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Caux F, Patsatsi A, Karakioulaki M, Antiga E, Baselga E, Borradori L, Caproni M, Cardones AR, Chandran NS, Dräger S, Drenovska K, Goebeler M, Günther C, Hofmann SC, Ioannides D, Joly P, Marinović B, Mariotti EB, Marzano AV, Morel KD, Murrell DF, Prost C, Sárdy M, Setterfield J, Skiljevic D, Uzun S, Vassileva S, Zambruno G, Schmidt E. S2k guidelines on diagnosis and treatment of linear IgA dermatosis initiated by the European Academy of Dermatology and Venereology. J Eur Acad Dermatol Venereol 2024; 38:1006-1023. [PMID: 38421060 DOI: 10.1111/jdv.19880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/19/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Linear IgA dermatosis (LAD) is a rare subepidermal autoimmune bullous disease (AIBD) defined by predominant or exclusive immune deposits of immunoglobulin A at the basement membrane zone of skin or mucous membranes. This disorder is a rare, clinically and immunologically heterogeneous disease occurring both in children and in adults. The aim of this project is to present the main clinical features of LAD, to propose a diagnostic algorithm and provide management guidelines based primarily on experts' opinion because of the lack of large methodologically sound clinical studies. METHODS These guidelines were initiated by the European Academy of Dermatology and Venereology (EADV) Task Force Autoimmune Bullous Diseases (AIBD). To achieve a broad consensus for these S2k consensus-based guidelines, a total of 29 experts from different countries, both European and non-European, including dermatologists, paediatric dermatologists and paediatricians were invited. All members of the guidelines committee agreed to develop consensus-based (S2k) guidelines. Prior to a first virtual consensus meeting, each of the invited authors elaborated a section of the present guidelines focusing on a selected topic, based on the relevant literature. All drafts were circulated among members of the writing group, and recommendations were discussed and voted during two hybrid consensus meetings. RESULTS The guidelines summarizes evidence-based and expert opinion-based recommendations (S2 level) on the diagnosis and treatment of LAD. CONCLUSION These guidelines will support dermatologists to improve their knowledge on the diagnosis and management of LAD.
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Affiliation(s)
- Frédéric Caux
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP and University Paris 13, Bobigny, France
| | - Aikaterini Patsatsi
- Autoimmune Bullous Diseases Unit, 2nd Department of Dermatology, Aristotle University School of Medicine, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Meropi Karakioulaki
- Department of Dermatology and Venereology, Medical Center, University Hospital Freiburg, Freiburg, Germany
| | - Emiliano Antiga
- Department of Health Sciences, Section of Dermatology, Azienda USL Toscana Centro, Rare Diseases Unit, European Reference Network-Skin Member, University of Florence, Florence, Italy
| | - Eulalia Baselga
- Department of Dermatology, Hospital Sant Joan de Deu, Barcelona, Spain
| | - Luca Borradori
- Department of Dermatology, University of Bern, Inselspital, Berne, Switzerland
| | - Marzia Caproni
- Department of Health Sciences, Section of Dermatology, Azienda USL Toscana Centro, Rare Diseases Unit, European Reference Network-Skin Member, University of Florence, Florence, Italy
| | - Adela R Cardones
- Division of Dermatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Nisha Suyien Chandran
- Division of Dermatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Sören Dräger
- Department of Dermatology, Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Kossara Drenovska
- Department of Dermatology and Venereology, University Hospital "Alexandrovska", Medical University-Sofia, Sofia, Bulgaria
| | - Matthias Goebeler
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Claudia Günther
- Department of Dermatology, University Hospital, Technical University Dresden, Dresden, Germany
| | - Silke C Hofmann
- Department of Dermatology, Allergy and Dermatosurgery, Helios University Hospital Wuppertal, University Witten-Herdecke, Wuppertal, Germany
| | - Dimitrios Ioannides
- 1st Department of Dermatology, Aristotle University School of Medicine, Hospital of Skin and Venereal Diseases, Thessaloniki, Greece
| | - Pascal Joly
- Department of Dermatology, Rouen University Hospital, INSERM 1234, Normandie University, Rouen, France
| | - Branka Marinović
- Department of Dermatology and Venereology, University Hospital Centre Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Elena Biancamaria Mariotti
- Department of Health Sciences, Section of Dermatology, Azienda USL Toscana Centro, Rare Diseases Unit, European Reference Network-Skin Member, University of Florence, Florence, Italy
| | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Kimberly D Morel
- Departments of Dermatology and Pediatrics at Columbia University Medical Center, Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Dedee F Murrell
- Department of Dermatology, St George Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Catherine Prost
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP and University Paris 13, Bobigny, France
| | - Miklós Sárdy
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
- Department of Dermatology and Allergy, University Hospital, LMU, Munich, Germany
| | - Jane Setterfield
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Host-Microbiome Interactions, King's College London Faculty of Dentistry, Oral & Craniofacial Sciences, London, UK
| | - Dusan Skiljevic
- Department of Dermatovenereology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Soner Uzun
- Department of Dermatology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Snejina Vassileva
- Department of Dermatology and Venereology, University Hospital "Alexandrovska", Medical University-Sofia, Sofia, Bulgaria
| | - Giovanna Zambruno
- Genodermatosis Unit, Translational Pediatrics and Clinical Genetics Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Enno Schmidt
- Department of Dermatology, Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
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Lupu VV, Sasaran MO, Jechel E, Starcea IM, Ioniuc I, Mocanu A, Rosu ST, Munteanu V, Nedelcu AH, Danielescu C, Salaru DL, Knieling A, Lupu A. Celiac disease - a pluripathological model in pediatric practice. Front Immunol 2024; 15:1390755. [PMID: 38715620 PMCID: PMC11074362 DOI: 10.3389/fimmu.2024.1390755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 04/03/2024] [Indexed: 05/23/2024] Open
Abstract
Being defined as an autoimmune, chronic pathology, frequently encountered in any age group, but especially in pediatrics, celiac disease (also called gluten enteropathy), is gaining more and more ground in terms of diagnosis, but also interest in research. The data from the literature of the last decades attest the chameleonic way of its presentation, there may be both classic onset symptoms and atypical symptoms. Given the impact played by celiac disease, especially in the optimal growth and development of children, the current narrative review aims to highlight the atypical presentation methods, intended to guide the clinician towards the inclusion of the pathology in the differential diagnosis scheme. To these we add the summary presentation of the general data and therapeutic lines regarding the underlying condition and the existing comorbidities. In order to place the related information up to date, we performed a literature review of the recent articles published in international databases. We bring forward the current theories and approaches regarding both classic celiac disease and its atypical manifestations. Among these we note mainly constitutional, skin or mucous, bone, neuro-psychic, renal, reproductive injuries, but also disorders of biological constants and association with multiple autoimmunities. Knowing and correlating them with celiac disease is the key to optimal management of patients, thus reducing the subsequent burden of the disease.
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Affiliation(s)
- Vasile Valeriu Lupu
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Maria Oana Sasaran
- Faculty of Medicine, “George Emil Palade” University of Medicine, Pharmacy, Science and Technology, Targu Mures, Romania
| | - Elena Jechel
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | | | - Ileana Ioniuc
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Adriana Mocanu
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Solange Tamara Rosu
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Valentin Munteanu
- Faculty of Medical Bioengineering, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Alin Horatiu Nedelcu
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Ciprian Danielescu
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Delia Lidia Salaru
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Anton Knieling
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Ancuta Lupu
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
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Fernández-Bañares F, Crespo L, Planella M, Farrais S, Izquierdo S, López-Palacios N, Roy G, Vidal J, Núñez C. Improving the Diagnosis of Dermatitis Herpetiformis Using the Intraepithelial Lymphogram. Nutrients 2024; 16:232. [PMID: 38257124 PMCID: PMC10819692 DOI: 10.3390/nu16020232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/04/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Dermatitis herpetiformis is a cutaneous manifestation of celiac disease. Phenotyping of intraepithelial lymphocytes in the small bowel mucosa can strengthen the diagnosis of celiac disease when it is not clear-cut. We aim to evaluate the usefulness of the intraepithelial lymphogram to confirm dermatitis herpetiformis in equivocal cases. We performed a retrospective multicenter study on patients diagnosed with dermatitis herpetiformis and collected data from the intraepithelial lymphogram assessed by flow cytometry. A total of 36 patients were analyzed in relation to the severity of intestinal damage (18 had non-atrophic mucosa) at baseline (N = 28) and/or after the adoption of a gluten-free diet (median follow-up of three years, N = 16). We observed that patients with atrophy more often had positive celiac serology (p = 0.019), celiac clinical symptoms (p = 0.018), and iron-deficiency anemia (p = 0.018), but the severity of skin damage was similar in both groups (p = 0.79). At baseline, increased TCRγδ+ cells were present in 94% of patients with atrophy and 67% with non-atrophic lesions (p = 0.13). After a gluten-free diet, increased TCRγδ+ cells persisted in 100% and 63% of cases, respectively (p = 0.21). We concluded that increased TCRγδ+ cells may be helpful in confirming the diagnosis of dermatitis herpetiformis in equivocal cases, even in patients who were started on a gluten-free diet.
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Affiliation(s)
- Fernando Fernández-Bañares
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, 08221 Terrasa, Spain;
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Laura Crespo
- Department of Gastroenterology, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain;
| | - Montserrat Planella
- Department of Gastroenterology, Hospital Arnau Vilanova, 25198 Lleida, Spain;
| | - Sergio Farrais
- Department of Gastroenterology, Hospital Fundación Jiménez Díaz, 28040 Madrid, Spain;
| | - Sandra Izquierdo
- Department of Gastroenterology, Hospital Clínico Universitario, 47003 Valladolid, Spain;
| | - Natalia López-Palacios
- Department of Gastroenterology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos, 28040 Madrid, Spain;
| | - Garbiñe Roy
- Department of Immunology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, 28034 Madrid, Spain;
| | - Judith Vidal
- Section of Flow Cytometry, CATLAB, 08232 Viladecavalls, Spain;
| | - Concepción Núñez
- Laboratorio de Investigación en Genética de Enfermedades Complejas, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos, 28040 Madrid, Spain
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), 28029 Madrid, Spain
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Mee JB. Diagnostic Techniques in Autoimmune Blistering Diseases. Br J Biomed Sci 2023; 80:11809. [PMID: 38074463 PMCID: PMC10704243 DOI: 10.3389/bjbs.2023.11809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/23/2023] [Indexed: 12/18/2023]
Abstract
Autoimmune blistering diseases (AIBD) comprise a heterogeneous group of uncommon disorders of the skin and mucous membranes, characterised by antibodies targeting structural proteins within epithelial tissue and the underlying basement membrane. There can be significant overlap in clinical presentation of these diseases and accurate diagnosis relies on the detection and characterisation of relevant autoantibodies. Immunofluorescence provides the gold-standard diagnostic tool for these diseases, identifying both tissue-bound autoantibodies in biopsy material using direct immunofluorescence and circulating antibodies in serum through indirect immunofluorescence. Following advances in the identification and subsequent characterisation of numerous antigenic targets in these diseases, the development of antigen-specific tests, in particular, enzyme-linked immunosorbent assays on serum specimens, has provided a third key tool to not only identify, but also quantify AIBD autoantibodies. This quantification has proven particularly useful in monitoring disease activity and informing clinical management decisions. Accurate diagnosis of these diseases is important since optimal treatment strategies differ between them and, prognostically, some diagnoses are associated with an increased risk of malignancy. This review outlines the molecular pathology underlying the major AIBD and describes how the three principal techniques can be used in combination, to provide best practice for diagnosis and treatment monitoring.
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Affiliation(s)
- John B. Mee
- Immunodermatology Laboratory, St John’s Institute of Dermatology, Synnovis Analytics, St Thomas’ Hospital, London, United Kingdom
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Patt YS, Lahat A, David P, Patt C, Eyade R, Sharif K. Unraveling the Immunopathological Landscape of Celiac Disease: A Comprehensive Review. Int J Mol Sci 2023; 24:15482. [PMID: 37895160 PMCID: PMC10607730 DOI: 10.3390/ijms242015482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 10/20/2023] [Accepted: 10/21/2023] [Indexed: 10/29/2023] Open
Abstract
Celiac disease (CD) presents a complex interplay of both innate and adaptive immune responses that drive a variety of pathological manifestations. Recent studies highlight the role of immune-mediated pathogenesis, pinpointing the involvement of antibodies against tissue transglutaminases (TG2, TG3, TG6), specific HLA molecules (DQ2/8), and the regulatory role of interleukin-15, among other cellular and molecular pathways. These aspects illuminate the systemic nature of CD, reflecting its wide-reaching impact that extends beyond gastrointestinal symptoms to affect other physiological systems and giving rise to a range of pathological landscapes, including refractory CD (RCD) and, in severe cases, enteropathy-associated T cell lymphoma. The existing primary therapeutic strategy, a gluten-free diet (GFD), poses significant challenges, such as low adherence rates, necessitating alternative treatments. Emerging therapies target various stages of the disease pathology, from preventing immunogenic gluten peptide absorption to enhancing intestinal epithelial integrity and modulating the immune response, heralding potential breakthroughs in CD management. As the understanding of CD deepens, novel therapeutic avenues are emerging, paving the way for more effective and sophisticated treatment strategies with the aim of enhancing the quality of life of CD patients. This review aims to delineate the immunopathology of CD and exploring its implications on other systems, its complications and the development of novel treatments.
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Affiliation(s)
- Yonatan Shneor Patt
- Department of Internal Medicine B, Sheba Medical Center, Ramat Gan 52621, Israel; (Y.S.P.); (P.D.); (C.P.); (R.E.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel;
| | - Adi Lahat
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel;
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Paula David
- Department of Internal Medicine B, Sheba Medical Center, Ramat Gan 52621, Israel; (Y.S.P.); (P.D.); (C.P.); (R.E.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel;
| | - Chen Patt
- Department of Internal Medicine B, Sheba Medical Center, Ramat Gan 52621, Israel; (Y.S.P.); (P.D.); (C.P.); (R.E.)
- The Adelson School of Medicine, Ariel University, Ariel 40700, Israel
| | - Rowand Eyade
- Department of Internal Medicine B, Sheba Medical Center, Ramat Gan 52621, Israel; (Y.S.P.); (P.D.); (C.P.); (R.E.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel;
| | - Kassem Sharif
- Department of Internal Medicine B, Sheba Medical Center, Ramat Gan 52621, Israel; (Y.S.P.); (P.D.); (C.P.); (R.E.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel;
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan 52621, Israel
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Alasmari B, Alkhodair R. Clinicopathological Profile of Dermatitis Herpetiformis Patients in Saudi Arabia. Cureus 2023; 15:e48045. [PMID: 38034235 PMCID: PMC10688508 DOI: 10.7759/cureus.48045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 12/02/2023] Open
Abstract
Objectives The aim of this study was to describe the clinical, serological, and histopathological features of patients with dermatitis herpetiformis (DH) in Saudi Arabia. Methods We retrospectively reviewed the medical charts of all patients diagnosed with DH in the dermatology departments of National Guard Health Affairs (NGHA) hospitals in five different cities, from 2016 to 2022. We included patients who had been diagnosed by a dermatologist and had a combination of typical DH skin lesions, positive immunoglobulin A (IgA) on direct immunofluorescence (DIF), and/or positive tissue transglutaminase (tTG) IgA. Results A total of 11 patients were included. Their average age was 43.6 ± 12.5 years, and the ratio of females: males was 2.7: 1. Among the eight skin biopsies performed, IgA was detected on DIF in five patients. Seven out of nine patients (77.8%) had positive tTG IgA. Nine patients were managed with dapsone and a gluten-free diet (GFD); they had excellent responses within months. Conclusion The profiles of Saudi patients with DH were similar to those of Caucasian patients, but DH appears to be less common in Saudi Arabia. The high positive rates of tTG IgA make it an important tool for diagnosis in unclear cases. Dermatitis herpetiformis is likely associated with underlying gluten-sensitive enteropathy in Saudi patients.
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Affiliation(s)
- Bushra Alasmari
- Department of Dermatology, King Abdulaziz Medical City Riyadh, Riyadh, SAU
| | - Rayan Alkhodair
- Department of Pediatric Dermatology, King Abdullah Specialized Children's Hospital, Riyadh, SAU
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Vats V, Makineni P, Hemaida S, Haider A, Subramani S, Kaur N, Butt AN, Scott-Emuakpor R, Zahir M, Mathew M, Iqbal J. Gluten Intolerance and Its Association With Skin Disorders: A Narrative Review. Cureus 2023; 15:e44549. [PMID: 37790051 PMCID: PMC10544948 DOI: 10.7759/cureus.44549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2023] [Indexed: 10/05/2023] Open
Abstract
Gluten sensitivity is defined as a chronic intolerance to gluten ingestion in genetically predisposed individuals. The etiology is thought to be immune-mediated and has a variable dermatologic presentation. Celiac disease (CD) is one of the most common forms of gluten intolerance and encompasses a wide range of extra-intestinal pathology, including cutaneous, endocrine, nervous, and hematologic systems. Psoriasis, another long-term inflammatory skin condition, has been linked to significant symptomatic improvement with a gluten-free diet (GFD). Palmoplantar pustulosis (PP), a variant of psoriasis, and aphthous stomatitis, which causes recurrent oral ulcers, have also exhibited beneficial results after the dietary elimination of gluten. In addition to this, dermatitis herpetiformis (DH), another immune-mediated skin disorder, is genetically similar to CD and has, therefore, shown tremendous improvement with a GFD. Another highly prevalent long-term skin condition called atopic dermatitis (AD), however, has revealed inconsistent results with gluten elimination and would require further research in the future to yield concrete results. Hereditary angioedema (HA) has shown an association with gluten intolerance in some patients who had symptomatic benefits with a GFD. Similarly, vitiligo and linear IgA bullous dermatosis have also shown some clinical evidence of reversal with a GFD. On the contrary, rosacea enhances the risk of developing CD. This narrative review emphasizes the potential impact of gluten intolerance on different cutaneous conditions and the potential therapeutic effect of a GFD on various symptomatic manifestations. There is a need for additional clinical and observational trials to further expand on the underlying pathophysiology and provide conclusive and comprehensive recommendations for possible dietary interventions.
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Affiliation(s)
- Vaibhav Vats
- Internal Medicine, Smt. Kashibai Navale Medical College and General Hospital, Mumbai, IND
| | - Pallavi Makineni
- Medicine, All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar, IND
| | | | - Anum Haider
- Internal Medicine, Bahria University Medical & Dental College, Karachi, PAK
| | | | - Navjot Kaur
- Medicine, Government Medical College, Amritsar, Amritsar, IND
| | - Amna Naveed Butt
- Medicine/Internal Medicine, Allama Iqbal Medical College, Lahore, PAK
| | | | - Mohammad Zahir
- Medicine, Ayub Medical College, Abottabad, Abottabad, PAK
| | - Midhun Mathew
- Internal Medicine, Pennsylvania Hospital, Philadelphia, USA
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Verdelli A, Corrà A, Mariotti EB, Aimo C, Quintarelli L, Ruffo di Calabria V, Donati ME, Bonciolini V, Antiga E, Caproni M. Skin gluten-related disorders: new and old cutaneous manifestations to be considered. Front Med (Lausanne) 2023; 10:1155288. [PMID: 37265490 PMCID: PMC10229844 DOI: 10.3389/fmed.2023.1155288] [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: 01/31/2023] [Accepted: 04/28/2023] [Indexed: 06/03/2023] Open
Abstract
The term gluten-related disorders (GRD) refer to a spectrum of different clinical manifestations triggered by the ingestion of gluten in genetically susceptible individuals, including coeliac disease (CD), wheat allergy and non-celiac gluten sensitivity (NCGS). GRD are characterized by a large variety of clinical presentations with both intestinal and extra-intestinal manifestations. The latter may affect almost every organ of the body, including the skin. Besides the well-known association between CD and dermatitis herpetiformis, considered as the cutaneous specific manifestation of CD, many other muco-cutaneous disorders have been associated to GRD. In this review, we analyzed the main features of dermatological diseases with a proven association with GRD and those that improve after a gluten-free diet, focusing on the newly described cutaneous manifestations associated with NCGS. Our main hypothesis is that a "cutaneous-gluten sensitivity," as specific cutaneous manifestation of NCGS, may exist and could represent a diagnostic marker of NCGS.
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Affiliation(s)
- Alice Verdelli
- Department of Health Sciences, Rare Dermatological Diseases Unit, Azienda USL Toscana Centro, European Reference Network-Skin Member, Florence, Italy
| | - Alberto Corrà
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Cristina Aimo
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Lavinia Quintarelli
- Department of Health Sciences, Rare Dermatological Diseases Unit, Azienda USL Toscana Centro, European Reference Network-Skin Member, Florence, Italy
| | | | - Marta Elettra Donati
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Emiliano Antiga
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Marzia Caproni
- Department of Health Sciences, Rare Dermatological Diseases Unit, Azienda USL Toscana Centro, European Reference Network-Skin Member, Florence, Italy
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Mania-Końsko A, Szponar E, Dańczak-Pazdrowska A, Bowszyc-Dmochowska M, Pazdrowski J, Wyganowska M. Immunopathological Assessment of the Oral Mucosa in Dermatitis Herpetiformis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2524. [PMID: 36767890 PMCID: PMC9915384 DOI: 10.3390/ijerph20032524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/19/2023] [Accepted: 01/27/2023] [Indexed: 06/18/2023]
Abstract
Dermatitis herpetiformis (Duhring's disease, DH) is a chronic blistering cutaneous condition with pruritic polymorphic lesions, consisting of vesicles, papules or nodules and erythema, found predominantly on the extensor surfaces of the limbs, buttocks, and neck. Diagnosis is based on characteristic clinical and immunopathological findings. Oral manifestations of DH have rarely been described. The aim of the study was to evaluate IgA, IgG, IgM and C3 complement deposits in the oral mucosa in DH patients. Direct immunofluorescence (DIF) was performed on the oral mucosa specimens collected from 10 DH patients. Biopsy was taken in a local anesthesia from perilesional site from the buccal mucosa and then preserved in a standard procedure using polyclonal rabbit IgG, IgA, IgM and C3 antibodies. Granular IgA and C3 deposits were found in 6 patients (60%), and in 3 subjects (30%) the result was indeterminate. Significant fluorescence of the deposits along the basement membrane was observed in 2 patients, moderate fluorescence in 3 patients, and in 4 cases the result was indeterminate. C3 deposits were found in 5 subjects (50%), 3 of them being moderate and 2 indeterminate. No IgM and IgG deposits were detected in the collected buccal mucosa specimens.
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Affiliation(s)
- Agnieszka Mania-Końsko
- Department of Dental Surgery, Periodontology and Oral Mucosa Diseases, Poznan University of Medical Sciences, 70, Bukowska St., 60-812 Poznań, Poland
| | - Elżbieta Szponar
- Department of Dental Surgery, Periodontology and Oral Mucosa Diseases, Poznan University of Medical Sciences, 70, Bukowska St., 60-812 Poznań, Poland
| | | | - Monika Bowszyc-Dmochowska
- Department of Dermatology, Poznan University of Medical Sciences, 49, Przybyszewskiego St., 61-701 Poznań, Poland
| | - Jakub Pazdrowski
- The Maria Skłodowska-Curie Greater Poland Cancer Center, Department of Head and Neck Surgery, Poznan University of Medical Sciences, Garbary St., 61-701 Poznań, Poland
| | - Marzena Wyganowska
- Department of Dental Surgery, Periodontology and Oral Mucosa Diseases, Poznan University of Medical Sciences, 70, Bukowska St., 60-812 Poznań, Poland
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10
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Zhang W, Wu C, Zhou K, Cao Y, Zhou W, Zhang X, Deng D. Clinical and immunological characteristics of TGM3 in pan-cancer: A potential prognostic biomarker. Front Genet 2023; 13:993438. [PMID: 36685895 PMCID: PMC9852731 DOI: 10.3389/fgene.2022.993438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/22/2022] [Indexed: 01/09/2023] Open
Abstract
Background: Recent studies have identified that transglutaminases (TGMs) are involved in a widespread epigenetic modification in tumorigenesis. However, it remains unclear how transglutaminase 3 (TGM3) affects in pan-cancer. The present study aimed to explore the clinical and prognostic function of TGM3 in pan-cancer as well as to explore the relationship of TGM3 expression with clinical stage, survival rate, prognosis condition, immune infiltration and mutation indicators. Methods: The relevant data of tumors were obtained from The Cancer Genome Atlas (TCGA), TARGET, Cancer Cell Line Encyclopedia (CCLE) and Genotype-Tissue Expression (GTEx) databases. According to the Human Protein Atlas (HPA) and TIMER databases, we evaluated the protein expression levels of TGM3 in different organs and tissues as well as their association with immune cell infiltration and immunotherapeutic response in pan-cancers. Expression differences between normal and tumor tissues as well as survival and prognosis situation, clinical data characteristics, tumor mutational burden (TMB), microsatellite instability (MSI), and RNA methylation were also assessed. Oncogenic analyses were also evaluated by GSEA. Results: Compared to normal tissues, some tumor tissues had a lower expression level of TGM3, while other tumor tissues had a high expression level of TGM3. Further studies showed that high TGM3 expression had a certain risk impact on pan-cancer as high TGM3 expression levels were detrimental to the survival of several cancers, except for pancreatic cancer (PAAD). High expression level of TGM3 was also related to higher clinical stages in most cancers. The expression level of TGM3 was significantly negatively correlated with the expression of immune infiltration-related cells, including B cells, CD8+ T cells, CD4+ T cells, neutrophils, macrophages and dendritic cells (DCs). Furthermore, in most cancer types, TGM3 was inversely correlated with TMB, MSI, and methylation, suggesting that TGM3 expression can be used to assess potential therapeutic response, especially immune-related targeted therapy. GSEA analysis elucidated the biological and molecular function of TGM3 in various cancer types. Taken together, these bioinformatic analyses identified TGM3 as an important biomarker for clinical tumor prognosis and evaluation of treatment efficacy. Conclusion: We comprehensively analyzed the clinical characteristics, tumor stages, immune infiltration, methylation level, gene mutation, functional enrichment analysis and immunotherapeutic value of TGM3 in pan-cancer, providing implications for the function of TGM3 and its role in clinical treatment.
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Affiliation(s)
- Wenqing Zhang
- Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China,Department of Dermatology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China,Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Chenglong Wu
- Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China,Department of Dermatology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China,Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Kaili Zhou
- Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China,Department of Dermatology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China,Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yu Cao
- Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China,Department of Dermatology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China,Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wange Zhou
- Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China,Department of Dermatology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China,Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xue Zhang
- Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China,Department of Dermatology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China,Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China,*Correspondence: Xue Zhang, ; Dan Deng,
| | - Dan Deng
- Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China,Department of Dermatology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China,Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China,Department of Dermatology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China,*Correspondence: Xue Zhang, ; Dan Deng,
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11
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Cao S, Zhou G, Yang B. A case of linear IgA bullous dermatosis localised on the genital area. Indian J Dermatol Venereol Leprol 2023; 89:88-89. [PMID: 36331857 DOI: 10.25259/ijdvl_321_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/01/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Shan Cao
- Shandong Provincial Hospital for Skin Diseases & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Guizhi Zhou
- Shandong Provincial Hospital for Skin Diseases & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Baoqi Yang
- Shandong Provincial Hospital for Skin Diseases & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China
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12
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Ludwig RJ, Schmidt E. Bullous Diseases of the Skin and Mucous Membranes. Clin Immunol 2023. [DOI: 10.1016/b978-0-7020-8165-1.00063-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
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13
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Affiliation(s)
- Ayodeji Ajayi
- Georgetown University School of Medicine, Washington, DC, USA
| | - Sruveera Sathi
- Georgetown University School of Medicine, Washington, DC, USA
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14
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Moennig E, Ott H. 3/m mit ringförmig angeordneten Blasen und Erosionen. Monatsschr Kinderheilkd 2022. [DOI: 10.1007/s00112-022-01560-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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15
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Urticarial dermatitis herpetiformis: A rare presentation of an uncommon disorder. JAAD Case Rep 2022; 26:27-29. [PMID: 35865727 PMCID: PMC9294481 DOI: 10.1016/j.jdcr.2022.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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16
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Felber J, Bläker H, Fischbach W, Koletzko S, Laaß M, Lachmann N, Lorenz P, Lynen P, Reese I, Scherf K, Schuppan D, Schumann M, Aust D, Baas S, Beisel S, de Laffolie J, Duba E, Holtmeier W, Lange L, Loddenkemper C, Moog G, Rath T, Roeb E, Rubin D, Stein J, Török H, Zopf Y. Aktualisierte S2k-Leitlinie Zöliakie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:790-856. [PMID: 35545109 DOI: 10.1055/a-1741-5946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Jörg Felber
- Medizinische Klinik II - Gastroenterologie, Hepatologie, Endokrinologie, Hämatologie und Onkologie, RoMed Klinikum Rosenheim, Rosenheim, Deutschland
| | - Hendrik Bläker
- Institut für Pathologie, Universitätsklinikum Leipzig AöR, Leipzig, Deutschland
| | | | - Sibylle Koletzko
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, LMU-Klinikum München, München, Deutschland.,Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, 10-719 Olsztyn, Polen
| | - Martin Laaß
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Deutschland
| | - Nils Lachmann
- Institut für Transfusionsmedizin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Pia Lorenz
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Petra Lynen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Imke Reese
- Ernährungsberatung und -therapie Allergologie, München, Deutschland
| | - Katharina Scherf
- Institute of Applied Biosciences Department of Bioactive and Functional Food Chemistry, Karlsruhe Institute of Technology (KIT), Karlsruhe, Deutschland
| | - Detlef Schuppan
- Institut für Translationale Immunologie, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland.,Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Michael Schumann
- Medizinische Klinik I für Gastroenterologie, Infektiologie und Rheumatologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland
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17
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What is causing this patient's severe itching? JAAPA 2022; 35:62-64. [DOI: 10.1097/01.jaa.0000823152.12182.6c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Kaunisto H, Salmi T, Lindfors K, Kemppainen E. Antibody Responses to Transglutaminase 3 in Dermatitis Herpetiformis: Lessons from Celiac Disease. Int J Mol Sci 2022; 23:ijms23062910. [PMID: 35328331 PMCID: PMC8953297 DOI: 10.3390/ijms23062910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 12/13/2022] Open
Abstract
Dermatitis herpetiformis (DH) is the skin manifestation of celiac disease, presenting with a blistering rash typically on the knees, elbows, buttocks and scalp. In both DH and celiac disease, exposure to dietary gluten triggers a cascade of events resulting in the production of autoantibodies against the transglutaminase (TG) enzyme, mainly TG2 but often also TG3. The latter is considered to be the primary autoantigen in DH. The dynamics of the development of the TG2-targeted autoimmune response have been studied in depth in celiac disease, but the immunological process underlying DH pathophysiology is incompletely understood. Part of this process is the occurrence of granular deposits of IgA and TG3 in the perilesional skin. While this serves as the primary diagnostic finding in DH, the role of these immunocomplexes in the pathogenesis is unknown. Intriguingly, even though gluten-intolerance likely develops initially in a similar manner in both DH and celiac disease, after the onset of the disease, its manifestations differ widely.
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Affiliation(s)
- Helka Kaunisto
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, FI-33520 Tampere, Finland; (H.K.); (T.S.); (K.L.)
| | - Teea Salmi
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, FI-33520 Tampere, Finland; (H.K.); (T.S.); (K.L.)
- Department of Dermatology, Tampere University Hospital, FI-33520 Tampere, Finland
| | - Katri Lindfors
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, FI-33520 Tampere, Finland; (H.K.); (T.S.); (K.L.)
| | - Esko Kemppainen
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, FI-33520 Tampere, Finland; (H.K.); (T.S.); (K.L.)
- Correspondence:
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19
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Bozca B, Mutlu D, Uzun S. Value of the BIOCHIP mosaic-based indirect immunofluorescent technique in the diagnosis of dermatitis herpetiformis among patients with chronic pruritus. TURKISH JOURNAL OF DERMATOLOGY 2022. [DOI: 10.4103/tjd.tjd_101_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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20
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Kotze LMDS, Kotze LR, Purim KSM, Nisihara R. THE MANAGEMENT OF DERMATITIS HERPETIFORMIS BY THE GASTROENTEROLOGIST. A SERIES OF CASES. ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:429-432. [PMID: 34909845 DOI: 10.1590/s0004-2803.202100000-78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 06/22/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Dermatitis herpetiformis (DH) is considered a skin celiac disease (CD). The individuals can be seen by primary care professionals or by dermatologists that could refer the patient to a gastroenterologist. OBJECTIVE The study aimed to investigate the clinical profile of patients diagnosed with DH and referred to a gastroenterologist and evaluate the treatment response. METHODS We retrospectively studied patients with DH referred to the same gastroenterologist at a private office in Curitiba, Brazil, between January 2010 to December 2019. We included adult patients with a confirmed DH diagnosis. Symptoms, clinical signs, laboratory and histological data, as well as treatment response, were collected. RESULTS Thirty-three patients were studied (60.6% women, mean age at diagnosis 40.8±12.61 years). The median delay for DH diagnosis was four years. Skin involvement was mild in 33.3%, moderate in 18.2%, and severe in 48.5%. The more frequent gastrointestinal complaints were abdominal distension (78.8%), flatulence (75.7%), and gastroesophageal reflux (51.5%). Depression and anxiety were observed in 81.8% and anemia in 51.1%. A higher prevalence of bone disorders was associated with higher age at DH diagnosis (P=0.035). Duodenal biopsy showed changes in all patients. Improvement after treatment only with a gluten-free diet (GFD) plus dapsone was verified in 81.2%. CONCLUSION Patients with DH referred to a gastroenterologist showed a high frequency of gluten intolerance and systemic complaints. Duodenal histological alterations were found in all the cases. The treatment based on GFD plus dapsone was effective in most patients.
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Affiliation(s)
| | - Luiz Roberto Kotze
- Universidade Federal do Paraná, Setor de Ciências da Saúde, Curitiba, PR, Brasil
| | | | - Renato Nisihara
- Universidade Federal do Paraná, Setor de Ciências da Saúde, Curitiba, PR, Brasil.,Universidade Positivo, Departamento de Medicina, Curitiba, PR, Brasil
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21
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Tsutsui Y, Hasegawa A, Uchida S, Terao K, Takei S, Yokoyama A, Sato A, Kabata Y, Hayashi R, Fujikawa H, Togashi K, Abe R. Dermatitis herpetiformis triggered by iodine contrast media. J Eur Acad Dermatol Venereol 2021; 36:e348-e350. [PMID: 34897819 DOI: 10.1111/jdv.17860] [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]
Affiliation(s)
- Y Tsutsui
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - A Hasegawa
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - S Uchida
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - K Terao
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - S Takei
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - A Yokoyama
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - A Sato
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Y Kabata
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - R Hayashi
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - H Fujikawa
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | | | - R Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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22
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Szaflarska-Popławska A. The Role of the Gluten-Free Diet in the Management of Seronegative Enteropathy. Nutrients 2021; 13:nu13114027. [PMID: 34836279 PMCID: PMC8619095 DOI: 10.3390/nu13114027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/04/2021] [Accepted: 11/09/2021] [Indexed: 11/16/2022] Open
Abstract
The differential diagnosis and treatment of seronegative enteropathy, also termed seronegative villous atrophy (SNVA), is a clinical challenge. Although seronegative coeliac disease (CD) is a frequent cause of SNVA, the aetiology can include immune-mediated, inflammatory, infectious, and drug-related forms. As a misdiagnosis of SNVA can result in patients being unnecessarily placed on a lifelong strict gluten-free diet or even given incorrect immunosuppressive therapy, the aim of this paper is to provide an evidence-based and practical approach for the workup and management of SNVA.
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Affiliation(s)
- Anna Szaflarska-Popławska
- Department of Paediatric Endoscopy and Gastrointestinal Function Testing, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, ul. Jagiellonska 13-15, 85-067 Bydgoszcz, Poland
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23
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Murthy S, Schilf P, Patzelt S, Thieme M, Becker M, Kröger L, Bremer T, Derenda-Hell A, Knebel L, Fagiani F, Ibrahim SM, Schmidt E, Zillikens D, Sadik CD. Dapsone Suppresses Disease in Preclinical Murine Models of Pemphigoid Diseases. J Invest Dermatol 2021; 141:2587-2595.e2. [PMID: 34033839 DOI: 10.1016/j.jid.2021.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/09/2021] [Accepted: 04/01/2021] [Indexed: 01/10/2023]
Abstract
Epidermolysis bullosa acquisita and mucous membrane pemphigoid are autoimmune blistering diseases characterized by mucocutaneous blisters elicited by an autoantibody-mediated immune response against specific proteins of the epidermal basement membrane. The antibiotic dapsone is frequently used to treat both diseases, but its therapeutic effectiveness is uncertain, and its mode of action in these diseases is largely unknown. We evaluated the effect of dapsone in antibody transfer mouse models of epidermolysis bullosa acquisita and mucous membrane pemphigoid, which do not allow the drawing of conclusions on clinical treatment regimens but can be instrumental to partially uncover the mode(s) of action of dapsone in these diseases. Dapsone significantly mitigated inflammation in both models, reducing the recruitment of neutrophils into the skin and disrupting their release of leukotriene B4 (LTB4) and ROS in response to immune complexes. LTB4 has been implicated in numerous diseases, but effective LTB4 inhibitors for clinical use are not available. Our findings indicate that the mode of action of dapsone in these models may be based on the inhibition of LTB4 and ROS release from neutrophils. Moreover, they encourage testing the use of dapsone as an effective, albeit nonspecific, inhibitor of LTB4 biosynthesis in other LTB4-driven diseases.
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Affiliation(s)
- Sripriya Murthy
- Department of Dermatology, Allergology, and Venereology, University of Lübeck, Lübeck, Germany
| | - Paul Schilf
- Department of Dermatology, Allergology, and Venereology, University of Lübeck, Lübeck, Germany
| | - Sabrina Patzelt
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Markus Thieme
- Department of Dermatology, Allergology, and Venereology, University of Lübeck, Lübeck, Germany
| | - Mareike Becker
- Department of Dermatology, Allergology, and Venereology, University of Lübeck, Lübeck, Germany
| | - Lasse Kröger
- Department of Dermatology, Allergology, and Venereology, University of Lübeck, Lübeck, Germany
| | - Tabea Bremer
- Department of Dermatology, Allergology, and Venereology, University of Lübeck, Lübeck, Germany
| | - Aleksandra Derenda-Hell
- Department of Dermatology, Allergology, and Venereology, University of Lübeck, Lübeck, Germany
| | - Lea Knebel
- Department of Dermatology, Allergology, and Venereology, University of Lübeck, Lübeck, Germany
| | - Francesca Fagiani
- Department of Dermatology, Allergology, and Venereology, University of Lübeck, Lübeck, Germany
| | - Saleh M Ibrahim
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany; Center for Research on Inflammation of the Skin (CRIS), University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany; Center for Research on Inflammation of the Skin (CRIS), University of Lübeck, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, Allergology, and Venereology, University of Lübeck, Lübeck, Germany; Center for Research on Inflammation of the Skin (CRIS), University of Lübeck, Lübeck, Germany
| | - Christian D Sadik
- Department of Dermatology, Allergology, and Venereology, University of Lübeck, Lübeck, Germany; Center for Research on Inflammation of the Skin (CRIS), University of Lübeck, Lübeck, Germany.
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24
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Balan RA, Lozneanu L, Grigoras A, Caruntu ID, Balan TA, Giusca SE, Amalinei C. Spongiotic reaction patterns in autoimmune bullous dermatoses (Review). Exp Ther Med 2021; 22:1334. [PMID: 34630688 PMCID: PMC8495556 DOI: 10.3892/etm.2021.10769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 08/06/2021] [Indexed: 11/11/2022] Open
Abstract
Spongiosis or a spongiotic reaction pattern is the histological hallmark of intercellular epidermal edema, viewed as clear spaces within the epidermis. Although considered a histopathological term, spongiosis has clinical correlations, with the variable degrees of spongiotic reaction leading to different dermatological findings. This review aimed to highlight the spongiotic reactive patterns found in different autoimmune bullous dermatoses, considering the paucity of publications in this domain. The pathogenesis of spongiosis assumes the passage of extravasated edema fluid from the dermis into the epidermis, frequently accompanied by dermal inflammatory cells, and classification of the spongiotic reaction patterns, as well as their associated spongiotic dermatitis, take into consideration the type and distribution of these inflammatory cells. It is mandatory to consider different reactive processes, specific for other skin disorders, which act as simulants of different spongiotic patterns for the diagnosis. Considering the possible transient occurrence, the heterogeneity and non-specificity of the histopathological features of these diseases, the diagnosis is very complex, requiring clinicopathological correlations and additional analyses. A deep insight into spongiosis pathogeny may open the perspectives of a classification refinement of autoimmune bullous dermatoses.
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Affiliation(s)
- Raluca Anca Balan
- Department of Morphofunctional Sciences I, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Ludmila Lozneanu
- Department of Morphofunctional Sciences I, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Adriana Grigoras
- Department of Morphofunctional Sciences I, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Irina Draga Caruntu
- Department of Morphofunctional Sciences I, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Teodora Ana Balan
- Department of Morphofunctional Sciences I, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Simona Eliza Giusca
- Department of Morphofunctional Sciences I, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Cornelia Amalinei
- Department of Morphofunctional Sciences I, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
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25
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Dermatitis Herpetiformis: An Update on Diagnosis, Disease Monitoring, and Management. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57080843. [PMID: 34441049 PMCID: PMC8400185 DOI: 10.3390/medicina57080843] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/15/2021] [Accepted: 08/18/2021] [Indexed: 12/13/2022]
Abstract
Dermatitis herpetiformis (DH), Duhring disease, is caused by gluten sensitivity and affects 11.2 to 75.3 per 100,000 people in the United States and Europe with an incidence of 0.4 to 3.5 per 100,000 people per year. DH is characterized by a symmetrical blistering rash on the extensor surfaces with severe pruritus. The diagnosis continues to be made primarily by pathognomonic findings on histopathology, especially direct immunofluorescence (DIF). Recently, anti-epidermal transglutaminase (TG3) antibodies have shown to be a primary diagnostic serology, while anti-tissue transglutaminase (TG2) and other autoantibodies may be used to support the diagnosis and for disease monitoring. Newly diagnosed patients with DH should be screened and assessed for associated diseases and complications. A gluten-free diet (GFD) and dapsone are still mainstays of treatment, but other medications may be necessary for recalcitrant cases. Well-controlled DH patients, managed by a dermatologist, a gastroenterologist, and a dietician, have an excellent prognosis. Our review comprehensively details the current diagnostic methods, as well as methods used to monitor its disease course. We also describe both the traditional and novel management options reported in the literature.
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Gornowicz-Porowska J, Seraszek-Jaros A, Jałowska M, Bowszyc-Dmochowska M, Kaczmarek E, Dmochowski M. Evaluation of a Bi-Analyte Immunoblot as a Useful Tool for Diagnosing Dermatitis Herpetiformis. Diagnostics (Basel) 2021; 11:diagnostics11081414. [PMID: 34441348 PMCID: PMC8392659 DOI: 10.3390/diagnostics11081414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/01/2021] [Accepted: 08/02/2021] [Indexed: 12/14/2022] Open
Abstract
Immune responses to tissue transglutaminase (tTG) and nonapeptides of gliadin (npG) are associated with dermatitis herpetiformis (DH), a gluten-related dermatosis. Recently, a bi-analyte immunoblot (b-aIB) was introduced to detect IgA antibodies in response to tTG and npG. We compared the utility of ELISA and b-aIB with tTG in serological diagnoses of DH and their agreement with direct immunofluorescence (DIF). In total, 55 sera (27 DIF-positive DH patients, 4 DIF-negative DH patients and 24 healthy controls) were examined. ELISA for anti-tTG IgA, b-aIB for anti-npG and anti-tTG IgA, and statistical analysis were performed. The b-aIB with tTG showed 78% sensitivity, 100% specificity, 100% positive predictive value, and 82% negative predictive value in relation to ELISA. A better rate of agreement (Cohen’s kappa values) in IgA detection was observed in the pair tTG ELISA and b-aIB with npG (0.85) than in pairs tTG ELISA and b-aIB with tTG (0.78) or b-aIB with tTG and b-aIB with npG (0.78). No degree of agreement was found between serological tests and DIF. Both serological tests may be used to detect the anti-tTG IgA in DH patients. Still, DH diagnosing requires careful consideration of clinical data as well as results of tissue imaging (crucial DIF) and immunoserological techniques detecting DH-type features.
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Affiliation(s)
- Justyna Gornowicz-Porowska
- Department and Division of Practical Cosmetology and Skin Diseases Prophylaxis, Poznan University of Medical Sciences, 33 Mazowiecka Street, 60-623 Poznań, Poland
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, 49 Przybyszewskiego Street, 60-355 Poznań, Poland; (M.J.); (M.D.)
- Correspondence: ; Tel.: +4861-869-13-67
| | - Agnieszka Seraszek-Jaros
- Department of Bioinformatics and Computational Biology, Poznan University of Medical Sciences, 4 Rokietnicka Street, 60-806 Poznań, Poland; (A.S.-J.); (E.K.)
| | - Magdalena Jałowska
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, 49 Przybyszewskiego Street, 60-355 Poznań, Poland; (M.J.); (M.D.)
| | - Monika Bowszyc-Dmochowska
- Cutaneous Histopathology and Immunopathology Section, Department of Dermatology, Poznan University of Medical Sciences, 49 Przybyszewskiego Street, 60-355 Poznań, Poland;
| | - Elżbieta Kaczmarek
- Department of Bioinformatics and Computational Biology, Poznan University of Medical Sciences, 4 Rokietnicka Street, 60-806 Poznań, Poland; (A.S.-J.); (E.K.)
| | - Marian Dmochowski
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, 49 Przybyszewskiego Street, 60-355 Poznań, Poland; (M.J.); (M.D.)
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Sabença C, Ribeiro M, de Sousa T, Poeta P, Bagulho AS, Igrejas G. Wheat/Gluten-Related Disorders and Gluten-Free Diet Misconceptions: A Review. Foods 2021; 10:1765. [PMID: 34441542 PMCID: PMC8391170 DOI: 10.3390/foods10081765] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 12/12/2022] Open
Abstract
In the last 10,000 years, wheat has become one of the most important cereals in the human diet and today, it is widely consumed in many processed food products. Mostly considered a source of energy, wheat also contains other essential nutrients, including fiber, proteins, and minor components, such as phytochemicals, vitamins, lipids, and minerals, that together promote a healthy diet. Apart from its nutritional properties, wheat has a set of proteins, the gluten, which confer key technical properties, but also trigger severe immune-mediated diseases, such as celiac disease. We are currently witnessing a rise in the number of people adhering to gluten-free diets unwarranted by any medical need. In this dynamic context, this review aims to critically discuss the nutritional components of wheat, highlighting both the health benefits and wheat/gluten-related disorders, in order to address common misconceptions associated with wheat consumption.
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Affiliation(s)
- Carolina Sabença
- Department of Genetics and Biotechnology, University of Trás-os-Montes and Alto Douro, 5000-801 Vila Real, Portugal; (C.S.); (M.R.); (T.d.S.)
- Functional Genomics and Proteomics Unity, University of Trás-os-Montes and Alto Douro, 5000-801 Vila Real, Portugal
- LAQV-REQUIMTE, Faculty of Science and Technology, University Nova of Lisbon, 2829-546 Lisbon, Portugal;
| | - Miguel Ribeiro
- Department of Genetics and Biotechnology, University of Trás-os-Montes and Alto Douro, 5000-801 Vila Real, Portugal; (C.S.); (M.R.); (T.d.S.)
- Functional Genomics and Proteomics Unity, University of Trás-os-Montes and Alto Douro, 5000-801 Vila Real, Portugal
- LAQV-REQUIMTE, Faculty of Science and Technology, University Nova of Lisbon, 2829-546 Lisbon, Portugal;
| | - Telma de Sousa
- Department of Genetics and Biotechnology, University of Trás-os-Montes and Alto Douro, 5000-801 Vila Real, Portugal; (C.S.); (M.R.); (T.d.S.)
- Functional Genomics and Proteomics Unity, University of Trás-os-Montes and Alto Douro, 5000-801 Vila Real, Portugal
- LAQV-REQUIMTE, Faculty of Science and Technology, University Nova of Lisbon, 2829-546 Lisbon, Portugal;
| | - Patrícia Poeta
- LAQV-REQUIMTE, Faculty of Science and Technology, University Nova of Lisbon, 2829-546 Lisbon, Portugal;
- Microbiology and Antibiotic Resistance Team (MicroART), Department of Veterinary Sciences, University of Trás-os-Montes and Alto Douro, 5000-801 Vila Real, Portugal
| | - Ana Sofia Bagulho
- National Institute for Agrarian and Veterinarian Research (INIAV), Estrada Gil Vaz, Ap. 6, 7350-901 Elvas, Portugal;
| | - Gilberto Igrejas
- Department of Genetics and Biotechnology, University of Trás-os-Montes and Alto Douro, 5000-801 Vila Real, Portugal; (C.S.); (M.R.); (T.d.S.)
- Functional Genomics and Proteomics Unity, University of Trás-os-Montes and Alto Douro, 5000-801 Vila Real, Portugal
- LAQV-REQUIMTE, Faculty of Science and Technology, University Nova of Lisbon, 2829-546 Lisbon, Portugal;
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Heydari P, Kharaziha M, Varshosaz J, Javanmard SH. Current knowledge of immunomodulation strategies for chronic skin wound repair. J Biomed Mater Res B Appl Biomater 2021; 110:265-288. [PMID: 34318595 DOI: 10.1002/jbm.b.34921] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/16/2021] [Accepted: 07/18/2021] [Indexed: 12/11/2022]
Abstract
In orchestrating the wound healing process, the immune system plays a critical role. Hence, controlling the immune system to repair skin defects is an attractive approach. The highly complex immune system includes the coordinated actions of several immune cells, which can produce various inflammatory and antiinflammatory cytokines and affect the healing of skin wounds. This process can be optimized using biomaterials, bioactive molecules, and cell delivery. The present review discusses various immunomodulation strategies for supporting the healing of chronic wounds. In this regard, following the evolution of the immune system and its role in the wound healing mechanism, the interaction between the extracellular mechanism and immune cells for acceleration wound healing will be firstly investigated. Consequently, the immune-based chronic wounds will be briefly examined and the mechanism of progression, and conventional methods of their treatment are evaluated. In the following, various biomaterials-based immunomodulation strategies are introduced to stimulate and control the immune system to treat and regenerate skin defects. Other effective methods of controlling the immune system in wound healing which is the release of bioactive agents (such as antiinflammatory, antigens, and immunomodulators) and stem cell therapy at the site of injury are reviewed.
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Affiliation(s)
- Parisa Heydari
- Department of Materials Engineering, Isfahan University of Technology, Isfahan, Iran
| | - Mahshid Kharaziha
- Department of Materials Engineering, Isfahan University of Technology, Isfahan, Iran
| | - Jaleh Varshosaz
- School of Pharmacy and Pharmaceutical Science, Isfahan University of Medical Science, Isfahan, Iran
| | - Shaghayegh Haghjooy Javanmard
- Applied Physiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
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Food Safety and Cross-Contamination of Gluten-Free Products: A Narrative Review. Nutrients 2021; 13:nu13072244. [PMID: 34210037 PMCID: PMC8308338 DOI: 10.3390/nu13072244] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/23/2021] [Accepted: 06/26/2021] [Indexed: 02/06/2023] Open
Abstract
A gluten-free diet (GFD) is currently the only effective treatment for celiac disease (CD); an individual’s daily intake of gluten should not exceed 10 mg. However, it is difficult to maintain a strict oral diet for life and at least one-third of patients with CD are exposed to gluten, despite their best efforts at dietary modifications. It has been demonstrated that both natural and certified gluten-free foods can be heavily contaminated with gluten well above the commonly accepted threshold of 20 mg/kg. Moreover, meals from food services such as restaurants, workplaces, and schools remain a significant risk for inadvertent gluten exposure. Other possible sources of gluten are non-certified oat products, numerous composite foods, medications, and cosmetics that unexpectedly contain “hidden” vital gluten, a proteinaceous by-product of wheat starch production. A number of immunochemical assays are commercially available worldwide to detect gluten. Each method has specific features, such as format, sample extraction buffers, extraction time and temperature, characteristics of the antibodies, recognition epitope, and the reference material used for calibration. Due to these differences and a lack of official reference material, the results of gluten quantitation may deviate systematically. In conclusion, incorrect gluten quantitation, improper product labeling, and poor consumer awareness, which results in the inadvertent intake of relatively high amounts of gluten, can be factors that compromise the health of patients with CD.
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Čelakovská J, Michaela K, Petra C, Martin N, Eva Č, Josef B, Ctirad A, Miloslav S. Dermatitis herpetiformis Duhring – evaluation of disease severity and tissue transglutaminase levels in 122 patients on dapsone therapy. FOOD AGR IMMUNOL 2021. [DOI: 10.1080/09540105.2021.1918067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Jarmila Čelakovská
- Department of Dermatology and Venereology Faculty Hospital and Medical Faculty of Charles University, Hradec Králové, Czech Republic
| | - Komorousová Michaela
- Department of Dermatology, Faculty Hospital and Medical Faculty of Charles University, Pilsen, Czech Republic
| | - Cetkovská Petra
- Department of Dermatology, Faculty Hospital and Medical Faculty of Charles University, Pilsen, Czech Republic
| | - Novák Martin
- Department of Dermatology, Faculty Hospital and Medical Faculty of Charles University, Pilsen, Czech Republic
| | - Čermáková Eva
- Department of Medical Biophysic, Medical Faculty of Charles University, Hradec Králové, Czech Republic
| | - Bukač Josef
- Department of Medical Biophysic, Medical Faculty of Charles University, Hradec Králové, Czech Republic
| | - Andrýs Ctirad
- Department of Clinical Immunology and Allergy, Faculty Hospital and Medical Faculty of Charles University, Hradec Králové, Czech Republic
| | - Salavec Miloslav
- Department of Dermatology and Venereology Faculty Hospital and Medical Faculty of Charles University, Hradec Králové, Czech Republic
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Caproni M, Capone M, Rossi MC, Santarlasci V, Maggi L, Mazzoni A, Rossettini B, Renzi D, Quintarelli L, Bianchi B, Ninci A, Lami G, Calabrò A, Cosmi L, Annunziato F, Liotta F. T Cell Response Toward Tissue-and Epidermal-Transglutaminases in Coeliac Disease Patients Developing Dermatitis Herpetiformis. Front Immunol 2021; 12:645143. [PMID: 33959126 PMCID: PMC8093623 DOI: 10.3389/fimmu.2021.645143] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/24/2021] [Indexed: 12/19/2022] Open
Abstract
The reason why only few coeliac patients develop the cutaneous manifestation of the disease, named dermatitis herpetiformis (DH), is still unknown. Epidermal transglutaminase (TG3) has been described as the main autoantigen of humoral immunity in DH but the mechanisms leading to this autoimmune response remain obscure. Here we characterized T cells from skin, gut and peripheral blood of DH and coeliac disease (CD) patients, evaluated the impact of the gluten-free diet on circulating T lymphocytes’ phenotype and investigated antigen specific T cell response toward epidermal and tissue transglutaminase (TG2). DH patients showed an increased frequency of skin-derived T cells producing TNFα when compared to CD patients. Moreover, circulating T cells producing TNFα and IL-17A positively correlated with clinical score of skin disease activity and decreased after gluten-free diet. Finally, TG2 and TG3-specific T cells resulted more reactive to antigens stimulation in DH patients and showed cross reactivity toward the two autoantigens in both the group of patients. Our data suggest a role of TNFα and IL-17A producing cells in the development of DH and, for the first time, show the existence of a crossed T cell response toward the two transglutaminases isoforms, thus suggesting new insights on T cells role in skin damage.
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Affiliation(s)
- Marzia Caproni
- Rare Diseases Unit, Section of Dermatology, Department of Health Sciences, USL Toscana Centro, University of Florence, European Reference Network-Skin Member, Florence, Italy
| | - Manuela Capone
- Department of Experimental and Clinical Medicine, School of Human Health Sciences, University of Florence, Florence, Italy
| | - Maria Caterina Rossi
- Department of Experimental and Clinical Medicine, School of Human Health Sciences, University of Florence, Florence, Italy
| | - Veronica Santarlasci
- Department of Experimental and Clinical Medicine, School of Human Health Sciences, University of Florence, Florence, Italy
| | - Laura Maggi
- Department of Experimental and Clinical Medicine, School of Human Health Sciences, University of Florence, Florence, Italy
| | - Alessio Mazzoni
- Department of Experimental and Clinical Medicine, School of Human Health Sciences, University of Florence, Florence, Italy
| | - Beatrice Rossettini
- Department of Experimental and Clinical Medicine, School of Human Health Sciences, University of Florence, Florence, Italy
| | - Daniela Renzi
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Lavinia Quintarelli
- Rare Diseases Unit, Section of Dermatology, Department of Health Sciences, USL Toscana Centro, University of Florence, European Reference Network-Skin Member, Florence, Italy
| | - Beatrice Bianchi
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Alessandra Ninci
- Medical Specialization School of Hygiene and Preventive Medicine, University of Florence, Florence, Italy
| | - Gabriele Lami
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Antonio Calabrò
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Lorenzo Cosmi
- Department of Experimental and Clinical Medicine, School of Human Health Sciences, University of Florence, Florence, Italy
| | - Francesco Annunziato
- Department of Experimental and Clinical Medicine, School of Human Health Sciences, University of Florence, Florence, Italy
| | - Francesco Liotta
- Department of Experimental and Clinical Medicine, School of Human Health Sciences, University of Florence, Florence, Italy
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Reply letter to "An update on direct immunofluorescence for diagnosing dermatitis herpetiformis". Could granular C3 deposits at the dermal epidermal junction be considered a marker of "cutaneous gluten sensitivity"? Postepy Dermatol Alergol 2021; 38:346-348. [PMID: 34408602 PMCID: PMC8362756 DOI: 10.5114/ada.2021.106218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/31/2020] [Indexed: 01/31/2023] Open
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Dukharan V, Thomas RM, Bender NR, Auerbach J, Motaparthi K. Palmar petechiae in a patient with diabetes mellitus. JAAD Case Rep 2021; 11:109-111. [PMID: 33948472 PMCID: PMC8081862 DOI: 10.1016/j.jdcr.2021.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Victoria Dukharan
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida
| | - Renee M Thomas
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida
| | - Nicole R Bender
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida
| | - Jena Auerbach
- Department of Pathology, University of Florida College of Medicine, Gainesville, Florida
| | - Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida
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Montagnon CM, Lehman JS, Murrell DF, Camilleri MJ, Tolkachjov SN. Subepithelial autoimmune bullous dermatoses disease activity assessment and therapy. J Am Acad Dermatol 2021; 85:18-27. [PMID: 33684494 DOI: 10.1016/j.jaad.2020.05.161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/17/2020] [Accepted: 05/21/2020] [Indexed: 12/18/2022]
Abstract
Subepidermal (subepithelial) autoimmune blistering dermatoses are a group of rare skin disorders characterized by the disruption of the dermal-epidermal junction through the action of autoantibodies. The fourth article in this continuing medical education series presents the current validated disease activity scoring systems, serologic parameters, treatments, and clinical trials for bullous pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita, bullous systemic lupus erythematosus, anti-p200 pemphigoid, linear IgA bullous dermatosis, and dermatitis herpetiformis.
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Affiliation(s)
| | - Julia S Lehman
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Dedee F Murrell
- Department of Dermatology, St George Hospital, University of New South Wales, Sydney, Australia
| | - Michael J Camilleri
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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Subepithelial autoimmune blistering dermatoses: Clinical features and diagnosis. J Am Acad Dermatol 2021; 85:1-14. [PMID: 33684496 DOI: 10.1016/j.jaad.2020.11.076] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 01/19/2023]
Abstract
Subepithelial autoimmune blistering dermatoses are a group of rare skin disorders that are characterized by the disruption of the dermal-epidermal junction through the action of autoantibodies. The third article in this continuing medical education series explores the background, epidemiology, clinical features, and diagnostic criteria of each of the major subepithelial autoimmune blistering dermatoses, including bullous pemphigoid, pemphigoid gestationis, lichen planus pemphigoides, mucous membrane pemphigoid, linear IgA bullous dermatosis, and dermatitis herpetiformis.
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Patel PP, Carter LE, Chirila RM. 21-Year-Old Woman With a Painful Rash. Mayo Clin Proc 2021; 96:237-241. [PMID: 33413821 DOI: 10.1016/j.mayocp.2020.05.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/07/2020] [Accepted: 05/11/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Payal P Patel
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Laurel E Carter
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Razvan M Chirila
- Advisor to residents and Consultant in Internal Medicine, Mayo Clinic, Jacksonville, FL.
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Antiga E, Maglie R, Fabbri P. T-Cell Response in Dermatitis Herpetiformis: May Epidermal Transglutaminase Play a Role in Predicting Clinical Relapse? J Invest Dermatol 2020; 141:1585. [PMID: 33307102 DOI: 10.1016/j.jid.2020.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/02/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Emiliano Antiga
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy.
| | - Roberto Maglie
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Paolo Fabbri
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
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38
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Abstract
Haematological malignancies induce important alterations of the immune system, which account for the high frequency of autoimmune complications observed in patients. Cutaneous immune-mediated diseases associated with haematological malignancies encompass a heterogeneous group of dermatoses, including, among others, neutrophilic and eosinophilic dermatoses, autoantibody-mediated skin diseases, vasculitis and granulomatous dermatoses. Some of these diseases, such as paraneoplastic pemphigus, are associated with an increased risk of death; others, such as eosinophilic dermatoses of haematological malignancies, run a benign clinical course but portend a significant negative impairment on a patient’s quality of life. In rare cases, the skin eruption reflects immunological alterations associated with an unfavourable prognosis of the associated haematological disorder. Therapeutic management of immune-mediated skin diseases in patients with haematological malignancies is often challenging. Systemic corticosteroids and immunosuppressive drugs are considered frontline therapies but may considerably augment the risk of serious infections. Indeed, developing a specific targeted therapeutic approach is of crucial importance for this particularly fragile patient population. This review provides an up-to-date overview on the immune-mediated skin diseases most frequently encountered by patients with onco-haematological disorders, discussing new pathogenic advances and therapeutic options on the horizon.
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Quintarelli L, Corrà A, Maglie R, Antiga E, Caproni M. The skin does not lie: a case of dermatitis herpetiformis in the setting of refractory celiac disease. Ital J Dermatol Venerol 2020; 156:267-268. [PMID: 33016667 DOI: 10.23736/s2784-8671.20.06639-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Lavinia Quintarelli
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy -
| | - Alberto Corrà
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Roberto Maglie
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Emiliano Antiga
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Marzia Caproni
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
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40
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Nätynki A, Tuusa J, Hervonen K, Kaukinen K, Lindgren O, Huilaja L, Kokkonen N, Salmi T, Tasanen K. Autoantibodies Against the Immunodominant Bullous Pemphigoid Epitopes Are Rare in Patients With Dermatitis Herpetiformis and Coeliac Disease. Front Immunol 2020; 11:575805. [PMID: 33072118 PMCID: PMC7544946 DOI: 10.3389/fimmu.2020.575805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 08/25/2020] [Indexed: 12/11/2022] Open
Abstract
Dermatitis herpetiformis (DH) is an extraintestinal manifestation of coeliac disease (CD). Patients with DH have an elevated risk of development of another autoimmune blistering skin disease, bullous pemphigoid (BP). In this study we investigated whether patients with DH and CD (mean age for both 49 years) have circulating autoantibodies against BP180, the major BP autoantigen. ELISA tests showed that only a few DH (3/46) and CD (2/43) patients had BP180-NC16A IgG autoantibodies. Immunoblotting found that more than half of the DH samples contained IgG autoantibodies against full-length BP180. Epitope mapping with 13 fusion proteins covering the BP180 polypeptide revealed that in DH and CD patients, IgG autoantibodies did not target the NC16A or other epitopes typical of BP but recognized other intracellular and mid-extracellular regions of BP180. None of the analyzed DH and CD patients with either ELISA or immunoblotting positivity had IgG or IgA reactivity against the cutaneous basement membrane in indirect immunofluorescence analysis or skin symptoms characteristic of BP. Although only a minority of middle-aged DH patients had IgG autoantibodies against the immunodominant epitopes of BP180, our results do not exclude the possibility that intermolecular epitope spreading could explain the switch from DH to BP in elderly patients.
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Affiliation(s)
- Antti Nätynki
- PEDEGO Research Unit, Department of Dermatology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Jussi Tuusa
- PEDEGO Research Unit, Department of Dermatology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Kaisa Hervonen
- Department of Dermatology, Tampere University Hospital, Tampere, Finland
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Katri Kaukinen
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Outi Lindgren
- PEDEGO Research Unit, Department of Dermatology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
- Department of Pathology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Laura Huilaja
- PEDEGO Research Unit, Department of Dermatology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Nina Kokkonen
- PEDEGO Research Unit, Department of Dermatology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Teea Salmi
- Department of Dermatology, Tampere University Hospital, Tampere, Finland
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Kaisa Tasanen
- PEDEGO Research Unit, Department of Dermatology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
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Chermnykh ES, Alpeeva EV, Vorotelyak EA. Transglutaminase 3: The Involvement in Epithelial Differentiation and Cancer. Cells 2020; 9:cells9091996. [PMID: 32872587 PMCID: PMC7563467 DOI: 10.3390/cells9091996] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/21/2020] [Accepted: 08/26/2020] [Indexed: 12/14/2022] Open
Abstract
Transglutaminases (TGMs) contribute to the formation of rigid, insoluble macromolecular complexes, which are essential for the epidermis and hair follicles to perform protective and barrier functions against the environment. During differentiation, epidermal keratinocytes undergo structural alterations being transformed into cornified cells, which constitute a highly tough outermost layer of the epidermis, the stratum corneum. Similar processes occur during the hardening of the hair follicle and the hair shaft, which is provided by the enzymatic cross-linking of the structural proteins and keratin intermediate filaments. TGM3, also known as epidermal TGM, is one of the pivotal enzymes responsible for the formation of protein polymers in the epidermis and the hair follicle. Numerous studies have shown that TGM3 is extensively involved in epidermal and hair follicle physiology and pathology. However, the roles of TGM3, its substrates, and its importance for the integument system are not fully understood. Here, we summarize the main advances that have recently been achieved in TGM3 analyses in skin and hair follicle biology and also in understanding the functional role of TGM3 in human tumor pathology as well as the reliability of its prognostic clinical usage as a cancer diagnosis biomarker. This review also focuses on human and murine hair follicle abnormalities connected with TGM3 mutations.
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Taraghikhah N, Ashtari S, Asri N, Shahbazkhani B, Al-Dulaimi D, Rostami-Nejad M, Rezaei-Tavirani M, Razzaghi MR, Zali MR. An updated overview of spectrum of gluten-related disorders: clinical and diagnostic aspects. BMC Gastroenterol 2020; 20:258. [PMID: 32762724 PMCID: PMC7409416 DOI: 10.1186/s12876-020-01390-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 07/21/2020] [Indexed: 02/06/2023] Open
Abstract
The incidence of gluten-related disorders (GRDs) continues to increase and its global prevalence is estimated at approximately 5% of the population. Celiac disease (CD), dermatitis herpetiformis (DH), gluten ataxia (GA), wheat allergy (WA), and non-celiac gluten sensitivity (NCGS) are the five major GRDs that present with a wide range of clinical manifestations. The diagnosis of GRDs can be challenging because the typical and atypical clinical manifestations of the GRDs overlap. In this review, the current definitions of gluten-related disorders, focusing on their clinical features, diagnostic and therapeutic approaches are presented. We concluded that GRDs are usually diagnosed using a combination of clinical features, serological tests, and histopathological findings. Treatment usually involves dietary modification.
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Affiliation(s)
- Nazanin Taraghikhah
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sara Ashtari
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nastaran Asri
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Bijan Shahbazkhani
- Division of Gastroenterology and Liver Diseases, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - David Al-Dulaimi
- Department of Gastroenterology, South Warwickshire Foundation Trust, Warwickshire, UK
| | - Mohammad Rostami-Nejad
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mostafa Rezaei-Tavirani
- Proteomics Research Center, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Razzaghi
- Laser Application in Medical Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Zali
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Kanazawa N. Designation of Autoinflammatory Skin Manifestations With Specific Genetic Backgrounds. Front Immunol 2020; 11:475. [PMID: 32256502 PMCID: PMC7093487 DOI: 10.3389/fimmu.2020.00475] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/02/2020] [Indexed: 11/20/2022] Open
Abstract
“Autoinflammatory disease (AiD)” has first been introduced in 1999 when the responsible gene for the familial Hibernean fever or autosomal dominant-type familial Mediterranean fever-like periodic fever syndrome was reportedly identified as tumor necrosis factor receptor superfamily 1. Linked with the rapid research progress in the field of innate immunity, “autoinflammation” has been designated for dysregulated innate immunity in contrast to “autoimmunity” with dysregulated acquired immunity. As hereditary periodic fever syndromes represent the prototype of AiD, monogenic systemic diseases are the main members of AiD. However, skin manifestations provide important clinical information and there are even some AiDs originating from skin diseases. Recently, AiD showing psoriasis and related keratinization diseases have specifically been designated as “autoinflammatory keratinization diseases (AiKD)” and CARD14-associated psoriasis and deficiency of interleukin-36 receptor antagonist previously called as generalized pustular psoriasis are included. Similarly, a number of autoinflammatory skin diseases can be proposed; autoinflamatory urticarial dermatosis (AiUD) such as cryopyrin-associated periodic syndrome; autoinflammatory neutrophilic dermatosis (AiND) such as pyogenic sterile arthritis, pyoderma gangrenosm, and acne syndrome; autoinflammatory granulomatosis (AiG) such as Blau syndrome; autoinflammatory chilblain lupus (AiCL) such as Aicardi-Goutieres syndrome; autoinflammatory lipoatrophy (AiL) such as Nakajo-Nishimura syndrome; autoinflammatory angioedema (AiAE) such as hereditary angioedema; and probable autoinflammatory bullous disease (AiBD) such as granular C3 dermatosis. With these designations, skin manifestations in AiD can easily be recognized and, even more importantly, autoinflammatory pathogenesis of common skin diseases are expected to be more comprehensive.
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Affiliation(s)
- Nobuo Kanazawa
- Department of Dermatology, Wakayama Medical University, Wakayama, Japan
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Harrell J, Rubio XB, Nielson C, Hsu S, Motaparthi K. Advances in the diagnosis of autoimmune bullous dermatoses. Clin Dermatol 2019; 37:692-712. [PMID: 31864451 DOI: 10.1016/j.clindermatol.2019.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Autoimmune bullous dermatoses are defined by autoantibodies directed against adhesion proteins in the epidermis or basement membrane zone, resulting in blister formation on the skin and mucosa. Diagnosis depends on lesional biopsy for histopathology and perilesional biopsy for direct immunofluorescence. Additional diagnostic methods include indirect immunofluorescence, enzyme-linked immunosorbent assay, and immunoblot (Western blot), which may be selected in specific clinical scenarios due to improved sensitivity and/or specificity. This contribution reviews the available evidence supporting the use of each method to provide a practical reference for clinicians when diagnosing autoimmune bullous disorders. Techniques and cost are reviewed, and newer diagnostic techniques with potential for clinical application are.
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Affiliation(s)
- Jane Harrell
- University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Colton Nielson
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Sylvia Hsu
- Department of Dermatology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA.
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