Ineke C. Janse

Sexual health and quality of life are impaired in hidradenitis suppurativa: a multicentre cross-sectional study

Hidradenitis suppurativa (HS) has a major impact on patients’ quality of life (QoL). Although it has commonly been assumed that HS impairs sexual health, only a single case–control study has been performed on sexual functioning in a small group of patients with HS.

Identification of Clinical and Genetic Parameters Associated with Hidradenitis Suppurativa in Inflammatory Bowel Disease

Background:Hidradenitis suppurativa (HS) has recently been associated with inflammatory bowel disease (IBD). The objective of this study is to investigate the prevalence of HS in IBD and to identify clinical and genetic parameters associated with HS in IBD. Methods:A questionnaire, validated for HS, was sent to 1969 patients suffering from IBD. Results:The prevalence of HS in our IBD cohort (1260 participating patients) was significantly higher than in the general population (6.8%–10.6% versus 1%–2%). IBD patients with HS were affected by IBD significantly earlier and more often treated with anti-TNF-&agr; therapy and surgical resection compared to IBD without HS. Female gender, smoking, a higher body mass index, and younger age were independent associated parameters for HS. Within cases allelic association analysis was performed for 59 cases (IBD with HS) and 293 controls (IBD without HS). We observed 2 promising new associations in genomic regions harboring ELOVL7 (rsnumber 10057395 P = 7.15 × 10−5, odds ratio = 0.4), and in the intergenic region between SULT1B1 and SULT1E1 (rsnumber 2014777 P = 7.48 × 10−5, odds ratio = 2.3). Conclusions:HS is present in 6.8% to 10.6% of IBD patients. Co-morbid HS is associated with an early onset of IBD in which anti–tumor necrosis factor-&agr; therapy and surgical resections are often needed. We identified a suggestive protective association with ELOVL7 and suggestive risk association with the genes SULT1B1 and SULT1E1 for HS, in the context of IBD. These genetic associations need further exploration and replication in additional independent cohorts.

No evidence of apoptotic cells in pemphigus acantholysis.

Background The exact mechanism by which autoantibodies against desmogleins induce acantholysis in pemphigus remains unsolved. Objectives In this study we explore the role of apoptosis in pemphigus acantholysis. Patients/ Methods Twenty–two skin biopsies from pemphigus vulgaris (PV) and pemphigus foliaceus (PF) patients and eight biopsies from a PV and PF in vitro skin model were included. In these biopsies immunofluorescence staining of cleaved caspase 3, cleaved caspase 8, poly (ADP-ribose) polymerase (PARP), fractin and TUNEL was performed. Fourteen skin biopsies from PV and PF patients were studied by electron microscopy for morphological features of apoptosis. Results In pemphigus patient skin and the in vitro skin model there was no expression of apoptotic markers. A few TUNEL positive cells were seen in three lesional PF biopsies and in the biopsies from the in vitro skin model. However, these observations did not differ from control biopsies. None of the PV and PF skin biopsies showed electron microscopic morphological features of apoptosis. Conclusions The absence of specific apoptotic signalling and morphological features of apoptosis in pemphigus patient skin does not support the hypothesis that apoptosis is involved in pemphigus acantholysis. Introduction Pemphigus is a group of rare mucocutaneous autoimmune bullous diseases that are characterized by intra–epidermal IgG deposition and loss of cohesion between keratinocytes, known as acantholysis. Although the pathogenic relevance of anti–desmosomal IgG has been clearly demonstrated, the exact mechanism by which IgG induces loss of adhesion remains unsolved. Cell signalling has received a lot of attention in the past years, including the death signalling (apoptotic) pathways. Apoptosis can be activated via an extrinsic or intrinsic pathway. In the extrinsic pathway, Fas L binds to the Fas receptor, which leads to the activation of caspase 8. In the intrinsic pathway, subsequently p53, bax, cytochrome c, and caspase 9 are activated. Both caspases 8 and 9 activate the common pathway caspase 3. Caspase 3 induces DNA fragmentation, which can be detected with poly (ADP–ribose) polymerase (PARP), fractin, and TUNEL.1,2 Apoptosis has been suggested as an upstream event in acantholysis, but alternatively, also as a downstream event after loss of cell–cell adhesion.3–5 4 Furthermore, it has been hypothesized that IgG might induce apoptotic enzymes but that these do not lead to cell death but instead to acantholysis, a mechanism referred to as apoptolysis.6 111 Acantholysis in pemphigus / CHAPTER 6 A thorough examination of the literature on apoptosis in pemphigus revealed that the possible involvement of apoptosis in acantholysis was mainly studied in cultured cell and/or mouse models, but rarely in patient skin.3 Despite this, the caspase pathway has already been suggested as a therapeutic target in pemphigus.7 This, together with, as mentioned before, conflicting results from various studies, propelled us to reinvestigate this topic. We therefore searched for evidence of apoptosis in pemphigus patient skin and in an in vitro skin model, wherein we induced acantholysis by patient IgG. We checked for activation of both the intrinsic and the extrinsic pathway by immunofluorescence and, furthermore, used electron microscopy to look for hallmarks of apoptosis. Materials and methods Pemphigus patient skin for immunofluorescence For immunofluorescence, we included 11 biopsies from 9 mucocutaneous pemphigus vulgaris (PV) patients (5 from healthy skin, 3 from perilesional skin, and 3 from lesional skin), and 11 biopsies from 7 pemphigus foliaceus (PF) patients (4 from healthy skin, 2 from perilesional skin, and 5 from lesional skin). Pemphigus biopsies were selected from patients with increased anti–Dsg antibodies determined by enzyme–linked immunosorbent assay (ELISA) (increased anti–Dsg1 and anti–Dsg3 index for mucocutaneous PV, increased anti–Dsg1 and normal Dsg3 index for PF). Moreover, all pemphigus biopsies needed to show pemphigus specific epithelial cell surface (ECS) IgG depositions. All samples were immediately frozen in liquid nitrogen and stored at –80°C. All used patient tissue was residual tissue, taken in the past for diagnostics. For this reason patient consent for experiments was not required. Immunofluorescent analysis was performed for cleaved caspase 3, cleaved caspase 8, cleaved PARP, fractin, and TUNEL. For all the stainings except TUNEL, one healthy skin sample was used as negative control9 and one basal cell carcinoma tissue sample, one colon carcinoma tissue sample and one toxic epidermal necrolysis (TEN) skin sample served as positive controls.10–12 For TUNEL four normal human skin samples served as negative controls and four samples of the same skin treated for 10 minutes with DNAse 1 and one TEN skin sample served as positive controls. The control samples were evaluated in the same experiment as the pemphigus specimens. Pemphigus in vitro model for immunofluorescence We used eight biopsies from a previously described pemphigus in vitro model experiment.8 In these experiments, healthy breast reduction skin biopsies had been incubated with purified 112 Acantholysis in pemphigus / CHAPTER 6 pemphigus IgG (for 4, 16, and 24 hours with PV IgG and for 24, 48, and 72 hours with PF IgG). The PV IgG dose was 12.2 mg/ml, the PF IgG dose was 10.8 mg/ml. After harvesting, the biopsies were frozen in liquid nitrogen and stored at –80°C. Again, the aforementioned controls (pemphigus patient skin for immunofluorescence) were evaluated in the same experiment as the in vitro model samples. Additionally, control incubations included three healthy IgG and two omission of IgG. Staining procedure The following antibodies were used to detect apoptosis: cleaved caspase–3 rabbit monoclonal antibody (Cell Signalling, Danvers, U.S.A) in a dilution of 1/50, cleaved caspase–8 rabbit monoclonal antibody (Cell Signalling, Danvers, U.S.A) in a dilution of 1/200, cleaved PARP rabbit monoclonal antibody (Cell signalling, 1 Danvers, U.S.A.) in a dilution of 1/200 and fractin rabbit polyclonal antibody in a dilution of 1/200 (Mybiosource, San Diego, U.S.A). Cryosections of 4 μm were incubated overnight with one of the selected antibodies in phosphate buffered saline containing 1% ovalbumine (PBS–OVA) at 4°C. Next, the sections were incubated with donkey anti rabbit fluorescein isothiocyanate (FITC) (dilution 1/100 in PBS–OVA) labeled secondary antibody for 1 hour at room temperature. Finally, the sections were counterstained with bisbenzimide (BB) (1:10000 diluted in PBS) for 5 minutes at room temperature and coverslipped under SlowFade® Antifade reagent (Invitrogen, Paisley, U.K.). TUNEL (Roche, Mannheim, Germany) was performed as follows. After fixation with paraformaldehyde (4% in PBS, pH 7.4) for 30 minutes, the sections were permeabilized with 0.1% Triton X–100 in 0.1% sodium citrate for 2 min on ice. Then, the sections were incubated with the TUNEL reaction mixture containing terminal deoxynucleotidyl transferase (TdT) and fluorescein dUTP (diluted 1:10 in label solution) in a humidified chamber for 60 minutes at 37oC in dark (sections covered with cover slip during incubation). After that, the sections were counterstained with BB (1:10000 diluted in PBS) for 5 minutes at room temperature and coverslipped under SlowFade® Antifade reagent. Evaluation of the samples Per sample 5 high power fields were evaluated. If staining was present, between 45 and 259 keratinocytes were evaluated in the most representative high power fields, and the percentage of TUNEL was counted by two independent observers. 113 Acantholysis in pemphigus / CHAPTER 6 Pemphigus patient skin for electron microscopy Finally, six skin biopsies (two lesional, one perilesional, and three non–lesional) from four mucocutaneous PV patients and nine skin biopsies (five lesional, one perilesional, and three non– lesional) from eight PF patients were investigated by electron microscopy for ultrastructural signs of apoptosis. Electron microscopy was performed as described before.8 For electron microscopy, pemphigus patient skin biopsies were selected that met the same inclusion criteria as described under ‘pemphigus patient skin for immunofluorescence’. The number of sections and cells examined differed per sample. PV lesional 1: 7 sections (1–10 cells), PV lesional 2: 5 sections (2–40 cells), PV perilesional 1: 5 sections (2–15 cells), PV non-lesional 1: 4 sections (1–8 cells), PV non-lesional 2: 4 sections (2–25 cells), PV non-lesional 3: 5 sections (3–15 cells), PF lesional 1: 4 sections (3–10 cells), PF lesional 2: 4 sections (2–22 cells), PF lesional 3: 4 sections (2–9 cells), PF lesional 4: 3 sections (2–22 cells), PF lesional 5: 3 sections (2–8 cells), PF perilesional 1: 1 section (8 cells), PF non-lesional 1: 4 sections (2–5 cells), PF non-lesional 2: 3 sections (2–10 cells), PF non-lesional 3: 5 sections (2–20 cells). Basal cell carcinoma served as a positive control (Figure S3). Figure S3 – Electron microscopy of basal cell carcinoma (BCC). Basal cell carcinoma tissue shows nuclear fragmentatie. * = nuclear fragmentation. Scale bar = 5 μm. 114 Acantholysis in pemphigus / CHAPTER 6 Results The apoptotic markers stained positive in the positive–control tissues but were absent in the negative controls (Figure S1). None of the pemphigus skin biopsies showed positive staining of cleaved caspase 3, cleaved caspase 8, fractin, or nuclear PARP. In PV, TUNEL was positive in 0.46% (range, 0–0.97%) of lesional epidermis and in 1.25% (range, 0–2.94%) of perilesional epidermis. In PF, these numbers were 4.42% (range, 0–17.78%) for lesional epidermis and 0.84% (range, 0–1.91%) for perilesional epidermis (Figure 1). In healthy pemphigus skin, positive cells were only sporadically present. In healthy control skin, 1.11% of the cells were TUNEL positive (range, 0–4.44%). Acantholysis was present in PV IgG–incubated

Surgical Procedures in Hidradenitis Suppurativa

Hidradenitis suppurativa is difficult to treat owing to its complex pathomechanism; beside the extensive inflammation with abscesses and inflammatory nodules, there is also an architectural loss with sinus tract formation and in severe cases with extensive scarring. Therefore, surgery is mandatory in moderate and severe HS.

Hurley staging refined: A proposal by the dutch hidradenitis suppurativa expert group

Sir, Hidradenitis suppurativa (HS) is a chronic, recurring, debilitating inflammatory skin disease, which mainly affects the inverse areas of the body leading to scarring and disfigurement (1, 2). The European S1 guideline for the treatment of HS summarized all published treatments for HS (1). The quality of evidence for these treatments is generally low, as was recently demonstrated in a Cochrane Review on interventions for HS, which identified only 12 randomized controlled trials (RCTs) (3). Moreover, HS is a heterogeneous disease with distinct clinical phenotypes that may require different treatment strategies, further complicating the therapeutic decision-making process (4). The European S1 guideline proposed a “Hurley severity grade-relevant treatment algorithm” (1). More recently Gulliver et al. (5) proposed another treatment algorithm based on disease severity measured by Hurley grade or PGA. Hurley stage is a 3-stage classification of severity. Hurley stage I is characterized by abscess formation with out sinus tracts and scarring. In Hurley II, patients have single or multiple separated areas of recurrent abscesses with sinus tracts and scarring, whereas in stage III the multiple interconnected sinus tracts and abscesses cover the whole affected anatomical area. This classification in its original form was created mainly for surgical purposes and does not take into account the inflammatory component. In addition, the extension of the disease, i.e. the number of anatomical areas involved, is not assessed. Accurate stratification of the wide variety of HS clinical phenotypes is therefore not possible with the original Hurley score. Furthermore, the recently invented dynamic scoring system Hidradenitis Suppurativa Clinical Response (6) focuses mainly on the inflammatory component and is more or less comparable with a PASI 50 improvement in psoriasis and therefore is mainly suitable for the follow-up of systemic treatments. How ever, these scores do not calculate or include the extensiveness of the disease. The number of anatomical areas involved is important in designing a holistic treatment plan as this should take into account the estimated number of surgical interventions needed (Fig. S11). Here, we (the Dutch HS expert group and as a part of the European Hidradenitis Suppurativa Foundation e.V.) propose a refinement of the current Hurley staging. Briefly, a 3 stepwise algorithm, including assessing the presence of sinus tracts, degree of inflammation and the extensiveness, enables the clinician to assess severity across the different phenotypes of HS and helps to guide treatment (Fig. 1). In the first step of the algorithm the presence of sinus tracts is assessed, clearly separating Hurley I from Hurley II and III. In Hurley I the differentiation between fixed and migratory lesions is essential. Hurley 1C is considered as severe HS and is characterized by the presence of migratory lesions and corresponds with the recently proposed scarring folliculitis and frictional furuncle phenotype (4). Since migratory lesions point to a strong inflammatory component, the cornerstone of treatment Hurley Staging Refined: A Proposal by the Dutch Hidradenitis Suppurativa Expert Group

Increased Expression of Integrin alpha 6 beta 4 in the Basement Membrane Zone Lining the Sebaceous Glands in Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is an inflammatory skin disease characterized by painful nodules, abscesses and sinus tracts. The disease is located primarily in the apocrine gland-bearing skin, including the armpits and groins (1). Previous studies have shown that follicular occlusion is present in the majority of patients at an early stage of the disease (2–5); however, the driving mechanism behind this follicular occlusion is unknown. Recently, diminished periodic acid-Schiff (PAS) staining was found in the basement membrane zone (BMZ) of the sebofollicular junction (SFJ) at the folliculopilosebaceous units (FPSU) in perilesional HS skin (6). The authors suggest that the PAS-negative gaps represent primary defects in the BMZ, leading to fragility of the hair follicle. Diminished expression in one of the glycoproteins in the BMZ of the SFJ might explain these PAS-negative gaps; however, there was no staining for specific glycoproteins in this study. Therefore, we investigated the expression of the most important BMZ components, including type XVII collagen, type VII collagen, laminin-332, and integrin α6β4, of the follicular epidermis relative to the interfollicular epidermis in HS and compared the expression ratio with that of healthy controls.

Hidradenitis suppurativa: A disease of infundibular epidermis, rather than pilosebaceous units?

although the exact pathogenesis of hidradenitis suppurativa (HS) is unknown, it is established that it is primarily an infundibulitis.(1,2) We consider infundibulum as epidermis and not as hair follicle according to Ackerman, as the type of epithelial tissue of infundibular epidermis is indistinguishable from that of interfollicular epidermis.(1) This article is protected by copyright. All rights reserved.