Photodynamic Therapy for Benign Cutaneous Neurofibromas Using Aminolevulinic Acid Topical Application and 633 nm Red Light Illumination

Background: Neurofibromatosis type 1 (NF1) has no current effective treatments beyond surgery. Topical photodynamic therapy (PDT) has the potential to provide a less invasive treatment modality.

Objective: Based on murine data, we hypothesized PDT could be used for the treatment of cutaneous neurofibromas (cNF).

Methods and results: We conducted a phase I trial to examine absorption and conversion of topical aminolevulinic acid (ALA) in cNF and determine safety in a dose escalation study. ALA or control vehicle was applied to neurofibromas through microneedle-assisted delivery (n = 4) and excised specimens were examined 24 h later for protoporphyrin IX fluorescence. Fluorescence was detected in the tumors at 304 ± 94 U/μm², while adjacent paralesional normal skin and vehicle-treated tumors showed no fluorescence (p < 0.0001). Subsequently, neurofibromas (n = 27) were treated with ALA and irradiated with 633 nm red light 18 h later, at escalating dosages of 50 and 100 mJ/cm². Maximum tolerable dose was established at 100 mJ/cm². Light microscopy study of tumors biopsied 48 h after PDT (ALA n = 14 and vehicle n = 4) showed mixed inflammatory infiltrate in the ALA, but not in the vehicle-treated tumors or perilesional normal skin. TUNEL evaluation showed 42.5 ± 19.9 apoptotic cells per visual field for ALA-treated and 1.1 ± 1.4 for vehicle-treated tumors (p = 0.002).

Conclusions: In the first reported clinical trial of PDT for NF1, PDT targeted neurofibromas specifically, and may offer a normal tissue-sparing treatment modality in the future.

This study is registered at Clintrials.gov (NCT01682811).

The microRNA landscape of cutaneous squamous cell carcinoma

Cutaneous squamous cell carcinoma (cSCC) is a keratinocyte-derived skin tumor. It is the second-most-common cancer affecting the Caucasian population and is responsible for >20% of all skin-cancer-related deaths. The estimated incidence of non-melanoma skin cancer in the USA is >1000000 cases per year, of which roughly 20-30% are squamous cell carcinoma. To better understand and treat this challenging cancer, current research focuses on development of novel strategies to improve the understanding of tumor biogenesis on an individual basis. microRNAs are becoming important biomarkers in the diagnosis, prognosis and treatment of cSCC. This review describes the current knowledge on miRNA expression in cSCC and its role as a biomarker for personalized medicine.

Building a global teledermatology collaboration

Skin disease is common in low-resource countries and is associated with significant morbidity. The disease burden is often heightened by lack of access to adequate diagnosis and treatment. Teledermatology is a growing healthcare delivery modality that allows access to subspecialty care at a distance. This article describes how a low-cost teledermatology program was launched through collaboration between the Medical College of Wisconsin and Hillside Healthcare International. Several factors are required for a teledermatology program to be successful, beginning with a partnership between two entities that targets a locally identified need and is mutually beneficial to invested partners. The program should utilize the expertise of each partner, be based on an agreed upon process with clearly defined objectives, and protect patient privacy. After a program is implemented, adaptation to address challenges and best meet the needs of all parties involved will allow for continued success and sustainability. This process can serve as a model for other programs desiring to establish similar teledermatology partnerships in an academic setting.

Disseminated Nocardia infection presenting as hemorrhagic pustules and ecthyma in a woman with systemic lupus erythematosus and antiphospholipid antibody syndrome

BACKGROUND

Nocardia is an opportunistic pathogen that can cause disseminated infection in immunocompromised hosts. The most common type of skin lesion reported with disseminated Nocardia is a subcutaneous nodule; however, there are reports with unusual cutaneous presentations. Long term corticosteroid treatment is one of the largest risk factors for developing disseminated Nocardia. Initial treatment is empiric as each strain has unique susceptibilities and it takes weeks to speciate and test sensitivities.

MAIN OBSERVATIONS

A 66-year-old female on long term corticosteroids for systemic lupus erythematosus (SLE) and antiphospholipid syndrome presented with a polymorphous skin eruption and systemic symptoms concerning for infection. Especially concerning were areas of hemorrhagic pustules on the lower legs, and two ecthymatous lesions on the thigh. Tissue culture Gram stain revealed Gram positive branching filamentous rods concerning for Nocardia. The patient improved with empiric treatment.

CONCLUSIONS

This case of Nocardiosis had unusual cutaneous findings that could have misguided the clinician, but the tissue culture and Gram stain proved to be useful for rapid diagnosis and proper treatment.

A novel humanized neonatal autoimmune blistering skin disease model induced by maternally transferred antibodies

All mammal neonates receive maternal Abs for protection against pathogenic organisms in the postnatal environment. However, neonates can experience serious adverse reactions if the Abs transferred from the mother recognize self-molecules as autoAgs. In this study, we describe a novel model for autoimmune disease induced by transferred maternal Abs in genetically transformed Ag-humanized mice progeny. Bullous pemphigoid is the most common life-threatening autoimmune blistering skin disease that affects the elderly, in which circulating IgG autoAbs are directed against epidermal type XVII collagen (COL17). We have established a genetically manipulated experimental mouse model in which maternal Abs against human COL17 are transferred to pups whose skin expresses only human and not mouse COL17, resulting in blistering similar to that seen in patients with bullous pemphigoid. Maternal transfer of pathogenic Abs to humanized neonatal mice is a unique and potential experimental system to establish a novel autoimmune disease model.

Cytokines and Langerhans cells in allergic contact dermatitis

Contact hypersensitivity (CHS) is a dendritic cell (DC)-dependent T-cell mediated cutaneous inflammatory reaction elicited by epicutaneous exposure to reactive chemicals, known as haptens, from cosmetic products or through environmental and occupational exposures. The best-studied haptens are low molecular weight chemicals (<1,000) that bind discrete amino acid residues on self or exogenous proteins/peptides in the skin and become immunogenic. Clinically, CHS typically occurs as a delayed type of allergic contact dermatitis. Haptens penetrate the skin and bind to self proteins to form complete antigens which are taken by antigen presenting cells to start a cascade of actions resulting in a delayed hypersensitivity reaction. Larger molecules such as proteins induce response involving the humoral immune system. The environment at the time of antigen presentation affects the innate immune system which in turn influences the expression of CHS. The subsequent immunologic response (or lack thereof) is a result of complex interaction between both the innate and the adaptive immune systems. This interaction results in either an inflammatory immune response or tolerance.

Humanization of autoantigen

Transmissibility of characteristic lesions to experimental animals may help us understand the pathomechanism of human autoimmune disease. Here we show that human autoimmune disease can be reproduced using genetically engineered model mice. Bullous pemphigoid (BP) is the most common serious autoimmune blistering skin disease, with a considerable body of indirect evidence indicating that the underlying autoantigen is collagen XVII (COL17). Passive transfer of human BP autoantibodies into mice does not induce skin lesions, probably because of differences between humans and mice in the amino acid sequence of the COL17 pathogenic epitope. We injected human BP autoantibody into Col17-knockout mice rescued by the human ortholog. This resulted in BP-like skin lesions and a human disease phenotype. Humanization of autoantigens is a new approach to the study of human autoimmune diseases.

CD200 is a novel p53-target gene involved in apoptosis-associated immune tolerance

During apoptotic cell death, biochemical processes modify self-proteins and create potential autoantigens. To maintain self-tolerance in the face of natural cell turnover, the immune system must prevent or control responses to apoptosis-associated autoantigens or risk autoimmunity. The molecular mechanisms governing this process remain largely unknown. Here, we show that expression of the immunoregulatory protein CD200 increases as murine dendritic cells (DCs) undergo apoptosis. We define CD200 as a p53-target gene and identify both p53- and caspase-dependent pathways that control CD200 expression during apoptosis. CD200 expression on apoptotic DCs diminishes proinflammatory cytokine production in response to self-antigens in vitro and is required for UVB-mediated tolerance to haptenated self-proteins in vivo. Up-regulation of CD200 may represent a novel mechanism, whereby immune reactivity to apoptosis-associated self-antigens is suppressed under steady state conditions.

A migratory population of skin-derived dendritic cells expresses CXCR5, responds to B lymphocyte chemoattractant in vitro, and co-localizes to B cell zones in lymph nodes in vivo

Chemokine receptors on dendritic cells (DC) and chemokines within lymph nodes (LN) contribute to trafficking of DC to appropriate sites within the LN. Here we show that DC that have migrated out of skin ex vivo (migratory DC, migDC) express 50-fold more CXCR5 mRNA than fresh Langerhans cells and migrate in response to B lymphocyte chemoattractant (BLC) in vitro. When injected into the footpad of mice, migDC emigrate to regional LN where up to 40% are found in B cell zones. By contrast, murine bone marrow-derived DC display 14-fold less CXCR5, do not migrate to BLC in vitro, and migrate strictly to T cell zones in LN. We propose that activated skin DC utilize CXCR5 and BLC as a possible mechanism to home to B cell zones of LN, where they may have direct effects on B cells.

Demonstration and functional analysis of IL-10 receptors in human epidermal cells: decreased expression in psoriatic skin, down-modulation by IL-8, and up-regulation by an antipsoriatic glucocorticosteroid in normal cultured keratinocytes

The chronic skin disease psoriasis is characterized by epidermal hyperproliferation and inflammation. The exact etiology of the disease is still unknown. At the molecular level, overexpression of growth factors and proinflammatory cytokines such as IL-8 and the corresponding receptor has been described in psoriatic plaques. On the other hand, the loss of inhibitory control mechanisms is involved in the pathogenesis of the disease, as exemplified by the reduced mRNA levels for the cell cycle inhibitor p53 found in lesional skin. Here we extend these findings to a cytokine with negative regulatory functions, IL-10. Only under certain conditions are human keratinocytes able to synthesize IL-10. In skin, pathological overexpression of IL-10 was described om atopic dermatitis. IL-10 exerts its effects via a specific receptor (IL-10R). We show here for the first time the presence and functionality of IL-10R in epidermal cells and its dramatically decreased expression in acute exanthematic psoriatic epidermis by in vitro and in situ binding studies. These results were substantiated using semiquantitative reverse transcriptase-PCR, demonstrating decreased expression of the IL-10R gene in psoriatic skin, its down-modulation by the proinflammatory cytokine IL-8, and its pharmacological induction in cultured cells. Biological responsiveness of epidermal cells toward IL-10 could also be demonstrated by a reduction of the growth rate and inhibition of IFN-gamma-induced HLA-DR expression. Our results provide the first evidence for a role of the IL-10R gene in the homeostasis of the epidermis and substantiate the concept of a loss of negative regulatory peptides as a step in the eruption of psoriasis.

Demonstration and functional analysis of IL-10 receptors in human epidermal cells: decreased expression in psoriatic skin, down-modulation by IL-8, and up-regulation by an antipsoriatic glucocorticosteroid in normal cultured keratinocytes

The chronic skin disease psoriasis is characterized by epidermal hyperproliferation and inflammation. The exact etiology of the disease is still unknown. At the molecular level, overexpression of growth factors and proinflammatory cytokines such as IL-8 and the corresponding receptor has been described in psoriatic plaques. On the other hand, the loss of inhibitory control mechanisms is involved in the pathogenesis of the disease, as exemplified by the reduced mRNA levels for the cell cycle inhibitor p53 found in lesional skin. Here we extend these findings to a cytokine with negative regulatory functions, IL-10. Only under certain conditions are human keratinocytes able to synthesize IL-10. In skin, pathological overexpression of IL-10 was described om atopic dermatitis. IL-10 exerts its effects via a specific receptor (IL-10R). We show here for the first time the presence and functionality of IL-10R in epidermal cells and its dramatically decreased expression in acute exanthematic psoriatic epidermis by in vitro and in situ binding studies. These results were substantiated using semiquantitative reverse transcriptase-PCR, demonstrating decreased expression of the IL-10R gene in psoriatic skin, its down-modulation by the proinflammatory cytokine IL-8, and its pharmacological induction in cultured cells. Biological responsiveness of epidermal cells toward IL-10 could also be demonstrated by a reduction of the growth rate and inhibition of IFN-gamma-induced HLA-DR expression. Our results provide the first evidence for a role of the IL-10R gene in the homeostasis of the epidermis and substantiate the concept of a loss of negative regulatory peptides as a step in the eruption of psoriasis.

The interleukin-8 receptor: a potential target for antipsoriatic therapy?

Interleukin-8 is assumed to play a central role in the pathogenesis of psoriasis. Since an increased expression of the interleukin-8 receptor has been observed both in polymorphonuclear leukocytes and in affected psoriatic epidermis, we were interested in whether the interleukin-8 receptor could be a molecular target of antipsoriatic compounds. Cyclosporine, calcitriol, calcipotriol or dithranol caused a dose-dependent decrease in interleukin-8 binding to cultured human keratinocytes, while interleukin-8 binding to granulocytes was not affected. In addition, the interleukin-8-induced human leukocyte antigen-DR (HLA-DR) expression of keratinocytes was nearly completely blocked by treatment of the cells with these substances. The inhibition of the keratinocyte interleukin-8 receptor and its function by antipsoriatic drugs may contribute to their therapeutic action.