Darier's disease: epidemiology, pathophysiology, and management

Hereditary benign intraepithelial dyskeratosis: an evaluation of diagnostic cytology

CONTEXT

Hereditary benign intraepithelial dyskeratosis (HBID) is a rare autosomal dominant disorder characterized by elevated epibulbar and oral plaques and hyperemic conjunctival blood vessels. The condition is predominantly seen in Native Americans belonging to the Haliwa-Saponi tribe located in northeastern North Carolina.

OBJECTIVE

To determine whether HBID can be diagnosed using cytologic preparations of the conjunctiva, and whether the cytologic findings correlated with the genetic linkage involving a duplication in chromosome 4 (4q35).

DESIGN

Cytologic preparations from conjunctival brushings in patients afflicted with HBID and from unaffected blood relatives with normal conjunctivas were compared in a masked fashion. Cytologic observations were correlated with molecular genetic analyses.

RESULTS

Papanicolaou-stained preparations from the conjunctiva showed the typical cytologic features of HBID, including rounded squamous epithelial cells with dense homogenous orange cytoplasm and hyperchromatic, pyknotic, or crenated nuclei. All cases with the diagnostic cytologic findings of HBID had a duplication in chromosome 4 (4q35).

CONCLUSION

HBID is an entity with distinct clinical, histopathologic, and genetic features. The results of this study indicate the diagnosis can also be supported in an appropriate clinical setting when adequate epibulbar cytology preparations are obtained and the characteristic genetic attributes are present.

Darier's disease: a calcium-signaling perspective

Ca(2+) influx evoked across the plasma membrane upon internal store depletion is essential for a myriad of cellular functions including gene expression, cell proliferation, differentiation and even apoptosis. Darier's disease (DD), an autosomal dominant inherited disorder of the skin, arising due to mutations in the isoform 2 of the sarco (endo) plasmic reticulum Ca(2+) ATPase (SERCA2), exemplifies an anomaly of Ca(2+) signaling disturbances. Owing to loss of function mutations in SERCA2, keratinocytes in DD patients have a reduced pool of endoplasmic reticulum (ER) Ca(2+). Importantly, the status of ER Ca(2+) is critical for the activation of a class of plasma membrane Ca(2+) channels referred to as store operated Ca(2+) channels (SOCs). The widely expressed transient receptor potential (TRP) family of channels is proposed to be SOCs. In this review we discuss DD from the viewpoint of Ca(2+) signaling and present a potential role for TRPC1 in the disease pathogenesis.

Photodynamic therapy plus topical retinoids in Darier's disease

Darier's disease is a rare, genetically determined, chronic disorder of keratinization. Characterized clinically by a symmetrical eruption of hypercheratotic papules with predilection for the seborrhoeic areas of the body. Many treatments have been suggested: emollients, topical retinoids, dermoabrasion, topical steroids and intermittent courses of oral antibiotics. Systemic retinoids are usually the treatment of choice. We present a small case series of patients treated with PDT and topical retinoids with good results. This therapeutic modality could represent an alternative to systemic retinoid treatment.

SERCA pumps and human diseases

Sarco(endo)plasmic reticulum (SER) Ca2+ ATPases represent a highly conserved family of Ca2+ pumps which actively transport Ca2+ from the cytosol to the SER against a large concentration gradient. In humans, 3 genes (ATP2A1-3) generate multiple isoforms (SERCAla,b, SERCA2a-c, SECA3a-f) by developmental or tissue-specific alternative splicing. These pumps differ by their regulatory and kinetic properties, allowing for optimized function in the tissue where they are expressed. They play a central role in calcium signalling through regenerating SER Ca2+ stores, maintaining appropriate Ca2+ levels in this organelle and shaping cytosolic and nuclear Ca2+ variations which govern cell response. Defects in ATP2A1 encoding SERCA1 cause recessive Brody myopathy, mutations in ATP2A2 coding for SERCA2 underlie a dominant skin disease, Darier disease and its clinical variants. SERCA2a expression is reduced in heart failure in human and in mice models. Gene-targeting studies in mouse confirmed the expected function of these isoforms in some cases, but also resulted in unexpected phenotypes: SERCA1 null mutants die from respiratory failure, SERCA2 heterozygous mutant mice develop skin cancer with age and SERCA3 null mice display no diabetes. These unique phenotypes have provided invaluable information on the role of these pumps in specific tissues and species, and have improved our understanding of Ca2+ regulated processes in muscles, the heart and the skin in human and in mice. Although the understanding of the pathogenesis of these diseases is still incomplete, these recent advances hold the promise of improved knowledge on the disease processes and the identification of new targets for therapeutic interventions.

[Possible genetic link between Darier's disease and depression. Review of the literature and case history]

Darier's disease is a rare, inherited autosomal dominant skin disorder caused by a mutation in the sarcoendoplasmatic reticulum calcium transporter (SERCA)-2-gene. In a number of pedigrees, Darier's disease closely relates with affective disorder. The most likely hypothesis for this is a susceptibility gene for affective disorder near the SERCA-2-gene. A 6.5-megabase region could be identified as a susceptibility locus. This region constitutes a susceptability locus also in affective disorder without Darier's disease. The underlying gene has not yet been identified.

Autosomal-dominant calcium ATPase disorders

Darier disease (DD) and Hailey-Hailey disease (HHD) are the only known autosomal-dominant Ca2+ ATPase disorders. Epidermal symptoms selectively occur in the affected individuals, the precise reason for which is still not fully understood. Here, we review the clinical, epidermal, and molecular features of the two genodermatoses. It is concluded that epidermal Ca2+ regulation disturbances and epigenetic factors may play an even more prominent role in the pathogenesis of DD and HHD than earlier appreciated.

Five mutations of ATP2A2 gene in Chinese patients with Darier’s disease and a literature review of 86 cases reported in China

Darier's disease (DD) is an autosomal dominantly inherited skin disorder characterized by loss of adhesion between epidermal cells (acantholysis) and abnormal keratinization. To date, at least 140 mutations in the ATP2A2 gene have been identified as the genetic basis of DD. Here we reported three familial and two sporadic Chinese DD patients totally with four missense mutations (N767D, M494I, M494L, C318F) and one splice-site mutation (1288-6A-->G) in ATP2A2 gene, and presented a literature review of DD cases reported in China since 1989. Our data add new variants to the repertoire of ATP2A2 gene in DD and confirms that most mutations in the ATP2A2 gene are private and missense type. Likewise, the literature review indicates that DD is not uncommon in China and presents more information about genotype-phenotype correlations.

A case of Darier's disease successfully treated with topical tacrolimus

Tacrolimus is a macrolide that inhibits T-cell activation. The most extensive experience with topical tacrolimus has been in treating atopic dermatitis but it has been used in various skin diseases, including Hailey-Hailey disease, with encouraging results. We report a case of extensive Darier's disease successfully treated with topical tacrolimus, after suspension of oral isotretrinoin due to major depression.

Darier disease: a case report

The diagnosis of Darier disease of the oral mucosa was made only after biopsying a leukoplakia-like lesion of the palate.

Effects of drugs and anticytokine antibodies on expression of ATP2A2 and ATP2C1 in cultured normal human keratinocytes

BACKGROUND

Darier's disease (DD) and Hailey-Hailey disease (HHD) are skin disorders arising, respectively, from autosomal dominant mutations in ATP2A2, encoding the sacro/endoplasmic reticulum calcium ATPase, and ATP2C1, encoding the Golgi apparatus calcium ATPase. Exposure to ultraviolet (UV) B irradiation exacerbates the skin lesions, which can be treated with corticosteroids and retinoids.

OBJECTIVES

To investigate the molecular basis for DD and HHD.

METHODS

We used quantitative reverse transcriptase-polymerase chain reactions to examine the effects of UVB irradiation on ATP2A2 and ATP2C1 mRNA levels in cultured normal keratinocytes.

RESULTS

We observed that UVB irradiation reduced ATP2A2 and ATP2C mRNA levels. The addition of retinoids or corticosteroids to the cell culture inhibited the UVB-induced suppression of both ATP2A2 and ATP2C1 mRNA levels, and UVB-induced suppression of ATP2C1 mRNA was also inhibited by the addition of ciclosporin, tacrolimus and vitamin D(3). The addition of anti-interleukin (IL)-6 antibody to the cell culture prevented the UVB-induced suppression of ATP2A2 and ATP2C1 mRNA; in contrast, the addition of anti-IL-8 antibody slightly accelerated the suppression.

CONCLUSIONS

These results suggest that drugs effective for DD and HHD act by modulating ATP2A2 and ATP2C1 mRNA expression, respectively, and that the proinflammatory cytokines IL-6 and IL-8 play important roles in the regulation of ATPA2 and ATP2C1 expression in homeostasis and/or inflammation of the skin.

Calcium pump disorders of the skin

The causes of Darier disease (DD) and Hailey-Hailey disease (HHD) have eluded clinicians and scientists for more than 60 years. DD is characterized by loss of adhesion between suprabasal epidermal cells associated with abnormal keratinization, while loss of epidermal cell-to-cell adhesion is predominant in HHD. The genes for both conditions have recently been identified using candidate positional cloning approaches. The gene for DD (ATP2A2) encodes a calcium transport ATPase of the sarco (endo)plasmic reticulum (SERCA2) Verboomen et al. [1992: Biochem J 286(Pt 2):591-595], while the gene for HHD (ATP2C1) codes for a secretory pathway for calcium and manganese transport ATPase of the Golgi apparatus (SPCA1) Hu et al. [2000: Nat Genet 24:61-65]. These results have provided completely new insights into the role of calcium and/or manganese in maintaining skin integrity. Although the precise disease mechanisms remain to be understood, these discoveries open a new field in research for the understanding and the treatment of these distressing disorders.

Dyskeratosis follicularis disease: case reports and review of the literature

BACKGROUND

Dyskeratosis follicularis (Darier's disease) is rare autosomal dominant disease characterized by the loss of adhesion between epidermal cells and by abnormal keratinization.

METHODS

We performed a retrospective study of all the patients diagnosed with Darier's disease at the Department of Dermatology of Charles Nicolle Hospital of Tunis, between 1971 and 2002.

RESULTS

During the observation period, we identified 12 patients with Darier's disease; five males and seven females with a mean age of 17.36 years. No family history was found in eight patients. Skin lesions in the form of keratotic papules were noted in seborrhoeic areas, essentially the face (nine patients), chest and scalp. Seven patients had nail lesions. UV light exposure exacerbated the disease symptoms in seven cases. The patients were treated with topical and systemic retinoids (six cases).

CONCLUSION

Although Darier's disease has a chronic course, most patients manage to lead a relatively normal life. Treatment is usually unsatisfactory despite much progress in understanding of the underlying abnormalities in Darier's disease.

Darier’s disease: from dyskeratosis to endoplasmic reticulum calcium ATPase deficiency

The skin is the body's largest organ and has an essential barrier protective function against physical, chemical, and pathogen aggressions and prevents fluid loss. The outer layer of the skin, known as the epidermis, plays a key role in this protection, through a tightly regulated differentiation programme from basal keratinocytes to the stratum corneum at the skin surface. During this process, keratinocytes from the base of the epidermis undergo major morphological and functional changes during their migration through the spinous and granular layers, to become terminally differentiated corneocytes which will be shed from the skin's surface. The role of extracellular Ca2+ in cell-to-cell adhesion and in epidermal differentiation was known to be important, but the identification of the sarco/endoplasmic reticulum Ca2+ transport ATPase (ATP2A2) as the defective gene in a rare genetic skin disease known as Darier's disease, came as a surprise and shed light on the key role of Ca2+ signaling in the homeostasis of the epidermis.

Keratosis follicularis of the oral mucosa with oral squamous cell carcinoma

Darier's disease or keratosis follicularis is a genodermatosis which may involve the oral mucosa. Malignant degeneration is rare. We report the first case of the combined manifestation of oral keratosis follicularis and oral squamous cell carcinoma and discuss the possible involvement of ATP2A2 (located in 12q23-24.1) which encodes the sarco/endoplasmic reticulum Ca(2+)-ATP isoform 2 (SERCA2), in the pathogenesis.

The intraepidermal blistering conditions

The intraepidermal vesiculobullous disorders constitute a wide variety of pathogenically unrelated disorders that share in common the formation of cleft or bullae formation within the epithelium. The etiologic, pathogenic, clinical and, in particular, the histopathologic attributes of the most important intraepidermal blistering conditions are described.