The first trial of CIM331, a humanized antihuman interleukin-31 receptor A antibody, in healthy volunteers and patients with atopic dermatitis to evaluate safety, tolerability and pharmacokinetics of a single dose in a randomized, double-blind, placebo-controlled study

BACKGROUND

The cytokine interleukin-31 (IL-31) is considered to be responsible for the development of pruritus in humans. At present, no available evidence has been provided on the safety and efficacy of blocking the IL-31 signal in humans for the amelioration of pruritus in atopic dermatitis (AD). CIM331 is a humanized antihuman IL-31 receptor A (IL-31RA) monoclonal antibody, which binds to IL-31RA to inhibit subsequent IL-31 signalling.

OBJECTIVES

To assess the tolerability, safety, pharmacokinetics and preliminary efficacy of CIM331 in healthy Japanese and white volunteers, and Japanese patients with AD.

METHODS

In this randomized, double-blind, placebo-controlled phase I/Ib study, CIM331 was administered in a single subcutaneous dose. The primary outcomes were safety and tolerability; the exploratory analysis was efficacy.

RESULTS

No deaths, serious adverse events (AEs) or discontinuations due to AEs were reported in any part of the study. No dose-dependent increase in the incidence of AEs occurred in any part of the study. In healthy volunteers, all AEs occurred once in the placebo groups, and increased creatine phosphokinase was more common in the CIM331 groups. In patients with AD, CIM331 reduced pruritus visual analogue scale score to about -50% at week 4 with CIM331 compared with -20% with placebo. CIM331 increased sleep efficiency and decreased the use of hydrocortisone butyrate.

CONCLUSIONS

A single subcutaneous administration of CIM331 was well tolerated in healthy volunteers and patients with AD. It decreased pruritus, sleep disturbance and topical use of hydrocortisone. CIM331 may become a novel therapeutic option for AD by inhibiting IL-31.

Low-dose prednisolone ameliorates acute renal failure caused by cholesterol crystal embolism

AIMS

The prognosis of renal cholesterol crystal embolism (CCE) is poor. Although various treatments for CCE have been attempted, there is no optimal therapy. We tested the effect of low-dose prednisolone (PS) on CCE-related acute renal failure (ARF).

PATIENTS AND METHODS

7 patients (mean age 69 years) diagnosed with CCE-related ARF were treated with oral PS at 15-20 mg/day for 2-4 weeks, which was then tapered at 5 mg/day over 2-4 weeks, followed by 5 mg/day maintenance dose. Recurrent ARF during PS tapering was treated with a larger dose of PS.

RESULTS

Inciting factors were identified in four patients: coronary angiography (n=3) and cerebral angiography (n=1). On admission, serum creatinine (SCr) was 2.1 +/- 0.3 mg/dl (mean +/- SEM). SCr and eosinophil count before treatment were 4.2 +/- 0.4 mg/dl and 682 +/- 73/microl, respectively. PS therapy improved ARF in all cases at week 2 (SCr 3.8 +/- 0.5 mg/dl) parallel to a decrease in eosinophilia (116 +/- 30/microl), and at week 4 (3.1 +/- 0.4 mg/dl and 134 +/- 20/microl, respectively). At last follow-up, renal function was improved or maintained in 5 patients compared with that at week 4 post-treatment. One patient died of lung cancer. Another required LDL apheresis and hemodialysis but died due to CCE-related multi-organ failure. A third patient had recurrent ARF and was re-treated with a larger dose of PS, which resulted in an immediate decrease in SCr. However, the patient developed acute renal dysfunction due to congestive heart failure, and required hemodialysis.

CONCLUSIONS

Low-dose PS improved CCE-related ARF, probably through amelioration of inflammatory reaction surrounding affected renal vessels.

Multiple palisading granulomas in the scalp of an infant: a case report

BACKGROUND

We describe an unusual lesion that represents an uncommon but important element in the differential diagnosis of subcutaneous scalp nodules in a child.

CASE DESCRIPTION

A 1-year-old boy presented with two clusters of subcutaneous scalp nodules. The lesions increased in size and number. Computed tomography showed no changes in underlying bone. Findings on magnetic resonance imaging were nonspecific. Serologic and clinical evaluation showed no evidence of rheumatic disease. Complete excision of the nodules, together with adjacent fascia and galea, was performed. Histopathologic examination showed the lesions to be palisading granulomas; given the absence of rheumatic disease, these represented deep granuloma annulare, a benign condition. No recurrence has been observed in our patient.

CONCLUSION

While we chose total excision because of preoperative concerns about a possible malignant tumor, some other authors have suggested that surgery be limited to confirmatory biopsy when a benign lesion such as palisading granuloma is strongly suspected.

Analytical method to examine the effects of carbon dioxide lasers on skin: a study using wrinkles induced in hairless mice

BACKGROUND AND OBJECTIVE

Investigation of the wrinkle smoothing process elicited by CO(2) laser treatment is important for understanding the mechanism involved in their repair.

STUDY DESIGN/MATERIALS AND METHODS

Hairless mice with wrinkles induced in their dorsal skin by long-term exposure to ultraviolet radiation in the wavelength range of 290-320 nm were treated with a CO(2) laser. By using this model, we investigated the external appearance, histologic changes, and the mechanical properties of the skin during the wrinkle repair.

RESULTS

Laser treatment with an appropriate intensity caused wrinkles to smooth completely. In the healing process, reepithelialization and collagen tissue regeneration in the upper dermis was observed. However, marked changes in the skin were noted, such as increases in the collagen layer and in the skin thickness, and changes in the mechanical properties of the skin, despite the favorable external appearance.

CONCLUSIONS

An abnormal state characterized by excessive collagen regeneration and other changes in the dermis occur concomitantly with wrinkle smoothing.

New formulation of chemical peeling agent: histological evaluation in sun-damaged skin model in hairless mice

BACKGROUND

chemical peelings injure the superficial skin, which is then restored by healing of the wound.

OBJECTIVES

to document the acute and chronic histological changes produced by applying chemical peeling agents used clinically to the UVB-irradiated skin of hairless mice, which served as a model of sun-damaged skin.

DESIGN

three chemical peeling agents, 30% salicylic acid, dissolved in macrogol (a new formulation), 35% trichloroacetic acid (TCA) dissolved in distilled water and 20% glycolic acid dissolved in glycerin were applied to the backs of UVB-irradiated hairless mice. Untreated, irradiated areas of skin served as controls. Specimens were evaluated histologically at 3, 14, 28, and 70 days.

RESULTS

chronic UVB irradiation produced an irregular hypertrophy of the epidermis. The treated areas of irradiated skin recovered by day 70. At 28 days, all skin specimens treated with chemical peeling agents exhibited a unique connective tissue layer composed of fine collagen fibers beneath the epidermis. While 35% TCA produced severe tissue damage marked by inflammation up to day 14, no inflammatory infiltrates were seen with 30% salicylic acid in macrogol at 70 days.

CONCLUSIONS

chemical peeling with 30% salicylic acid dissolved in macrogol led to reorganization of the epidermis and a rebuilding of the superficial dermal connective tissue important in reducing wrinkles, and without evidence of inflammatory infiltrates in an animal model of sun-damaged skin. Findings suggest a possible clinical benefit.

Carbon dioxide laser treatment promotes repair of the three-dimensional network of elastic fibres in rat skin

BACKGROUND

We have previously reported that ultraviolet (UV) B irradiation induces a loss of linearity in the three-dimensional structure of dermal elastic fibres, which results in the reduction of elastic properties of the skin and leads to wrinkle formation. We further reported that repair of wrinkles by all-trans retinoic acid is accompanied by recovery of the linearity of elastic fibres. Carbon dioxide (CO2) lasers are widely used for treating wrinkles in cosmetic surgery.

OBJECTIVES

To perform CO2 laser treatment of wrinkles induced in rat skin by UVB irradiation and to evaluate changes in the three-dimensional structure of dermal elastic fibres during wrinkle repair.

METHODS

Wrinkles were induced in the hind limb skin of Sprague-Dawley rats by UVB irradiation (130 mJ cm-2 three times weekly for 6 weeks), followed by CO2 laser treatment (11.3 J cm-2). The surface appearance of the skin was evaluated by replica observation 6 and 10 weeks after CO2 laser treatment followed by measurement of mechanical properties using a Cutometer. Subsequently, perfusion fixation and digestion with formic acid were performed and elastic fibres were observed by scanning electron microscopy (SEM). Image analysis of SEM micrographs was carried out to evaluate the linearity in the three-dimensional structure of elastic fibres.

RESULTS

Six weeks after CO2 laser treatment, all parameters of skin mechanical properties in the UVB-irradiated group recovered to levels of the control non-irradiated group, accompanied by repair of wrinkles and a significant increase in linearity of the three-dimensional structure of elastic fibres.

CONCLUSIONS

These findings indicate that CO2 laser treatment has a therapeutic potential to repair wrinkles to non-irradiated levels through recovery of the three-dimensional structure of elastic fibres.

Malignant melanoma cells in the eccrine apparatus

A case of malignant melanoma arising on the sole of a 75-year-old Japanese man is presented. Histopathologically, in addition to the intraepidermal and intradermal malignant melanoma cells reaching the upper part of the dermis, cells were also found in the deep part of the ductal epithelium of the eccrine apparatus. Melanoma cells, and melanocytic nevus cells as well, are rarely found within the epithelial structure of sweat glands, yet they are frequently found in that of hair follicles. In order to avoid a residue of melanoma cells in the deep part of the eccrine apparatus, a fairly deep excision should be performed even for this melanoma.

Histologic changes in the skin of hairless mice following peeling with salicylic acid

OBJECTIVE

To clarify the histologic alterations produced by the application of salicylic acid solution, which has been used effectively in chemical peeling without producing a wound or inflammation.

DESIGN

We applied 7.5%, 15.0%, and 30.0% salicylic acid in solutions of ethanol or macrogol to the backs of hairless mice for 20 minutes. The skin was histologically evaluated immediately and at 1, 3, 12, 24, and 48 hours following treatment.

SETTING

The Department of Dermatology, Faculty of Medicine, Kyushu University, Fukuoka, Japan.

MAIN OUTCOME MEASURES

A loss of cornified cells was the only morphologic alteration associated with the treatment, and was followed by the activation of the epidermal basal cells and the underlying fibroblasts.

RESULTS

The 7.5% and 15. 0% salicylic acid solutions produced few histologic changes, whereas the 30.0% salicylic acid in both vehicles macerated and then exfoliated the cornified cells. As the epidermis became thinner, the residual epidermal cells became flattened and were rearranged parallel to the tensile surface load. The cornified material within the hair follicles also became macerated, dilated the follicles, and then dropped off. An apparent increase occurred in the number of cells in the S phase in the epidermal basal cells in 24 hours, leaving the follicular cells unchanged. As the cornified layer thickened in 48 hours, the epidermal cells below it and the underlying fibroblasts resumed their random pretherapy arrangement. Except for the occasional infiltrate of lymphocytes, no degenerative or inflammatory changes occurred. While similar changes occurred with each vehicle, they were relatively faster with the ethanol preparations.

CONCLUSION

The present results suggest that the architecture of the epidermis and the papillary dermis can be regenerated by simply injuring the cornified layer by using topical agents such as salicylic acid that do not cause degeneration or inflammation.

Response of naevus of Ota to Q-switched ruby laser treatment according to lesion colour

Lesions of naevus of Ota range in colour from light brown to blue, and even greenish-black. To develop guidelines for optimal treatment, we evaluated the number of Q-switched ruby laser treatments required to eliminate the pigmentation of such lesions classified by colour. Over a period of 6 years, we evaluated 151 Japanese patients with naevus of Ota who had been treated with the Q-switched ruby laser at a low energy level (wavelength 694.3 nm; pulse duration 28 x 10-9 s; energy fluence 5 J/cm2; spot size 6.5 mm) every 2 months. Each lesion was classified by colour as brown (n = 22), brown-violet (n = 42), violet-blue (n = 81) and blue-green (n = 6). The 22 predominantly brown lesions attained an excellent (100-95%) or good (95-75%) cosmetic result following three laser treatments in all patients who received this number of treatments. In the 42 brown-violet lesions, 25 of the 29 good or excellent results were achieved after four treatments; the 13 less successful results were in patients who had one to three treatments. In the 81 violet-blue lesions, 54 of the 65 good or excellent results were achieved after four treatments and 64 of 65 after five treatments, whereas all 16 less good results were in patients who had only one to three treatments. However, in the six blue-green lesions, six or more treatments were required to achieve a similarly favourable result. At the end of treatment, the area was virtually free of scarring, and its texture resembled that of the surrounding normal skin. We have confirmed that the use of the Q-switched ruby laser at a low energy level can eliminate the pigmentation of naevus of Ota. While the desired improvement can be obtained within 1 year, the number of treatments appears to depend on the predominant colour of the lesion.

Molecular cloning, sequencing, and expression of the gene encoding alkaline ceramidase from Pseudomonas aeruginosa. Cloning of a ceramidase homologue from Mycobacterium tuberculosis

We previously reported the purification and characterization of a novel type of alkaline ceramidase from Pseudomonas aeruginosa strain AN17 (Okino, N., Tani, M., Imayama, S., and Ito, M. (1998) J. Biol. Chem. 273, 14368-14373). Here, we report the molecular cloning, sequencing, and expression of the gene encoding the ceramidase of this strain. Specific oligonucleotide primers were synthesized using the peptide sequences of the purified ceramidase obtained by digestion with lysylendopeptidase and used for polymerase chain reaction. DNA fragments thus amplified were used as probes to clone the gene encoding the ceramidase from a genomic library of strain AN17. The open reading frame of 2,010 nucleotides encoded a polypeptide of 670 amino acids including a signal sequence of 24 residues, 64 residues of which matched the amino acid sequence determined for the purified enzyme. The molecular weight of the mature enzyme was estimated to be 70,767 from the deduced amino acid sequence. Expression of the ceramidase gene in Escherichia coli, resulted in production of a soluble enzyme with the identical N-terminal amino acid sequence. Recombinant ceramidase was purified to homogeneity from the lysate of E. coli cells and confirmed to be identical to the Pseudomonas enzyme in its specificity and other enzymatic properties. No significant sequence similarities were found in other known functional proteins including human acid ceramidase. However, we found a sequence homologous to the ceramidase in hypothetical proteins encoded in Mycobacterium tuberculosis, Dictyostelium discoideum, and Arabidopsis thaliana. The homologue of the ceramidase gene was thus cloned from an M. tuberculosis cosmid and expressed in E. coli, and the gene was demonstrated to encode an alkaline ceramidase. This is the first report for the cloning of an alkaline ceramidase.

Long- and short-term histological observations of congenital nevi treated with the normal-mode ruby laser

OBJECTIVE

To evaluate histologically the long- and short-term changes associated with cosmetic improvement or failure of normal-mode ruby laser treatment of patients with congenital nevi.

DESIGN

A biopsy of the laser-treated lesions of 10 patients with good or poor cosmetic results was performed at periods up to 8 years 10 months after treatment (mean, 4 years 9 months). Short-term findings were evaluated in 3 patients.

SETTING

Ueda Setsuko Clinic and the Dermatology Unit of the Kyushu University, Fukuoka, Japan.

PATIENTS

Of the 85 Japanese patients with relatively large congenital nevi who had been treated with the normal-mode ruby laser since 1990, 13 gave informed consent for biopsy and histological examination of the treated area.

RESULTS

A long-term follow-up study of the 8 patients with good cosmetic results showed the presence of residual nevus cells 1.11 +/- 0.35 mm (mean +/- SD) (range, 0.63-2.05 mm) below the skin surface. Above these cells was a layer of connective tissue that formed a subtle microscopic scar that preserved the normal structure of the papillary dermis. Hair follicles were damaged at the base, and the hairs were attenuated. However, in the 2 patients with poor cosmetic results, nests of pigmented cells were commonly seen in the epidermis, and melanin was relatively abundant in basal keratinocytes. No malignant changes were observed in any patient. A short-term study in 3 patients showed damage to pigmented cells in the epidermis and upper dermis as observed following electrodesiccation.

CONCLUSIONS

Multiple treatments with the normal-mode ruby laser produced immediate thermal damage to the superficial nests of nevus cells and a subsequent remodeling of the superficial connective tissue. When the thickness of the subtle microscopic scar reached 1 mm, it masked the underlying residual nevus cells and achieved a good cosmetic result. Follow-up for at least 8 years after laser treatment showed no evidence of malignant change in the treated areas.

All-trans retinoic acid promotes the repair of tortuosity of elastic fibres in rat skin

To elucidate the repair effects of all-trans retinoic acid (t-RA) on ultraviolet (UV)-induced tortuosity of elastic fibres in rat skin, the hind limbs of Sprague-Dawley rats were irradiated at a suberythemal dose of UV (three times/week for 6 weeks) and 0.025% t-RA in ethanol was applied topically five times/week for 6 weeks. The three-dimensional arrangement of elastic fibres with special reference to their linearity was quantified by image analysis using a scanning electron microscope following a combination of intravascular resin injection and selective digestion using formic acid. When t-RA was topically applied for 6 weeks on wrinkles formed by 6 weeks' exposure of the skin of rat hind limbs to UV radiation, the wrinkles disappeared to control levels, concomitant with an improvement in skin elasticity. The linearity of the elastic fibres was significantly (P < 0.01) increased compared with age-matched UV-irradiated controls. These findings suggest that the degeneration and deposition of elastic fibres accompanied by an increase in their linearity is involved in the process of wrinkle repair by topical application of t-RA.

Reduced amount of secretory component of IgA secretion in tears of patients with atopic dermatitis

Coupled with the previous finding that sIgA excretion was reduced onto the surface of the skin, we demonstrated that sIgA secretion in the tears of patients with atopic dermatitis (AD) was significantly lower than that of normal subjects, using a small stick made of nitrocellulose membrane. In the bacterial cultures, we have also detected a higher frequency of Staphylococcus aureus in the tears from patients with AD compared to normal subjects. These findings suggested reduced sIgA secretion on the mucous membrane might play a crucial role in the pathomechanisms of the ocular lesions, such as abnormal bacterial flora and ocular complications as well as the establishment of skin lesions in AD.

Ceramidase activity in bacterial skin flora as a possible cause of ceramide deficiency in atopic dermatitis

A marked decrease in the content of ceramide has been reported in the horny layer of the epidermis in atopic dermatitis (AD). This decrease impairs the permeability barrier of the epidermis, resulting in the characteristic dry and easily antigen-permeable skin of AD, since ceramide serves as the major water-holding molecule in the extracellular space of the horny layer. On the other hand, the skin of such patients is frequently colonized by bacteria, most typically by Staphylococcus aureus, possessing genes such as those for sphingomyelinase, which are related to sphingolipid metabolism. We therefore tried to identify a possible correlation between the ceramide content and the bacterial flora obtained from the skin of 25 patients with AD versus that of 24 healthy subjects, using a thin-layer chromatographic assay of the sphingomyelin-associated enzyme activities secreted from the bacteria. The findings of the assay demonstrated that ceramidase, which breaks ceramide down into sphingosine and fatty acid, was secreted significantly more from the bacterial flora obtained from both the lesional and the nonlesional skin of patients with AD than from the skin of healthy subjects; sphingomyelinase, which breaks sphingomyelin down into ceramide and phosphorylcholine, was secreted from the bacterial flora obtained from all types of skin at similar levels for the patients with AD and the healthy controls. The finding that the skin of patients with AD is colonized by ceramidase-secreting bacteria thus suggests that microorganisms are related to the deficiency of ceramide in the horny layer of the epidermis, which increases the hypersensitivity of skin in AD patients by impairing the permeability barrier.

Clinical, immunological and MRI features of myelitis with atopic dermatitis (atopic myelitis)

In order to clarify the characteristic features of myelitis with atopic dermatitis (AD), we compared the clinical, immunological and MRI findings between 14 myelitic patients with AD and 12 myelitic patients without AD. The myelitic patients with AD showed the following distinct features, compared with those without AD. (1) A preferential involvement of the cervical cord, as shown by neurologic as well as MRI examinations (14/14 vs. 5/12; P=0.0012), (2) paresthesia/dysesthesia as the predominant symptoms and a rare occurrence of definite muscle weakness (0/14 vs. 5/12; P=0.0120) and dysuria (1/14 vs. 8/12; P=0.0029), (3) a lower Expanded Disability Status Scale score (mean, 1.5 vs. 3.5; P=0.0018), (4) normal cerebrospinal fluid (CSF) findings including those for the IgG index and oligoclonal IgG bands and (5) a persistence of neurologic symptoms and MRI lesions during the follow-up periods (mean, 17 months). In addition, both the serum total IgE level and the frequency of specific IgE to Dermatophagoides farinae were significantly higher in the myelitic patients with AD (median IgE=1266 U/ml, specific IgE 14/14) than in those without AD (145 U/ml, P=0.0034 and 8/12, P=0.0331, respectively) and in 40 healthy controls (86 U/ml, P<0.0001 and 12/40, P<0.0001, respectively). Since myelitis with AD has distinct features and atopy to mite antigens appears to be the underlying cause of this condition, it may therefore be a distinct subtype of myelitis.

On rugged shape of skin tumor (basal cell carcinoma)

Basal cell carcinoma (BCC) is the most common cancer of the skin that is made of transformed basal cells of the human epidermis, and spreads along the epidermis--dermis junction. It often forms tumor cell mass that protrudes towards the dermal connective tissue with many branches. Histopathological examination of the cancer demonstrates the cell mass of a rugged shape appearing as many regular spaced islands in a two-dimensional section. We study the process of cell proliferation and spatial pattern formation of the skin tumor by a pair of partial differential equations of tumor cells and nutrients. The assumptions are: (1) proliferation rate of tumor cells depends on the availability of nutrients, which simply diffuse out of capillaries through connective tissue; (2) nutrients are consumed by active tumor cells; (3) cell diffusion coefficient expressing tumor cell movements increase with the cell density and the nutrient availability. Starting from the initial condition with a single layer of tumor cells. the model develops a smooth colony if n'0 is large, but a characteristic rugged spatial pattern of tumor cell mass if n'0 is small, in which n'0 is nutrient concentration multiplied by square root of growth efficiency divided by diffusion coefficient of nutrients. The proportion of the area occupied by tumor cells increases with n'0. The coefficient of variation in the width of "islands" of tumor cell mass is rather small (0.2 reverse similar0.6), implying the regularity of the spatial pattern. We also analyses the photographs of a two-dimensional section of tumor cell mass and compare the spatial patterns generated by the model.

Purification and characterization of a novel ceramidase from Pseudomonas aeruginosa

We report here a novel type of ceramidase of Pseudomonas aeruginosa AN17 isolated from the skin of a patient with atopic dermatitis. The enzyme was purified 83,400-fold with an overall yield of 21.1% from a culture supernatant of strain AN17. After being stained with a silver staining solution, the purified enzyme showed a single protein band, and its molecular mass was estimated to be 70 kDa on SDS-polyacrylamide gel electrophoresis. The enzyme showed quite wide specificity for various ceramides, i.e. it hydrolyzed ceramides containing C12:0-C18:0 fatty acids and 7-nitrobenz-2-oxa-1, 3-diazole-labeled dodecanoic acid, and not only ceramide containing sphingosine (d18:1) or sphinganine (d18:0) but also phytosphingosine (t18:0) as the long-chain base. However, the enzyme did not hydrolyze galactosylceramide, sulfatide, GM1, or sphingomyelin, and thus was clearly distinguished from a Pseudomonas sphingolipid ceramide N-deacylase (Ito, M., Kurita, T., and Kita, K. (1995) J. Biol. Chem. 270, 24370-24374). This bacterial ceramidase had a pH optimum of 8.0-9.0, an apparent Km of 139 microM, and a Vmax of 5.3 micromol/min/mg using N-palmitoylsphingosine as the substrate. The enzyme appears to require Ca2+ for expression of the activity. Interestingly, the 70-kDa protein catalyzed a reversible reaction in which the N-acyl linkage of ceramide was either cleaved or synthesized. Our study demonstrated that ceramidase is widely distributed from bacteria to mammals.

The proliferative properties of tumor cells differentially correlate with the host immune responses in anogenital Bowen's disease

Bowen's disease is a squamous cell carcinoma in situ that rarely invades into the underlying dermis. In order to evaluate the relationship between the cytological properties of the tumor cells and the host immune response, we have examined the expression of p53 and proliferating cell nuclear antigen (PCNA), and the number of mitotic cells, clumping cells, koilocytes, Langerhans cells (LCs) and dermal lymphoid cell infiltration in 18 cases of anogenital Bowen's disease. When compared with normal anogenital skins (n = 10), a statistically significant number of p53-positive cells, PCNA-positive cells, mitotic cells, clumping cells, koilocytes and dermal lymphoid cells was observed in the cases of Bowen's disease. Importantly, there existed a very strong correlation between the number of PCNA-positive tumor cells and the number of infiltrated dermal lymphoid cells. Moreover, the number of mitotic cells significantly correlated with the number of intratumoral LCs. The in situ hybridization technique for human papilloma virus (HPV) demonstrated that the HPV-infected Bowen's disease showed a similar histological and immunohistological pattern as the HPV-non-infected counterparts, except for increased koilocyte formation and decreased p53 positivity. The present data suggest that the proliferative activity of Bowen's disease significantly correlates with the host immune reaction, and that the host immune system may differentially recognize the different cytological properties of tumor cells in the Bowen's disease.

Intradermal administration of viral vaccines

Intradermal administration maybe useful in lowering the cost of vaccination against hepatitis B significantly, and may also be helpful for the rapid induction of antibodies, reversing non-responsiveness, improving postexposure prophylaxis and immunising immunocompromised people. In addition, delayed type hypersensitivity skin reaction to the vaccine could serve as a useful marker for the acquisition of T helper type 1 immunoreactivity in vivo. However, there are some disadvantages when using intradermal vaccinations, including the requirement for skilful administration, the absence of approval from licensing authorities, the development of local skin reactions and a lower antibody response when 1/10 of the standard vaccine dose is used. This requires that appropriate vaccination regimens, including the correct vaccine dosage, and vaccination schedule are followed. In the future, a similar vaccination strategy might also be applied for the prevention and control of other infectious diseases. Copyright 1998 John Wiley & Sons, Ltd.

A case of episodic angioedema associated with blood eosinophilia: upregulated C5a receptor expression on eosinophils

A 47-year-old woman was admitted to hospital complaining of swelling and pain of the extremities, accompanied by high fever and generalized erythema. Laboratory examination showed marked blood eosinophilia with elevation of IgM, IgE, and C-reactive protein. All autoantibodies examined were negative. The heart and lungs showed no untoward findings. Biopsies of the skin and muscle revealed cellular infiltration of eosinophils around small blood vessels. Quantitation of C5a receptor (C5aR) expression by flow cytometry using anti-C5aR antibody showed upregulated expression of C5aR on blood eosinophils but downregulated expression on neutrophils. The abnormal C5aR expression on eosinophils and neutrophils became normal after spontaneous resolution of symptoms and blood eosinophilia. The possibility that C5aR expression on granulocytes is related to the pathogenesis of this syndrome may be considered.

Sulfidoleukotriene release test (CAST) in hypersensitivity to nonsteroidal anti-inflammatory drugs

There is a great need to develop a method for making an accurate and reliable in vitro diagnosis of adverse hypersensitivity reactions to drugs. We measured the amount of sulfidoleukotriene (sLT) released from the peripheral blood leukocytes obtained from 25 patients who developed hypersensitivity reactions following the administration of nonsteroidal anti-inflammatory drugs (NSAIDs); 12 patients demonstrated reactions to Voltaren, 8 patients to Bufferin, and 5 patients to Sedes G. The stimulation index, the ratio of the amounts of sLT (pg/ml) incubated with and without drugs, was considerably higher in the patients than in the controls, which consisted of 5 nonallergic healthy subjects. The sensitivity of the CAST (cellular antigen stimulation test) was evaluated to range from 62.5 to 80%, while the specificity was 70-100%. The CAST may thus be useful as a novel in vitro test system in order to screen for possible hypersensitive reactions to NSAIDs with both reliability and safety.

Increased number of IgE positive Langerhans cells in the conjunctiva of patients with atopic dermatitis

AIM

To determine the role of Langerhans cells (LCs) found to bear IgE in patients with atopic dermatitis (AD) by evaluating the surface distribution of these cells in the conjunctival epithelium and epidermis of skin lesions in patients with AD.

METHODS

The double labelling method was used to evaluate IgE positive cells that were positive for anti-CD1a or anti-CD23 antibody in an epithelial sheet of the conjunctival limbus. Specimens of conjunctiva were obtained from 12 men, six of whom had AD and ocular complications. Five patients without atopic disease served as controls, plus one additional patient with asthma but no AD. A similar study was conducted using epidermal sheets obtained from two patients with AD and from one without AD.

RESULTS

The number of CD1a+ cells present in the conjunctival epithelium of the patients with AD significantly exceeded that of the patients without AD. Most CD1a+ cells in the conjunctival epithelium and epidermis from the patients with AD bore IgE on their surfaces. Few such cells from patients without AD bore IgE. No CD23+ cells were found in the patients with or without AD.

CONCLUSIONS

The presence of an increased number of LCs bearing IgE on their surfaces in the conjunctival epithelium of patients with AD suggests that these cells may be involved in eliciting the hypersensitivity reaction and participate in ocular inflammation.

Normal-mode ruby laser for treating congenital nevi

BACKGROUND

Q-switched laser therapy is known to be highly effective in treating dermal melanocytosis and pigmented epidermal lesions. However, to our knowledge, there are no reports on the effectiveness of laser therapy for congenital nevi. We evaluated the clinical efficacy and side effects of normal-mode ruby laser therapy for congenital pigmented lesions containing abundant melanin.

OBSERVATIONS

A normal-mode ruby laser (pulse duration, 0.3-1.0 x 10(-3) seconds; energy fluence, 10-30 J/cm2; and spot size, 10 x 10 or 15 x 15 mm) (Toshiba Corp, Tokyo, Japan) was used to treat 3 patients with congenital nevi at intervals of 1 to 4 months. In all 3 cases, the pigmented lesions were significantly reduced almost to the level of the surrounding normal skin after 4 laser treatments. The treated areas were virtually free of scarring, and the skin texture resembled that of the surrounding normal skin. Unsightly hair growth was also reduced.

CONCLUSIONS

The normal-mode ruby laser was effective in treating congenital nevi and produced good cosmetic results. The risk of recurrence is unknown, but the 3 patients in our study did not have any recurrences during the 18- to 39-month study period.

Leser-Trélat sign with anaplastic ependymoma--an autopsy case

A 36-year-old Japanese male, who 7 years previously had been diagnosed as having an ependymoma in the left parietal region, had received surgery, chemotherapy and radiotherapy. He later developed a rapid growth of multiple skin lesions on his back and extremities, which coincided with a regrowth of the tumor. Postmortem examination revealed that the ependymoma showed anaplastic transformation and necrosis; however, no malignancy was observed in the extracranial organs. The skin lesions were histologically diagnosed as seborrheic keratoses. We have, therefore, diagnosed the patient as having Leser-Trélat sign associated with anaplastic ependymoma.

Presence of elevated carcinoembryonic antigen on absorbent disks applied to nipple area of breast carcinoma patients

BACKGROUND

Carcinoembryonic antigen (CEA) is used as a serum marker to detect and monitor the status of various kinds of malignant tumors. To determine whether CEA might be detected in secretions collected topically from around the nipple area, and whether its secretion might differ in a cancerous versus a noncancerous breast, we developed a simple method for collecting and measuring CEA, using a small cellulose membrane disk and an enzyme immunoassay.

METHODS

We measured the amount of CEA excreted from the nipple area of 22 healthy control women and 32 women with unilateral breast carcinoma confirmed histologically. Secretions were collected from the nipple area by affixing a small (20 mm diameter) absorbent disk made of nitrocellulose membrane backed with filter paper to that area for 24 hours. Substances absorbed by the membrane were then subjected to an immunoassay for CEA using anti-CEA antibodies.

RESULTS

In the 22 healthy subjects, a small amount of CEA (0.6 +/- 0.9 units) was secreted from each nipple, which was equally low regardless of the phase of the menstrual cycle. In contrast, 30 of the 32 women with breast carcinoma secreted significantly greater amounts of CEA from the cancerous (16.1 +/- 8.2) than the noncancerous (2.0 +/- 2.2) breast. Such a difference (14.1 +/- 8.0) in CEA excretion was not observed in the healthy controls (0 +/- 0).

CONCLUSIONS

These findings suggest that such disks may provide a simple and noninvasive method of collecting trace molecules, including CEA, in skin secretions around the nipple to evaluate functional disorders of the mammary glands, particularly breast carcinoma. Additional studies are indicated in larger groups of women with various stages of breast carcinoma as well as with benign breast diseases.

Case report: Gianotti-Crosti syndrome associated with human herpesvirus-6 infection

We report a case of Gianotti-Crosti syndrome associated with human herpesvirus-6 (HHV-6) infection. An eight-month-old girl developed monomorphous papules on her cheeks, buttocks, and extremities after the subsidence of exanthema subitum. Viral antibody analysis confirmed primary HHV-6 infection. HHV-6 may be added to the list of causative agents of Gianotti-Crosti syndrome.

Hair cortex comedo

We report two cases of skin lesions that clinically resemble a comedo. Both lesions demonstrated a firm black papule which was histopathologically reminiscent of a dilated hair follicle associated with an abnormality of the hair cortex. These findings are thus considered to represent a unique and peculiar variant of the dilated pore of Winer, and the term "hair cortex comedo" is therefore believed to be suitable for such lesions.

Spontaneous architectural organization of mammalian epidermis from random cell packing

The cells of the stratum corneum in the epidermis of some mammalian species are precisely stacked in columns in a honeycomb fashion. The epidermis constantly loses surface cells, which are replaced by basal cells that have differentiated during migration to the surface. The path of this migration is seen as precisely defined columns of cells that are in compressed Kelvin's tetrakaidecahedral form. We present a computer simulation of this architectural organization based on the assumption that the cells that migrate upward occupy less crowded regions. The simulation not only explained the mechanism by which the architecture is maintained during the process of cell replacement, but also showed that the architecture was spontaneously organized from initial cells supplied at random. Living organisms consist of self-organizing systems at various levels; however, self-organizing systems have been investigated mostly at the molecular level. The present computer simulation clarified the self-organizing system at the cellular level.

Angiocentric immunoproliferative lesions of the skin show lobular panniculitis and are mainly disorders of large granular lymphocytes

Eleven patients with angiocentric immunoproliferative lesion (AIL) of the skin were studied. Histologically, three patients were grouped into AIL grade II (AIL-II), whereas eight showed angiocentric lymphoma (AIL-III). All the patients' specimens exhibited lobular panniculitis. Infiltrating atypical lymphocytes in nine patients possessed electron-dense membrane bound granules in electron microscopy. Phenotypically, the lymphoid cells in the AIL-II patients were positive for CD3 epsilon; two of these showed a positive reaction to CD2, CD7, and CD8, but lacked natural killer-associated (NKa) antigens CD16, CD56, and CD57. In six AIL-III patients, lymphoma cells were positive for CD2 in all patients, CD56 in five, CD3 epsilon in four, CD7 in four, interleukin-2 beta receptor in four, a pore-forming protein in four, and CD30 in three patients. The remaining two AIL-III patients had B-cell lymphoma. By the Southern blot analysis, three patients with AIL-III showed a rearranged T-cell-receptor beta-gene or a deletion of its germline. The preceding results in nine of 11 patients suggest that abnormal or neoplastic large granular lymphocytes with the characteristics of T and NK cells have an important role in producing the angiocentric/angiodestructive features and lobular panniculitis. Clinically, all three patients with AIL-II and four with AIL-III showed liver dysfunction, cytopenia, and abnormal coagulopathy during the clinical course. Five patients with AIL-III died within 8 months. The histological grading of AIL, patients' age, and limited clinical stage of the disease seem to correlate with response to the treatment and prognosis.

Effect of 5-(p-hydroxyphenyl)-5-phenylhydantoin (p-HPPH) enantiomers, major metabolites of phenytoin, on the occurrence of chronic-gingival hyperplasia: in vivo and in vitro study

The purpose of this study was to assess the possible role of the (R)- and (S)- enantiomers of the phenytoin metabolite p-HPPH in the pathogenesis of gingival hyperplasia (GH). About 98% of circulating p-HPPH is in the (S)-form. There were significant differences between patients with and without GH in (R)-p-HPPH level (0.055 vs 0.042 microgram.ml-1), both enantiomer/racemate level ratios, and R/S enantiomeric ratio (0.0313 vs 0.0232); an increase in serum (R)-p-HPPH level was observed in patients with GH. In separate experiments, the effect of p-HPPH enantiomers on the proliferation of the normal human dermal fibroblast was studied. The in vitro study showed that (R)-p-HPPH selectively stimulated fibroblast growth. The results suggest that the least abundant metabolite, (R)-p-HPPH, is the most toxic with respect to gingival hyperplasia.

Increased serum level of interleukin-6 in patients with psoriatic arthritis and thrombocytosis

The role of elevations of serum cytokines in psoriasis is a provocative issue. We report two patients with psoriasis who had episodes of fever, arthritis, and general fatigue. Their symptoms seemed to be associated with increases in serum levels of interleukin (IL)-6, which paralleled the severity of clinical symptoms as well as elevated serum titers of C-reactive protein (CRP) and platelet counts. Since IL-6 is a multipotential cytokine with B-cell activating, T-cell activating, and thrombocytopoietic functions, the symptoms and abnormal laboratory findings in these patients may have been related to their increased serum levels of IL-6. Monitoring the serum level of this cytokine may thus be useful in evaluating the clinical status of patients with psoriatic arthritis.

Degree of ultraviolet-induced tortuosity of elastic fibers in rat skin is age dependent

To elucidate differential effects of ultraviolet (UV) exposure on three-dimensional networks of elastic fibers during maturation of rat skin, Sprague-Dawley rat hind limbs were irradiated with suberythemal doses of UV light (UVB, 130 mJ/cm2, or UVA, 27 J/cm2) in three different time courses of exposure: 3-9 weeks old, 9-15 weeks old, and 3-15 weeks old. Three-dimensional arrangement with special reference to linearity of elastic fibers was quantified by image analysis using a scanning electron microscope after a combination of intravascular resin injection and selective digestion technique using formic acid. Among the three irradiation groups, the group irradiated with UVB or UVA between 3 and 15 weeks old (UVB, three times per week; UVA, five times per week) elicited the most marked decrease in the linearity of elastic fibers. Despite the same irradiation period, there was a significant difference in the decreased linearity between the two irradiation groups of 3-9 and 9-15 weeks old, with the former irradiation group exhibiting greater loss of linearity than the latter irradiation group. The magnitude of the decreased linearity was greater in the UVB-exposed groups than in the UVA-exposed group. These findings indicate that the three-dimensional linearity of elastic fibers is more susceptible to disruption by UV exposures during the growth period than that after the growth period.

A simple method for measuring the amount of immunoglobulin A secreted onto the skin surface

We developed a simple method for measuring the amount of the secretory form of immunoglobulin A (sIgA) present in sweat. A small disk (10 x 10 mm) made of cellulose membrane was attached to the skin surface for periods of 1 to 24 h. SIgA was absorbed to the membrane and accumulated during the period of application. Enzyme immunoassay using anti-sIgA and antisecretory component (SC) antibodies revealed distinct dots on the disk that corresponded to the eccrine excretory ducts. A densitograph was used to determine the number and density of the dots, thus obtaining the amount of sIgA excreted to the surface of the skin (per mm2). The amount of skin sIgA excreted differed inter-individually as well as intra-individually. That is, it varied according to the region of the skin, and its distribution roughly reflected that of the sweat ducts. SIgA excretion was maintained at a certain level, regardless of the increased sweating produced by either heat or exercise, which raised the output of sweat 3- to 15-fold. Immunohistochemical studies revealed that fewer glandular cells expressed SC in their cytoplasm as the amount of sIgA decreased. Such an independence of the excretion of sIgA from that of sweat may be necessary to the local immune defenses of the skin.

Differential cell surface distribution of adhesion molecules demonstrated by immuno-scanning electron microscopy

Scanning electron microscopy with immuno-gold labeling revealed that epidermal keratinocytes expressed ICAM-1 and HLA-DR molecules on their surfaces in patterns that differed in mycosis fungoides (MF) and lichenoid reaction (LR). ICAM-1 molecules, visualized as deposits of gold particles, were present as clusters adjacent to the junctions interconnecting the keratinocytes of MF lesions. LFA-1 molecules were seen as granules on the surfaces of all infiltrates, most of which also expressed ICAM-1. HLA-DR molecules were seen continuously along the borders of the individual keratinocytes. In LR, ICAM-1 and HLA-DR were expressed only sparsely on the undersurface of the epidermis, whereas the infiltrates expressed LFA-1 molecules on their surfaces. These findings may explain the differing histological features of MF and LR: ICAM-1 molecules present on the intercellular junctions of MF epidermis lead the LFA-1-bearing cells to migrate into the interspaces of the keratinocytes, thus producing "epidermotropism". These cells aggregate by means of co-expressed ICAM-1 to thus produce the appearance of a "microabscess". In LR, on the other hand, the minimal expression of ICAM-1 on the epidermal undersurface leaves most infiltrates within the dermis, thus producing a "band-like infiltrate" beneath the epidermis.

Clinical and immunohistochemical studies of skin eruptions: relationship to administration of interferon-alpha

We observed transient, erythematous skin eruptions in 6 patients during the intravenous administration of interferon (INF)-alpha for chronic active hepatitis C. The eruptions appeared 5 to 14 days (mean: 6.8 days) after initiating its administration. They were localized or disseminated and consisted of edematous, erythematous, and/or papular changes. Vesicles and petechiae also appeared in some cases. The eruptions disappeared in 10 to 14 days, despite the continuance of INF-alpha and without specific treatment. Histological examination obtained from skin eruptions revealed perivascular infiltration of lymphoid cells, the majority which were CD4-positive, of the upper dermis. Edematous changes were present in the papillary dermis. Vascular endothelial cells in the upper dermis expressed both intercellular adhesion molecule-1 (ICAM-1) and endothelial leukocyte adhesion molecule-1 (ELAM-1), while the epidermal keratinocytes produced neither. These findings suggested a nonallergic mechanism for such eruptions.