THE ROLE OF KERATINOCYTES IN THE PATHOPHYSIOLOGY OF CONTACT DERMATITIS

Toll-Like Receptors and Contact Dermatitis

Contact dermatitis (CD) is a common cutaneous inflammatory condition that affects millions of people worldwide. Xenobiotic agents are frequently encountered in substances used in everyday life, making it difficult to avoid personal and occupational exposure. Toll-like receptors (TLRs) are transmembrane receptors that modulate the innate immune system in response to tissue injury or infection. TLRs play a key role in the pathophysiology of contact dermatitis. TLR signaling is involved in three major forms of CD: protein CD, allergic contact dermatitis (ACD), and irritant CD. Of the 10 TLRs found in humans, three play an important role in ACD. This makes TLRs a useful potential therapeutic target to consider against CD. In this review, we discuss the role of TLRs in CD and summarize current and emerging treatments for CD that target TLRs.

A central role for transcription factor C/EBP-beta in regulating CD1d gene expression in human keratinocytes

CD1d is a nonclassical Ag-presenting molecule that presents glycolipid Ags to NKT cells that are involved in immune defense and tumor rejection. It also plays a role in immunoregulatory functions in the epidermis. The mechanisms controlling the expression of CD1d are not well understood. Therefore, we cloned the CD1d gene promoter and characterized its activities in primary human keratinocytes and other cell lines of epithelial origin. We found that a CCAAT box in the CD1d promoter is required for its expression in keratinocytes. We show here that transcription factor C/EBP-beta binds to the CCAAT box in the CD1d promoter in vitro and in vivo. Consistent with these observations, deletion of the gene encoding for C/EBP-beta caused a loss of CD1d expression. The in vivo regulation of CD1d has significant implications for the pathologic mechanisms of certain immunologic skin diseases in which NKT cells play a role, such as allergic contact dermatitis and psoriasis. Together, these data show a central role for C/EBP-beta in regulating CD1d transcription.

Other Allergic Skin Disorders

In this chapter we discuss allergic skin disorders other than atopic dermatitis (AD): the urticaria-angioedema syndrome, allergic contact dermatitis (ACD), protein contact dermatitis (PCD), phytodermatitis, allergic photodermatitis and allergic vasculitis.

Effect of arylhydroxylamine metabolites of sulfamethoxazole and dapsone on stress signal expression in human keratinocytes

The initiation of an immune response to small molecules is believed to require the release of stress/danger signals that activate resident dendritic cells, presumably secondary to the formation of reactive metabolites. We hypothesized that exposure to arylhydroxylamine metabolites of dapsone and sulfamethoxazole lead to the expression/release of numerous stress signals in the skin. To test this hypothesis, we examined the effect of these metabolites on the expression of selected heat shock proteins, uric acid, cytokines, adhesion molecules, and costimulatory molecules in normal human epidermal keratinocytes (NHEKs). NHEKs showed a time-dependent up-regulation of heat shock protein 70 and translocation of heat shock protein 27 when exposed to the arylhydroxylamine metabolites. In addition, the secretion of several proinflammatory cytokines was increased upon incubation of these cells with metabolite. In contrast, the uric acid concentration was not altered. Moreover, intercellular adhesion molecule-1, CD80, and CD86 expressions did not change when NHEKs were exposed to these reactive metabolites. Our data suggest that NHEKs selectively up-regulate certain danger signals when exposed to arylhydroxylamine metabolites. These signals may subsequently activate dendritic cells and initiate an immune response within skin.

Colocalization of glial fibrillary acidic protein, metallothionein, and MHC II in human, rat, NOD/SCID, and nude mouse skin keratinocytes and fibroblasts

The expression of glial fibrillary acidic protein (GFAP) by perivascular cells of many mammalian organs suggests an as yet unknown function of this intermediate filament protein in the maintenance of homeostasis and vascular permeability at the blood-tissue interface. Although a similar situation may exist at the air-tissue interface, the cellular distribution of GFAP in skin tissue has never been demonstrated. To approach this issue, we have employed immunofluorescence and Western blotting techniques to detect GFAP in skin sections of young and adult humans, normal rodents, and two types of mutant mice, as well as in rat lung sections, and in cultured human keratinocytes and fibroblasts. Colocalization with antigens known to be associated with GFAP in other tissues was also tested. Epidermal and hair follicle keratinocytes and dermal fibroblasts showed distinct staining for GFAP as well as colocalization with alpha-actin, metallothionein, and antigens of the class-II major histocompatibility complex (MHC II). GFAP was also identified in rat alveolar fibroblasts which, in common with keratinocytes, form part of the air-tissue interface. GFAP was upregulated together with MHC II in nude mice but was barely detectable in the skin of non-obese diabetic severe combined immunodeficiency mice, suggesting a possible involvement in antigen-presenting functions. The intriguing distribution of a common set of antigens both in certain cells of the integumentary system and at the blood-tissue interfaces of internal organs suggests the involvement of these proteins in universal mechanisms controlling tissue homeostasis and protection.

Immune response to xenobiotics in the skin: from contact sensitivity to drug allergy

Skin is the most frequent target of adverse drug reactions. These cutaneous drug reactions (CDRs) show varied clinical manifestations ranging from mildly discomforting rashes to life-threatening Stevens-Johnson syndrome or toxic epidermal necrolysis. Most CDRs appear to be immune mediated, although the mechanism by which they are initiated remains unclear. In this review, current knowledge of the mechanisms by which xenobiotics provoke immune responses in the skin after epicutaneous administration and how similar reactions may occur after systemic routes are summarised. This review also discusses a variety of genetic or environmental factors that may determine the susceptibility of individuals towards immune responses in skin following drug exposure.

Ceramide-Dependent Regulation of Human Epidermal Keratinocyte CD1d Expression during Terminal Differentiation

Human keratinocytes (KC), when cultured under conditions to remain undifferentiated or to terminally differentiate, changed their cellular distribution of CD1d. As studied by confocal microscopy, undifferentiated KC had a pool of cytoplasmic CD1d, whereas after terminal differentiation, this molecule localized in the cell membrane, which recapitulates CD1d expression in vivo. A comparison of undifferentiated and differentiated cultured KC did not reveal any differences in the association with beta(2)-microglobulin, invariant chain of class II MHC, or patterns of glycosylation, suggesting that these biochemical properties are not regulating the cellular distribution of CD1d. Time-course studies of CD1d gene expression indicated that KC slowly increased gene expression with CaCl(2)-induced terminal differentiation. Increased CD1d gene expression was dependent on ceramide synthesis, because fumonisin B1, a ceramide synthetase inhibitor, blocked the increase in CD1d gene expression during terminal differentiation. Similarly, exogenous ceramide or the ceramidase inhibitor, B13, induced CD1d gene expression by undifferentiated, but not terminally differentiated, KC. A protein kinase C-zeta (PKC-zeta) inhibitor (a pseudosubstrate oligopeptide), but not a PKC-alphabeta inhibitor, significantly decreased CD1d gene expression by undifferentiated or ceramide-stimulated cultured, undifferentiated KC. As expected, downstream signaling events of PKC-zeta (JNK phosphorylation and NF-kappaBeta accumulation in the nucleus) were also attenuated. The calcineurin phosphatase inhibitor cyclosporine A, which blocks KC terminal differentiation, also blocked CD1d gene expression by cultured KC. In conclusion, this novel function of cellular ceramides extends the importance of this class of biologically active lipids beyond that of terminal differentiation and barrier function in normal human skin.

Allergic contact dermatitis

The pathophysiology of ACD follows an intricate design and results in the characteristic, delayed inflammatory response. Although the astute physician may correctly diagnose ACD from its initial, classic history and presentation, alternative diagnoses should be considered and excluded. Patch testing performed with a relevant panel of contact allergens is the ultimate confirmatory test of ACD. Correctly identifying the inciting allergen permits appropriate personal avoidance. Corticosteroids remain the principal treatment options.

Keratinocyte-derived, CD80-mediated costimulation is associated with hapten-specific IgE production during contact hypersensitivity to TH1 haptens

Background B7-1 transgenic mice exhibit exaggerated and persistent contact hypersensitivity responses compared with normal mice. Objective Because B7-1 and B7-2 deliver different costimulatory signals to T cells during antigen presentation, the purpose of this study was to compare B7-1 and B7-2 on keratinocytes and to compare their effects on contact hypersensitivity. Methods Contact hypersensitivity was studied in transgenic mice whose keratinocytes constitutively expressed B7-1, B7-2, or no costimulatory molecules (nontransgenic mice). Results B7-1 transgenic mice, and to a lesser extent B7-2 transgenic mice, developed exaggerated ear swelling responses after sensitization and challenge with haptens such as trinitrochlorobenzene or dinitrofluorobenzene. Ear swelling responses in B7-1 transgenic mice were characterized by the presence of markedly elevated inflammatory cytokine transcripts (IL-6, TNF-alpha, and lymphotoxin beta) as well as IL-10 compared with either B7-2 or nontransgenic mice. Hapten-specific IgE was detected by ELISA in B7-1 transgenic mice but not B7-2 transgenic or nontransgenic mice. Only B7-1 transgenic mice exhibited significant immediate type ear swelling responses to the hapten trinitrochlorobenzene. In addition, their sera can passively transfer cutaneous anaphylaxis to naive C57BL/6 mice, indicating that the hapten-specific IgE was relevant to the immediate ear swelling responses. Conclusion These data suggest that keratinocyte-derived costimulation mediated by B7-1 but not B7-2 results in the emergence of T H 2-lymphocyte immune responses to T H 1 haptens. Because human keratinocytes have been noted to express B7-1-like molecules in certain inflammatory skin diseases, this model may be important in understanding the pathophysiology of T H 2-lymphocyte-mediated skin diseases such as atopic dermatitis.

Reflectance confocal microscopy may differentiate acute allergic and irritant contact dermatitis in vivo

BACKGROUND

Acute irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD) may be difficult to distinguish by clinical or histologic assessment. Reflectance confocal microscopy (RCM) enables real-time, high-resolution skin imaging in vivo.

OBJECTIVE

We sought to image, characterize, and distinguish acute ACD and ICD in vivo.

METHODS

Volunteers with ACD were patch tested with an allergen and the irritant, sodium lauryl sulfate. RCM imaging and transepidermal water loss measurements were performed at 24 and 72 hours. Biopsy specimens were correlated with RCM images.

RESULTS

Spongiosis, epidermal inflammatory cell infiltrate, and vesicle formation were observed in ACD and ICD. Compared with ACD, ICD showed greater disruption of the stratum corneum, and more parakeratosis. There was a significantly greater increase in transepidermal water loss for ICD compared with ACD.

CONCLUSION

RCM is a promising tool for dynamic, noninvasive assessment and may help to differentiate acute ACD and sodium lauryl sulfate-induced ICD.

Occupational dermatoses

PURPOSE OF REVIEW

All terms referring to job-related (occupational) rashes are clearly defined. Ranking as the second most common occupational disorder, the importance of occupational dermatoses is illustrated.

RECENT FINDINGS

90-95% of occupational dermatoses result from a contact-type dermatitis. Until recently, 4/5 cases were believed to be of the irritant, rather than allergic type of contact dermatitis, however, with more extensive patch testing, more than half the cases were found to be allergic.

SUMMARY

The direct causes of occupational dermatoses: chemical, mechanical, physical, and biological in nature are presented. The implications of assigning the degree and type of occupational dermatoses are explained. Workmans compensation is based on a no-fault arrangement, stating that unrestricted treatment and compensation is allowable only when negligence on the part of the employer is proven. Employee benefits are then determined by the duration and degree of disability sustained - all of which becomes litigational. Predisposing host factors, i.e. intellectual ability, anatomic site, atopy, skin pigmentation, age of skin, and immunosuppression (by disease or medication) are usually ignored. Environmental factors at the workplace must be considered conducive to occupational diseases. The full spectrum of irritant contact dermatitis is discussed with examples of each described. Allergic contact dermatitis and patch testing - the gold standard for identification of putative allergens is extensively discussed. Differentiating irritant contact dermatitis from allergic contact dermatitis is elucidated. The other non-contact type skin reactions are briefly mentioned.

Eyelid dermatitis

Cosmetic alteration of a patient's orbital skin is a common reason for professional consultation. This review presents the differential diagnosis and recommended evaluation of inflamed eyelids. To better understand the diseases, each is individually addressed clinically, pathogenetically, and therapeutically. It is critical to recognize the lesions correctly and to have full knowledge of the putative clinical disease process. An algorithm for an appropriate work-up for each disease is offered. With this background, a successful therapeutic response can be anticipated.