Christoph M. Lanschuetzer

Treatment‐resistant classical epidermolysis bullosa acquisita responding to rituximab

SIR, Epidermolysis bullosa acquisita (EBA) is a chronic severe subepidermal blistering disease of the skin and mucous membranes characterized by marked resistance to topical and systemic therapy. We report a patient with a 6-year history of EBA refractory to any immunosuppressive medication (Fig. 1), who responded well to a treatment with the anti-CD20 monoclonal antibody rituximab. A 71-year-old woman presented with blisters and erosions on mechanically strained areas including hands, elbows and feet, that healed with scarring and milia formation and resulted in nail dystrophy, loss of toenails and scarring alopecia. Involvement of mucous membranes was initially confined to the oral cavity (Fig. 2), and later also occurred on oesophageal and pharyngolaryngeal mucosa. Histological examination of perilesional skin showed subepidermal blister formation and a mild infiltrate composed of lymphocytes and neutrophils. Conventional direct immunofluorescence of perilesional skin detected linear deposition of IgG and C3 at the dermoepidermal junction. No IgA or IgM deposits were found. Indirect immunofluorescence (IIF) with the patient’s serum on salt-split skin revealed an exclusive dermal binding of circulating IgG antibasement membrane zone (BMZ) antibodies at a titre of 1 : 2560. These antibodies recognized a band at 290 kDa, and a 145-kDa band corresponding to the a-chain of collagen VII in immunoblotting on keratinocyte extracts. Thus, the diagnosis of a classical mechanobullous type of EBA was made. Over a 6-year period several immunosuppressive agents, including corticosteroids, azathioprine, ciclosporin, plasmapheresis, mycophenolate mofetil, colchicine, gold preparations, highand low-dose immunoglobulins and daclizumab were administered but none of them resulted in prolonged clinical benefit (Fig. 1). Then in 2004, disease activity increased, mainly due to massive erosions of the pharyngolaryngeal and oesophageal mucosa, which resulted in upper and lower oesophageal stenoses. The anti-BMZ titre (1 : 320) was at this time point lower than in the previous years of the disease. The patient required endoscopic dilatation of oesophageal stenoses, percutaneous endoscopic gastrostomy and tracheotomy because of severe obstruction of the upper airways. We therefore decided to initiate an anti-CD20 monoclonal antibody therapy attempt. Concomitantly, vaccination against influenza A and Streptococcus pneumoniae was carried out. Five rituximab infusions were given intravenously at a frequency of one infusion per week. Because of the poor health condition of our patient and to avoid potential side-effects we used a reduced dose of 144 mg m each time. Concomitant immunosuppressive therapy was azathioprine 2Æ0 mg kg daily. Our patient tolerated the rituximab therapy well with absence of any side-effects or infections. Four weeks after the first rituximab infusion the patient showed marked improvement of the skin and mucous membrane condition (Fig. 2b) and concomitant therapy of azathioprine was discontinued. Transiently, IIF became negative and a repeated immunoblotting study could no longer detect antibodies reactive with the

Pathogenic mechanisms in epidermolysis bullosa naevi.

Epidermolysis bullosa naevi are large, eruptive melanocytic naevi which frequently arise in areas of former blisters in patients suffering from inherited epidermolysis bullosa. Morphologically, these naevi are similar to malignant melanoma, although so far no malignant transformation has been observed. To investigate the pathogenesis of these moles we documented their clinical evolution and their histopathological and immunocytological characteristics in three patients with epidermolysis bullosa. Clinically, we observed signs of malignant transformation, such as explosive growth and the occurrence of satellite lesions of epidermolysis bullosa naevi. However, malignant melanoma was excluded by histopathological evaluation. In addition, we evaluated the concentrations of various factors known to stimulate melanocyte growth in blister fluid. Human interleukin 8, basic fibroblast growth factor, human hepatocyte growth factor, GM-CSF, leukotriene B4 and prostaglandin E2 revealed concentrations comparable with the levels in inflammatory blisters. We were able to detect individual melanocytes/naevus cells in blister fluid from a blister over an epidermolysis bullosa naevus. The factors detected in the blister fluid might therefore promote the proliferation, migration and melanogenesis of disconnected melanocytes/naevus cells representing the basis of the highly dynamic appearance of epidermolysis bullosa naevi.

Herlitz Junctional Epidermolysis Bullosa

Junctional epidermolysis bullosa type Herlitz (JEB-H) is the autosomal recessively inherited, more severe variant of lucidolytic JEB. Characterized by generalized, extensive mucocutaneous blistering at birth and early lethality, this devastating condition is most often caused by homozygous null mutations in the genes LAMA3, LAMB3, or LAMC2, each encoding for 1 of the 3 chains of the heterotrimer laminin-332. The JEB-H subtype usually presents as a severe and clinically diverse variant of the EB group of mechanobullous genodermatoses. This article outlines the epidemiology, presentation, and diagnosis of JEB-H. Morbidity and mortality are high, necessitating optimized protocols for early (including prenatal) diagnosis and palliative care. Gene therapy remains the most promising perspective.

Epidermolysis bullosa nevi.

Epidermolysis bullosa (EB) nevi are large, eruptive, asymmetrical, often irregularly pigmented melanocytic lesions. Such nevi may give rise to small satellite nevi surrounding the primary nevus, and thus frequently manifest clinical features suggestive of melanoma. They usually arise in sites of previous bullae or erosions. At least twice a year all persisting wounds and EB nevi should be evaluated with a low threshold for histopathologic examination if warranted. Our practice is to punch biopsy EB nevi showing dermoscopic features of concern as well as dermoscopically featureless lesions. Given the skin fragility and potentially impaired wound healing in EB patients, we avoid prophylactic total excision of large EB nevi, but rather use the dermoscope to select appropriate sites for punch biopsies within giant EB nevi.

Cytokeratin-related loss of cellular integrity is not a major driving force of human intrinsic skin aging.

The contribution of extracellular matrix components to intrinsic skin aging has been investigated thoroughly, however, there is little information as to the role of the cytoskeletal proteins in this process. Therefore, we compared the expression of the constituents of the cytoskeleton, keratins 1-23 (K1-K23) as well as junction-plakoglobin (JUP), alpha-tubulin (TUBA), and beta-actin (ACTB) in human foreskins of both young (mean 6.4 years) and aged (mean 54.3 years) individuals. By applying RNA expression analysis to intrinsically aged human skin, we demonstrated that the mRNA levels of the genes for K1, K3, K4, K9, K13, K15, K18, K19 and K20 are downregulated in aged skin, K5 and K14 are unchanged, and K2, K16 and K17 are upregulated in aged skin. The mRNA data were confirmed on the protein level. This diverse picture is in contrast to other cytoskeletal proteins including components of the desmosome (JUP), microtubuli (TUBA) and microfilaments (ACTB) - often regarded as house-keeping genes - that were all reduced in aged skin. These cytoskeletal features of intrinsic aging highlight the importance of the cellular compartment in this process and demonstrate that special attention has to be given to RNA as well as protein normalization in aging studies.

Vaginal adenosis induced by Stevens–Johnson syndrome

896 JEADV 2006, 20, 868–902

Skin grafting as a therapeutic approach in pretibially restricted junctional epidermolysis bullosa.

an immunocompromised host may be coincidental. However, it is also conceivable that long-term immunosuppression and, in addition, fair complexion and a stay in the tropics represent cofactors for tumour development. Although cutaneous MFHs in RTRs are very rare, the case reported here shows that cutaneous MFH with a poor prognosis may arise after RT, especially in patients with several risk factors. To our knowledge, this is the first reported case of cutaneous MFH of the scalp in an RTR.

Introducing a fast and simple PCR-RFLP analysis for the detection of mutant thiopurine S-methyltransferase alleles TPMT*3A and TPMT*3C.

Backgroundu2002 Azathioprine, in combination with corticosteroids, is the first‐line therapy of severe forms of pemphigus vulgaris. Patients with an impaired thiopurine S‐methyltransferase (TPMT) activity are at risk of developing severe myelo‐suppression upon treatment with thiopurines such as azathioprine. Analysis of the TPMT status prior to drug administration is therefore highly recommended. However, because of the limited availability of TPMT testing outside of specialized centres, pre‐emptive TPMT testing is not widespread. To avoid laborious biochemical and sequencing assays, we evaluated a new restriction fragment length polymorphism (RFLP) analysis.

Haploinsufficiency due to deletion within the 3'-UTR of C1-INH-gene associated with hereditary angioedema.

Purpose: Sequences within the non-coding 3′UTR (untranslated region) of genes were reported to be involved in the regulation of gene expression by modifying pathways of (co)transcription, post-transcriptional processing and RNA transport. However, direct biological evidence (i.e., knock-out models) is sparse. This report intends to correlate the first reported alteration within the 3′UTR of the C1 inhibitor (C1-INH) gene with clinical presentation of hereditary angioedema (HAE).Methods and Results: Direct sequencing of genomic DNA revealed in all affected members of a family suffering from HAE a heterozygous 155 bp deletion 100 bp downstream of the physiological stop-codon in exon 8. A substantial reduction of both mRNA as well as C1-INH protein expression was revealed by RT-PCR and nephelometry, respectively.Conclusion: We suppose that the mutation within the 3′UTR interferes with integral pathways of gene expression leading to pathogenic haploinsufficiency in this family.

Nonsense-associated altered splicing of the Patched gene fails to suppress carcinogenesis in Gorlin syndrome.

Mutations in the gene coding for the transmembrane receptor protein Patched (PTCH) are implicated in the autosomal dominant disorder Gorlin syndrome (also known as naevoid basal cell carcinoma syndrome), characterized by congenital abnormalities and cancer predisposition. Tumour promotion is thought to be associated with aberrant function of PTCH, leading to misregulation of the hedgehog signalling network. However, the transcriptional events that underlie the reduced tumour suppression effects of PTCH have not been studied in detail. We describe a patient with Gorlin syndrome who had three molecular aberrations resulting in biallelic disruption of the PTCH gene, leading to abnormal protein expression and development of basal cell carcinoma. Remarkably, within tumour cells, the somatic nonsense mutation G1019X was associated with activation of a cryptic splice donor site, in which an in‐frame deletion of the exon sequence containing the nonsense mutation occurred. However, the function of the resulting PTCH protein variant was still compromised. The pathogenetic alterations described give insights into the sequence of events leading to cellular transformation and underscore the importance of the PTCH protein in skin homeostasis.