Elizabeth A. Duell

Cyclosporine for plaque-type psoriasis: Results of a multidose, double-blind trial

BACKGROUND Severe plaque-type psoriasis has been successfully treated with orally administered cyclosporine, but there has been no comparative, controlled evaluation of various dosages and their efficacy and side effects. METHODS In a 16-week, double-blind trial, we randomly assigned 85 patients with severe psoriasis to receive 3, 5, or 7.5 mg of cyclosporine per kilogram of body weight per day or a placebo consisting of the vehicle for the drug. After eight weeks the dose could be adjusted to improve safety or efficacy while maintaining blinding. RESULTS The psoriasis improved in a dose-dependent fashion. After eight weeks of fixed-dose therapy, 36, 65, and 80 percent of the patients receiving 3, 5, and 7.5 mg of cyclosporine per kilogram per day, respectively, were rated as being clear or almost clear of psoriasis; each group had significant improvement (P less than 0.0001) as compared with the group receiving vehicle, in which none of the patients were rated as clear or almost clear. The patients who received 5 mg per kilogram were the least likely to require dosage adjustments because of side effects or a lack of efficacy. The glomerular filtration rate, measured in a subgroup of 34 patients receiving cyclosporine, decreased by a median of 16 percent. Higher doses of cyclosporine had greater adverse effects on systolic blood pressure, glomerular filtration rate, and serum levels of creatinine, uric acid, bilirubin, and cholesterol. Delayed-type hypersensitivity reactions to skin-test antigens were reduced by cyclosporine administration. Cyclosporine appears to become concentrated in skin. CONCLUSIONS Cyclosporine therapy leads to a rapid and thorough clearing of psoriasis; an initial dose of 5 mg per kilogram per day seems to be appropriate. However, the safety of cyclosporine for the long-term treatment of psoriasis remains to be determined.

Effect of topical cyclosporine rinse on oral lichen planus. A double-blind analysis.

BACKGROUND Oral lichen planus is a relatively common disorder of the mouth that can be debilitating. It is frequently palliated with topical or systemic corticosteroids and retinoids. These treatments require prolonged use, however, and are not always effective. METHODS In a double-blind trial, 16 patients with symptomatic oral lichen planus were randomly assigned to receive either topical cyclosporine or its vehicle. The patients swished and expectorated 5 ml of medication (containing 100 mg of cyclosporine per milliliter) three times daily. RESULTS After eight weeks, the eight recipients of cyclosporine had marked improvement in erythema (P = 0.003), erosion (P = 0.02), reticulation (presence of white lacelike lesions; P = 0.007), and pain (P = 0.002), whereas the eight recipients of vehicle had no change or minimal improvement. After a switch to cyclosporine for eight weeks, the vehicle-treated patients had improvement similar to that seen in the patients who initially received cyclosporine. There were no systemic side effects. In most cases blood cyclosporine levels were low or undertectable. Cyclosporine levels present in specimens of oral mucosa at the end of therapy four hours after the patients swished were similar to the levels previously reported in psoriatic lesions after treatment with systemic cyclosporine (14 mg per kilogram of body weight per day). CONCLUSIONS As a topical preparation, cyclosporine may be useful in the treatment of oral lichen planus and possibly other cutaneous disorders.

Human skin levels of retinoic acid and cytochrome P-450-derived 4-hydroxyretinoic acid after topical application of retinoic acid in vivo compared to concentrations required to stimulate retinoic acid receptor-mediated transcription in vitro.

Metabolism of retinoic acid to a less active metabolite, 4-hydroxyretinoic acid, occurs via cytochrome P-450 isozyme(s). Effect of a pharmacological dose of retinoic acid on the level of retinoic acid in skin and on cytochrome P-450 activity was investigated. A cream containing 0.1% retinoic acid or cream alone was applied topically to adult human skin for four days under occlusion. Treated areas were removed by a keratome and a microsomal fraction was isolated from each biopsy. In vitro incubation of 3H-retinoic acid with microsomes from in vivo retinoic acid treated sites resulted in a 4.5-fold increase (P = 0.0001, n = 13) in its transformation to 4-hydroxyretinoic acid in comparison to in vitro incubations with microsomes from in vivo cream alone treated sites. This cytochrome P-450 mediated activity was oxygen- and NADPH-dependent and was inhibited 68% by 5 microM ketoconazole (P = 0.0035, n = 8) and 51% by carbon monoxide (P = 0.02, n = 6). Cotransfection of individual retinoic acid receptors (RARs) or retinoid X receptor-alpha (RXR-alpha) and a chloramphenicol acetyl transferase (CAT) reporter plasmid containing a retinoic acid responsive element into CV-1 cells was used to determine the ED50 values for stimulation of CAT activity by retinoic acid and its metabolites. Levels of all trans and 13-cis RA in RA-treated tissues were greater than the ED50 values determined for all three RARs with these compounds. Furthermore, the level of all trans RA was greater than the ED50 for RXR-alpha whereas the 4-OH RA level was greater than the ED50 for RAR-beta and RAR-gamma but less than for RAR-alpha and RXR-alpha. These data suggest that there are sufficient amounts of retinoic acid in treated skin to activate gene transcription over both RARs and RXR-alpha.

Increased cyclic GMP and decreased cyclic AMP levels in the hyperplastic, abnormally differentiated epidermis of psoriasis

Summary The genetic skin disease psoriasis has been examined as a model system that may provide an understanding of the control of normal epidermal specialization (differentiation) and the perturbed regulatory processes in proliferatioe diseases . The excessive glycogen accwnulation, increased proliferation and decreased tissue specialization characteristic of psoriasis involve cellular pro- cesses that have been shown to be regulated by cyclic AMP in other cells and tissues . It has also been suggested that cyclic GMP is a cellular ef- fector that may be involved in promoting cell pro- liferation and other events that oppose those be- lieved to be mediated by cyclic AMP . It was postulated, therefore, that the epidermis of the psoriasis lesion might exhibit an imbalance in the cellular concentrations of these two cyclic nucleo- tides . In this study the levels of cyclic AMP were measured in the involved epidermis (IE) and unin- volved epidermis (UE) from 25 psoriasis patients . The concentrations of cyclic AMP were found as reported previously using a different analytical procedure, to be significantly lower in IE based on protein and DNA . A comparison of the levels of cyclic .GMP in IE versus UE of 12 other psoriasis patients showed the levels of this cyclic nucleo- tide to be significantly increased in IE based on protein, DNA and wet weight . We suggest that this imbalance in the ratio of these two cyclic nucleo- tides may have pathophysiological relevance to the initiation and/or the maintenance of the psoriasis lesion .

Effect of Topical Cyclosporine Rinse on Oral Lichen Planus

BACKGROUND Oral lichen planus is a relatively common disorder of the mouth that can be debilitating. It is frequently palliated with topical or systemic corticosteroids and retinoids. These treatments require prolonged use, however, and are not always effective. METHODS In a double-blind trial, 16 patients with symptomatic oral lichen planus were randomly assigned to receive either topical cyclosporine or its vehicle. The patients swished and expectorated 5 ml of medication (containing 100 mg of cyclosporine per milliliter) three times daily. RESULTS After eight weeks, the eight recipients of cyclosporine had marked improvement in erythema (P = 0.003), erosion (P = 0.02), reticulation (presence of white lacelike lesions; P = 0.007), and pain (P = 0.002), whereas the eight recipients of vehicle had no change or minimal improvement. After a switch to cyclosporine for eight weeks, the vehicle-treated patients had improvement similar to that seen in the patients who initially received cyclosporine. There were no systemic side effects. In most cases blood cyclosporine levels were low or undertectable. Cyclosporine levels present in specimens of oral mucosa at the end of therapy four hours after the patients swished were similar to the levels previously reported in psoriatic lesions after treatment with systemic cyclosporine (14 mg per kilogram of body weight per day). CONCLUSIONS As a topical preparation, cyclosporine may be useful in the treatment of oral lichen planus and possibly other cutaneous disorders.

Topical cyclosporine A inhibits the phorbol ester induced hyperplastic inflammatory response but not protein kinase C activation in mouse epidermis

Cyclosporine A (CsA) is efficacious in the treatment of psoriasis. Although CsA is known to inhibit T-lymphocyte proliferation in vitro, whether this is its mode of action in psoriasis is uncertain. 12-0-tetradecanoylphorbol-13-acetate (TPA) induces an inflammatory, hyperplastic response in mouse skin, with many of the biochemical and histologic aberrations that occur in psoriatic epidermis. Protein kinase C is the major cellular phorbol ester receptor, and most responses of cells to TPA are mediated by PK-C, which is directly activated by TPA. We therefore have investigated the effects of CsA on pleiotypic responses induced by TPA and whether CsA acts in vivo as a direct inhibitor of PK-C. Simultaneous application of CsA (1.7 mumol) and TPA (10 nmol) to mouse skin significantly reduced inflammatory cell infiltration and increased epidermal thickness induced by TPA treatment alone. CsA had to be applied within 30 min of TPA application in order to have a significant inhibitory effect. Optimal doses of CsA inhibited TPA-induced ODC activity, TGase activity, arachidonic acid release, and interleukin-1 beta (IL-1 beta) mRNA to the same degree (approximately 80%), despite measurement at widely different times (30 min-12 h) required to obtain maximal induction by TPA. CsA did not, however, directly inhibit activation of PK-C by TPA. These data demonstrate that CsA blocks the pleiotypic responses of mouse skin to TPA treatment involving biochemical events, inflammatory cell infiltration, and epidermal hyperplasia. The molecular site(s) of action of CsA appears to be distal to the initial activation of PK-C by TPA and clearly inhibits PK-C inducible events. Furthermore, the above data suggest that CsA may directly affect keratinocytes in vivo.

A retinoic acid-inducible skin-specific gene (RIS-1/psoriasin): molecular cloning and analysis of gene expression in human skin in vivo and cultured skin cells in vitro.

A retinoic acid (RA) inducible skin-specific gene transcript (RIS-1) was isolated by differential hybridization screening of a RA-treated human skin cDNA library. The library was constructed from pooled RNA derived from normal adult human skin treated with alltrans-RA for 4 h (n=6) and 12 h (n=6)in vivo. RIS-1 cDNA corresponded to a 0.6 kb transcript that was barely detectable in normal adult human skin but was significantly induced by 8 h in RA-treated compared to vehicle-treated skin (range 1.1–3.6 fold). Prolonged RA treatment for up to 24 h further increased relative RIS-1 mRNA levels by 1.3–5.5 fold. HPLC analysis of the RA content of 0.1% RA-treated skinin vivo revealed significant levels at 6 h (18.8–120.6 ng RA/g wet weight tissue; approximately 240 nM), immediately preceding the time point at which the increased RIS-1 mRNA level was first seen. This concentration of RA also induced the mRNA levels for cellular RA binding protein II (1.6–19 fold), a marker of RA activity in human skin. RIS-1 mRNA was detected by Northern and dot blotting only in normal skin but not in any other normal human tissues examined, indicating a tissue-specific pattern of gene expression. RIS-1 transcripts were detected at very low levels in untreated cultured human epidermal keratinocytes, while no expression was seen in dermal fibroblasts and melanocytes, the other major cell types in skin. Southern analysis of human and mouse DNA indicated the existence of evolutionarily conserved sequences for RIS-1 between these two species. The polypeptide sequence derived from the partial RIS-1 cDNA was found to be identical to the calcium binding domain found in ‘psoriasin’, a gene whose expression appears to be increased in the skin of psoriasis patients.

Identification of a beta2-adrenergic receptor in mammalian epidermis

Abstract The presence of a beta 2 -adrenergic receptor in the epidermis has been demonstrated, based on the following pieces of information: (1) the addition of salbutamol, a beta 2 -agonist, to slices of epidermal tissue increased the levels of cyclic AMP in the tissue above control levels in a dose-dependent manner with a maximum response after 5 min of incubation in 5 × 10 −5 M salbutamol, (2) the addition of butoxamine, a beta 2 -antagonist, in conjunction with isoproterenol or salbutamol reduced the epidermal cyclic AMP levels when compared to levels obtained with agonist alone, (3) practolol, a beta 1 -antagonist. had little effect on the salbutamol-induced increases in the cyclic AMP levels and further elevated the levels of cyclic AMP obtained by the addition of isoproterenol, (4) the addition of propranolol to the tissue in conjunction with isoproterenol or salbutamol reduced the levels of cyclic AMP to near control values, and (5) Ro 20-1724, a cyclic nucleotide phosphodiesterase inhibitor, maintained the salbutamolelevated cyclic AMP levels for a longer period of time.

EPR measurements showing that plasma membrane viscosity can vary from 30 to 100 cP in human epidermal cell strains

Abstract A rigorous technique for the measurement of human membrane viscosity by electron paramagnetic resonance (EPR) spectroscopy has been developed by designing a sample preparation procedure to optimize the spin labeling process and using a special (grown in essential fatty acid free medium) epidermal cell strain. The essential fatty acid deficient cell strains (keratinocytes) were also grown in fatty acid supplemented media formulated to alter the fatty acid composition of the phospholipids that form the cell membrane. Fatty acid free bovine serum albumin was used as a carrier for the spin label (16-doxyl stearate methyl ester) at an approximately equimolar ratio. Monolayers grown in T-75 flasks were labeled for 15 min at 4°C with 12 μM bovine serum albumin plus 20 μM spin label. The cells were then washed and transferred (at 4°C) to a flatcell for EPR studies at 37°C. The spectra were computer simulated and the results were interpreted by comparison with a “standard curve” obtained from the EPR spectra of the spin label in oil at multiple temperatures. Arguments are presented for preferring this measurement technique over the more conventional use of order parameters and over the use of some other spin labels. The EPR spectra were completely insensitive to the effects of molecular dioxygen in the growth medium and cytoplasm, but remarkabley sensitive to the fatty acid composition of the cellular phospholipids. Fatty acid modified epidermal cells showed a very strong correlation between membrane fluidity (a three-fold change in the membrane viscosity) and a fatty acid double bond index.

Arachidonic acid metabolites: effects on inflammation of fetal rabbit excisional wounds.

Uncovered fetal rabbit excisional wounds do not exhibit any classic signs of healing; wounds covered with an impermeable cover do contract, reepithelialize, and exhibit inflammation. Prostaglandin E2 (PGE2) is elevated in amniotic fluid, acting as an immunosuppressant at the maternal-fetal interface. Full-thickness excisional wounds were made on 25-day gestational age rabbit fetuses. Half the wounds were covered with an impermeable cover. Tissue from covered, uncovered, and nonwounded fetuses was examined 72 h after wounding for arachidonic acid metabolites. Uncovered wounds had significantly (P≤0.05) elevated levels of PGE2, PGE2α, and 12-HETE versus covered wounds and control tissue. Covered wounds had significantly elevated levels of 15-HETE compared to uncovered and control tissue. The elevated PGE2 in uncovered wounds may act as a fetal immunosuppressant; covered wounds (lower PGE2) developed cellular inflammation. Further investigations of these interactions may permit modulation of adult inflammation.