Genetically Modified Skin to Treat Disease: Potential and Limitations

An approach to achieve long-term expression in skin gene therapy

For gene therapy purposes, the skin is an attractive organ to target for systemic delivery of therapeutic proteins to treat systemic diseases, skin diseases, or skin cancer. To achieve long-term stable expression of a therapeutic gene in keratinocytes (KC), we have developed an approach using a bicistronic retroviral vector expressing the desired therapeutic gene linked to a selectable marker (multidrug resistant gene, MDR) that is then introduced into KC and fibroblasts (FB) to create genetically modified human skin equivalent (HSE). After grafting the HSE onto immunocompromised mice, topical colchicine treatment is used to select and enrich for genetically modified keratinocyte stem cells (KSC) that express MDR and are resistant to colchicine's antimitotic effects. Both the apparatus for topical colchicine delivery and the colchicine doses have been optimized for application to human skin. This approach can be validated by systemic delivery of therapeutic factors such as erythropoietin and the antihypertensive atrial natriuretic peptide.

Gene therapy and dermatology: more than just skin deep

BACKGROUND

Recent advances in the molecular characterization of dermatologic disease have substantively augmented the understanding of the pathogenetic processes underlying disorders of the skin. This new knowledge coupled with progress in gene delivery technologies has paved the way for introducing cutaneous gene therapy into the dermatologic therapeutic armamentorium.

OBJECTIVE

This review article includes an overview of the current strategies for delivery of gene therapy with an emphasis on the potential role of cutaneous gene delivery in the treatment of skin and systemic diseases.

CONCLUSIONS

Accessibility for gene delivery, clinical evaluation, and topical modulation of gene expression render the skin a very attractive tissue for therapeutic gene delivery. However, there are several key hurdles to be overcome before cutaneous gene therapy becomes a viable clinical option. These include difficulties in inducing sustained expression of the desired gene in vivo, the challenge of targeting genes to long-lived stem cells, and the difficulty in achieving specific and uniform transfer to different compartments of the skin. However, these problems are not insurmountable and will likely be resolved in conjunction with ongoing advances in delineating gene expression profiles and other molecular properties of the skin, strategies for stem cell isolation, and improved approaches to regulating gene delivery and expression. These advances should create the framework for translating the enormous potential of cutaneous gene therapy into the clinical arena and, thereby, substantively improving the management of both cutaneous and systemic disease.

Skin substitutes from cultured cells and collagen-GAG polymers

Engineering skin substitutes provides a potential source of advanced therapies for the treatment of acute and chronic wounds. Cultured skin substitutes (CSS) consisting of human keratinocytes and fibroblasts attached to collagen-glycosaminoglycan substrates have been designed and tested in preclinical and clinical studies. Cell culture techniques follow general principles of primary culture and cryopreservation in liquid nitrogen for long-term storage. Biopolymer substrates are fabricated from xenogeneic (bovine) collagen and glycosaminoglycan that are lyophilised for storage until use. At maturity in air-exposed culture, CSS develop an epidermal barrier that is not statistically different from native human skin, as measured by surface electrical capacitance. Preclinical studies in athymic mice show rapid healing, expression of cytokines and regulation of pigmentation. Clinical studies in burn patients demonstrate a qualitative outcome with autologous skin that is not different from 1:4 meshed, split-thickness autograft skin, and with a quantitative advantage over autograft skin in the ratio of healed skin to biopsy areas. Chronic wounds resulting from diabetes or venous stasis have been closed successfully with allogeneic CSS prepared from cryopreserved skin cells. These results define the therapeutic benefits of cultured skin substitutes prepared with skin cells from the patient or from cadaver donors. Future directions include genetic modification of transplanted cells to improve wound healing transiently or to deliver gene products systemically.

Gene therapy for tissue repair: approaches and prospects

Recent advances in molecular biology have resulted in the development of new technologies for the introduction and expression of genes in human somatic cells. This emerging field, known as gene therapy, is broadly defined as the transfer of genetic material to cells/tissues in order to achieve a therapeutic effect for inherited as well as acquired diseases. We and others are exploring the potential application of this technology to tissue repair. One primary focus has been to transfer genes encoding wound healing growth factors, a broad class of proteins which control local events in tissues such as cell proliferation, cell migration and the formation of extracellular matrix. Using several different strategies for gene transfer, wound healing growth factor genes have been introduced and expressed in cells and tissues in vitro as well as in vivo. Various experimental models of wound healing and tissue repair have been used to evaluate the efficacy of this new and exciting approach to tissue repair.

Topical application of viral vectors for epidermal gene transfer

Efficient gene transfer with extended gene expression is essential for successful treatment of skin diseases using gene therapy. Previously we evaluated a physical gene transfer method (gene gun delivery) for its ability to transfect the epidermis in vivo. In this study, we tested two viral vectors for their ability to transduce murine epidermis through topical application. Both an adenoviral vector and a herpes simplex virus (HSV) amplicon vector transduced murine epidermis with high efficiency after topical application. Differences in amount and duration of transgene expression were compared between these two vectors. Quantitative analysis of reporter lacZ gene expression showed that the viral vector-mediated gene transfers were superior to gene-gun delivery of plasmid DNA. Significant necrosis and cytotoxicity, however, were observed in the HSV-treated skin. In addition, we show that murine epidermis developed hyperkeratosis and acanthosis 4 d after an adenoviral vector containing a human TGF-alpha expression unit was applied topically. Finally we demonstrate the feasibility of transduction of fetal skin in utero by intraamniotic injection of an adenovirus vector.

Transfection with aFGF cDNA improves wound healing

Somatic gene therapy is a potentially useful strategy for the delivery of growth factors or cytokines to enhance wound healing. Experimental excisional and incisional wounds in impaired-healing diabetic mice (db/db) were treated with aFGF and with a plasmid coding for aFGF. A eukaryotic expression plasmid composed of the Hst signal peptide sequence in-frame with the human aFGF sequence was used. Transfection of tissues was accomplished either by direct plasmid uptake or by uptake facilitated with cationic liposomes. The results show that the closure of excisional wounds was significantly accelerated (p < 0.05) by topical application of human recombinant aFGF or by transfection with the aFGF plasmid but not by vehicle or control plasmid not containing the aFGF sequence. In incisional wounds, aFGF or transfection with the plasmid significantly increased the wound-breaking strength compared to their corresponding controls (p < 0.05). Quantitative histology of the plasmid-treated incisional wound sections revealed improved wound quality. The transcription of mRNA from human aFGF cDNA in the incisional wound tissue extracts was confirmed by RT-PCR, and the expressed aFGF was detected by immune dot blot and immunohistochemistry assays. The transfection was a transient process with a peak at 9 d in db/+ (littermates of the diabetic mice) incisional wounds, at 36 d in db/db incisional wounds, and at 27 d in db/db excisional wounds. Cells transfected with human aFGF occupied up to 6.4% of the transectional area in the wound sites. Thus, aFGF gene delivery resulted in both gene expression and a functional improvement in healing.

Engineering epidermal growth factor for enhanced mitogenic potency

Successful use of growth factors in therapeutic and bioprocessing applications requires overcoming two attenuation mechanisms: growth factor depletion and receptor down-regulation. Current ameliorative strategies use physiologically inappropriate high growth-factor concentrations, along with periodic media refeeding in vitro and reinjection or controlled-release devices in vivo. We demonstrate a new approach derived from understanding how these attenuation mechanisms arise from ligand/receptor trafficking processes. Specifically, a recombinant epidermal growth factor (EGF) mutant with reduced receptor binding affinity is a more potent mitogenic stimulus for fibroblasts than natural EGF or transforming growth factor alpha because of its altered trafficking properties.

Sustained production of human transferrin by transduced fibroblasts implanted into athymic mice: a model for somatic gene therapy

Somatic gene therapy has been proposed as a means of treating inherited diseases involving defective or absent plasma proteins, viral diseases, and cancer. Introduction of the gene of interest into fibroblasts and implantation of these genetically modified fibroblasts using a skin equivalent system may be an attractive model for gene therapy because skin fibroblasts are easily obtained and propagated in culture. This study evaluated expression of the gene for human transferrin (hTf) by genetically modified fibroblasts in vitro and in vivo. NIH 3T3 fibroblasts, which form non-metastasizing tumors in athymic mice, were transduced with a retroviral vector encoding hTf. The transduced cells were cloned by limiting dilution and hTf production by the cloned cells measured. Two clones of cells producing high levels of hTf were used to seed collagen-coated nylon matrices, which were maintained in culture for up to 53 d. The rate of synthesis of hTf by the seeded matrices was constant after 22 d in vitro. Matrices seeded with cloned, transduced cells were implanted subcutaneously into seven athymic mice, and plasma levels of hTf were assessed biweekly. In all animals, the plasma level of hTf was detectable at week 6 after implantation. Levels of hTf remained elevated in the animals until the implants were removed at week 12. At week 10, the level of hTf in the plasma correlated with tumor volume in tumors less than 2000 mm3 in size. The half-life of hTf in the mice was 39.5 h. In this model, gene expression did not decline for the 12-week observation period.