Immunological Aspects of Skin Aging in Atopic Dermatitis

The cutaneous immune response is important for the regulation of skin aging well as for the development of immune-mediated skin diseases. Aging of the human skin undergoes immunosenescence with immunological alterations and can be affected by environmental stressors and internal factors, thus leading to various epidermal barrier abnormalities. The dysfunctional epidermal barrier, immune dysregulation, and skin dysbiosis in the advanced age, together with the genetic factors, facilitate the late onset of atopic dermatitis (AD) in the elderly, whose cases have recently been on the rise. Controversial to the healthy aged skin, where overproduction of many cytokines is found, the levels of Th2/Th22 related cytokines inversely correlated with age in the skin of older AD patients. As opposed to an endogenously aged skin, the expression of the terminal differentiation markers significantly increases with age in AD. Despite the atenuated barrier disturbances in older AD patients, the aged skin carries an impairment associated with the aging process, which reflects the persistence of AD. The chronicity of AD in older patients might not directly affect skin aging but does not allow spontaneous remission. Thus, adult- and elderly subtypes of AD are considered as a lifelong disease.

Luteolin as a modulator of skin aging and inflammation

Luteolin belongs to the group of flavonoids and can be found in flowers, herbs, vegetables and spices. It plays an important role in defending plants, for example against UV radiation by partially absorbing UVA and UVB radiation. Thus, luteolin can also decrease adverse photobiological effects in the skin by acting as a first line of defense. Furthermore, anti-oxidative and anti-inflammatory activities of luteolin were described on keratinocytes and fibroblasts as well as on several immune cells (e.g., macrophages, mast cell, neutrophils, dendritic cells and T cells). Luteolin can suppress proinflammatory mediators (e.g., IL-1β, IL-6, IL-8, IL-17, IL-22, TNF-α and COX-2) and regulate various signaling pathway (e.g., the NF-κB, JAK-STAT as well as TLR signaling pathway). In this way, luteolin modulates many inflammatory processes of the skin. The present review summarizes the recent in vitro and in vivo research on luteolin in the field of skin aging and skin cancer, wound healing as well as inflammatory skin diseases, including psoriasis, contact dermatitis and atopic dermatitis. In conclusion, luteolin might be a promising molecule for the development of topic formulations and systemic agents against inflammatory skin diseases.

The Role of Platelet Homeostasis in a Novel Topical PRP Formulation

BACKGROUND

Topical platelet-rich plasma (PRP) must demonstrate stability to insure biologic activity in aesthetic medicine.

OBJECTIVE

The objective of this research was to evaluate the role of platelet homeostasis in a novel PRP topical cosmetic formulation to provide facial appearance improvement.

METHODS

The stability of the topical PRP formulation was evaluated in vitro followed by clinical in vivo testing. The in vitro evaluation examined platelet stability and morphology over a 90-day period within the preservative cosmetic base utilizing ELISA and light microscopy (LM)/scanning electron microscopy (SEM). The in vivo clinical study enrolled 20 subjects in a 120-day double blind split face study to evaluate the effect of 5–7x concentrated PRP compared to 2–3x concentrated PRP on facial photoaging. Cosmetic effect was evaluated by the subject and the dermatologist investigator on a 5-point ordinal scale at baseline, week 8, and week 16.

RESULTS

90-day stability for the topical PRP formulation was verified via ELISA and LM/SEM. ELISA showed the PRP was more inactive than control conditions via analyte concentration curves (PDGF-AB, EGF, and P-Selectin). LM/SEM demonstrated the PRP had less aggregation/activation over time within the cosmetic base and that refrigeration is superior to room-temperature storage thus delaying full platelet degranulation. The in vivo clinical study demonstrated parity between 20ml and 60ml PRP in terms of clinical efficacy.

CONCLUSION

Platelets remain viable for up to 90 days in a refrigerated cosmetic vehicle with demonstrated topical clinical PRP facial benefits. PRP kits of 20ml and 60ml volumes for topical PRP are equally efficacious. J Drugs Dermatol. 2020;19(12): doi:10.36849/JDD.2020.5495.

Biological Effects of Hyaluronic Acid-Based Dermal Fillers and Laser Therapy on Human Skin Models

Injection of dermal fillers is one of the most frequently performed aesthetic procedures. The aim of the present study was to investigate the biological effects of different stabilized hyaluronan (HA) and poly-l-lactic acid fillers with and without subsequent additional fractional laser co-treatment on skin morphology and gene expression. Intradermal injection resulted in a significant enhancement of epidermal thickness detected by histological analysis. Combining HA fillers with ablative fractional CO2- or Er:YAG laser irradiation enhanced this effect. Gene expression profiling revealed an upregulation of modulators of tissue remodeling (eg TIMP3, SERPIN E1) and collagens (COL11A1). On the other hand, we detected a downregulation of differentiation markers (eg FLG, LOR, KRT1) and proinflammatory cytokines (eg IL-36, IL-1β). Interestingly, HA-based fillers revealed a specific upregulation pattern of chemokines such as CXCL5 andCCL20 suggesting a secondary effect of these fillers on the immune cells of the skin, especially monocytes and macrophages. Taken together, our data show enhancing effects of dermal fillers on epidermal thickness and prove the proliferating effects of these products on epidermal cells on the molecular level. Moreover, our findings reveal synergistic effects of fractional ablative laser treatment and HA dermal filler injection suggesting a combination of both treatments. J Drugs Dermatol. 2020;19(9):897-899. doi:10.36849/JDD.2020.4856.

Biological Effects of Hyaluronic Acid-Based Dermal Fillers and Laser Therapy on Human Skin Models

Injection of dermal fillers is one of the most frequently performed aesthetic procedures. The aim of the present study was to investigate the biological effects of different stabilized hyaluronan (HA) and poly-l-lactic acid fillers with and without subsequent additional fractional laser co-treatment on skin morphology and gene expression. Intradermal injection resulted in a significant enhancement of epidermal thickness detected by histological analysis. Combining HA fillers with ablative fractional CO2- or Er:YAG laser irradiation enhanced this effect. Gene expression profiling revealed an upregulation of modulators of tissue remodeling (eg TIMP3, SERPIN E1) and collagens (COL11A1). On the other hand, we detected a downregulation of differentiation markers (eg FLG, LOR, KRT1) and proinflammatory cytokines (eg IL-36, IL-1β). Interestingly, HA-based fillers revealed a specific upregulation pattern of chemokines such as CXCL5 andCCL20 suggesting a secondary effect of these fillers on the immune cells of the skin, especially monocytes and macrophages. Taken together, our data show enhancing effects of dermal fillers on epidermal thickness and prove the proliferating effects of these products on epidermal cells on the molecular level. Moreover, our findings reveal synergistic effects of fractional ablative laser treatment and HA dermal filler injection suggesting a combination of both treatments. J Drugs Dermatol. 2020;19(9):897-899. doi:10.36849/JDD.2020.4856.

Protective Effects of Kuding Tea (Ilex kudingcha C. J. Tseng) Polyphenols on UVB-Induced Skin Aging in SKH1 Hairless Mice

In this study, the protective effects of Kuding tea polyphenols (KTPs) on ultraviolet B (UVB)-induced skin injury of SKH1 hairless mice were studied. The ion precipitation method was used for extraction of polyphenols from Kuding tea. High-performance liquid chromatography showed that KTPs contains chlorogenic acid, cryptochlorogenic acid, isochlorogenic acid B, isochlorogenic acid A, and isochlorogenic acid C. SKH1 hairless mice were induced skin aging using 2.0 mW/s intensity of 90 mJ/cm² UV light once a day for seven weeks. The 2.5% and 5% KTPs solution was smeared on 2 cm² of back skin of skin aging mice twice a day. Mouse experiments showed that KTP strongly increased the serum levels of total superoxide dismutase (T-SOD) and catalase (CAT) and reduced those of malondialdehyde, interleukin 6 (IL-6), IL-1β, and tumor necrosis factor alpha (TNF-α) in mice with UVB-induced skin damage. KTP also increased the levels of type 1 collagen (Col I), hydroxyproline, and hyaluronic acid and reduced those of Col III and hydrogen peroxide in the damaged skin tissues of mice. Pathological observations of tissues stained with H & E, Masson’s trichrome, Verhoeff, and toluidine blue showed that KTPs could protect skin cells, collagen, and elastin and decrease the number of mast cells, thus inhibiting skin damage. Quantitative PCR and western blot assays showed that KTP upregulated the mRNA and protein expression of tissue inhibitor of metalloproteinase 1 (TIMP-1), TIMP-2, copper/zinc-SOD, manganese-SOD, CAT, and glutathione peroxidase and downregulated the expression of matrix metalloproteinase 2 (MMP-2) and MMP-9. In addition, the same concentration of KTP had stronger protective effects than vitamin C. The results of this study demonstrate that KTPs have good skin protective effects, as they are able to inhibit UVB-induced skin damage.

Effects of collagen and collagen hydrolysate from jellyfish umbrella on histological and immunity changes of mice photoaging

Jellyfish collagen (JC) was extracted from jellyfish umbrella and hydrolyzed to prepare jellyfish collagen hydrolysate (JCH). The effects of JC and JCH on UV-induced skin damage of mice were evaluated by the skin moisture, microscopic analyses of skin and immunity indexes. The skin moisture analyses showed that moisture retention ability of UV-induced mice skin was increased by JC and JCH. Further histological analysis showed that JC and JCH could repair the endogenous collagen and elastin protein fibers, and could maintain the natural ratio of type I to type III collagen. The immunity indexes showed that JC and JCH play a role in enhancing immunity of photoaging mice in vivo. JCH showed much higher protective ability than JC. These results suggest that JCH as a potential novel antiphotoaging agent from natural resources.

Skin immune systems and inflammation: protector of the skin or promoter of aging?

The immune system may either have a protective role against sunburn and skin cancer or, conversely, promote solar damage. The skin is poised to react to infections and injury, such as sunburn, with rapidly acting mechanisms (innate immunity) that precede the development of acquired immunity and serve as an immediate defense system. Some of these mechanisms, including activation of defensins and complement, modify subsequent acquired immunity. An array of induced immune-regulatory and pro-inflammatory mediators is evident, at the gene expression level, from the microarray analysis of both intrinsically aged and photoaged skin. Thus, inflammatory mechanisms may accentuate the effect of UV radiation to amplify direct damaging effects on molecules and cells, including DNA, proteins, and lipids, which cause immunosuppression, cancer, and photoaging. A greater understanding of the cutaneous immune system's response to photo-skin interactions is essential to comprehensively protect the skin from adverse solar effects. Sunscreen product protection measured only as reduction in redness (current "sun" protection factor) may no longer be sufficient, as it is becoming clear that protection against UV-induced immune changes is of equal if not of greater importance. Greater knowledge of these processes will also enable the development of improved strategies to repair photodamaged skin.

Dietary Lutein/Zeaxanthin Partially Reduces Photoaging and Photocarcinogenesis in Chronically UVB-Irradiated Skh-1 Hairless Mice

Lutein and zeaxanthin are xanthophyll carotenoids with potent antioxidant properties protecting the skin from acute photodamage. This study extended the investigation to chronic photodamage and photocarcinogenesis. Mice received either a lutein/zeaxanthin-supplemented diet or a standard nonsupplemented diet. Dorsal skin of female Skh-1 hairless mice was exposed to UVB radiation with a cumulative dose of 16,000 mJ/cm(2) for photoaging and 30,200 mJ/cm(2) for photocarcinogenesis. Clinical evaluations were performed weekly, and the animals were sacrificed 24 h after the last UVB exposure. For photoaging experiments, skin fold thickness, suprapapillary plate thickness, mast cell counts and dermal desmosine content were evaluated. For photocarcinogenesis, samples of tumors larger than 2 mm were analyzed for histological characterization, hyperproliferation index, tumor multiplicity, total tumor volume and tumor-free survival time. Results of the photoaging experiment revealed that skin fold thickness and number of infiltrating mast cells following UVB irradiation were significantly less in lutein/zeaxanthin-treated mice when compared to irradiated animals fed the standard diet. The results of the photocarcinogenesis experiment were increased tumor-free survival time, reduced tumor multiplicity and total tumor volume in lutein/zeaxanthin-treated mice in comparison with control irradiated animals fed the standard diet. These data demonstrate that dietary lutein/zeaxanthin supplementation protects the skin against UVB-induced photoaging and photocarcinogenesis.

Constitutive expression and regulated release of the transmembrane chemokine CXCL16 in human and murine skin

The CXC-chemokine ligand 16 (CXCL16) is expressed as a transmembrane adhesion molecule and can be released as a chemoattractant. Both functions are carried out by binding of CXCL16 to its receptor, CXC-chemokine receptor 6 (CXCR6). We here provide early evidence that CXCL16 is expressed in situ by epidermal keratinocytes of normal skin on messenger RNA and protein level and released into the wound exudate upon injury. Cultured human and murine keratinocyte cell lines (HaCaT and PAM212, respectively) as well as primary keratinocyte cultures constitutively express transmembrane CXCL16 on the cell surface. Soluble CXCL16 is released by its limited proteolytic cleavage involving the disintegrin-like metalloproteinase (ADAM)10 but not the closely related ADAM17, as shown by specific inhibitors and small-interfering RNA knockdown experiments. This shedding of CXCL16 is reduced by serum starvation but enhanced by cell stimulation with ionomycin or by UVB irradiation. Soluble CXCL16 from keratinocytes was shown to bind and activate CXCR6, and marked expression of this receptor was found on a subpopulation of T cells in the dermis. Thus, CXCL16 is constitutively expressed on the surface of human epidermal keratinocytes, released upon cell activation or photodamage and may then target CXCR6-expressing T cells in the dermis.

Pathophysiology of photoaging of human skin: focus on neutrophils

UV-induced skin damage is the result of a complex cascade of events. Many studies have focused on the skin effects induced by UV-B or UV-A separately. Recently a UV-source that emits UV-B and UV-A together in a ratio comparable to daily sunlight has been introduced: i.e. solar simulated radiation (SSR). By exposing human skin type I-III to erythematogenic doses of UV (> or =1 MED) emitted by a SSR source we have noticed that: (a) neutrophils are initially the main infiltrating cell type in the dermis and (b) these infiltrating cells are the a key source of in vivo enzymatically [corrected] active enzymes such as elastase, [corrected] matrix metallo proteinases-1 and -9 (MMPs-1 and -9). These enzymes are relevant to the process of photoaging, as they break down the extracellular matrix. Keratinocytes and fibroblasts also produce matrix degrading enzymes, but to a lesser extent. Our results indicate a primary role for infiltrating neutrophils in the initial steps of photoaging. This is further supported by the observation that after exposure of skin type VI to physical doses of SSR, equivalent to those used for skin types I-III, no neutrophils and neutrophil-derived enzymatic activity were observed, explaining why skin type VI is [corrected] less susceptible to photoaging than skin types [corrected] I-III. Statement: Although most of the data, referred to, have been published, the current perspective in which they are put together is completely novel and has not been published elsewhere.

Responses of Black and White Skin to Solar-Simulating Radiation: Differences in DNA Photodamage, Infiltrating Neutrophils, Proteolytic Enzymes Induced, Keratinocyte Activation, and IL-10 Expression

Black skin is more resistant to the deleterious effects of ultraviolet radiation than white skin. A higher melanin content and a different melanosomal dispersion pattern in the epidermis are thought to be responsible for this. Our purpose was to compare skin responses in black and white skin following exposure to solar-simulating radiation (SSR) to further investigate the photoprotective properties of black skin. Six volunteers of skin phototype I-III (white) were exposed to (doses measured directly with a Waldmann UV detector device) 12,000-18,000 mJ per cm2 (2 MED) of SSR and compared with six volunteers of skin phototype VI (black) exposed to 18,000 mJ per cm2 (<1 MED) of SSR. The presence and distribution of skin pigment, DNA photodamage, infiltrating neutrophils, photoaging associated proteolytic enzymes, keratinocyte activation, and the source of interleukin 10 (IL-10) in skin biopsies taken before and after exposure were studied. In all white skinned subjects, 12,000-18,000 mJ per cm2 of SSR induced DNA damage in epidermal and dermal cells, an influx of neutrophils, active proteolytic enzymes, and diffuse keratinocyte activation. Additionally, in three of the white skinned volunteers IL-10 positive neutrophils were found to infiltrate the epidermis. Except for DNA damage in the supra basal epidermis, none of these changes was found in black skinned subjects. Increased skin pigmentation appears to be primarily responsible for the observed differences in skin responses. Our data could provide an explanation as to why black skin is less susceptible to sunburn, photoaging, and skin carcinogenesis.

Imiquimod-Induced Interleukin-1α Stimulation Improves Barrier Homeostasis in Aged Murine Epidermis

In response to acute disruption of the permeability barrier of aged mammals there is a diminished capacity for barrier recovery, analogous to other aged organs when stressed. Acute barrier disruption increases levels of epidermal cytokines, and cytokines are known regulators of keratinocyte mitogenesis, as well as lipid synthesis in extracutaneous tissues. Underlying the sluggish barrier recovery in aged skin are diminished mRNA and protein levels for the interleukin-1 cytokine family, and its receptors. To further elucidate the role of the interleukin-1 family of cytokines in the barrier repair response, cytokine production was stimulated in aged murine skin with topical imiquimod application. Imiquimod accelerated barrier recovery after acute insults to aged and young skin. These functional results correlated temporally with increased interleukin-1 alpha production in the epidermis following topical imiquimod administration to murine skin. Furthermore, intracutaneous injections of interleukin-1 alpha accelerated barrier recovery in aged mice. Finally, we showed that interleukin-1 alpha added to cultured human keratinocytes stimulates epidermal lipid synthesis. These studies provide further evidence for the role of reduced interleukin-1 alpha signaling in the decline of permeability barrier function in aged skin, and point to the potential use of cytokine augmentation in barrier dysfunction of the aged.

Clinical review: topical retinoids

With sensible patient education, the multitude of benefits that topical retinoid therapy can provide may be enjoyed. Hopefully, retinoid therapy will heighten awareness of the detrimental effects of sun exposure and motivate future generations to become "sun smart." Evidence-based medicine, current research, and case studies can arm practitioners with the resources and guidance to effectively provide current, innovating therapies for a variety of dermatologic conditions. With the strategic use of topical retinoids, several dermatologic conditions can be addressed concurrently.

Photoageing shows histological features of chronic skin inflammation without clinical and molecular abnormalities

BACKGROUND

Photodamage is characterized by degradation of collagen and accumulation of abnormal elastin in the superficial dermis. Mast cells and macrophages, which are found in higher numbers in photoaged skin, have been implicated in this process.

OBJECTIVES

To analyse the phenotype of haematopoietic-derived infiltrating cells in photodamaged skin.

METHODS

Chronically sun-exposed (preauricular) and control sun-protected (postauricular) skin was recovered from eight healthy subjects undergoing cosmetic surgery (facial lifting).

RESULTS

Histological analysis showed that sun-exposed skin harboured more infiltrating mononuclear cells than sun-protected skin. Cellular infiltrates were found at the periphery of areas of elastolysis around hair follicles in sun-exposed sites, whereas they were found in the interfollicular dermis around blood vessels and around hair follicles in sun-protected samples. Immunohistochemical analysis revealed an increased number of mast cells, macrophages and CD4+ CD45RO+ T cells in sun-exposed dermis as well as a higher number of CD1a+ dendritic cells in sun-exposed epidermis, compared with the sun-protected samples. Thus photoageing displays histological features of chronic skin inflammation. However, no molecular sign of inflammation was observed and we even found a decreased expression of interleukin-1beta mRNA in sun-exposed compared with sun-protected sites. Furthermore, the patients' skin looked normal and did not display any clinical inflammation.

CONCLUSIONS

Collectively, these data show that chronic ultraviolet irradiation induces alterations of innate immune cells which are recruited in sun-exposed skin without being activated.

CD11b+ cells are the major source of oxidative stress in UV radiation-irradiated skin: possible role in photoaging and photocarcinogenesis

Exposure of skin to solar UV radiation induces oxidative stress and suppression of cell-mediated immune responses. These effects are associated with the greater risk of several skin disorders including photoaging and photocarcinogenesis. We have shown that UV-induced infiltrating leukocytes contribute in developing oxidative stress in UV-irradiated skin. The peak period of UV-induced infiltrating leukocytes lies between 48 and 72 h after UV exposure of the skin. In this study we demonstrated that UV (90 mJ/cm2)-induced infiltrating CD11b+ cells in C3H/HeN mice skin were the major source of oxidative stress. Hydrogen peroxide (H2O2) was determined as a marker of oxidative stress. Flow cytometric analysis of viable cells revealed that the number of CD11b+H2O2+ cells were significantly higher (31.8%, P < 0.001) in UV-irradiated skin in comparison with non-UV-exposed skin (0.4%). Intraperitoneal administration of monoclonal antibodies to CD11b (rat IgG2b) to C3H/HeN mice inhibited UVB-induced infiltration of leukocytes, as evidenced by reduction in myeloperoxidase activity (64-80%, P < 0.0005), concomitant with significant reduction in H2O2 production both in epidermis and dermis (66-83%, P < 0.001-0.0005) when compared with the administration of rat IgG2b isotype of anti-CD11b. Furthermore, CD11b+ and CD11b- cell subsets were separated by immunomagnetic cell isolation technique from total epidermal and dermal single cell suspensions obtained 48 h after UV irradiation of the skin and analyzed for H2O2 production. Analytical data revealed that CD11b+ cell population from UV-irradiated skin resulted in significantly higher production of total H2O2 in both epidermis and dermis (87-89%, P < 0.0001) in comparison with CD11b- cell population (11-13% of total H2O2). These data revealed that infiltrating CD11b+ cells were the major source of oxidative stress in UV-irradiated skin and thus may contribute to photoaging and promotion of skin tumor growth within the UV-irradiated skin. Together, these data suggest that reduction in UV-induced skin infiltration of CD11b+ cells may be an alternative and effective strategy to reduce solar UV light-induced oxidative stress-mediated skin disorders including photoaging and photocarcinogenesis.

Alterations in cytokine regulation in aged epidermis: implications for permeability barrier homeostasis and inflammation. I. IL-1 gene family

Acute disruption of the cutaneous permeability barrier with either solvents or tape-stripping stimulates a homeostatic metabolic response in the subjacent nucleated layers of the epidermis that results in a rapid restoration of normal permeability barrier function. When the aged epidermal permeability barrier is stressed, it reveals a diminished capacity for recovery, in comparison to young epidermis, analogous to other organs in the aged when stressed. Although the signals that regulate this homeostatic response by the epidermis have not yet been resolved, acute permeability barrier disruption stimulates release of prestored IL-1alpha, and increased production of potentially regulatory cytokines, including IL-1alpha and TNFalpha in the epidermis. In these studies, we addressed the hypothesis that cytokine dysregulation explains the permeability barrier abnormality in aged epidermis, assessing the regulation of IL-1 and TNF signaling in aged vs young mice. To determine whether the IL-1 family of cytokines plays a key role in the permeability barrier abnormality of the aged, permeability barrier recovery rates were compared in transgenic mice lacking the functional IL-1 type 1 receptor vs wild-type mice at various ages. Knockout of the IL-1 type 1 receptor exacerbates the defect in permeability barrier homeostasis that is seen in age-matched, wild-type counterparts. Furthermore, the sluggish permeability barrier recovery in aged epidermis is associated with, and at least in part attributable to, altered expression of the IL-1 family of cytokines and receptors both under basal conditions and after acute barrier perturbations. Whereas modulations in cytokine expression with epidermal permeability barrier perturbation are qualitatively similar in aged epidermis, they greatly differ quantitatively. In contrast, examination of TNFalpha mRNA and protein basally, and following barrier perturbation revealed no alterations in aged epidermis. Together, these results show that selective alterations in the IL-1 family of cytokines occur with aging and that defects in IL-1 signaling may contribute to the epidermal permeability barrier abnormality of aged skin.

Photoimmunosuppression

Ultraviolet (UV) radiation can exert a variety of biological effects, including induction of skin cancer, premature skin ageing and inhibition of the immune system. The immunosuppressive properties of UV radiation are of major biological relevance since suppression of the immune system by UV radiation is not only responsible for the exacerbation of infectious diseases following UV exposure, but also contributes to the induction of skin cancer. Hence, understanding of the mechanisms by which UV radiation compromises the immune system is of primary importance. UV radiation suppresses the immune system in multiple ways. It inhibits antigen presentation, stimulates the release of immunosuppressive cytokines and induces the generation of lymphocytes of the suppressor subtype. In the following, some of the basic mechanisms underlying UV-induced immunosuppression will be discussed.

Factors of skin ageing share common mechanisms

Ageing has been defined as the accumulation of molecular modifications which manifest as macroscopic clinical changes. Human skin, unique among mammalians insofar as it is deprived of fur, is particularly sensitive to environmental stress. Major environmental factors have been recognized to induce modifications of the morphological and biophysical properties of the skin. Metabolites from ingested or inhaled substances do affect skin, which is also sensitive to endogenous hormone levels. Factors as diverse as ultraviolet radiation, atmospheric pollution, wounds, infections, traumatisms, anoxya, cigarette smoke, and hormonal status have a role in increasing the rate of accumulation of molecular modifications and have thus been termed 'factors of ageing'. All these factors share as a common feature, the capability to directly or indirectly induce one of the steps of the micro-inflammatory cycle, which includes the expression of ICAM-1 in endothelial cells. This triggers a process leading to the accumulation of damages in the skin resulting in skin ageing since ICAM-1 expression provokes recruitment and diapedesis of circulating immune cells, which digest the extracellular matrix (ECM) by secreting collagenases, myeloperoxidases and reactive oxygen species. The activation of these lytic processes provokes random damage to resident cells, which in turn secrete prostaglandines and leukotrienes. These signaling molecules induce the degranulation of resident mast cells which release the autacoid histamine and the cytokine TNF-alpha thus activating endothelial cells lining adjacent capillaries which release P-selectin and synthesize ICAM-1. This closes a self-maintained micro-inflammatory cycle, which results in the accumulation of ECM damage, i.e. skin aging. In this paper we review the evidence that two factors able to induce macroscopical and molecular modifications in the skin, protein glycation and stretch, activate the micro-inflammatory cycle. We further present evidence that three additional factors, two external factors (electromagnetic fields and psychological stressors) and one internal factor (neuropeptides) also activate the micro-inflammatory cycles and may therefore be considered as factors of skin ageing.

Immune-mediated dermatologic skin disorders in the senior patient

The baby boomer population, marching on the journey from infancy through the portals of middle life, now enters an uncertain period of life in which the only certainty is the fact that all the biological clocks continue the countdown toward the inevitable failure of a previously well-served immune system. We are faced with the ever-increasing probability that the very immune system that sustained us so well throughout our youth will eventually falter, predisposing us to a vast array of disorders resulting in immune dysregulation. It is in this setting that I will review the dermatologic disorders that may befall the "senior" patient as we journey toward that stage of life where we, as physicians and as an aging population ourselves, encounter a whole new set of medical challenges as we make the turn at the bend in the road. Accordingly, this review will focus on autoimmune bullous disorders, cutaneous manifestations of systemic disease, endocrine disorders, skin cancers, and paraneoplastic syndromes.

The roles of cytokines in photoaging

Photoaging comprises characteristic changes in appearance and function of the skin as a result of repeated sun exposure rather than to passage of time alone. Clinically, wrinkles, laxity, coarseness, mottled pigmentation, lentigenes, teleangiectasia and purpura characterize photoaging. Photoaging is also characterized by atrophy, fibrotic depigmented areas termed pseudoscars, and ultimately premalignant and malignant neoplasms on sun exposed areas. These features are the result of ultraviolet radiation (UVR) in the sunlight. UVR stimulates and activates various cells and tissues to produce and release cytokines that may play a significant role in the process of photoaging. However, cytokines are the major orchestrators of the host defense processes and are involved in response to exogenous and endogenous insults, and repair and restore homeostasis. Therefore, cytokines may be beneficial in the course of photoaging. Considering the complex cytokine network in the skin, focus will be taken on several subjects that have seen major changes during the last few years. I will first outline our knowledge of cytokines in the skin together with their functions, then review our knowledge of the involvement of cytokines in photoaging, and finally summarize the defense system related to cytokines.

Histological increase in inflammatory infiltrate in sun-exposed skin of female subjects: the possible involvement of matrix metalloproteinase-1 produced by inflammatory infiltrate on collagen degradation

To investigate morphological changes occurring during cutaneous photoageing, a correlation between the number of infiltrating cells in the dermis and the degree of collagen damage was examined using sections from clinically normal chronically sun-exposed and sun-protected skin of Japanese female subjects. Haematoxylin and eosin-stained sections from 134 sun-exposed (subjects aged 3-82 years) and 73 sun-protected (subjects aged 1-86 years) areas demonstrated a predominant lymphoid cell and to a lesser extent histiocyte infiltration. The mean +/- SD number of lymphoid cells and histiocytes in the sun-exposed skin sections (427.0+/-192.2 and 147.8+/-83.3 cells/mm2, respectively) was significantly higher than in the sun-protected skin sections (292.6+/-98.3 and 125.9+/-59.0 cells/mm2, respectively) (P < 0.001 and P < 0.05, respectively), and the number of lymphoid cells in the sun-exposed skin sections increased significantly with age up to 50 years (r = 0.400, P < 0.001). Sun-exposed skin sections with severe collagen degeneration had a significantly higher number of lymphoid cells than those with slightly degenerated collagen (mean 626.3 vs. 482.4 cells/mm2, P < 0.01). The mean count of mast cells in sun-exposed skin was 202.0 cells/mm2; this did not vary with the age of the subjects or the level of collagen damage. Immunohistochemical studies using 24 frozen sections identified most of the lymphoid cells infiltrating sun-exposed skin as memory T lymphocytes (CD3+, CD4+ and CD45RO+). The number of cells which displayed immunoreactivity to matrix metalloproteinase (MMP)-1 in the sun-exposed skin sections was significantly higher than in the sun-protected skin sections (mean 170.2 vs. 113.6 cells/mm2, P < 0.05). Among these cells were observed CD3 and MMP-1 double-stained T lymphocytes, and T lymphocytes contacting MMP-1-positive cells. These morphological observations suggest that T lymphocytes infiltrating photodamaged skin may play a part in the degeneration and reduction of collagen through MMP-1 activity.

Effect of topical tretinoin on epidermal Langerhans' cells in photodamaged skin

BACKGROUND

Topical tretinoin has been successfully applied to treat photoaging; however, a decrease in the number of Langerhans' cells (LC) has been reported after its topical application in Macaque skin. A study was performed to evaluate the possible effect of topical tretinoin on the number of LC in human beings.

METHODS

Eight patients were studied. Topical tretinoin was applied in progressively increasing concentrations: 0.025% for 1 month, 0.05% for one month and 0.1% for 4 months. A skin biopsy from the malar area was taken before this therapy and 6 months later. To study LC, 4 mu frozen sectionswere stained with the anti-CD1 antibody.

RESULTS

The number of CD1+ cells did not change when they were counted per unit of epidermal length, but they decreased when they were counted per unit of epidermal surface.

CONCLUSIONS

These results indicate that topical tretinoin might damage epidermal Langerhans' cells, when it is applied for long periods of time; future studies are necessary to clarify this point.

Experimental photoaging in C3H/HeN, C3H/HeJ, and Balb/c mice: comparison of changes in extracellular matrix components and mast cell numbers

Chronic exposure of human or murine skin to ultraviolet B (UVB) radiation alters dermal extracellular matrix composition and increases the number of mast cells and inflammatory cells. Experiments were designed to test the possible role of UVB-induced tumor necrosis factor-alpha in these photoaging changes based on reports that C3H/HeN, but not C3H/HeJ or Balb/c mice, produce excess TNF-alpha in response to UVB exposure. Pigmented C3H/HeN and C3H/HeJ strains were exposed to a total of 75 J/cm2 of UVB radiation, and unpigmented Balb/c mice were exposed to 19 J/cm2. The UVB-induced increases in collagen, glycosaminoglycans, and neutrophil number were similar or the same in all three strains. The elastin increase was greater in C3H/HeJ than in C3H/HeN mice. The most striking difference between the strains was a 7.7-fold UVB-induced increase in mast cells in C3H/HeN mice compared to no increase in irradiated C3H/HeJ mice and a 2.3-fold increase in Balb/c mice. These results suggest that excess TNF-alpha (or other mediator) produced in C3H/HeN skin (but not C3H/HeJ skin) in response to UVB exposure is involved in the mast cell increase and partial inhibition of elastin increase, but that neither these mediators nor mast cell products are important mediators for the chronic UVB-induced increases in neutrophils, glycosaminoglycans, and collagen. When a possible source of the excess TNF-alpha was investigated, it was found that isolated epidermal cells from all three strains produced increases in TNF-alpha in response to UVB radiation. These results, as well as the previous results showing differences between these strains in UVB-induced effects on cutaneous immune function, are consistent with a model in which UVB-induced mediators from the epidermis stimulate another cell type to produce excess TNF-alpha (and other mediators) in the C3H/HeN but not C3H/HeJ or Balb/c mice.

Topical application of isotretinoin did not modify human Langerhans cell allostimulatory function

The beneficial effect of isotretinoin on the repair of photodamaged skin is well documented. Little is known, however, on the action of this compound on immunological functions of epidermis. In a double-blind study, we analyzed the effect of topical applications of isotretinoin on human Langerhans cell (LC) function by using the mixed epidermal cell lymphocyte reaction (MELR). Isotretinoin cream (0.1%) was applied daily for 4 months on the back of one hand of 5 healthy volunteers, 50-60 years of age. The back of the other hand received vehicle alone and was used as control. Skin biopsy specimens were taken at the end of treatment. Epidermal cell (EC) suspensions were obtained by the use of trypsin and allogeneic T cells were purified from the peripheral blood of allogeneic donors. MELR was performed in microtiter plates and T cell proliferation was assessed by 3H-thymidine incorporation during the last 18 h of culture. Results did not show any differences between allogeneic T cell responses to EC from isotretinoin-treated or nontreated skin. These results therefore suggest that isotretinoin, applied topically onto photodamaged skin, did not alter human LC antigen-presenting function.

Features of an autoimmune process in mid-dermal elastolysis

Mid-dermal elastolysis is a rare disorder that is manifested clinically by wrinkling and histologically by the selective absence of elastic fibers in the mid dermis. We describe a young woman who developed abnormal wrinkling after augmentation mammoplasty with silicone implants. Histologic examination confirmed the diagnosis of mid-dermal elastolysis. In addition, a positive antinuclear antibody titer and a false-positive Lyme titer were subsequently detected. In a previously reported case a patient who had mid-dermal elastolysis also had an unusual false-positive pattern for Lyme disease. Silicone mammoplasty has been associated with connective tissue diseases. This report adds mid-dermal elastolysis to the list of diseases associated with augmentation mammoplasty and, along with the presence of autoantibodies, supports autoimmune involvement in mid-dermal elastolysis.

[Cutaneous senescence and carcinogenesis]

A variety of clinical, topographical, histological, epidemiological and geographical arguments attribute to the effects of solar radiation and to ultraviolet rays (UV) in particular, a decisive role in the processes of cutaneous carcinogenesis. This carcinogenicity is part of a series of chronic changes affecting the integument which constitute heliodermatitis or photosenescence. The effects of UV are cumulative. DNA is the main target of UV rays. Man possesses several DNA repair systems. The hereditary malfunction of part of these systems result in xeroderma pigmentosum, which constitutes a pathological model of photocarcinogenesis. Intrinsic skin ageing (non-photodependent) appears to promote this process of photocarcinogenicity by several mechanisms: summation of DNA changes, progressive deterioration of repair systems, dermal-epidermal atrophy, melanocytic changes, immuno-surveillance deficit.

[Aging and the cutaneous immune system]

The changes in the immune system during the ageing process have been described in numerous publications, which are sometimes contradictory. The study of cell mediated immunity and of hormonal immunity provide only a partial reflection of the smooth working of the cutaneous immune system, which is dependent on fragile cell interactions between T lymphocytes, cells of Langerhans and keratinocytes, which involves numerous soluble mediators. Three possible mechanisms leading to or contributing to the decline in immune function with age should be considered: a modification of the distribution of lymphocyte subpopulations (the T helper lymphocytes and T-suppressing lymphocytes are affected by age in particular), changes in the mechanisms of suppression and changes in the maturation of B and T lymphocytes.

Skin ageing and immune competence

Ageing is associated with impairment of immune function, the most significant changes being a decrease in T-cell-mediated immunity and antibody-mediated effector functions, and an increase in autoantibodies and other dysregulatory phenomena, such as an abnormal production of monoclonal antibodies and other immune complexes. Elderly subjects are increasingly susceptible to cutaneous pathological changes that are known to correlate with immune deficiencies, such as viral and fungal infections, and skin cancers. Antigenic responses in skin may be an indicator of immune status. The recall antigens elicit fewer delayed-type hypersensitivity reactions in the elderly, particularly in subjects over 75 years old. Sensitivity to contact allergens, such as dinitrochlorobenzene, and inflammatory responses and the cutaneous response to histamine are reduced in the elderly. The pathophysiology of deficiencies in the skin's immune system in the elderly is not clear; it probably reflects not only a general decline in the immune system but also more specific changes. Age-related changes in epidermal immune functions have been observed, such as morphological and functional changes in Langerhans cells and decreased production of various cytokines. Evaluation of these changes is difficult and the results may be disputed, but it is probable that sun-induced ageing plays an important role. Few substances seem to be capable of stimulating the immunoactive cells of the skin or of modifying the production of epidermal cytokines. One possibility may be vitamin A and its derivatives, and studies of other molecules such as interferons are being carried out.

Physiological changes in ageing skin

The principal functions of the skin include protection, excretion, secretion, absorption, thermoregulation, pigmentogenesis, accumulation, sensory perception and regulation of immunological processes. These functions are all affected by the structural changes in the skin with ageing and, after middle age, most functions are reduced, some by as much as 50-60%. The physiological changes associated with these reductions include impairment of the barrier function, decreased turnover of epidermal cells, reduced numbers of keratinocytes and fibroblasts, and a reduced vascular network particularly around hair bulbs and glands. These changes result in fibrosis and atrophy, and decreases in hair and nail growth, vitamin D synthesis and the density of Langerhans cells. Production of epidermal thymocyte-activating factor, which enhances the T-cell response, is reduced leading to a decrease in the immune response; there is also a decreased functioning of Meissner's and Pacinian corpuscles. An increased generation of free radicals is observed. Certain environmental factors, particularly exposure to sun, accelerate the ageing of skin and are important in cutaneous carcinogenesis.

[Immunology in the aged]

On account of their katabolic status in general, elderly people show increasing involution of every organ and tissue. In addition to the decrease in functional vitality, we find morphologic reduction of highly differentiated cells. This process does also affect the immune system. Many diseases of old age (such as infections, malignomas, auto-immunopathies) seems to be brought about by immunodeficiency due to senescence. These diseases are promoted by the reduced production of antibodies against foreign antigens and by the decreased functions of T-suppressor subpopulations. On the other hand, we observe increasing auto-immunity, a rise of circulating immune complexes, and a higher tolerance towards alloantigenetic tissue. It is not easy to decide whether the pathologic immune status is the result of multimorbidity, or whether diseases of old age develop because of senile immunodeficiency. In this connection, our lacking knowledge regarding immunology in old age becomes obvious; moreover, the problem of answering these questions by means of systematic investigation has not yet been solved.