Exploring the role of autophagy in psoriasis pathogenesis: Insights into sustained inflammation and dysfunctional keratinocyte differentiation

Psoriasis is a common and prevalent chronic papulosquamous cutaneous disorder characterized by sustained inflammation, uncontrolled keratinocyte proliferation, dysfunctional differentiation, and angiogenesis. Autophagy, an intracellular catabolic process, can be induced in response to nutrient stress. It entails the degradation of cellular constituents through the lysosomal machinery, and its association with psoriasis has been well-documented. Nevertheless, there remains a notable dearth of research concerning the involvement of autophagy in the pathogenesis of psoriasis within human skin. This review provides a comprehensive overview of autophagy in psoriasis pathogenesis, focusing on its involvement in two key pathological manifestations: sustained inflammation and uncontrolled keratinocyte proliferation and differentiation. Additionally, it discusses potential avenues for disease management.

The role of dermal fibroblasts in autoimmune skin diseases

Fibroblasts are an important subset of mesenchymal cells in maintaining skin homeostasis and resisting harmful stimuli. Meanwhile, fibroblasts modulate immune cell function by secreting cytokines, thereby implicating their involvement in various dermatological conditions such as psoriasis, vitiligo, and atopic dermatitis. Recently, variations in the subtypes of fibroblasts and their expression profiles have been identified in these prevalent autoimmune skin diseases, implying that fibroblasts may exhibit distinct functionalities across different diseases. In this review, from the perspective of their fundamental functions and remarkable heterogeneity, we have comprehensively collected evidence on the role of fibroblasts and their distinct subpopulations in psoriasis, vitiligo, atopic dermatitis, and scleroderma. Importantly, these findings hold promise for guiding future research directions and identifying novel therapeutic targets for treating these diseases.

Single cell and spatial sequencing define processes by which keratinocytes and fibroblasts amplify inflammatory responses in psoriasis

The immunopathogenesis of psoriasis, a common chronic inflammatory disease of the skin, is incompletely understood. Here we demonstrate, using a combination of single cell and spatial RNA sequencing, IL-36 dependent amplification of IL-17A and TNF inflammatory responses in the absence of neutrophil proteases, which primarily occur within the supraspinous layer of the psoriatic epidermis. We further show that a subset of SFRP2+ fibroblasts in psoriasis contribute to amplification of the immune network through transition to a pro-inflammatory state. The SFRP2+ fibroblast communication network involves production of CCL13, CCL19 and CXCL12, connected by ligand-receptor interactions to other spatially proximate cell types: CCR2+ myeloid cells, CCR7+ LAMP3+ dendritic cells, and CXCR4 expressed on both CD8+ Tc17 cells and keratinocytes, respectively. The SFRP2+ fibroblasts also express cathepsin S, further amplifying inflammatory responses by activating IL-36G in keratinocytes. These data provide an in-depth view of psoriasis pathogenesis, which expands our understanding of the critical cellular participants to include inflammatory fibroblasts and their cellular interactions.

Comprehensive assessment of the dynamics of angiogenesis in patients with psoriasis treated with methotrexate

Background: evaluation of the severity of pathological angiogenesis in patients with psoriasis can be considered as a promising direction for monitoring the activity of disease and effectiveness of systemic therapy. Aims: evaluation of interconnections between indicators of angiogenesis in the skin and nail bed of psoriasis patients with clinical characteristics of disease course and therapeutic response to the use of methotrexate by a comprehensive study of the morphometric data dynamics of videodermatoscopy in vascular bed of the skin, the severity of blood flow in the dermis and nail bed during ultrasonic power dopplerography and plasma concentrations of vascular endothelial growth factor (VEGF) and endothelin-1 (En-1). Materials and methods: work is based on the data analysis from a survey of 82 patients with moderate to severe psoriasis vulgaris in acute stage, who were first prescribed methotrexate in the form of subcutaneous injections at a dose of 10-15 mg per week in combination with folic acid 5 mg per week. Before treatment and three months after start of methotrexate therapy, all patients underwent videodermatoscopy with dimension of density and size of dilated skin capillaries, ultrasonography of psoriatic plaques and nail bed of affected nails and measurement of doppler blood flow parameters and concentration of VEGF and En-1 in blood plasma. Results: a direct correlation was established between the average diameter of dilated skin capillaries (vascular glomeruli), the degree of increased blood flow in the doppler energy study of ​​psoriatic plaques skin area and the plasma concentration of VEGF and En-1 and values ​​of PASI, BSA, sPGA and DLQI indices, as well as the severity of doppler blood flow of the nail bed and NAPSI index.Under the influence of methotrexate treatment, a decrease in diameter and density of vascular glomeruli, the degree of blood flow in area of psoriatic plaques and the concentration of VEGF and En-1 was observed. Conclusions: studied indicators of angiogenesis can be used as additional criteria for assessing degree of activity and achieving clinical improvement/remission during systemic therapy in patients with moderate and severe psoriasis.

A mechanistic physiologically based model to assess the effect of study design and modified physiology on formulation safe space for virtual bioequivalence of dermatological drug products

Physiologically based pharmacokinetic (PBPK) models are widely accepted tools utilised to describe and predict drug pharmacokinetics (PK). This includes the use of dermal PBPK models at the regulatory level including virtual bioequivalence (VBE) studies. The current work considers the Topicort® Spray formulation, which contains 0.25% desoximetasone (DSM), as an example formulation. Quantitative formulation composition and in vitro permeation testing (IVPT) data were obtained from the public literature to develop a mechanistic model using the multi-phase, multi-layer (MPML) MechDermA IVPT module in the Simcyp Simulator. In vitro-in vivo extrapolation functionality was used to simulate in vivo PK for various scenarios and predict a 'safe space' for formulation bioequivalence using the VBE module. The potential effect of vasoconstriction, impaired barrier function, and various dosing scenarios on the formulation safe space was also assessed. The model predicted 'safe space' for formulation solubility suggesting that a 50% change in solubility may cause bio-in-equivalence, whereas viscosity could deviate by orders of magnitude and the formulation may still remain bioequivalent. Evaporation rate and fraction of volatile components showed some sensitivity, suggesting that large changes in the volume or composition of the volatile fraction could cause bio-in-equivalence. The tested dosing scenarios showed decreased sensitivity for all formulation parameters with a decreased dose. The relative formulation bioequivalence was insensitive to vasoconstriction, but the safe space became wider with decreased barrier function for all parameters, except viscosity that was unaffected.

Topical Corticosteroids in the Treatment of Vulvar Lichen Sclerosus: A Review of Pharmacokinetics and Recommended Dosing Frequencies

Topical corticosteroids are often utilized as the first-line treatment for vulvar lichen sclerosus (VLS). However, there is wide variability in dosing regimens, as well as a lack of consensus on maintenance dosing. Available guidelines on dosing frequency and regimen continuation for VLS are based on clinical expert opinion and do not necessarily reflect the pharmacokinetics of topical corticosteroids. Over the past few decades, there have been many advances in the techniques used to measure the local and systemic absorption of topical corticosteroids. These techniques have led to a greater understanding of the pharmacokinetics and bioavailabilities of these medications. However, it is not clear how this new information has been applied in evaluating dosing regimens and commonly cited risks when considering short- and long-term use in different vulvar dermatoses. This purpose of this review is to evaluate the available evidence on pharmacokinetics, absorption rates, and concentration levels of topical corticosteroids in lesional and nonlesional skin. Additionally, the evidence regarding commonly cited risks of topical corticosteroid use, including dermal thinning, adrenal suppression, systemic immunosuppression, and tachyphylaxis are reviewed. Differences in the effects of topical corticosteroids on the varied tissues of the vulva are specifically explored. Finally, these considerations are applied to evaluate the current treatment guidelines for VLS to provide direction in determining an evidenced-based dosing regimen and to inform future research in this area. Mautz TT, Krapf JM, Goldstein AT. Topical Corticosteroids in the Treatment of Vulvar Lichen Sclerosus: A Review of Pharmacokinetics and Recommended Dosing Frequencies. Sex Med Rev 2021;XX:XXX-XXX.

Evaluation of capillary density in psoriasis: An intrapatient study and literature review

Background

Dilated and tortuous vessels within elongated dermal papillae represent a histopathological clue of psoriasis. However, the number of dilated capillaries (capillary density) in psoriasis remains undefined as the results from the available studies differ significantly.

Objectives

To evaluate the capillary density in psoriasis using dermoscopy and horizontal histopathological sections (HHS), two techniques that share the horizontal view of the skin, and to compare the results with the existing data.

Methods

Twenty adult patients with stable plaque psoriasis were enrolled and, in each patient, a target area of the examined plaque, previously engraved by gently rotating a 5-mm biopsy punch device, underwent dermoscopy and biopsy for HHS. In all examined fields, capillary density was evaluated in a centered 4-mm diameter area, counting the number of red dots at dermoscopy and of dermal papillae at HHS.

Results

A total of 20 target lesions located on the trunk, arms and tights were evaluated. The mean capillary density resulting from dermoscopy was 43.02±6.60/mm 2 whereas that from HHS was 50.30±9.05/mm 2. These data showed a statistically significant difference (p = 0.006), with a strong correlation at Pearson’s test (r = 0.88).

Conclusions

Our results when compared with those from the existing literature showed some differences. The peculiarity of our work is represented by the precise measurement and correlation of the capillary density using two different methods, as the preliminary skin engraving allowed a perfect match between the area undergoing dermoscopy and that of skin sampling for HHS. Compared to dermoscopy in which deep-located vessels might have gone undetected, HHS seems to reflect more precisely and reliably the real capillary density showing an average of 50 capillaries/mm 2 that in a common 5x5 cm psoriatic patch corresponds to an average of 125.000 capillaries. These results highlight the extraordinary potential of psoriatic skin to develop such a complex and intricate vascular network.

Reflectance Confocal Microscopy, Optical Coherence Tomography, and Multiphoton Microscopy in Inflammatory Skin Disease Diagnosis

BACKGROUND AND OBJECTIVES

Technological advances in medicine have brought about many novel skin imaging devices. This review aims to evaluate the scientific evidence supporting the use of noninvasive optical imaging techniques to aid in the diagnosis and prognosis of inflammatory skin diseases.

STUDY DESIGN/MATERIALS AND METHODS

PubMed and Scopus were searched in September 2020 according to PRISMA guidelines for articles using reflectance confocal microscopy (RCM), optical coherence tomography (OCT), and multiphoton microscopy (MPM) in inflammatory skin diseases, excluding studies monitoring treatment efficacy.

RESULTS

At the time of the study, there were 66 articles that addressed the utilization of noninvasive imaging in interface, spongiotic, psoriasiform, vesiculobullous, and fibrosing/sclerosing inflammatory skin dermatoses: RCM was utilized in 46, OCT in 16, and MPM in 5 articles. RCM was most investigated in psoriasiform dermatoses, whereas OCT and MPM were both most investigated in spongiotic dermatoses, including atopic dermatitis and allergic contact dermatitis.

CONCLUSIONS

There is preliminary evidence to support the diagnostic potential of noninvasive optical imaging techniques in inflammatory skin diseases. Improvements in the devices and further correlation with histology will help broaden their utility. Additional studies are needed to determine the parameters for diagnostic features, disease differentiation, and staging of inflammatory skin conditions. Lasers Surg. Med. © 2021 Wiley Periodicals LLC.

In Vivo Reflectance Confocal Microscopy-Diagnostic Criteria for Actinic Cheilitis and Squamous Cell Carcinoma of the Lip

Actinic cheilitis (AC) is one of the most frequent pathologies to affect the lips. Studies show that the most commonplace oral malignancy, squamous cell carcinoma (SCC), often emerges from AC lesions. Invasive diagnostic techniques performed on the lips carry a high risk of complications, but reflectance confocal microscopy (RCM), a non-invasive skin imaging technique, may change the current diagnostic pathway. This retrospective study was aimed at consolidating the RCM diagnostic criteria for AC and lip SCC. The study was conducted in two tertiary care centers in Bucharest, Romania. We included adults with histopathologically confirmed AC and SCC who also underwent RCM examination. Of the twelve lesions included in the study, four were AC and eight were SCC. An atypical honeycomb pattern and the presence of target cells in the epidermis were RCM features associated with AC. SCC was typified by the presence of complete disruption of the epidermal architecture and dermal inflammatory infiltrates. The mean blood vessel diameter in SCC was 18.55 µm larger than that in AC (p = 0.006) and there was no significant difference (p = 0.64) in blood vessel density, as measured by RCM, between SCC and AC. These data confirm that RCM can be useful for the in vivo distinction between AC and lip SCC.

Value of reflectance confocal microscopy for the monitoring of rosacea during treatment with topical ivermectin

Background: Reflectance confocal microscopy (RCM) enables noninvasive Demodex mite detection in rosacea. Objective scoring of rosacea severity is currently lacking.Objectives: To determine the value of RCM for monitoring Demodex, inflammation and vascular parameters in rosacea during treatment.Methods: In 20 rosacea patients, clinical and RCM examination were performed before, during, and 12 weeks after a 16-week treatment course with topical ivermectin. Using RCM, number of mites and inflammatory cells, epidermal thickness, and vascular density and diameter were measured. RCM features were correlated with clinical assessment.Results: Treatment resulted in clinical reduction of inflammatory lesions. Mites were detected in 80% of patients at baseline, 30% at week 16, and 63% at week 28. The number of mites reduced significantly during treatment, but no changes in inflammatory cells, epidermal thickness or vascular parameters were observed. Correlation between number of inflammatory lesions and mites was low. None of the RCM variables were significant predictors for clinical success.Conclusions: RCM enables anti-inflammatory effect monitoring of topical ivermectin by determining mite presence. Quantifying exact mite number, and inflammatory and vascular characteristics is challenging due to device limitations. In its current form, RCM seems of limited value for noninvasive follow-up of rosacea in clinical practice.

Evaluation of the Th17 pathway in psoriasis and geographic tongue

Background

Psoriasis is a skin-articular disease with unclear etiopathogenesis. It has been suggested that the disease is immune-mediated by T-lymphocytes, predominantly Th17 cells. Similar to psoriasis, geographic tongue is an inflammatory disease with participation of Th17 cells and direct correlation with psoriasis.

Objective

To investigate and compare the inflammatory responses and the Th17 pathway in psoriasis and geographic tongue.

Methods

This was a cross-sectional study with 46 participants that were categorized into three groups: (A) patients with psoriasis vulgaris; (B) patients with geographic tongue and psoriasis; (C) patients with geographic tongue without psoriasis. All patients underwent physical examination, and a skin and oral biopsy for histopathological examination and immunohistochemical analysis with anti-IL6, anti-IL17, and anti-IL23 antibodies.

Results

Histological analysis of all lesions showed mononuclear inflammatory infiltrate. However, moderate intensity was prevalent for the patients with geographic tongue and psoriasis and geographic tongue groups. Immunopositivity for the antibodies anti-IL6, anti-IL17, and anti-IL23 revealed cytoplasmic staining, mainly basal and parabasal, in both psoriasis and geographic tongue. Regarding IL-6, in patients with geographic tongue and psoriasis cases the staining was stronger than in patients with geographic tongue without psoriasis cases. IL-17 evidenced more pronounced and extensive staining when compared to the other analyzed interleukins. IL-23 presented similar immunopositivity for both geographic tongue and psoriasis, demonstrating that the neutrophils recruited into the epithelium were stained.

Study limitation

This study was limited by the number of cases.

Conclusion

The inflammatory process and immunostaining of IL-6, IL-17, and IL-23 were similar in geographic tongue and psoriasis, suggesting the existence of a type of geographic tongue that represents an oral manifestation of psoriasis.

In vivo confocal laser scanning microscopy imaging of skin inflammation: Clinical applications and research directions

In vivo confocal laser scanning microscopy (CLSM) is a novel imaging technique that provides noninvasive, morphological characterization of skin structures with a resolution that is very close to that of light microscopy. Moreover, as it allows repeated imaging of the same skin area at different time-points, it is an excellent method for monitoring disease course, response to treatment or specific stimuli and a path to study dynamic phenomena in real-time. To date, two different variants of in vivo CLSM have been authorized in dermatological field, namely the reflectance confocal microscopy predominantly for clinical diagnosis and the fluorescence confocal microscopy mainly for research purposes. This study describes the principles of in vivo CLSM technique, its role in the diagnosis and monitoring of inflammatory skin diseases, as well as some promising research directions to study the dynamics of skin inflammation using this method. In vivo CLSM evaluation of inflammatory dermatoses and of the skin inflammatory component in various diseases has an undoubted potential with broad applications ranging from clinical, morphological to experimental, functional studies involving the skin.

Ultrastructural and Molecular Analysis of Ribose-Induced Glycated Reconstructed Human Skin

Aging depicts one of the major challenges in pharmacology owing to its complexity and heterogeneity. Thereby, advanced glycated end-products modify extracellular matrix proteins, but the consequences on the skin barrier function remain heavily understudied. Herein, we utilized transmission electron microscopy for the ultrastructural analysis of ribose-induced glycated reconstructed human skin (RHS). Molecular and functional insights substantiated the ultrastructural characterization and proved the relevance of glycated RHS beyond skin aging. In particular, electron microscopy mapped the accumulation and altered spatial orientation of fibrils and filaments in the dermal compartment of glycated RHS. Moreover, the epidermal basement membrane appeared thicker in glycated than in non-glycated RHS, but electron microscopy identified longitudinal clusters of the finest collagen fibrils instead of real thickening. The stratum granulosum contained more cell layers, the morphology of keratohyalin granules decidedly differed, and the stratum corneum lipid order increased in ribose-induced glycated RHS, while the skin barrier function was almost not affected. In conclusion, dermal advanced glycated end-products markedly changed the epidermal morphology, underlining the importance of matrix⁻cell interactions. The phenotype of ribose-induced glycated RHS emulated aged skin in the dermis, while the two to three times increased thickness of the stratum granulosum resembled poorer cornification.

Healing effect of Dillenia indica fruit extracts standardized to betulinic acid on ultraviolet radiation-induced psoriasis-like wounds in rats

CONTEXT

Dillenia indica Linn. (Dilleniaceae) is traditionally used to treat skin inflammation.

OBJECTIVE

This study evaluated the healing effect of Dillenia indica fruit extracts on induced psoriasis-like wounds in Wistar rats.

MATERIALS AND METHODS

Extracts were standardized to betulinic acid, including an aqueous ethanolic extract (AEE), ethyl acetate extract (EAE) and petroleum ether extract. Effects against lipid peroxidation were assessed in vitro. Wounds were created at rat tails (n = 12). Topical treatments were applied once daily for 7 days (1 mL of AEE or EAE at 5 or 50 mg/mL). Maximal dose was defined by the extract solubility. A 10-fold lower dose was also tested. Positive and negative controls were treated with clobetasol (0.5 mg/mL) or excipient. Half of each group was euthanized for histology. The remaining animals were observed for 20 days for wound measurements.

RESULTS

Yields of AEE and EAE were 4.3 and 0.7%, respectively. Betulinic acid concentrations in AEE and EAE were 4.6 and 107.6 mg/g. Extracts neutralized lipid peroxidation in vitro at 0.02 μg/mL, accelerating healing at 50 mg/mL. Complete healing in mice treated with AEE occurred 16 days after wound induction. This time was 14 and 12 days in mice treated with EAE and clobetasol. Compared to orthokeratosis, parakeratosis was reduced by AEE (25%), EAE (45%) and clobetasol (55%). EAE caused superior protection against biomolecules oxidation of skin compared to AEE.

DISCUSSION AND CONCLUSION

EAE exhibited activity closer to that of clobetasol. Betulinic acid may be an active constituent, which should be assessed in future studies.

Assessment of dermal papillary and microvascular parameters in psoriasis vulgaris using in vivo reflectance confocal microscopy

In vivo reflectance confocal microscopy (RCM) is a modern, non-invasive imaging technique, which allows for real-time examination of the upper layers of the skin at a resolution similar to that of classic microscopy. In addition, it has the advantage of real-time evaluation of blood flow and dynamic monitoring of cutaneous changes while preserving tissue integrity. The present study reported on the in vivo RCM technique as an objective method for the noninvasive assessment of psoriasis vulgaris that is potentially applicable in clinical studies and in monitoring the evolution of lesions under treatment. In psoriasis lesions, RCM virtual horizontal sections at the level of the dermo-epidermal junction featured numerous and prominent dermal papillae that were not surrounded by bright rings of basal cells. Micromorphological examination of the lesions using this technique revealed that mean values of the section area, the perimeter and the Feret's diameter of the dermal papillae were significantly higher in psoriatic lesions than in normal skin. An increased number of capillary vessels per lesional dermal papilla as compared to healthy skin was observed. Furthermore, micromorphological parameters of dermal capillaries were increased in psoriatic skin. These observations point to the utility of in vivo RCM as a promising technique for the non-invasive diagnosis of psoriasis vulgaris, for monitoring the evolution of lesions at a micromorphological level under various treatments and for gaining a better understanding of the pathophysiological processes that occur in the evolution of this disease.

Reflectance confocal microscopy for the evaluation of sensitive skin

BACKGROUND

Nowadays, the diagnosis for sensitive skin relies on subjective assessment or on the combination of subjective and objective evaluation. No quantitative evaluation is available. It could be expected that confocal microscopy imaging could be of interest to better define the condition.

METHODS

Total 166 healthy female subjects were recruited in this study. Firstly, all subjects completed the sensitive questionnaire. Then, the cutaneous structures were measured by the reflectance confocal microscopy (RCM) on the face and fossa cubitalia. The lactic acid sting test was conducted finally. According to the results of self-perception sensitive skin questionnaire and lactic acid stinging test to evaluate facial skin sensitivity the both positive subjects were regarded as sensitive skin group and both negative group as healthy control group.

RESULT

The results of RCM indicating that the proportion of 'disarranged honeycomb pattern' and 'spongiform edema' in the sensitive group and healthy control group were statistically different (P < 0.05), respectively; The following report 'damaged dermal papilla rings' was not a distinctive pattern, with no significant statistical difference (P > 0.05). The epidermal thickness was 38.88 ± 6.81 μm, healthy control group was 40.31 ± 9.37 μm in, respectively, sensitive skin group and healthy control group, there was no significant statistical difference between the two groups (P > 0.05). The honeycomb structure depth of sensitive group was 20.57 ± 4.86 μm. It was for 23.27 ± 6.38 μm, healthy control group the difference being statistically different between the two groups (P < 0.05).

CONCLUSION

Based on the RCM results, 'epidermal honeycomb structure' and 'spongiform edema' may be used as new skin signs of RCM evaluation of sensitive skin effectively. Indeed, sensitive skin honeycomb structure depth was thinner compared with healthy control group. Such a specific pattern has good clinical and monitoring value for the further exploration. RCM could provide new data and patterns for the evaluation of sensitive skin.

The influence of different shavers on the skin quantified by non-invasive reflectance confocal microscopy

BACKGROUND

The impact of personal care devices on skin is mainly assessed using subjective tools. However, new objective, accurate non-invasive in vivo imaging techniques have been developed. The aim of this study was to evaluate the ability of reflectance confocal microscopy (RCM) in quantifying morphological impact of shavers on skin. Furthermore, tape stripping (TS) as method to study morphological impact of shavers was evaluated.

METHODS

In 12 healthy male subjects, for two consecutive days, a split-face test was performed in the neck; on one side a shaver was applied, while the other side was exposed to TS. The stratum corneum (SC) thickness was quantified using RCM and sensory observations were evaluated using questionnaires.

RESULTS

Shavers with a different impact on skin, can be discriminated by RCM; shaver B removed more SC after application than the skin friendlier shaver A. Furthermore, the changes in SC thickness induced by TS corresponded well to that of the shavers.

CONCLUSION

RCM is able to quantify the impact of different shavers on skin. Besides, TS appeared to be a suitable model mimicking the mechanical impact of shavers on skin. RCM in combination with the TS model appeared to be a suitable minimally invasive model to obtain morphological and cell biological data on skin-material interactions caused by different personal care devices.

Constitutive Autophagy and Nucleophagy during Epidermal Differentiation

Epidermal keratinocytes migrate through the epidermis up to the granular layer where, on terminal differentiation, they progressively lose organelles and convert into anucleate cells or corneocytes. Our report explores the role of autophagy in ensuring epidermal function providing the first comprehensive profile of autophagy marker expression in developing epidermis. We show that autophagy is constitutively active in the epidermal granular layer where by electron microscopy we identified double-membrane autophagosomes. We demonstrate that differentiating keratinocytes undergo a selective form of nucleophagy characterized by accumulation of microtubule-associated protein light chain 3/lysosomal-associated membrane protein 2/p62 positive autolysosomes. These perinuclear vesicles displayed positivity for histone interacting protein, heterochromatin protein 1α, and localize in proximity with Lamin A and B1 accumulation, whereas in newborn mice and adult human skin, we report LC3 puncta coincident with misshaped nuclei within the granular layer. This process relies on autophagy integrity as confirmed by lack of nucleophagy in differentiating keratinocytes depleted from WD repeat domain phosphoinositide interacting 1 or Unc-51 like autophagy activating kinase 1. Final validation into a skin disease model showed that impaired autophagy contributes to the pathogenesis of psoriasis. Lack of LC3 expression in psoriatic skin lesions correlates with parakeratosis and deregulated expression or location of most of the autophagic markers. Our findings may have implications and improve treatment options for patients with epidermal barrier defects.

A four-phase strategy for the implementation of reflectance confocal microscopy in dermatology

BACKGROUND

Reflectance confocal microscopy (RCM) is gradually implemented in dermatology. Strategies for further implementation and practical 'hands on' guidelines are lacking.

OBJECTIVE

The primary outcome was to conduct a general strategy for further implementation of RCM. The secondary outcome was the diagnosis of psoriasis and differentiation of stable from unstable psoriatic plaques by means of the 'hands on' protocol, derived from the strategy.

METHODS

We used a four-phased model; an exploring phase, a systematic literature search, a clinical approach and, finally, an integration phase to develop a clinical guideline for RCM in psoriasis. Receiver operating characteristic curve statistics was applied to define the accuracy for the diagnosis of unstable psoriasis.

RESULTS

A general strategy for further implementation of RCM and practical approach was developed to examine psoriasis by RCM and to distinguish stable from unstable psoriasis. Unstable psoriasis was diagnosed by epidermal inflammatory cell counts with a sensitivity and specificity of 91.7% and 98.3%, respectively, and with an accuracy of 0.92 (area under the curve). In addition, a monitoring model was proposed.

CONCLUSION

This is the first study that shows a method for implementation of RCM in dermatology. The strategy and hands on protocol for psoriasis may serve as a model for other dermatological entities and additionally may lead to specialized ready-to-use RCM protocols for clinical dermatological practice.

[Confocal laser scanning microscopy]

Reflectance confocal microscopy (RCM) allows the in vivo evaluation of melanocytic and nonmelanocytic skin tumours with high sensitivity and specificity. RCM represents an optical imaging technique, which enables us to examine the skin at high resolution. Today, RCM represents not only an interesting tool for dermatologic research but has also been introduced as a diagnostic tool in every day clinical practice. As such, RCM is applied for improvement of skin cancer diagnosis adjunct to clinical and dermatoscopic examination. In combination with dermatoscopy RCM has shown an increased specificity with similar sensitivity. In this regard RCM helps to decrease the rate of unnecessary biopsies of benign lesions. Despite its use in dermatooncology RCM may also be used for diagnosis and monitoring of inflammatory diseases. Future developments include technical improvements, teledermatology solutions and the application of ex vivo RCM in Moh's micrographic surgery.

Advances in non-invasive techniques as aids to the diagnosis and monitoring of therapeutic response in plaque psoriasis: a review

Plaque psoriasis is a common, chronic, inflammatory disease with a multifactorial etiopathogenesis. Although its diagnosis is often based on clinical features, in ambiguous cases a biopsy with histopathologic confirmation may be necessary. Advanced high-definition imaging techniques may be useful in the study of skin properties in vivo and may facilitate therapeutic monitoring. Available imaging tools vary in their resolution, depth of penetration and visual representation (horizontal, vertical, three-dimensional), and in the type of skin structures visualized. The purpose of this review is to analyze a variety of non-invasive techniques that may assist in establishing definitive diagnoses, as well as in the therapeutic monitoring of psoriasis. These include dermoscopy, videocapillaroscopy (VC), high-frequency ultrasound (HFUS), reflectance confocal microscopy (RCM), laser Doppler imaging (LDI), optical coherence tomography (OCT), optical microangiography (OMAG) and multiphoton tomography (MPT). Their characteristics, indications, advantages, and limits are reviewed and discussed. Dermoscopy may be useful for a first, rapid outpatient evaluation. Videocapillaroscopy and HFUS represent the imaging techniques with the longest history of use in psoriasis. However, whereas VC is useful in both diagnosis and therapeutic monitoring, the utility of HFUS appears to be limited to the monitoring of response to therapy only. Both devices are cost-effective and easy to use in the office setting. Both RCM and OCT allow high-resolution microscopic imaging of psoriatic plaque in a manner comparable with that of virtual histopathology and represent more promising techniques. The utility of LDI, OMAG, and MPT in psoriasis skin imaging requires further study and validation.

Reflectance confocal microscopy: non-invasive distinction between actinic keratosis and squamous cell carcinoma

BACKGROUND

Early recognition of squamous cell carcinoma (SCC) is difficult. Non-invasive reflectance confocal microscopic (RCM) imaging of the skin is a promising diagnostic technique. Although several RCM features for SCC and AK have been described, it is not determined whether RCM has the ability to distinguish between SCC and actinic keratosis (AK).

OBJECTIVE

To determine in vivo reflectance confocal microscopic features that are specific for making a distinction between AK and SCC.

METHODS

In 24 patients, 30 lesions clinically suspicious for AK or SCC were selected for RCM imaging. Following the imaging procedure, a 3 mm skin biopsy was obtained for confirmation of the histopathological diagnosis. Two observers evaluated the RCM images according to a literature based list of RCM features. The obtained data were evaluated by an univariate and forward multivariate logistic regression analysis, kappa analysis and independent T-test.

RESULTS

The univariate logistic regression showed statistically significant odds ratios for several RCM features, including architectural disarray in the stratum granulosum, architectural disarray in the spinous layer and nest-like structures in the dermis. The forward multivariate logistic regression analysis showed that the combination of these features increased the ability to make the correct diagnosis AK and SCC non-invasively. The interobserver agreement between a starting and an experienced RCM observer ranged from poor to no agreement.

CONCLUSION

This study revealed specific RCM features that can distinguish between AK and SCC, stimulating further prospective, large cohort research in this field. This will result in correct, efficient and adequate diagnosis and treatment of clinically difficult to distinguish AK and SCC lesions.

Proteomics focusing on immune markers in psoriatic arthritis

The immune-pathogenesis of psoriatic arthritis represents a subject of intense research, as a still unknown factor can trigger the chronic inflammation that, upon a defective immune terrain, generates this auto-immune/auto-inflammatory condition. The pathogenesis complexity of psoriatic arthritis resides in the psoriatic synovitis milieu, where intricate immune relations are emerging during disease development. Innate immune response generates inflammatory cytokines driving effectors functions for immune and non-immune cells that sustain the chronical character of the synovitis. Herein, we review the updated information regarding biomarkers/immune markers that sustain the heterogeneity and complexity of psoriatic arthritis pathogenesis, this complexity leading to multifaceted methodological approaches for disease investigation. New immune proteomic or genomic biomarkers can enlarge and identify new therapeutic targets.

In-vivo imaging of psoriatic lesions with polarization multispectral dermoscopy and multiphoton microscopy

Psoriasis is a skin autoimmune disease characterized by hyperkeratosis, hyperproliferation of the epidermis and dilatation of dermal papillary blood vessels. Healthy skin (5 volunteers) and psoriatic lesions (3 patients) were visualized in vivo, with high contrast and resolution, with a Polarization Multispectral Dermoscope and a Multiphoton Microscope. Psoriatic features were identified and quantified. The effective diameter of the superficial blood vessels was measured at 35.2 ± 7.2 μm and the elongated dermal papillae had an effective diameter of 64.2 ± 22.6 μm. The methodologies developed could be employed for quantitative diagnostic purposes and furthermore serve as a monitoring method of the effect of personalized treatments.

Psychosensorial assessment of skin damage caused by a sliding on artificial turf: the development and validation of a skin damage area and severity index

OBJECTIVES

Injury prevention is an important reason for the development of performance standards in football. Currently, there is no objective method available to classify sliding induced skin injuries, which includes the perceived sliding friendliness of football pitches. The purpose of this study was to develop a non-invasive method for quantification of the observed sliding induced skin damage and evaluate whether there is a correlation between the subjective perceived skin irritation and sliding friendliness.

STUDY DESIGN

Randomized controlled trial.

METHODS

Previously obtained clinical images of sliding induced skin lesions where rated by a dermatologist on the degree of abrasion, erythema and type of exudation. To test the practical feasibility of a proposed Skin Damage and Severity Index (SDASI) to characterize sliding induced skin lesions, a randomized user trial with nine amateur football players was performed. The sliding friendliness of three different grades of infill materials was tested.

RESULTS

The Skin Damage and Severity Index correlates both with the perceived skin irritation (r=-0.53, P=0.02) and sliding friendliness (r=-0.58, P=0.01). Statistical analysis of the individual clinical scores showed that perception of skin irritation and sliding friendliness correlate very well with the degree of erythema and abrasion. However, these scores are independent of the size of the lesion and type of exudation. There was no statistical significant difference found between the three evaluated types of infill and their sliding performance.

CONCLUSIONS

This study demonstrated that the Skin Damage and Severity Index, which is a tool for quantification of a sliding induced skin lesion, correlates very well with the perceived skin irritation and the sliding friendliness.

Psoriasis plaque test with confocal microscopy: evaluation of different microscopic response pathways in NSAID and steroid treated lesions

BACKGROUND

Pathophysiology of psoriasis is complex and characterized by microscopic, specific changes. In vivo reflectance confocal microscopy (RCM) provides tissue and cell morphology information in non-invasive way, generating quasi-histologic resolution. Concerning plaque psoriasis, confocal criteria have been described disclosing high agreement between RCM and conventional histology.

OBJECTIVE

We sought to evaluate the in vivo microscopic changes in plaque psoriasis occurring during treatment with two distinct actives (aceclofenac and betamethason).

METHODS

A total of 32 patients with psoriasis were recruited. Two lesions from the same body area or symmetrical were evaluated at baseline and after 3-6 weeks by RCM.

RESULTS

Aceclofenac induced clinical improvement in 32% of patients after 3 weeks and in 76% after 6 weeks. With betamethason, at the end of the 3rd week, the 45% of patients showed improvement that increased to 81% at the end of the study. Single confocal criteria was evaluated and results underwent to statistical analysis considering the modification of the microscopical changes during the two treatments.

CONCLUSION

RCM followed the microscopic changes during treatment and enabled to differentiate effects of different actives. Although data are preliminary and based on a limited sample, aceclofenac seems to be effective in the treatment for psoriasis.

High-definition optical coherence tomography: adapted algorithmic method for pattern analysis of inflammatory skin diseases: a pilot study

High-definition optical coherence tomography (HD-OCT) is a non-invasive technique for morphological investigation of tissue with cellular resolution filling the imaging gap between reflectance confocal microscopy and conventional optical coherence tomography. The aim of this study is first to correlate dermatopathologic descriptors of inflammatory skin conditions with epidermal alteration to features observed by HD-OCT. Secondly, to assess the discriminative accuracy of common inflammatory reaction patterns with epidermal alteration using HD-OCT by applying Ackerman’s algorithmic method of pattern recognition. The generated HD-OCT images of 160 patients presenting an inflammatory skin disease were analyzed with respect to the following criteria: visualization of individual cells in the epidermis and dermis and morphology of dermo-epidermal junction, papillary dermis and reticular dermis. A set of morphological features corresponding to dermatopathological descriptors are obtained and the discriminative accuracy of HD-OCT of inflammatory reaction patterns could be demonstrated. These patterns are spongiotic dermatitis, psoriasiform dermatitis, interface dermatitis and ballooning dermatitis. Additional studies to test the sensitivity and specificity of the proposed algorithm for pattern analysis are essential. The other categories of Ackerman’s pattern recognition need to be evaluated. This study provides a set of morphological features generated by HD-OCT imaging very similar to those described for reflectance confocal microscopy but with the advantages not only to visualize individual cells up to a depth of 570 μm but also in both slice and en face mode. An adapted algorithmic method for pattern analysis of common inflammatory skin diseases could be proposed. This new technique appears to be a promising method for non-invasive diagnosis, evaluation and management of common inflammatory skin diseases.