fluoroscopic or ultrasound guidance. The introduction of high-molecular-weight hyaluronic acid in the treatment permits a single administration and has helped diffuse hip infiltration treatment. A single infiltration reduces patient discomfort caused by the procedure and allows treatment of a larger number of patients. Although the literature has unequivocally proven the possibility of reducing pain in patients affected by hip arthritis following infiltration, the molecular weight and density, the number of infiltrations required for long-term results, and the most appropriate indications for infiltration treatment have yet to be clarified. Selecting the patient is the first obstacle to be overcome. Therefore, infiltration should be considered as an option for patients with initial pain symptoms who have not yet been listed for joint prosthesis surgery. The radiographic criteria require at least a partly preserved joint space, and the clinical criteria of persistent hip pain and full joint mobility seem to be sufficiently effective for selection.

Microrheology of human synovial fluid of arthritis patients studied by diffusing wave spectroscopy

The viscoelastic properties of synovial fluid (SF) are critical to its functions of lubrication and shock-absorption of joints in human body; a change in the viscoelastic properties, even of only a few percents, is often concomitant with arthritis. In this work, the elastic modulus G '(f) and the viscous modulus G ''(f) of SF from patients suffering from three kinds of joint diseases, namely, osteoarthritis (OA), rheumatoid arthritis (RA), and gouty arthritis (GA), were determined as a function of frequency "f " (in the low frequency range from f ∼ 0.1 to 10 Hz) by Diffusing Wave Spectroscopy (DWS) and correlated with the white blood cell (WBC) count. A strong correlation was observed, showing a higher WBC count corresponding to lower elastic and viscous moduli, G ' and G ''; further details depend on inflammatory vs. non-inflammatory, and on the severity of inflammation. Different types of arthritis lead to different degrees of decreasing viscoelasticity. Identical measurements were carried out with a commercial visco-supplementation (or artificial SF) to serve as reference. In general, the reduction in both G ' and G '' was most severe in the case of GA and least severe in the case of OA. Besides, in all cases, the reduction in G ' was more prominent than the reduction in G '', indicating that in general, the deterioration in the elasticity of SF by inflammation is more severe than that in the viscosity. This simple method for quantitative physical characterization of synovial fluid may serve as a useful complementary metric to the conventional biochemical analysis in clinical diagnosis of arthritis.

Engagement of CD44 by hyaluronan suppresses TLR4 signaling and the septic response to LPS

Fragments of hyaluronan released after injury bind and activate TLR4 in a complex with CD44. Here we investigated if the recognition of hyaluronan by CD44 and TLR4 alters lipopolysaccharide (LPS) responsiveness and thus could alter the septic response. In contrast to mice injected with LPS, mice exposed to hyaluronan prior to LPS had greatly decreased serum IL-6 and TNFalpha and were protected from symptoms of sepsis. The protective effect of HA was not seen in Cd44(-/-) mice. Consistent with our findings in vivo, addition of hyaluronan to macrophages before LPS exposure significantly decreased the release of IL-6 and TNFalpha and this effect was not seen in macrophages from Cd44(-/-) mice. Investigation of the mechanism responsible for inhibition of LPS activation showed hyaluronan treatment resulted in an increase in peritoneal macrophage A20 mRNA expression, and that this was significantly reduced in macrophages from Cd44(-/-) mice and Tlr4(-/-) mice. Suppression of the A20 response with siRNA inhibited the ability of hyaluronan to protect against the cytokine response to LPS. Therefore, our results show that hyaluronan acts through TLR4, CD44 and A20 to stimulate a unique cellular response that can protect against the septic response to LPS.

Anti-oxidant inhibition of hyaluronan fragment-induced inflammatory gene expression

Background

The balance between reactive oxygen species (ROS) and endogenous anti-oxidants is important in maintaining healthy tissues. Excessive ROS states occur in diseases such as ARDS and Idiopathic Pulmonary Fibrosis. Redox imbalance breaks down the extracellular matrix component hyaluronan (HA) into fragments that activate innate immune responses and perpetuate tissue injury. HA fragments, via a TLR and NF-κB pathway, induce inflammatory gene expression in macrophages and epithelial cells. NAC and DMSO are potent anti-oxidants which may help balance excess ROS states.

Methods

We evaluated the effect of H₂O₂, NAC and DMSO on HA fragment induced inflammatory gene expression in alveolar macrophages and epithelial cells.

Results

NAC and DMSO inhibit HA fragment-induced expression of TNF-α and KC protein in alveolar and peritoneal macrophages. NAC and DMSO also show a dose dependent inhibition of IP-10 protein expression, but not IL-8 protein, in alveolar epithelial cells. In addition, H₂O₂ synergizes with HA fragments to induce inflammatory genes, which are inhibited by NAC. Mechanistically, NAC and DMSO inhibit HA induced gene expression by inhibiting NF-κB activation, but NAC had no influence on HA-fragment-AP-1 mediated gene expression.

Conclusion

ROS play a central role in a pathophysiologic "vicious cycle" of inflammation: tissue injury generates ROS, which fragment the extracellular matrix HA, which in turn synergize with ROS to activate the innate immune system and further promote ROS, HA fragment generation, inflammation, tissue injury and ultimately fibrosis. The anti-oxidants NAC and DMSO, by inhibiting the HA induced inflammatory gene expression, may help re-balance excessive ROS induced inflammation.

The anti-rheumatic gold salt aurothiomalate suppresses interleukin-1beta-induced hyaluronan accumulation by blocking HAS1 transcription and by acting as a COX-2 transcriptional repressor

Gold compounds are among the oldest disease-modifying drugs and are still widely used today for treating rheumatoid arthritis. Despite decades of use, little is known about the mode of action of this class of drugs. Here we have demonstrated that aurothiomalate (AuTM) suppresses hyaluronan accumulation by blocking interleukin (IL)-1beta-induced hyaluronan synthase-1 transcription. We have further demonstrated that, in fibroblast-like synoviocytes (FLSs), AuTM acts as a specific COX-2 transcriptional repressor in that IL-1beta-induced COX-2 transcription is blocked, whereas COX-1 transcription and translation is unaffected. As a consequence, PGE2 levels released by FLS are dose-dependently reduced in cells exposed to AuTM. Of similar importance is the demonstration that AuTM does block NFkappaB-DNA interaction. In addition, two other transcription factors implicated in inflammatory events, namely AP-1 and STAT3, are blocked as well. The effect on NFkappaB likely explains the inhibition of COX-2 as well as that of HAS1, as both are genes that depend on the activation of NFkappaB. Interestingly, AuTM does not interfere with IL-1beta-induced IkappaB alpha degradation, in most cases a prerequisite for subsequent NFkappaB activation. Furthermore, evidence is presented that, in FLS, AuTM blocks NFkappaB-DNA interaction neither by binding to NFkappaB binding sites nor by interacting with activated NFkappaB proteins. Taken together, AuTM treatment of FLS blocks two of the most important proinflammatory events that are associated with rheumatoid arthritis. AuTM blocks the release of PGE2 and prevents the activation of NFkappaB, therefore blocking IL-1beta-induced hyaluronan accumulation and likely a series of other pro-inflammatory NFkappaB-dependent genes.

Aspects of the biology of hyaluronan, a largely neglected but extremely versatile molecule

HA takes part in a surprisingly large number of biological processes such as embryogenesis, angiogenesis, cell motility, wound healing and cell adhesion. While substantial progress in HA research has indeed been made over the last years, many important questions have not yet been answered. One of the most pertinent questions awaiting an answer is the quest for functional differences of HA synthesized by the three HAS genes. Of similar importance would be investigations into intracellular signaling pathways involved in the activation of this gene family, a field in which to date very little is known. A better understanding of functional differences between the HAS encoding genes not only holds the promise for a better understanding of a series of biological processes but also the opportunity for selective intervention in a number of maladies characterized by abnormalities of HA levels.

Raised Serum Chondroitin Sulfate Epitope Level in Ovarian Epithelial Cancer

OBJECTIVE

To determine the value of serum chondroitin sulfate epitope WF6 and hyaluronan (HA) levels as a biomarker for early detection of ovarian epithelial cancer and other gynecological disorders.

METHOD

Serum WF6 CS epitope and HA were measured in 91 patients with ovarian epithelial cancer, 39 patients with non-cancer gynecological disorders and 30 healthy women. Serum chondroitin sulfate (CS) WF6 epitope was determined by a competitive immunoassay with the monoclonal antibodies WF6, which specifically recognizes an epitope in native CS chains. In addition, serum HA concentration was measured by an ELISA-based assay with a biotinylated affinity HA-binding proteins.

RESULTS

The serum concentration of CS (WF6) epitope was highly increased in epithelial types of ovarian cancer and at all stages of development (p < 0.005). Serum HA in ovarian cancer patients was significantly higher than normal controls (p < 0.05).

CONCLUSION

These results reflect changes in ECM metabolism in progressive ovarian cancer, which cause an increase in serum CS epitopes and HA. Therefore, serum CS epitopes may provide useful biomarkers for cancers and other disorders of the ovary. Measurement of serum HA provided complementary information, which may be useful as a discriminator between benign ovarian disorders and malignant ovarian diseases.

Raised chondroitin sulfate epitopes and hyaluronan in serum from rheumatoid arthritis and osteoarthritis patients

OBJECTIVES

Serum hyaluronan (HA) and chondroitin sulfate (CS) epitopes WF6 and 3B3 (+) were determined to investigate disease association in patients with osteoarthritis (OA), rheumatoid arthritis (RA) and healthy controls.

METHODS

Specific assays for HA and CS epitopes WF6 and 3B3 (+) were established and applied to a cross-sectional study of serum samples from patients (96 OA, 57 RA and 50 healthy controls).

RESULTS

Both CS epitopes were increased in serum of many OA and RA patients and average levels were significantly above in healthy controls. In contrast serum HA was increased in RA, but only in few OA patients.

CONCLUSIONS

CS epitopes WF6 and 3B3 (+) are raised in serum of patients with both OA and RA and were thus distinct from serum HA. The results suggest that OA may be detected systemically as well as RA. The range of levels of CS epitopes detected in OA and RA was wide and correlation with any aspect of disease activity is yet to be determined.

Differential stimulation of three forms of hyaluronan synthase by TGF-beta, IL-1beta, and TNF-alpha

This study compares the regulation of three isoforms of hyaluronan synthase (HAS1, HAS2, and HAS3) transcripts and hyaluronan (HA) production by cytokines in human synovial fibroblastic cells derived from tissue from patients with rheumatoid arthritis (RA) and osteoarthritis (OA). Levels of HAS mRNA of the cells with or without stimulation were detected using a real-time fluorescence polymerase chain reaction detection system. Concentrations of HA in the culture supernatants of the cells were measured by a sandwich binding protein assay. Molecular weight of HA was evaluated by agarose gel electrophoresis. The relative proportions of the expression pattern of HAS isoforms was similar between RA and OA tissue-derived cells. HAS1 mRNA was upregulated by transforming growth factor-beta and HAS3 mRNA was upregulated by interleukin-1beta and somewhat by tumor necrosis factor-alpha in the RA cells. HAS2 remained unchanged. Differences in the expression pattern of HAS1, HAS2, and HAS3 mRNA by cytokines suggest that these three isoforms are independently and differentially regulated, and each isoform of HAS may have a different role in arthritic joint disease.

Cartilage oligomeric matrix protein (COMP) levels in digital sheath synovial fluid and serum with tendon injury

Cartilage oligomeric matrix protein (COMP) is a noncollagenous extracellular matrix protein found predominantly in cartilage, but also in tendon, ligament and meniscus. Studies in man have demonstrated that it may be used as a prognostic marker in rheumatoid arthritis and osteoarthritis. The present study investigated whether tendon injury contributes to serum and tendon sheath synovial fluid levels of COMP in horses. COMP levels, analysed by competitive ELISA, in the digital sheath synovial fluid were more than 10-fold higher than in the serum. Levels were significantly raised when tendon damage or sepsis was present within the tendon sheath but showed only mild, statistically insignificant, elevation in cases of tenosynovitis alone. COMP concentrations in serum were found to vary with age. Foals (age < or = 1 year) had significantly (P<0.001) higher levels in comparison to older control horses. Total COMP concentrations in an age-matched group with tendinitis were not significantly different from the control group. Measurements of COMP levels in tendon sheath synovial fluid are therefore useful in depicting processes in tendon tissue, while elevated serum levels are likely to be more representative of joint disease than tendinitis.

Clinical assessment and significance of inflammation in knee osteoarthritis

The recognition of the role of cytokines in osteoarthritis (OA) has suggested new approaches for therapy of the disease, and also increases the importance of clinical assessment of inflammation. Accurate identification of the presence and degree of inflammation might allow the clinician to predict which individuals would respond to therapy with anti-inflammatory drugs. Several laboratory and clinical markers have been evaluated which may also serve as predictors and indicators of response to therapy and overall outcome.

Changes in serum chondroitin sulphate epitopes 3-B-3 and 7-D-4 in early rheumatoid arthritis

OBJECTIVES

The aims of the present rheumatoid arthritis (RA) study were (1) to examine the levels of serum 3-B-3 and 7-D-4 to find out whether they are different from controls, (2) to find out whether the concentrations of these epitopes change with disease duration in early RA and (3) whether the serum concentrations of 3-B-3 and 7-D-4 in early RA are prognostic for subsequent disease progression.

METHODS

The concentrations of 3-B-3 and 7-D-4 in sera were quantitated by immunoassays.

RESULTS

The levels of 3-B-3 and 7-D-4 were significantly lower in RA than in controls (3- to 30-fold, P < 0.001). Changes in 3-B-3 and 7-D-4 were apparent with disease duration. At first presentation, the 3-B-3 concentration was lowest and increased at 12 months (3-fold, P < 0.001). This increase was transient since by 24 and 36 months the concentrations were not different to those at first presentation. The level of 7-D-4 was also lowest when the patients first presented at clinic and increased with time at 6 months (2-fold, P < 0.001). The increase was more prolonged for 7-D-4, remaining elevated at 12, 24 and 36 months. The lack of correlations of serum 3-B-3 and 7-D-4 with clinical measurements showed that these markers were not prognostic for disease severity.

CONCLUSIONS

The levels of 3-B-3 and 7-D-4 differed between RA and control sera, and changed with disease duration. These markers were not prognostic in predicting disease outcome.

Serum markers of articular cartilage damage and repair

Joint cartilage is a dynamic tissue that reacts to trauma, inflammation, and other insults by attempting to repair its matrix. This reaction results in the release of cartilage macromolecules into the body fluids. Analysis of these fluids has identified a limited number of at least somewhat tissue-specific markers of altered cartilage metabolism. Analyses of serum are less specific and less sensitive than analyses of synovial fluid, but their use as research tools in clinical studies, drug development, and experimental work in animal models is increasing.

Nitric oxide products degrade chondroitin sulfates

Nitric oxide (NO) is a potent endogenous vasodilator that is elevated in response to inflammation. Inflammation also produces high levels of superoxide, which combines with NO to produce peroxynitrite (PN). We have previously reported that NO degrades heparin and heparan sulfate under acidic conditions and that PN degrades hyaluronan (HA) at neutral pH. Heparin and HA are glycosaminoglycans (GAGs) widely distributed in the extracellular matrix of tissues. Disruption of intestinal GAGs, particularly the chondroitin sulfates, were linked to inflammatory bowel diseases. Chondroitin sulfate A (CSA), chondroitin sulfate B (CSB), and chondroitin sulfate C (CSC) are constituents of the basement membranes of many tissues, including the intestine. The purpose of this study is to determine whether the NO donor S-nitroso-N-acetylpenicillamine (SNAP) and PN can degrade chondroitin sulfates in vitro. The NO donor SNAP (2 mM, pH 4.0) or PN (5 mM, pH 7.4) was incubated for at least 1 week at 37 degrees C with CSA, CSB, or CSC. Breakdown of CSA, CSB, and CSC was assessed by gel filtration chromatography and compared with untreated controls. Percentage degradation was calculated based on the change in peak height compared to the control. SNAP treatment partially degraded CSB and CSC, whereas PN partially degraded all three chondroitin sulfates. Nitric oxide mediated degradation of GAGs, and particularly chondroitin sulfates, may be an important pathway of inflammatory tissue damage.

Elimination of tritium-labelled hyaluronic acid from normal and osteoarthritic rabbit knee joints

The half-life of [3H]hyaluronic acid in rabbit knee joints was estimated using two methods: (i) by following the [3H]hyaluronan content of the synovial fluid after intra-articular injection and (ii) by following the 3H2O radioactivity of plasma after intra-articular injection of [3H]hyaluronan. For normal rabbits we obtained a half-life of 15.8 hours (method I) and 17.5 +/- 1.0 hours (mean +/- SEM, method II), respectively. The second method was used to estimate the kinetics of the hyaluronan elimination from normal, sham-operated, as well as from osteoarthritic rabbit knee joints (Colombo model of osteoarthritis). Four weeks after injury, during the developing phase of osteoarthritis, the half-life of hyaluronan rose significantly to 23.5 +/- 2.1 hours and returned to normal levels (17.4 +/- 2.7 hours) 12 weeks after the operation (osteoarthritis developed). At the stage of developed osteoarthritis, the clearance rates were considerably higher than in normal rabbits.

Serum hyaluronan as a disease marker

Hyaluronan is a connective tissue polysaccharide which has also been found in blood serum in concentrations < 100 micrograms/L (average 30-40 micrograms/L in middle-aged persons). The serum level is regulated by the influx of the polysaccharide from the tissues via lymph and its receptor-mediated clearance by liver endothelial cells. Markedly high serum levels are noted in certain liver diseases, especially in patients with cirrhosis, when the clearance is impaired. In these cases serum hyaluronan can be used to follow the development of the disease. Serum hyaluronan is also a sensitive marker for impending rejection of liver transplants. Patients with rheumatoid arthritis constitute another major group with increased serum hyaluronan, but in this case the level varies markedly during the day corresponding to physical activity. There are good indications that in these subjects the excess hyaluronan comes from the joints. Under stringent sampling conditions of serum it should be possible to extract interesting information on the inflammatory joint process. Increased hyaluronan levels are also seen in other inflammatory diseases and it is of special interest that high hyaluronan levels in patients with septic conditions is a sign of poor prognosis. Certain tumours, notably Wilms' tumour and mesothelioma, produce factors which activate synthesis of hyaluronan and increase its serum level. Rare hereditary diseases with disturbances of hyaluronan metabolism and elevated blood levels have also been discovered, e.g. Werner's syndrome and cutaneous hyaluronanosis. Information accumulated during the last decade regarding the metabolism of hyaluronan has made this polysaccharide an interesting clinical marker for a number of pathological conditions.