Swiss S1 guideline for the treatment of rosacea

Rosacea (in German sometimes called 'Kupferfinne', in French 'Couperose' and in Italian 'Copparosa') is a chronic and frequently relapsing inflammatory skin disease primarily affecting the central areas of the face. Its geographic prevalence varies from 1% to 22%. The differential diagnosis is wide, and the treatment is sometimes difficult and varies by stage of rosacea. For erythematous lesions and telangiectasia, intense pulsed light (IPL) therapy and lasers are popular treatment option. In addition, a vasoconstrictor agent, brimonidine, has recently been developed. For papulopustular rosacea, topical antibiotics, topical and systemic retinoids, as well as systemic antibiotics are used. A topical acaricidal agent, ivermectin, has undergone clinical development and is now on the market. In the later stages, hyperplasia of the sebaceous glands develops, resulting in phymatous growths such as the frequently observed bulbous nose or rhinophyma. Ablative laser treatments have largely replaced classical abrasive tools. Here, we reviewed the current evidence on the treatment of rosacea, provide a guideline (S1 level) and discuss the differential diagnosis of rosacea.

Intra-individual comparison of the cutaneous safety and efficacy of calcitriol 3 microg g(-1) ointment and calcipotriol 50 microg g(-1) ointment on chronic plaque psoriasis localized in facial, hairline, retroauricular or flexural areas

BACKGROUND

Psoriasis involving sensitive skin areas remains difficult to treat because of the side-effects of topical corticosteroids and the irritancy potential of vitamin D3 derivatives. Several clinical trials have demonstrated that calcitriol, the naturally occurring and hormonally active form of vitamin D3, is effective and safe at the dose of 3 microg g(-1) for the treatment of psoriasis affecting the trunk and limbs.

METHODS

We compared the safety and efficacy of calcitriol 3 microg g(-1) ointment and calcipotriol 50 microg g(-1) ointment in a multicentre, randomized, investigator-blinded, left-right comparison in mild to moderate chronic plaque psoriasis affecting sensitive areas, defined as being the face, hairline, retroauricular and flexural areas. One pair of symmetrical and bilateral target lesions was selected from each area and assessed for perilesional erythema, oedema, and stinging/burning. Global assessment of local tolerability and global improvement were rated by the investigator, and the subjects were asked to evaluate the tolerability and efficacy of each product and to express their global preference.

RESULTS

In the 75 subjects, calcitriol and calcipotriol both led to clearing of at least one target lesion in 21 (28%) of the subjects each. Perilesional erythema (P < 0.001), perilesional oedema (P < 0.02) and stinging/burning (P < 0.001) were all significantly less severe with calcitriol than with calcipotriol. The subjects' evaluation of local tolerability was significantly (P < 0.0001) in favour of calcitriol. Ten treatment-related dermatological events occurred in eight subjects, including one subject who experienced skin discomfort on both sides. All other events occurred only on the calcipotriol-treated side (irritant dermatitis, six subjects; contact dermatitis, one subject). Global assessment of improvement from baseline by the investigators was significantly greater for the calcitriol-treated lesions (P < 0.02). The subjects' global preference was significantly in favour of calcitriol (P < 0.02).

CONCLUSIONS

In the present study, calcitriol ointment was found to be better tolerated and would appear to be more effective than calcipotriol ointment in the treatment of psoriasis in sensitive areas.

Adapalene biochemistry and the evolution of a new topical retinoid for treatment of acne

The emergence of oral and topical retinoids was a major advance in the clinical management of acne vulgaris. However, the benefits of these agents were somewhat limited by the degree of side effects caused by these drugs. Over the last 15 years, researchers have sought compounds that can provide the manifold therapeutic benefits obtained with tretinoin and isotretinoin while minimizing the potential for irritation and other unwanted effects. Adapalene, a naphthoic-acid derivative, is one result of this search, and it serves as an example of rational drug development: the formulation of a novel substance with specific pharmacological properties and clinical objectives in mind. These goals included enhancing stability, enhancing anti-inflammatory effects, maintaining effectiveness and minimizing cutaneous irritation. This paper reviews the history of the development of adapalene, its unique physical and biochemical properties, and the pharmacological studies that demonstrate a wide range of retinoid-receptor, genetic and anti-inflammatory effects, all of which contribute to the therapeutic efficacy and improved tolerability of adapalene observed in the clinical use of this agent for the treatment of acne.

A randomized trial of amorolfine 5% solution nail lacquer combined with oral terbinafine compared with terbinafine alone in the treatment of dermatophytic toenail onychomycoses affecting the matrix region

In view of recent advances in the development of antifungal agents, this study examined the possible synergy of two new antifungal agents, terbinafine and amorolfine. The study compared two different courses of terbinafine treatment combined with amorolfine 5% solution nail lacquer. Terbinafine was given orally for 6 (AT6 group) or 12 weeks (AT12 group) and amorolfine nail lacquer applied weekly for 15 months. A control group received terbinafine alone for 12 weeks. This was a randomized, prospective, open study of severe dermatophyte toenail onychomycosis with matrix region involvement. Nail samples were taken before the start of the study, at inclusion and at the visits at 6 weeks, 3, 9, 15 and 18 months. To assess the value of such combined therapy we chose an early parameter as the principal outcome variable, which was the result of mycological examination, including direct microscopy and culture, at 3 months (allowing a margin of 15 days). The secondary parameters of success were the mycological results at the later visits, clinical evaluation and a combined mycological-clinical response. Safety and tolerance were also assessed. Adverse events were recorded and liver function tests were performed monthly during the terbinafine treatment. Of the 147 patients included in the trial, 121 attended the 3-month visit, within a time limit of 15 days of 3 months after the beginning of treatment: 40 in the AT6 group, 40 in the AT12 group and 41 in the control group. In all, 32 of 121 patients (26. 4%) had negative mycological results on direct microscopy and culture: 14 of 40 (35.0%) in the AT6 group, 11 of 40 (27.5%) in the AT12 group and seven of 41 (17.1%) in the control group. The cure rate for the global (mycological and clinical cure) response measured at 18 months in 145 patients was 44.0% (22 patients) in the AT6 group, 72.3% (34 patients) in the AT12 group and 37.5% (18 patients) in the terbinafine group. These results suggest that the combination of amorolfine and terbinafine may be of value in the treatment of severe onychomycosis. At the same time a pilot pharmacoeconomic analysis was performed demonstrating a better cost per cure ratio for the patients receiving combination treatment.

Clinical efficacy and safety comparison of adapalene gel and tretinoin gel in the treatment of acne vulgaris: Europe and U.S. multicenter trials

BACKGROUND

Adapalene is a new chemical entity that exhibits tretinoin-like activities in the terminal differentiation process.

OBJECTIVE

We evaluated a dose range effect of two concentrations of adapalene gel as acne treatment and compared adapalene 0.1% gel with tretinoin 0.025% gel in the treatment of acne patients in two large multicenter studies.

METHODS

Multicenter, investigator-masked, parallel group studies including 89 acne patients in the dose range study and 591 patients in the concurrent controlled studies were conducted.

RESULTS

Adapalene gel 0.1% was significantly more effective in treating acne lesions than 0.03% adapalene gel. Adapalene gel 0.1% was significantly more effective than 0.025% or tretinoin gel in one study and of the same effectiveness in the other study. Adapalene gel was always better tolerated than tretinoin gel.

CONCLUSION

Adapalene 0.1% gel is a safe and effective treatment of acne vulgaris.

Adapalene 0.1% gel is better tolerated than tretinoin 0.025% gel in acne patients

BACKGROUND

Adapalene is a new naphthoic acid derivative developed for the topical treatment of acne vulgaris.

OBJECTIVE

We describe the results of a combined safety analysis of two multicenter trials conducted in the U.S. and Europe in which adapalene 0.1% gel was compared with tretinoin 0.025% gel in the treatment of mild to moderate acne vulgaris.

METHODS

A total of 591 acne patients were enrolled in these investigator-masked, randomized, controlled, parallel group studies. In the two studies, each patient was randomly assigned to receive topical adapalene 0.1% gel or tretinoin 0.025% gel once daily at bedtime, for 12 weeks. In addition to assessments of efficacy and facial skin tolerance, data on adverse events were recorded at each visit or at any other time the patient reported problems. We extracted data concerning adverse reactions (i.e., adverse events judged to be related to the study treatment) from both studies and combined the results to obtain a global comparison of safety of the two products.

RESULTS

A total of 15 of 296 patients (5.1%) reported 19 adverse reactions in the adapalene-treated groups, compared with 27 of 295 patients (9.1%) reporting 39 adverse reactions in the tretinoin-treated groups (p < 0.05). The number of patients discontinuing the study because of adverse events was approximately twice as low with adapalene (1.3% compared with 2.4%). Most adverse reactions for both products were related to skin irritation. No systemic adverse reactions were reported.

CONCLUSION

The results of these two multicenter clinical studies indicate that adapalene gel is better tolerated than tretinoin gel.

Adapalene 0.1% gel has low skin-irritation potential

BACKGROUND

Adapalene is a new naphthoic acid derivative with potent retinoid and antiinflammatory properties, developed for the topical treatment of acne vulgaris.

OBJECTIVE

We compare the cutaneous safety of adapalene in different gel vehicles with tretinoin 0.025% gel.

METHODS

A total of 42 healthy human subjects were enrolled in two randomized, double-blind, controlled, intraindividual studies. In the first study (study A), adapalene aqueous 0.03% and 0.1% gels were evaluated for their 21-day cumulative irritation potential compared with vehicle alone, patch alone, and tretinoin 0.025% gel under occlusion. In the second study (study B), adapalene aqueous (0.03% and 0.1%) gels and adapalene alcoholic (0.03% and 0.1%) gels were evaluated for their 5-day cumulative irritation potential compared with their respective vehicles and tretinoin 0.025% gel. Transepidermal water loss (TEWL) was measured daily at each visit.

RESULTS

In study A, adapalene had a slight irritation potential that was in the same range as the gel vehicle and the patch alone, whereas tretinoin 0.025% gel was a severe irritant. In study B, no irritation was seen with either adapalene aqueous gels or adapalene gel vehicles or patch alone. The adapalene alcoholic gels were slightly irritating, and tretinoin gel produced intense irritation reactions in the majority of subjects. TEWL increased fourfold at the tretinoin site but remained unchanged at all adapalene sites.

CONCLUSION

Adapalene 0.1% gel was significantly less irritating than tretinoin 0.025% gel.

A comparison of the efficacy and safety of adapalene gel 0.1% and tretinoin gel 0.025% in the treatment of acne vulgaris: a multicenter trial

BACKGROUND

Adapalene is a new synthetic retinoid analogue developed for the topical treatment of acne vulgaris.

OBJECTIVE

The study was designed to compare the efficacy and safety and adapalene gel 0.1% with tretinoin gel 0.025% in the treatment of grade II to II facial acne vulgaris.

METHODS

Three hundred twenty-three patients were enrolled in this investigator-masked, randomized, parallel group, multicenter trial. Patients applied the test materials to the entire facial area daily, for a period of 12 weeks. Efficacy and cutaneous tolerance were assessed at baseline and weeks 2,4,8, and 12. Efficacy was determined by investigator counts of noninflammatory open and closed comedones, and inflammatory papules and pustules, as well as global improvement. Cutaneous tolerance was evaluated by erythema, scaling, and dryness, along with burning and pruritus.

RESULTS

Staring at weeks 2 and 4, adapalene gel produced numerically greater lesion reductions than did tretinoin gel for all lesion types. At week 12, the mean percent reduction in the different lesion counts was as follow: 49% versus 37% for total lesions (p<0.01); 46% versus 33% for noninflammatory lesions (p=0.02); 48% versus 38% for inflammatory lesions (p=0.06) in adapalene and tretinoin gel treatment groups, respectively. Cutaneous side effects were limited to a mild "retinoid dermatitis" occurring in both treatment groups; however, patients treated with adapalene gel tolerated this therapy significantly better than those treated with tretinoin gel. Laboratory test evaluations (hematology, blood chemistries, urinalysis) were performed in 54 patients before and after 3 months of treatment. No clinically significant changes were observed.

CONCLUSION

Adapalene gel 0.1% applied once daily was significantly more effective in reducing acne lesions and was better tolerated than tretinoin gel 0.025% in the treatment of acne vulgaris.

Chronic topical application of all-trans-retinoic acid in man does not affect corneocyte surface area

The potential therapeutic activity of topically applied novel analogues of retinoic acid is currently measured in many different animal models. In most cases, the technique used is invasive and biopsy specimens are required. Furthermore, efficacy in these models is not a guarantee of success in treatment of humans. Therefore, predictive human pharmacology tests are required in order to quantify a retinoid effect on human skin before conducting large clinical trials. The aim of this study was to determine whether changes in corneocyte surface area could be used as a predictive measure for the efficacy of topical retinoids in man. Topical applications of all-trans retinoic acid gel (Aberel), salicylic acid gel and the gel vehicle were made once daily for 4 weeks to skin of the lumbar region of healthy human volunteers. Corneocytes were recovered from these three treated zones as well as from one zone of untreated skin, and their surface areas were measured by image analysis using a MOP-Videoplan. The results showed that at no point during the 4 weeks of daily application to healthy human skin was there a statistically significant difference in the surface area of corneocytes recovered from Aberel, salicylic acid-, vehicle-treated or untreated sites. No specific effect of retinoic acid could be detected. However, although no between-treatment differences were found, significant cyclical changes in the mean surface areas with respect to baseline were observed.

The vellus hair follicle in acne: hair growth and sebum excretion

In this study we investigated the activity of the vellus hair follicle in acne. Hair growth and sebum excretion in vellus hair follicles were measured on the forehead and back of men, and on the forehead, cheek, and back of women with acne. Hair growth was assessed by computerized image analysis (phototrichogram), and sebum excretion by computer analysis using Sebutape. In patients with acne, marked differences were revealed when results were compared with recent data from healthy persons. In particular, the mean growth rate of vellus hairs was higher, whereas the percentage of anagen hairs was lower, and the duration of the anagen phase shorter in patients with acne than in healthy individuals. Hair growth and sebum excretion depended significantly (P < 0.01) on the anatomical site (forehead 414 hairs/cm2, 0.053 mm/day, 34%; back 93 hairs/cm2, 0.16 mm/day, 21%). In addition, analysis of hair growth revealed significantly higher values in females than in males for (i) percentage of anagen hairs (P > 0.01), (ii) for vellus hair length (P < 0.05), and (iii) for the duration of the anagen phase (P < 0.01). The present study demonstrates that the activity of the vellus hair follicle is influenced by acne, and vice versa, and therefore its role in the aetiopathogenesis of acne should be reconsidered.

Migration of Langerhans cells into human epidermis of "reconstructed" skin, normal skin, or healing skin, after grafting onto the nude mouse

Human skin equivalents composed of keratinocytes cultured on a lattice constituted of human fibroblasts embedded in type I collagen were grafted onto the nude mouse. It is demonstrated, by indirect immunofluorescence and electron microscopy, that, after grafting, mouse Langerhans cells migrate into the human epidermis. Human Langerhans cells are not present in this system. In split-thickness human skin grafts, at long periods (5 and 12 months) after transplantation, a progressive migration of murine Ia(+) cells in the human epidermis and the presence of human Langerhans cells were shown by indirect immunofluorescence. Creation of a wound at the center of the grafted human skin and identification of the Langerhans cell origin shows a repopulation with human Langerhans cells provided the injury was performed early (2 months) after grafting. Injury at a later stage (5 months) resulted in presence of both human and murine Langerhans cells. These observations show 1) that, after grafting of "reconstructed" human skin or of split-thickness human skin onto nude mice, mouse Langerhans cells migrate into the grafted human epidermis; and 2) that the Langerhans cells repopulating a healing grafted epidermis devoid of Langerhans cells derived from the non-injured surrounding epidermis. The present work thus shows that besides bone marrow, lymph nodes, or/and spleen, surrounding cutaneous regions can also serve as sources of Langerhans cells.

Topical retinoids. Their uses in dermatology

The retinoids provide an important new way of treating dermatologic disorders. They have also proved to have a role in the prevention of new lesion formation. New retinoids, of which adapalene is one, have recently been synthesized in order to obtain similar or better efficacy while reducing skin irritation potential. These new molecules are currently under clinical investigation. Preliminary results are encouraging. In the near future, an expanded range of topical retinoids should be available.

Migration of Langerhans cells into the epidermis of human skin grafted into nude mice

In a previous study, it was demonstrated that human Langerhans cells (LC) are preserved in human skin grafted onto a nude mouse. Moreover, although it was observed that mouse LC of the host invade skin grafts from allogeneic mouse or rat, they do not penetrate in human skin grafts. In most of the human skin equivalent systems produced in vitro, LC appear to be lost. The present study was designed to investigate whether the mouse LC will repopulate a human skin equivalent. For this purpose, two different systems of skin equivalent have been grafted into the nude mouse. They were composed of human keratinocytes deposited on dead human dermis, or on lattice composed of human fibroblasts embedded in type I collagen. At different times after grafting, the presence of LC in the transplants was assayed either by indirect immunofluorescence or by electron microscopy. Indirect immunofluorescence was performed on frozen sections or on epidermal sheets with anti-Ia, anti-HLA-DR, or OKT6 antibodies. It was observed that, at 2 months after grafting, Ia(+) HLA-DR(-) OKT6(-) cells are present in grafted human epidermis. Moreover, LC with typical Birbeck granules are also detected by electron microscopy. It could be concluded, from this study, that mouse LC can repopulate human epidermis devoid of human LC.

Sequence of morphological events during topical application of retinoic acid on the rhino mouse skin

In a study of the comedolytic action of retinoids on the epidermal pseudocomedones of rhino mouse skin, the earliest changes and the sequence of events induced by the treatment were investigated. Rhino mice were treated topically with all-trans retinoic acid and at various time intervals from day 0 to 3 weeks, histological and ultrastructural studies as well as quantification of mast cells were performed. The earliest changes occurred in the dermis after 2 days of treatment and were characterized by degranulation of mast cells, clumping and association of Langerhans cells and lymphocytes. During the second week of treatment there was hyperplasia, hypergranulosis and an increase in the number of membrane coating granules with disorganization of the horny layer both of the epidermis and the follicular epithelium. These changes in the proliferation and the differentiation of keratinocytes resulted in a comedolytic effect. Associated with these epidermal changes there were changes in the dermis with an increased number of mast cells and a decreased number of Langerhans cells.

Processing and statistical analysis of laser Doppler data applied to the assessment of systemic anti-inflammatory drugs

Continuous laser Doppler measurements of methyl nicotinate-induced skin inflammation have been used to evaluate the activities of three oral non-steroidal anti-inflammatory drugs, indomethacin 50 mg (Indocid), tiaprofenic acid 100 mg (Surgam) and sodium acetylsalicylate 1 g (Catalgine). They were compared in a single-blind, randomized, intra-individual comparison (N = 16) versus placebo (lactose). One hour after each drug was ingested, four concentrations of methyl nicotinate were applied to the subject's forearms. Simultaneous skin blood flow (SBF) measurements were then carried out on the four tested zones, by use of four calibrated laser Doppler flowmeters. Computerized processing of recorded SBF levels provided data related to flow amplitude, kinetics and magnitude (area under the curve) of the reactions. A detailed statistical analysis was performed to establish the selectivity of this type of test and the following points were demonstrated: adjustment of SBF data to baseline did not improve precision, data had to be log-transformed before analysis, and magnitude data gave the best product discrimination. Under the conditions of this study, i.e. one hour after oral administration and for the indicated doses, the tested products could be classified, in terms of anti-inflammatory activity, as follows: Lactose less than Indomethacin 50 mg = Tiaprofenic acid 100 mg less than Sodium acetylsalicylate 1 g.

[Clinical trials in dermatology. The phase I trials]

Application of the new topical product on the diseased skin should be preceded by its safety evaluation on the healthy skin in human volunteers. We propose here guidelines for the evaluation of the irritation, sensitization, phototoxicity and photoallergy potentials for topical products. The methods for evaluation of percutaneous absorption are also discussed. The studies presented here are not the object of any regulations. Therefore, we propose here an approach for the safety evaluation of topical products in human volunteers.

[Clinical trials in dermatology. Evaluation of the tolerability and efficacy of a topical anti-inflammatory treatment in atopic dermatitis]

Study designs for assessment of topical anti-inflammatory drugs in atopic dermatitis are discussed. Atopic dermatitis is a chronic disease with symmetrically distributed lesions. In order to avoid individual and spontaneous variation and to obtain an early impression of the efficacy of a new topical drug, bilaterally paired lesions can be used. Further drug development requires controlled double-blind parallel group design. General recommendations regarding inclusion criteria, and the measurement of efficacy and safety parameters are presented. Methods available for data evaluation and the particularities of different clinical designs are discussed.

[Clinical trials in dermatology. Statistical support]

To determine the efficacy or safety of new topical treatments, more or less standardized studies must be performed. This article presents several examples of statistical analyses of the data currently seen in the dermatology area, and some guidelines for study sample size determination. More importantly, it indicates, for as soon as phase I studies, the need for preliminary informations such as development strategy, historical data, literature references or pilot studies, to determine or adapt appropriate designs and sample sizes. This need can be filled by close collaboration among clinicians, statisticians and sponsor.

[Clinical trials in dermatology. Evaluation of the tolerability and efficacy of a topical antipsoriatic treatment]

There has been considerable variations between different authors in the evaluation of antipsoriatic therapies. Improvement homogeneity must be achieved in this field. The main specific methods have been investigated: inclusion criteria, assessment of disease progress and safety parameters in phase II and III clinical trials, evaluating antipsoriatic treatment.

[Clinical trials in dermatology. Evaluation of the tolerability and efficacy of a topical antifungal agent in the treatment of superficial mycoses]

There is no single method for evaluating topical antifungal drugs. The localisation and the type of fungal, determine the treatment duration (from few days to several months). The main methodological characteristics of clinical trials in tinea pedis treatment (athlete's foot type) are reported. Aspects related to other clinical forms such as tinea versicolor and onychomycosis are also described. In any case, the main criteria of activity remains the mycological examination based on KOH microbiology and culture performed at the end of the treatment and again afterwards.

[Clinical trials in dermatology. Evaluation of the tolerability and efficacy of a topical anti-acne]

Acne is a frequent dermatologic disease of the teenagers. Methodology of antiacne preparations clinical trials has evolved recently, leading to better comprehension of acne treatment on acne lesions. The main rules for good clinical evaluation of acne treatments are: an objective counting of each individual lesions on a defined area (face, back), a global acne assessment, a therapy duration from 1 to 3 months or more, a skin safety evaluation for erythema, desquamation, dryness, itching, burning and oiliness with a 0 to 3 scoring system.

Efficacy and safety of CD 271 alcoholic gels in the topical treatment of acne vulgaris

CD 271, a naphthoic acid, is a powerful modulator of epidermal differentiation. This double-blind, randomized study compared the efficacy and safety of two concentrations (0.03% w/w and 0.1% w/w) of CD 271 alcoholic gel, with 0.025% w/w tretinoin gel in 72 male patients with acne vulgaris over a period of 12 weeks. Efficacy was measured by counting facial inflammatory and non-inflammatory lesions and by grading the severity of the acne at each visit. Skin tolerance was assessed with subjective symptoms, such as burning and pruritus, as well as clinical assessment of erythema, dryness and scaling on the treated areas. The alcoholic 0.1% CD 271 gel was as effective as 0.025% tretinoin gel in reducing total comedone counts (83% reduction for both products after 12 weeks' treatment). The reduction in the number of inflammatory lesions and the total number of acne lesions were significantly greater with 0.1% CD 271 gel than with tretinoin gel (69% and 79% for 0.1% CD 271, 50% and 73% for tretinoin gel, respectively, P less than 0.05). All three treatments were well tolerated and there were no changes in any major blood parameters. No CD 271 could be detected in blood plasma at the end of the study (detection limit = 1 ng/ml).

Comparison of eicosanoid generation by highly purified human Langerhans cells and keratinocytes

The present study was conducted to investigate the eicosanoid metabolism of highly enriched human Langerhans cells and keratinocytes. Arachidonic acid (100 microM) was added to the cells which were then stimulated with 1 microM calcium ionophore A 23187 for 10 and 30 min. The supernatants were examined for cyclooxygenase and lipoxygenase products using different chromatographic systems and radioimmunoassays. Compounds were identified by comparison with authentic standards. The major cyclooxygenase product of both cell types was prostaglandin D2, with minor amounts of prostaglandin E2. The main products of the lipoxygenase pathway were 5-hydroxyeicosatetraenoic acid (5-HETE), 12-HETE, 15-HETE, and their corresponding hydroperoxy derivatives, with small amounts of leukotrienes B4 and C4. The major differences in the metabolism of the two cell types were related to faster kinetics of generation of the mediators and a more complete conversion of arachidonic acid by the LC. Because eicosanoids have been implicated to be potent mediators of inflammation and immunomodulators, the present data underline the potential contributory role of epidermal cells to eicosanoid-associated pathologic processes.

Objective assessment of topical corticosteroids and non-steroidal anti-inflammatory drugs in methyl-nicotinate-induced skin inflammation

The aim of this study was to compare the activities of the two main classes of topical anti-inflammatory drugs in methyl-nicotinate-induced skin inflammation, using a new methodology based on laser-Doppler velocimetry. Six topical non-steroidal anti-inflammatory drugs (NSAIDs) (bufexamac, diclofenac, ibuprofen, indomethacin, phenylbutazone and niflumic acid) and three topical corticosteroids (clobetasol propionate, hydrocortisone and hydrocortisone butyrate) were tested. Drugs were commercially available (except indomethacin) and were applied under occlusion for 4 h to the forearms of 16 healthy male volunteers. Thirty minutes after excess drug removal, skin inflammation was induced by a 1-min application of methyl nicotinate (3 mM). This was repeated 44 h later. Each methyl-nicotinate application was followed by continuous skin blood flow recordings over 1 h. Overall, NSAIDs proved more effective than corticosteroids in inhibiting methyl-nicotinate-induced increases in skin blood flow. Diclofenac and indomethacin showed a potent prolonged inhibitory effect. Different types of activity were observed in the corticosteroid group: (a) At 30 min, hydrocortisone and hydrocortisone butyrate moderately inhibited methyl-nicotinate reactions whereas clobetasol propionate produced no detectable effects; (b) at 44 h, clobetasol propionate produced a significant inhibition whereas hydrocortisone butyrate and hydrocortisone exhibited either weak or no inhibitory action at all. These pharmacodynamic discrepancies between the corticosteroids tested could be related to differences in drug affinity to cutaneous receptors and in vasoconstrictive potency.

Objective assessment of topical anti-inflammatory drug activity on experimentally induced nickel contact dermatitis: comparison between visual scoring, colorimetry, laser Doppler velocimetry and transepidermal water loss

Four topical anti-inflammatory drugs were investigated for their effect on allergic contact dermatitis. Nickel dermatitis was chosen for its high incidence in European healthy volunteers. Experimental lesions were treated twice daily with two steroids, two non-steroidal anti-inflammatory drugs and a blank base for 4.5 days without occlusion. The influence of treatments was assessed by daily visual grading and one site was left untreated for comparison over the same period. To quantify drug activities objectively, skin colour (colorimetry), skin blood flow (laser Doppler velocimetry) and transepidermal water loss (evaporimetry) were measured before drugs were first applied, then 6 hr after the last application. As expected, only Dermoval cream significantly improved the spontaneous clinical evolution in comparison with the other creams (Hydrocortisone Aster à 1%. Parfenac, indomethacin 2.5% and Skinbase) and the untreated site. Colorimetric parameter a* (redness) and L* (luminance) showed more differences between treatments than the other criteria and a close relationship was obtained between these two parameters and skin blood flow, all three being highly correlated to visual grading. Transepidermal water loss appeared less related to clinical improvement but this parameter could prove helpful for detecting compounds which could be irritant to diseased skin.

Detection of distinct subpopulations of Langerhans cells by flow cytometry and sorting

Flow cytometry was found to be a very appropriate tool for the study of Langerhans cells (LC), which represent a minor cell population (2-3%) of human epidermis, and allowed us to obtain new phenotypic, functional, and cell cycle data on these rare cells. The phenotypic analysis of cell surface antigens demonstrates the existence of two subpopulations of LC: the former is HLA-DR+ and OKT 6+ (about 90% of total HLA-DR+ cells) and the latter is HLA-DR+ and OKT 6- (about 10% of total HLA-DR+ cells). These subpopulations of LC are both able to stimulate the proliferation of peripheral blood lymphocytes (PBL) in the presence of keratinocytes i.e., in mixed skin lymphocyte reaction (MSLR). Analysis of the cell cycle could be performed on OKT 6+ LC. Results show that they can be found in the various phases of the cell cycle, suggesting that the large majority of Langerhans cells are able to proliferate in situ in normal human epidermis.

Biology of human epidermal Langerhans cells: cell cycle studies

Langerhans cells (LC) are considered to play an important role in the initiation of the immune response in the skin. This study was performed to analyse the kinetics of LC in normal human epidermis. Using flow cytometry (FCM), we have applied three methods to estimate LC DNA distribution: FCM DNA measurement in LC-enriched suspensions (70-90% purity), FCM-correlated analysis of DNA and OKT6-positive cells in original epidermal cell suspensions, and staining of LC-enriched suspensions by the Feulgen technique on microscopic slides and counter labelling of contaminating keratinocytes with anti-keratin antiserum to eliminate them from the LC DNA estimation. All three methods clearly showed that human LC are a cycling cell population, and it was suggested that LC may represent a stable, self-reproducing cell population in normal epidermis.

Epidermal Langerhans cells--a cycling cell population

The limited number of Langerhans cells (LC) in human epidermis and the resultant technical difficulties have left open the question of LC kinetics. In the present study using flow cytometry (FCM) we have applied 3 methods to estimate LC-DNA distribution: (1) FCM-DNA measurement on highly enriched LC suspensions, (2) FCM-correlated analysis of DNA and OKT-6(+) cells in total epidermal cell suspensions, (3) LC-enriched suspensions (70-90%) were FACS (fluorescence-activated cell sorter) sorted on microscopic slides, and stained with the Feulgen technique, and DNA was measured densitometrically. In the latter method, contaminating keratinocytes were counterlabeled with antikeratin serum to eliminate them from LC-DNA estimation. All 3 in vitro analyses clearly showed that human LC are a cycling cell population in the epidermis. The number of LC in S (1.3-3.3%) and G2/M (1.0-2.5%) phase compares with those found for keratinocytes. Assuming that this percentage of keratinocytes in S and G2/M phases is sufficient to maintain the structural integrity of the epidermis, it was suggested that LC may represent a stable, self-reproducing cell population in normal epidermis.

Human Langerhans cells in epidermal cell culture, in vitro skin explants and skin grafts onto "nude" mice

In order to find a model system which best preserves human Langerhans cells (LC) outside of the human body, three possibilities were examined: epidermal cell culture, skin explants, and skin grafts onto "nude" mice. Using OKT-6 and anti-HLA-DR monoclonal antibodies, we quantified LC in epidermal sheets or epidermal cell cultures. All observations were carried out over a period of 4 weeks. We found that under epidermal cell culture conditions, LC rapidly disappeared, to the extent that after 10 days only rare HLA-DR-positive cells could be observed. In contrast, in the presence of intact dermis (explants and grafts), 60%-80% of the original number of LC, morphologically unchanged, dendritic and OKT-6 and HLA-DR-positive, were seen. These findings suggest that human LC are either a long-lived cell population or else can proliferate locally. The systems studied may be a useful tool for future investigation of LC function.

In vitro effect of UV radiation on immune function and membrane markers of human Langerhans cells

Human Langerhans cells (LC) are located in the epidermal tissue which is naturally accessible to UV irradiation. They may be the first immunocompetent cells exposed to its effect. In the present study, the epidermal tissue was dissociated with trypsin, and epidermal cell (EC) suspensions, which contain keratinocytes, melanocytes, and LC were irradiated with UVB (10 or 20 mJ/cm2). After irradiation LC retained their surface determinants: T-6 and HLA-Dr. In addition, their number did not decrease during 3 days of culture following UVB exposure as compared with nonirradiated EC cultured in parallel. On the contrary, UV irradiation of EC resulted in decreased lymphocyte-stimulating ability in a mixed skin cell-lymphocyte culture reaction (MSLR). EC used directly after irradiation in MSLR induced about half the lymphocyte response compared to nonirradiated EC. After 24-h culture, the irradiated EC did not produce any lymphocyte response, whereas the 48-h cultures showed a slight lymphocyte stimulation. At 72 h the cultures from irradiated and nonirradiated EC showed similar responses in MSLR. The doses of UV radiation which decreased MSLR responses did not affect EC viability and did not significantly reduce their DNA content. It is suggested that under the experimental conditions used in this study the defect induced by UV irradiation was essentially functional and was the result of the transient inhibition of the antigen processing function of LC rather than of an alteration in membrane antigen expression (T-6 and HLA-Dr).

In vitro mixed skin cell lymphocyte culture reaction (MSLR) in man: analysis of the epidermal cell and T cell subpopulations

The nature of normal human epidermal cells (EC) and peripheral blood (PB) cells that react in vitro in allogeneic mixed skin cell lymphocyte culture reaction (MSLR) was investigated using monoclonal antibodies (MCAB) specific for cell subpopulations. T cells and helper-inducer and suppressor-cytotoxic T cell subsets were defined by OKT3, OKT4, OKT8 MCAB, respectively, whereas, among EC, Langerhans cells were characterized by reactivity with OKT6 or anti-HLA-DR MCAB. MSLR were conducted with untreated cell suspensions as controls and cells suspensions depleted of various functionally active cell subset(s). Two approaches were used for cell depletion: (1) complement (C')-mediated lysis by MCAB of T cells, T cell subsets, HLA-DR or OKT6 positive cells; (2) panning of PB cells or EC after pre-incubation with the appropriate MCAB to deplete or enrich (OKT6) cell suspensions with the respective cell subset. Responses in MSLR were abolished after treatment of PB cells with OKT3 + C' or OKT4 + C', significantly reduced with OKT8 + C'; they were abolished after incubation of EC with anti-HLA-DR + C' and significantly reduced with OKT6 + C'. After panning, OKT3 and OKT4 depleted populations did not proliferate in MSLR while OKT8 depleted populations respond as controls. OKT6 depleted EC were not able to stimulate PB cells, yet proliferation rates were increased after stimulation by OKT6 enriched EC. Data show that helper-inducer T cells (OKT3+; OKT4+) play the major role in MSLR and that the presence of Langerhans cells is necessary for the stimulation of PB cells. They also suggest that co-operation between helper and suppressor cells is necessary for an optimal response. Differences in results using either OKT6 or anti-HLA-Dr-C'-mediated treatment of EC may be related to differences in the cellular expression of these markers by EC.

[Autologous and allogeneic mixed lymphocyte-epidermal cell cultures in man. In vitro approach to lymphoepidermal interactions]

The ability of human normal skin epidermal cells (EC) to induce the proliferation of allogeneic and autologous lymphocytes was investigated in vitro in mixed skin cell-lymphocyte culture reaction (MSLR) as an in vitro approach of the lympho-epidermal interactions that are suspected to be involved in the pathogenesis of cutaneous inflammatory skin diseases and T cell lymphomas in man. Normal human EC were able to stimulate either allogeneic or autologous lymphocytes in MSLR in culture conditions similar to that previously reported in animals. The stimulation was higher in allogeneic than in autologous MSLR. MSLR did not appear to be affected by the trypsin treatment used to obtain EC in suspensions. Lymphocytes proliferation was maximal with a lymphocytes/EC ratio of 1:1. This suggests that autologous and allogeneic MSLR in man depends upon in vitro conditions similar to that studied in animals, and that MSLR may provide an useful tool for the study and the understanding of lympho-epidermal interactions in man.

Numeration of T cell subsets in sarcoidosis using monoclonal antibodies: decreased levels of peripheral blood T cells and cells with suppressor T cell phenotype

Peripheral blood lymphocytes frm 16 patients with sarcoidosis (9 patients with skin sarcoids, 7 patients with erythema nodosum and bilateral hilar adenopathy) and cutaneous anergy and from 23 age-matched healthy controls were characterized by reactivity with monoclonal antibodies OKT3, OKT4, OKT8 directed to surface antigens of T lymphocytes, helper-inducer and suppressor-cytotoxic T cell subsets, respectively. In contrast to healthy controls, patients with sarcoidosis had reduced percentages of OKT3+, OKT4+ and OKT8+ cells and a major decrease in the OKT8+ (suppressor) subset. However, these changes were significant only in the group of patients with acute sarcoidosis (erythema nodosum). This abnormal T cell distribution correlates with the alterations in cell-mediated immunity previously observed and suggests the presence of a defective circulating suppressor T cell activity in acute sarcoidosis.