Thomas Herzinger

Analysis of 14-3-3|[sigma]| expression in hyperproliferative skin diseases reveals selective loss associated with CpG-methylation in basal cell carcinoma

The p53-regulated 14-3-3σ gene encodes an inhibitor of cell cycle progression essential for senescence and clonal evolution of keratinocytes in vitro. Here we analysed the in vivo expression of 14-3-3σ protein in several skin diseases, which are characterized by hyperproliferative keratinocytes. Unexpectedly, the 14-3-3σ protein was expressed at high levels in psoriasis (11 of 11 patients), condylomata acuminata (11/11), actinic keratoses (11/11) and squamous cell carcinomas (SCC) (11/11). However, keratinocytes that had undergone transformation to basal cell carcinoma (BCC) showed partial (10 of 41; 24.4%) or complete (19 of 41; 46.3%) loss of 14-3-3σ protein expression. BCC (5/5), SCC (6/6) and actinic keratoses (7/7) concomitantly expressed the p53-homolog p63 and 14-3-3σ at high levels, ruling out potential inhibitory effects of p63 isoforms on 14-3-3σ transcription as the basis for loss of 14-3-3σ expression. Of 41 BCC samples isolated by laser-capture microdissection, 28 (68.3%) showed CpG-hypermethylation of the 14-3-3σ promoter combined with reduced or absent 14-3-3σ protein levels in 22 cases (78.6%). Since it has been reported that BCC retain wild-type p16INK4A and here BCC with CpG-methylation of 14-3-3σ did not show CpG-methylation of p16INK4A (0/17), silencing of 14-3-3σ may contribute to evasion of senescence in BCC. As experimental removal of 14-3-3σ sensitizes to DNA damage, silencing of 14-3-3σ may explain the high efficacy of radiation therapy in the treatment of BCC.

Discrimination of the irritancy potential of surfactants in vitro by two cytotoxicity assays using normal human keratinocytes, HaCaT cells and 3T3 mouse fibroblasts: Correlation with in vivo data from a soap chamber assay

Cell cultures have been proposed as a promising model for local tolerance testing. This study evaluated the cytotoxic effects of surfactants on early passage normal human keratinocytes, transformed human keratinocytes (HaCaT cells) and Swiss 3T3 embryonic mouse fibroblasts. Cell membrane integrity, as assessed by the release of the vital dye neutral red, and cell proliferation, as assessed by measurement of the total protein content, were both affected in a dose-dependent manner in response to surfactant exposure. There was a close correlation between the dose-response characteristics for the three cell types. Two surfactants exhibited differential effects on membrane integrity and proliferation, and thus no significant correlation was found between the two endpoints. The irritation potential of the surfactants to human forearm skin in vivo was assessed in a soap chamber test using transepidermal water loss and skin redness as quantitative endpoints. A comparison between the responses in vivo and in vitro yielded the highest correlation for the neutral red release test on normal keratinocytes. The total protein test did not significantly correlate with the soap chamber assay for keratinocytes and HaCaT cells. These results suggest that cultured normal human keratinocytes may be predictive for the irritancy of various surfactants in man. Definite judgement, however, has still to be based on confirmation in human volunteers of larger groups of compounds with diverse physico-chemical properties.

Sphingosine-1-phosphate signaling and the skin.

Sphingolipids have long been viewed as rather passive structural components of cellular membranes. More recently, it has become evident that metabolism of sphingomyelin yields several lipid mediators that evoke diverse and specific responses in different cell types. One sphingomyelin derivate, sphingosine-1-phosphate (S1P), has attracted particular attention for its effect on epidermal cells, which differs from those on most other cell types. S1P inhibits keratinocyte proliferation and induces keratinocyte differentiation and migration, suggesting a role for S1P in the re-epithelialization of wounds. The migratory response involves the phosphorylation and activation of Smad3. In epithelial tumors, S1P signaling has been linked with potential oncogenic effects, but has also been found to inhibit metastasis in a mouse melanoma model. S1P promotes endothelial cell survival, acts as a chemoattractant for vascular cells, and exerts a protective effect on the endothelial barrier. Conversely, S1P receptor knockout leads to embryonic lethality mainly due to impaired vascular maturation. S1P presumably modulates peripheral T-lymphocyte levels by stimulating their egress from lymphoid organs rather than by promoting T-cell proliferation. The S1P analog FTY720 (fingolimod) acts as a functional antagonist by inhibiting lymphocyte egress, and thus holds great promise as an immunosuppressant drug for the prevention of allograft rejection and treatment of T-lymphocyte-driven inflammatory skin diseases, such as lupus erythematosus, psoriasis, and atopic dermatitis. Topical use of S1P and other sphingosine compounds is also under investigation, particularly for the treatment of acne vulgaris.

Phototherapy and photochemotherapy of sclerosing skin diseases

The treatment of sclerosing skin diseases [systemic sclerosis, localized scleroderma, lichen sclerosus et atrophicus, sclerodermoid graft‐vs.‐host disease, scleredema adultorum (Buschke), scleromyxedema and necrobiosis lipoidica] is difficult and remains a great challenge. Numerous treatments, some with potentially hazardous side effects, are currently used with only limited success. The introduction of phototherapy and photochemotherapy for sclerosing skin diseases has considerably enriched the therapeutic panel and proven useful in a number of sclerosing skin diseases especially in localized scleroderma. Two phototherapeutic modalitites are used for the treatment of sclerosing skin diseases, long‐wave ultraviolet A and psoralen plus ultraviolet A (PUVA). This article reviews current knowledge about the application of phototherapy and photochemotherapy to various sclerosing skin disorders.

IgE-Mediated Hypersensitivity Reactions to Cannabis in Laboratory Personnel

Background: There have been sporadic reports of hypersensitivity reactions to plants of the Cannabinaceae family (hemp and hops), but it has remained unclear whether these reactions are immunologic or nonimmunologic in nature. Objective: We examined the IgE-binding and histamine-releasing properties of hashish and marijuana extracts by CAP-FEIA and a basophil histamine release test. Methods: Two workers at a forensic laboratory suffered from nasal congestion, rhinitis, sneezing and asthmatic symptoms upon occupational contact with hashish or marijuana, which they had handled frequently for 25 and 16 years, respectively. Neither patient had a history of atopic disease. Serum was analyzed for specific IgE antibodies to hashish or marijuana extract by research prototype ImmunoCAP, and histamine release from basophils upon exposure to hashish or marijuana extracts was assessed. Results were matched to those of 4 nonatopic and 10 atopic control subjects with no known history of recreational or occupational exposure to marijuana or hashish. Results: Patient 1 had specific IgE to both hashish and marijuana (CAP class 2), and patient 2 to marijuana only (CAP class 2). Controls proved negative for specific IgE except for 2 atopic individuals with CAP class 1 to marijuana and 1 other atopic individual with CAP class 1 to hashish. Stimulation of basophils with hashish or marijuana extracts elicited histamine release from basophils of both patients and 4 atopic control subjects. Conclusions: Our results suggest an IgE-related pathomechanism for hypersensitivity reactions to marijuana or hashish.

Photodynamic therapy of genital condylomata in men.

Current treatments for genital condylomata are not completely satisfactory, as they fail to clear lesions in a proportion of patients, and relapses after successful treatment are frequently seen. Photodynamic therapy (PDT) using topical 5‐aminolaevulinic acid (5‐ALA) has been suggested as a novel treatment option. We performed a small open study using topical 5‐ALA and red light (630 nm) in nine men with genital condylomata and a history of at least one previous unsuccessful conventional treatment. Complete cure was achieved in three patients, one of whom experienced a relapse after 3 weeks. Three patients showed partial responses, and three showed no response. Based on the currently available evidence, PDT is a viable treatment option for selected cases that fail to respond to other therapies.

Treatment of Darier disease with oral alitretinoin

Darier disease (DD) is an autosomal dominant skin disease. Treatment is often difficult and unsatisfactory because of the chronic nature of the condition and the irritant potential of various therapeutic agents. Systemic vitamin A derivatives such as acitretin and isotretinoin are the treatment of choice, but their use is often limited by class‐specific side‐effects. Alitretinoin (9‐cis‐retinoic acid), has antiproliferative and anti‐inflammatory potential, and is licensed for the systemic treatment of chronic hand eczema in a number of countries. Unlike acitretin, alitrenoin requires contraception in women of childbearing age to be extended for only 1 month after the end of treatment. There is evidence that alitretinoin might be a well‐tolerated alternative for the systemic treatment of various retinoid‐responsive skin diseases. We present two cases of women with refractory DD successfully treated with alitretinoin without marked side‐effects, who both obtained near‐complete remission of their skin lesions.

Anaphylaxis to wheat beer

BACKGROUND Despite its worldwide and abundant consumption, beer has rarely been found to cause anaphylaxis. Barley malt contained in lager beers seems to be an important elicitor. OBJECTIVE To report the unusual case of severe anaphylaxis following the ingestion of wheat beer. METHODS A 59-year-old man experienced angioedema, generalized urticaria, and unconsciousness after ingestion of wheat beer. He tolerated lager beer well. For diagnostic evaluation, skin prick tests, oral challenge tests, and identification of specific IgE antibodies were performed. RESULTS Skin prick test results with standard series of common aeroallergens and food allergens were negative with the exception of a 1 + reaction to wheat flour. The results of skin prick tests with native materials were positive for 2 brands of wheat beer and wheat malt shred but negative for bakers yeast, hops, and a brand of lager beer. Oral challenges with wheat beer or wheat flour elicited urticaria. By CAP-FEIA, specific IgE antibodies to wheat and barley flour but not to hops or bakers yeast were found in serum. Immunoblot analysis revealed that patients IgE was bound to a protein of approximately 35 kDa in wheat extract. CONCLUSIONS This is the first report, to our knowledge, on anaphylaxis to beer attributable to wheat allergy.

Solar urticaria: long‐term rush hardening by inhibition spectrum narrow‐band UVB 311nm

Idiopathic solar urticaria (SU) constitutes a severe and potentially life-threatening photos induced disease, and usually represents a therapeutic challenge that may not be manageable by antihistamines or sun protection only. Each case of SU presents with sensitivity to individual ultraviolet (UV) light spectra, which trigger urticarial lesions. We present the case of a patient with SU with sensitivity to both visible light and UVA1, who was treated effectively with a narrowband (NB)-UVB regimen. A 25-year-old man with Fitzpatrick skin type II presented with a 1-month history of severe generalized SU for months before admission. After a session of sunbathing, he had experienced dizziness, nausea and grade II anaphylaxis-like symptoms. Urticarial lesions had also been provoked indoors by glass-filtered sunlight. Sunscreens with high levels of UVA and UVB protection, oral antihistamines, and steroids had little effect. Laboratory investigations showed normal results for serum tryptase, porphyrin levels in faeces and for blood cell count, including numbers of erythrocytes and mast cells, routine serum and urine analysis, and levels of C-reactive protein, antinuclear antibodies, double-stranded DNA antibodies, and total serum IgE. Physical urticaria to heat or cold was excluded by challenge testing. Phototesting produced an immediate urticarial response to both visible light (from a slide projector at 380 W and 300 mm distance for 15 min) and UVA1 [minimal urticarial dose (MUD) = 7 J/cm; Dermalight; Dr H€ onle AG, Martinsried, Germany], which extended beyond the margins of the test area without generalization (Fig. 1a,b). A treatment method known as action-spectrum hardening using the causative wavelengths has been shown to be effective in UVA-induced SU, but the treatment is time-consuming, risks SU exacerbation, and induces only short-term tolerance that requires maintenance treatment at close intervals. In addition, our patient reacted to a very broad spectrum of light, making it difficult to define the best wavelength for hardening. Therefore, we used an alternative treatment, starting the patient on total body irradiation with an inhibitory NB-UVB spectrum, which was tolerated well without causing urticarial lesions. The initiating NB-UVB dose used was 0.03 J/cm, and corresponded to one-third of the dose usually used for phototherapy in patients with skin type II. For subsequent treatments, the NB-UVB dose was increased by approximately 30%. The patient received a total dose of 1.49 J/cm, given as 10 irradiations of 0.32 J/cm on successive weekdays (Monday to Friday), resulting in a clinical reduction and delay in the urticarial response to UVA1(MUD = 20 J/cm). After an additional 10 NB-UVB applications with a dose escalation to 0.52 J/cm (cumulative dose 7.02 J/cm), the physiological responses to UVA1 and visible light had completely normalized (Fig. 1c). Neither extensive UVA1 nor visible light exposure after this point could provoke further SU reactions, and UVA1 application only induced immediate pigment darkening at a minimal tanning dose of 20 J/ cm. To sustain the achieved hardening effect, the patient was treated with a further 10 irradiations at a final maintenance dose of 0.55 J/cm, reaching a cumulative NB-UVB dose of 12.52 J/cm. During this time, the patient increased his exposure to natural sunlight as well, without experiencing any adverse skin or systemic reactions. The B-UVB therapy was stopped, and the patient experienced no SU relapse despite continued sunbathing during the summer. The remission lasted for several months, but the SU relapsed the following summer. This case illustrates the clinical and therapeutic challenge of SU. For diagnosis, it is necessary to assign the causative action spectrum to either UVA, UVB or Correspondence: Dr Ronald Wolf, Department of Dermatology and Allergology, Ludwig Maximilian University Munich, Frauenlobstrasse 9-11, 80337, Munich, Germany E-mail: ronald.wolf@med.uni-muenchen.de

Sensitization to Common Ragweed in Southern Bavaria: Clinical and Geographical Risk Factors in Atopic Patients

Background: Sensitization to common ragweed (Ambrosia artemisiifolia) is associated with a variety of risk factors, which are incompletely defined. Our aim was to evaluate the association of a variety of clinical, geographical and demographical variables with ragweed sensitization and also to determine its frequency in southern Bavaria. Methods: In this cross-sectional multicentre study, we enrolled 977 patients with a documented or suspected atopic disease or food allergy. Data were collected on aeroallergen sensitization, age, sex, type and history of allergic disease, place of residence and potential local ragweed exposure. For this last variable, county ragweed cover was taken as a surrogate variable. Relative rates were calculated with multiple additive logistic regression models. Randomly selected patients with ragweed sensitization had a conjunctival provocation test. Results: According to skin prick tests, 190 patients (19.5%) were sensitized to ragweed. The frequency of this finding increased significantly with a rising number of additional sensitizations. Other less important predictors for a ragweed sensitization were male gender, mugwort sensitization, food allergy and a maximum of complaints in September or October. County of residence, extent of local ragweed cover or type of residential area were without relevance. Of 48 sensitized patients, 26 (54.2%) had a positive conjunctival provocation test. Discussion: Patients with multiple sensitizations may be more readily sensitized to a new aeroallergen. Local geographic or environmental conditions are presumably of minor importance for becoming sensitized to ragweed. The frequency of ragweed allergy among sensitized patients might be high.