Rodrigo Cepeda-Valdes

Fibroblast-Derived Dermal Matrix Drives Development of Aggressive Cutaneous Squamous Cell Carcinoma in Patients with Recessive Dystrophic Epidermolysis Bullosa

Patients with the genetic skin blistering disease recessive dystrophic epidermolysis bullosa (RDEB) develop aggressive cutaneous squamous cell carcinoma (cSCC). Metastasis leading to mortality is greater in RDEB than in other patient groups with cSCC. Here we investigate the dermal component in RDEB using mRNA expression profiling to compare cultured fibroblasts isolated from individuals without cSCC and directly from tumor matrix in RDEB and non-RDEB samples. Although gene expression of RDEB normal skin fibroblasts resembled that of cancer-associated fibroblasts, RDEB cancer-associated fibroblasts exhibited a distinct and divergent gene expression profile, with a large proportion of the differentially expressed genes involved in matrix and cell adhesion. RDEB cancer-associated fibroblasts conferred increased adhesion and invasion to tumor and nontumor keratinocytes. Reduction of COL7A1, the defective gene in RDEB, in normal dermal fibroblasts led to increased type XII collagen, thrombospondin-1, and Wnt-5A, while reexpression of wild type COL7A1 in RDEB fibroblasts decreased type XII collagen, thrombospondin-1, and Wnt-5A expression, reduced tumor cell invasion in organotypic culture, and restricted tumor growth in vivo. Overall, our findings show that matrix composition in patients with RDEB is a permissive environment for tumor development, and type VII collagen directly regulates the composition of matrix proteins secreted by dermal and cancer-associated fibroblasts.

Position effect on FGF13 associated with X-linked congenital generalized hypertrichosis

X-linked congenital generalized hypertrichosis (Online Mendelian Inheritance in Man 307150) is an extremely rare condition of hair overgrowth on different body sites. We previously reported linkage in a large Mexican family with X-linked congenital generalized hypertrichosis cosegregating with deafness and with dental and palate anomalies to Xq24-27. Using SNP oligonucleotide microarray analysis and whole-genome sequencing, we identified a 389-kb interchromosomal insertion at an extragenic palindrome site at Xq27.1 that completely cosegregates with the disease. Among the genes surrounding the insertion, we found that Fibroblast Growth Factor 13 (FGF13) mRNA levels were significantly reduced in affected individuals, and immunofluorescence staining revealed a striking decrease in FGF13 localization throughout the outer root sheath of affected hair follicles. Taken together, our findings suggest a role for FGF13 in hair follicle growth and in the hair cycle.

Immunofluorescence Mapping for the Diagnosis of Epidermolysis Bullosa

Immunofluorescence mapping is based on the detection of structural proteins of keratinocytes or of the dermo-epidermal junction using specific poly- or monoclonal antibodies. Through this method, the level of split formation can be determined by investigating the location of a given antigen in a natural or induced blister. This method also allows testing for the normal expression, reduction or absence of various structural proteins depending on the antibodies used. It has widely replaced transmission electron microscopy and is used as the initial laboratory test to prove the clinical diagnosis of epidermolysis bullosa.

Progress in epidermolysis bullosa: summary of a workshop in CILAD-2010*

Background  Epidermolysis bullosa (EB), a group of blistering disorders, manifests with fragility of skin and mucous membranes, with considerable phenotypic variability. As many as 15 distinct genes have been shown to harbor mutations inheritable forms of EB. The types and combinations of mutations in these genes and their consequences at the mRNA and protein levels, when placed on the affected individuals’ genetic background and the external trauma, explain the spectrum of phenotypes encountered in this disorder.

No Evidence That Human Papillomavirus Is Responsible for the Aggressive Nature of Recessive Dystrophic Epidermolysis Bullosa–Associated Squamous Cell Carcinoma

TO THE EDITOR Recessive dystrophic epidermolysis bullosa (RDEB) is a devastating inherited skin disease caused by mutations in the gene encoding type VII collagen (Christiano et al., 1993). The condition is characterized by skin fragility, trauma-induced skin blistering and chronic non-healing wounds (Mellerio et al., 2007). Patients with RDEB are at strongly increased risk of developing aggressive cutaneous squamous cell carcinoma (SCC) which is the cause of death by age 45 years in 70% of individuals with the most severe form of RDEB (Fine et al., 2009). Potential similarities between the microenvironment of non-healing wounds and mucosal epithelia where human papillomaviruses (HPV) have been shown to induce the development of SCC (Zur Hausen, 2009) led us to investigate whether HPV infection could be responsible for the increased incidence and aggressive nature of RDEB SCC. The involvement of HPV in the development of cutaneous SCC remains controversial except in the rare genodermatosis epidermodysplasia verruciformis (EV) where up to 60% of patients develop SCC containing high copy numbers of beta-PV (β-PV) (Harwood and Proby, 2002) which_may be restricted to a minority of tumor cells (Dell’Oste et al., 2009). The possibility that HPV are also involved in RDEB SCC has not been addressed. HPV are a diverse group of small double-stranded DNA viruses that infect squamous epithelial cells. The two largest genera are alpha-PV (α-PV), comprising all HPV genotypes found in mucosal lesions as well as many of those associated with benign skin warts, and β-PV, containing HPV types which have most frequently been associated with EV and cutaneous SCC (de Villiers et al., 2004). Because vaccines against prevalent high risk mucosal/genital HPV (HPV16/18) are available and effective at preventing cancer development (Zur Hausen, 2009), we tested RDEB SCC for the presence of 18 high risk α-PV types using the digene HPV genotyping reverse hybridization assay (RHA) detection kit (Qiagen, Leiden, The Netherlands). We tested DNA prepared from 21 separate SCC isolated from 12 RDEB patients as well as DNA from 39 organ transplant recipient (OTR) SCC and 18 immunocompetent (ICP) SCC collected for a separate study (Purdie et al., 2009) with 6 vulval SCC samples included as positive controls. All DNA were isolated from frozen tissue collected after informed consent and in accordance with Helsinki guidelines following research ethics committee approval. All cutaneous SCC from RDEB and non-RDEB individuals were negative, whereas 9 different α -PV types were detected in the vulval SCC samples. Next we tested the presence of beta-PV using the RHA kit skin (β) HPV detection system (Diassay, Rijswijk, The Netherlands) (de Koning et al., 2006). In addition to the cutaneous SCC samples described we tested 7 peri-tumoral skin samples from 5 of our SCC RDEB patients and normal uninvolved skin from 11 RDEB patients who had not yet developed SCC. As before, all DNA were isolated from frozen tissue. Data are summarized in Table 1. The overall detection rate of β-PV in RDEB SCC was 90% compared with 74% and 78% for OTR SCC and ICP SCC respectively, with similar frequencies observed in RDEB peri-tumoral and normal skin. As β-PV infection has been shown to be prevalent at low copy number in non-tumour bearing normal skin and hair follicles, a role for these viruses is perhaps more plausible in lesions with higher viral load (Feltkamp et al., 2008). We next examined viral load for β-PV using quantitative PCR (Q-PCR) as described (Weissenborn et al., 2010), with input cell equivalents determined by normalization to β-globin. HPV β types were chosen for investigation on the basis of their frequent detection in at least 2 of the 3 groups of SCC samples (Table 1). Data are summarized in Table 2. Only 25-38% of the RHA-positive SCC samples analyzed were above the detection threshold for Q-PCR, suggesting that the initial RHA detection method was extremely sensitive. The Q-PCR detection efficiency in RDEB SCC was not significantly different from that reported in a previous study of predominantly ICP SCC (Weissenborn et al., 2005) where 46% of samples showed detectable β-PV viral load (p=0.248, Fisher’s exact test). Furthermore, the relative viral load in the two studies were very similar, with all SCC showing comparatively low overall HPV-DNA copy numbers of less than one per five cell equivalents. It must be emphasized however that these data do not exclude the possibility of a considerably higher viral load in a subset of tumor cells, as recently demonstrated for EV SCC (Dell’Oste et al., 2009). With the exception of 2 HPV8-positive samples where viral load were comparable, the RDEB peri-tumoral and normal skin samples examined were below the Q-PCR detection threshold. These combined data imply that high copy number HPV infection is not a general feature of RDEB skin, despite its unique microenvironment. In particular, RDEB SCC does not appear significantly different from other cutaneous SCC in overall prevalence of HPV infection or viral load. Table 1 Percentage samples positive for β-HPV by reverse hybridization assay with multiple infection indicated. Table 2 Analysis of viral load for HPV types 5, 8, 15, 23 and 24 in each sample group. To our knowledge the possible contribution of HPV infection to RDEB-SCC pathogenesis is previously unreported. Although our numbers are small, 21 cases of RDEB SCC is a significant series for this rare disease and compares favorably with other examples of analysis in this tumor group (23 RDEB SCC examined for p53 immuno-staining (Slater et al., 1992) and 25 RDEB SCC analyzed for matrix metalloproteinase (MMP) immuno-staining (Kivisaari et al., 2008) for example. The use of highly sensitive PCR methodology to detect relatively ubiquitous viral DNA sequences together with confounding factors such as type of tissue analysed have yielded conflicting data on HPV prevalence in OTR versus ICP individuals, actinic keratosis versus SCC, and normal skin (Harwood and Proby, 2002; Weissenborn et al., 2005; Feltkamp et al., 2008; Mackintosh et al., 2009). Nevertheless, combined viral load data have shown that in contrast to α-PV and cervical cancer, β-PV presence is not necessary in each tumor cell for maintenance of the malignant phenotype, although this does not preclude a role for HPV in cutaneous SCC. Our results from RDEB SCC lie within the range of other cutaneous SCC data and show no evidence of HPV contribution to the increased incidence and aggressive nature of RDEB SCC.

Further insights in trichothiodistrophy: a clinical, microscopic, and ultrastructural study of 20 cases and literature review.

Background: Trichothiodistrophy (TTD) is a rare autosomal recessive condition that is characterized by a specific congenital hair shaft dysplasia caused by deficiency of sulfur associated with a wide spectrum of multisystem abnormalities. In this article, we study clinical, microscopic, and ultrastructural findings of 20 patients with TTD with the aim to add further insights regarding to this rare condition. Additionally, analyses of our results are compared with those extracted from the literature in order to enhance its comprehensibility. Materials and Methods: Twenty cases of TTD were included: 7 from Mexico and 14 from Spain. Clinical, microscopic, scanning electron microscopy (SEM) studies and X-ray microanalysis (XrMa) were carried out in all of them. Genetic studies were performed in all seven Mexican cases. Patients with xeroderma pigmentosum and xeroderma pigmentosum/TTD-complex were excluded. Results: Cuticular changes and longitudinal crests of the hair shaft were demonstrated. These crests were irregular, disorganized, following the hair longest axis. Hair shaft sulfur deficiency was disposed discontinuously and intermittently rather than uniformly. This severe decrease of sulfur contents was located close to the trichoschisis areas. Only five patients did not show related disturbances. Micro-dolichocephaly was observed in five cases and represented the most frequent facial dysmorphism found. It is also remarkable that all patients with urologic malformations also combined diverse neurologic disorders. Moreover, three Mexican sisters demonstrated the coexistence of scarce pubic vellus hair, developmental delay, onychodystrophy, and maxillar/mandibullar hypoplasia. Conclusions: TTD phenotype has greatly varied from very subtle forms to severe alterations such as neurologic abnormalities, blindness, lamellar ichthyosis and gonadal malformations. Herein, a multisystem study should be performed mandatorily in patients diagnosed with TTD.

Patterns of oral mucosa lesions in patients with epidermolysis bullosa: comparison and agreement between oral medicine and dermatology

BACKGROUND The oral mucosa in patients with epidermolysis bullosa (EB) can be affected with different lesions and degrees of severity. However, patterns of oral lesions in distinct types of EB are still unclear. OBJECTIVES The purpose of this study was to determine the frequency and distribution of four types of lesions (erythema, erosion, atrophy, and blister) for each oral site and to calculate the interobserver reliability for each type of lesion in each site. METHODS Ninety-two patients with different EB types were assessed independently by an oral medicine specialist and a dermatologist. The degree of agreement was calculated by the intraclass correlation coefficient (ICC). RESULTS The most affected oral site was the tongue, with the most frequent lesion being erythema and atrophy [54(58.7%) patients] for the oral medicine specialist and erosion [54(58.7%) patients] for the dermatologist. Patients with recessive dystrophic EB-severe generalized (RDEB-sev gen) showed the highest mean of sites involved by each lesion for both oral medicine and dermatology. The interobserver reliability on the total of lesions was excellent on only 3 sites: lower lip (ICC: 0.89; 95%CI:0.83-0.92), hard palate (ICC:0.85; 95%CI:0.72-0.91), and tongue (ICC:0.89; 95%CI:0.84-0.92), whereas the interobserver reliability calculated for each single oral lesion showed a lower agreement. CONCLUSION Total distribution of sites involved by four types of lesions was higher in RDEB-sev gen than in the rest of EB types, with a predominance of erythema followed by erosion. The agreement on the type of lesion was found to be poor-moderate for many oral sites.

Role of dystrophic epidermolysis bullosa in anxiety, depression and self-esteem: A controlled cross-sectional study.

The psychological aspect in patients with dystrophic epidermolysis bullosa (DEB) is poorly documented. We sought to determine the role of DEB in anxiety, depression and self‐esteem. We conducted a cross‐sectional study, collecting data from 27 DEB patients and 26 healthy individuals. DEB patients and healthy controls completed three different psychometric scales for anxiety and depression and one scale for self‐esteem. DEB patients and healthy controls were homogeneous for age and sex (P > 0.05), but not for employment, marital status and economic level (P < 0.05). Median values of all psychometric battery scales were not statistically significant between DEB patients and healthy controls, except for Goldberg scale for anxiety (P = 0.003) and depression (P = 0.037) and slightly significant for Zung Scale for anxiety (P = 0.048) with no difference between DEB patients with dominant versus recessive form in all scales (P > 0.05). Among DEB patients, only employment showed a significant difference in all scales (P < 0.05) but Hamilton for depression, whereas self‐esteem seemed to be affected by marriage (P = 0.04) and education (P = 0.016). DEB patients apparently are not more anxious and/or depressed and do not have less self‐esteem than healthy individuals.

Primary Cutaneous Coccidioidomycosis: Incidental Finding

Volume 3 • Issue 2 • 1000147 J Clin Exp Dermatol Res ISSN:2155-9554 JCEDR, an open access journal *Corresponding author: Julio C. Salas-Alanis, MD, Department of Dermatology, Facultad de Medicina y Hospital Universitario Dr. José E. González, Universidad Autónoma de Nuevo León. Av. Francisco I. Madero y Dr. Eduardo Aguirre Pequeño Col. Mitras Centro, 64460 Monterrey, México, Tel: +52 81 83676060; E-mail: drjuliosalas@gmail.com

Pain in Patients with Dystrophic Epidermolysis Bullosa: Association with Anxiety and Depression

Objective We investigate the presence and the quality of pain in patients with dystrophic epidermolysis bullosa (DEB), and its correlation with the level of anxiety and depression. Methods We collected data from 27 DEB patients and 26 healthy individuals. DEB patients and controls completed 1 scale for the quality of pain, and 1 scale for anxiety and depression. Pain was assessed with the short form of the McGill Pain Questionnaire, whereas anxiety and depression were assessed with the Hamilton rating scale for anxiety and depression. Results DEB patients and healthy control individuals were homogeneous for age and gender (p>0.05). A statistically significant difference in the two groups was seen for sensory pain rating scale (p<0.001), affective pain rating scale (p=0.029), total pain rating scale (p<0.001), visual analogue scale (p=0.012) and present pain intensity (p=0.001), but not for anxiety (p=0.169) and depression (p=0.530). The characteristics of pain that showed a significant difference between DEB patients and healthy controls were shooting, splitting, tender and throbbing (p<0.05). In DEB patients pain was not correlated with anxiety or depression (p>0.05), whereas a slight correlation between pain and anxiety was found in healthy controls (p<0.05). No difference was found between quality of pain and anxiety-depression in DEB patients (p>0.05), but was between the DEB dominant and the recessive form of DEB (p=0.025). Conclusion The perception of pain in DEB patients appears greater than in healthy individuals, with splitting and tender characteristics being the most significant ones, but was not associated with anxious and/or depressive symptoms.