1
|
Sagonas I, Daoussis D. Treatment of digital ulcers in systemic sclerosis: recent developments and future perspectives. Clin Rheumatol 2023; 42:2589-2599. [PMID: 36847929 PMCID: PMC10497679 DOI: 10.1007/s10067-023-06511-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 03/01/2023]
Abstract
Digital ulcers (DUs) comprise the main manifestation of vasculopathy and are a major cause of disability in patients with systemic sclerosis (SSc). A literature search in Web of Science, PubMed and Directory of Open Access Journals was performed in December 2022 to identify articles published in the last decade regarding the management of DUs. Prostacyclin analogues, endothelin antagonists and phosphodiesterase 5 inhibitors have shown promising results both as a stand-alone treatment and in combination for the treatment of existing and prevention of new DUs. Moreover, autologous fat grafting and botulinum toxin injections, although not readily available, can be of use in recalcitrant cases. Many investigational treatments with promising results could pave the way for a paradigm shift in the treatment of DUs in the future. Despite these recent advances, challenges remain. Better-designed trials are of paramount importance to optimise DU treatment in the years to come. Key Points • DUs are a major cause of pain and reduced quality of life in patients with SSc. • Prostacyclin analogues and endothelin antagonists have shown promising results both as a stand-alone treatment and in combination for the treatment of existing and prevention of new DUs. • In the future, a combination of more powerful vasodilatory drugs, perhaps in conjunction with topical approaches, may improve outcomes.
Collapse
Affiliation(s)
- Ioannis Sagonas
- Rheumazentrum Ruhrgebiet, Ruhr-University Bochum, Herne, Germany
| | - Dimitrios Daoussis
- Department of Rheumatology, Patras University Hospital, University of Patras Medical School, Patras, Greece.
| |
Collapse
|
2
|
Fujimoto M, Asai J, Asano Y, Ishii T, Iwata Y, Kawakami T, Kodera M, Abe M, Amano M, Ikegami R, Isei T, Isogai Z, Ito T, Inoue Y, Irisawa R, Ohtsuka M, Omoto Y, Kato H, Kadono T, Kaneko S, Kanoh H, Kawaguchi M, Kukino R, Kono T, Koga M, Sakai K, Sakurai E, Sarayama Y, Shintani Y, Tanioka M, Tanizaki H, Tsujita J, Doi N, Nakanishi T, Hashimoto A, Hasegawa M, Hayashi M, Hirosaki K, Fujita H, Fujiwara H, Maekawa T, Matsuo K, Madokoro N, Motegi SI, Yatsushiro H, Yamasaki O, Yoshino Y, Pavoux AJLE, Tachibana T, Ihn H. Wound, pressure ulcer and burn guidelines - 4: Guidelines for the management of connective tissue disease/vasculitis-associated skin ulcers. J Dermatol 2020; 47:1071-1109. [PMID: 31960490 DOI: 10.1111/1346-8138.15186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 11/17/2019] [Indexed: 11/30/2022]
Abstract
The Japanese Dermatological Association prepared guidelines focused on the treatment of skin ulcers associated with connective tissue disease/vasculitis practical in clinical settings of dermatological care. Skin ulcers associated with connective tissue diseases or vasculitis occur on the background of a wide variety of diseases including, typically, systemic sclerosis but also systemic lupus erythematosus (SLE), dermatomyositis, rheumatoid arthritis (RA), various vasculitides and antiphospholipid antibody syndrome (APS). Therefore, in preparing the present guidelines, we considered diagnostic/therapeutic approaches appropriate for each of these disorders to be necessary and developed algorithms and clinical questions for systemic sclerosis, SLE, dermatomyositis, RA, vasculitis and APS.
Collapse
Affiliation(s)
- Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Jun Asai
- Department of Dermatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshihide Asano
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Takayuki Ishii
- Department of Dermatology, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Yohei Iwata
- Department of Dermatology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Tamihiro Kawakami
- Department of Dermatology, St Marianna University School of Medicine, Kawasaki, Japan
| | - Masanari Kodera
- Department of Dermatology, JCHO Chukyo Hospital, Nagoya, Japan
| | | | - Masahiro Amano
- Department of Dermatology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Ryuta Ikegami
- Department of Dermatology, JCHO Osaka Hospital, Osaka, Japan
| | - Taiki Isei
- Department of Dermatology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Zenzo Isogai
- Division of Dermatology and Connective Tissue Medicine, Department of Advanced Medicine, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Takaaki Ito
- Department of Dermatology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yuji Inoue
- Suizenji Dermatology Clinic, Kumamoto, Japan
| | - Ryokichi Irisawa
- Department of Dermatology, Tokyo Medical University, Tokyo, Japan
| | - Masaki Ohtsuka
- Department of Dermatology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yoichi Omoto
- Department of Dermatology, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Hiroshi Kato
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takafumi Kadono
- Department of Dermatology, St Marianna University School of Medicine, Kawasaki, Japan
| | - Sakae Kaneko
- Department of Dermatology, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Hiroyuki Kanoh
- Department of Dermatology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masakazu Kawaguchi
- Department of Dermatology, Yamagata University, Faculty of Medicine, Yamagata, Japan
| | | | - Takeshi Kono
- Department of Dermatology, Nippon Medical School Chiba Hokusoh Hospital, Inzei, Japan
| | - Monji Koga
- Department of Dermatology, School of Medicine, Fukuoka University, Fukuoka, Japan
| | - Keisuke Sakai
- Department of Dermatology, Minamata City General Hospital & Medical Center, Minamata, Japan
| | | | | | | | | | - Hideaki Tanizaki
- Department of Dermatology, Osaka Medical College, Takatsuki, Japan
| | - Jun Tsujita
- Department of Dermatology, Social Insurance Inatsuki Hospital, Fukuoka Prefecture Social Insurance Hospital Association, Fukuoka, Japan
| | - Naotaka Doi
- Department of Dermatology, Wakayama Medical University, Wakayama, Japan
| | - Takeshi Nakanishi
- Department of Dermatology, Shiga University of Medical Science, Otsu, Japan
| | - Akira Hashimoto
- Department of Dermatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Minoru Hasegawa
- Department of Dermatology, Faculty of Medical Sciences, University of Fukui, Yoshida-gun, Japan
| | - Masahiro Hayashi
- Department of Dermatology, Yamagata University, Faculty of Medicine, Yamagata, Japan
| | | | - Hideki Fujita
- Division of Dermatological Science, Department of Dermatology, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroshi Fujiwara
- Department of Dermatology, Niigata University Graduate, School of Medical and Dental Sciences, Niigata, Japan.,Department of Dermatology, Uonuma Kikan Hospital, Minamiuonuma, Japan
| | - Takeo Maekawa
- Department of Dermatology, Jichi Medical University, Shimotsuke, Japan
| | | | - Naoki Madokoro
- Department of Dermatology, MAZDA Hospital, Aki-gun, Japan
| | - Sei-Ichiro Motegi
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | | | - Osamu Yamasaki
- Department of Dermatology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Yuichiro Yoshino
- Department of Dermatology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | | | - Takao Tachibana
- Department of Dermatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | | |
Collapse
|
3
|
Fukui Y, Miyagawa T, Hirabayashi M, Yamashita T, Saigusa R, Miura S, Nakamura K, Yoshizaki A, Sato S, Asano Y. Possible association of decreased serum CXCL14 levels with digital ulcers in patients with systemic sclerosis. J Dermatol 2019; 46:584-589. [PMID: 31087594 DOI: 10.1111/1346-8138.14914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 04/12/2019] [Indexed: 01/05/2023]
Abstract
CXCL14 serves as a chemoattractant for activated macrophages, immature dendritic cells and natural killer cells, as well as an antiangiogenic factor by preventing the migration of endothelial cells. CXCL14 also exerts an inhibitory effect on the CXCL12/CXCR4 signaling pathway, which is involved in the maintenance of T-helper (Th)2 bias, and promotes Th1 immune response under the physiological and pathological conditions. Because CXCL14-mediated biological processes seem to be involved in the development of systemic sclerosis (SSc), which is characterized by Th2/Th17-skewed immune polarization and impaired neovascularization, we investigated the clinical correlation of serum CXCL14 levels in patients with this disease. Serum CXCL14 levels were significantly decreased in SSc patients compared with healthy individuals and in diffuse cutaneous SSc patients relative to limited cutaneous SSc patients. SSc patients with digital ulcers had serum CXCL14 levels significantly lower than those without. Furthermore, i.v. cyclophosphamide pulse significantly increased serum CXCL14 levels as compared with the baseline in SSc patients with interstitial lung disease successfully treated with this therapy. These results indicate that decreased CXCL14 expression may contribute to the maintenance of Th2-skewed immune polarization and dysregulated neovascularization, both of which underlie the developmental process of SSc.
Collapse
Affiliation(s)
- Yuki Fukui
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Takuya Miyagawa
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Megumi Hirabayashi
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Takashi Yamashita
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Ryosuke Saigusa
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Shunsuke Miura
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Kouki Nakamura
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Ayumi Yoshizaki
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Shinichi Sato
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Yoshihide Asano
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| |
Collapse
|
4
|
Asano Y, Jinnin M, Kawaguchi Y, Kuwana M, Goto D, Sato S, Takehara K, Hatano M, Fujimoto M, Mugii N, Ihn H. Diagnostic criteria, severity classification and guidelines of systemic sclerosis. J Dermatol 2018; 45:633-691. [PMID: 29687465 DOI: 10.1111/1346-8138.14162] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/06/2017] [Indexed: 01/17/2023]
Abstract
Several effective drugs have been identified for the treatment of systemic sclerosis (SSc). However, in advanced cases, not only their effectiveness is reduced but they may be also harmful due to their side-effects. Therefore, early diagnosis and early treatment is most important for the treatment of SSc. We established diagnostic criteria for SSc in 2003 and early diagnostic criteria for SSc in 2011, for the purpose of developing evaluation of each organ in SSc. Moreover, in November 2013, the American College of Rheumatology and the European Rheumatology Association jointly developed new diagnostic criteria for increasing their sensitivity and specificity, so we revised our diagnostic criteria and severity classification of SSc. Furthermore, we have revised the clinical guideline based on the newest evidence. In particular, the clinical guideline was established by clinical questions based on evidence-based medicine according to the New Minds Clinical Practice Guideline Creation Manual (version 1.0). We aimed to make the guideline easy to use and reliable based on the newest evidence, and to present guidance as specific as possible for various clinical problems in treatment of SSc.
Collapse
Affiliation(s)
- Yoshihide Asano
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masatoshi Jinnin
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasushi Kawaguchi
- Institute of Rheumatology, Tokyo Woman's Medical University, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Daisuke Goto
- Department of Rheumatology, Faculty of Medicine, Univertity of Tsukuba, Ibaraki, Japan
| | - Shinichi Sato
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Takehara
- Department of Molecular Pathology of Skin, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Masaru Hatano
- Graduate School of Medicine Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoki Mugii
- Section of Rehabilitation, Kanazawa University Hospital, Ishikawa, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| |
Collapse
|
5
|
Pauling JD. The challenge of establishing treatment efficacy for cutaneous vascular manifestations of systemic sclerosis. Expert Rev Clin Immunol 2018; 14:431-442. [PMID: 29641934 DOI: 10.1080/1744666x.2018.1464390] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The cutaneous vascular manifestations of systemic sclerosis (SSc) comprise Raynaud's phenomenon, cutaneous ulceration, telangiectasia formation and critical digital ischaemia; each of which are associated with significant disease-related morbidity. Despite the availability of multiple classes of vasodilator therapy, many of which have been the subject of RCTs, a limited number of pharmacological interventions are currently approved for the management of cutaneous vascular manifestations of SSc. Areas covered: A major challenge has been demonstrating treatment efficacy with examples of promising therapies yielding contrasting results in controlled trial settings. Differences between consensus best-practice guidelines, evidence-based recommendations and marketing approvals in different jurisdictions has resulted in geographic variation in clinical practice concerning the management of cutaneous vascular manifestations of SSc. Difficulty demonstrating treatment efficacy risks waning industry engagement for drug development programmes in this field. This article highlights the key challenges in establishing treatment efficacy and barriers that must be overcome to support successful clinical trial programmes across the spectrum of cutaneous vascular manifestations of SSc. Expert commentary: The paucity of approved treatments for cutaneous vascular manifestations of SSc relates as much to challenges in clinical trial design and the need for reliable clinical trial endpoints, as to lack of therapeutic options.
Collapse
Affiliation(s)
- John D Pauling
- a Department of Rheumatology, Royal National Hospital for Rheumatic Diseases , Royal United Hospitals NHS Foundation Trust , Bath , UK.,b Department of Pharmacy and Pharmacology , University of Bath , Bath , UK
| |
Collapse
|
6
|
Caimi G, Canino B, Lo Presti R, Urso C, Hopps E. Clinical conditions responsible for hyperviscosity and skin ulcers complications. Clin Hemorheol Microcirc 2017; 67:25-34. [DOI: 10.3233/ch-160218] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Gregorio Caimi
- Dipartimento Biomedico di Medicina Interna eSpecialistica, Università di Palermo, Italy
| | - Baldassare Canino
- Dipartimento Biomedico di Medicina Interna eSpecialistica, Università di Palermo, Italy
| | - Rosalia Lo Presti
- Dipartimento Biomedico di Medicina Interna eSpecialistica, Università di Palermo, Italy
| | - Caterina Urso
- Dipartimento Biomedico di Medicina Interna eSpecialistica, Università di Palermo, Italy
| | - Eugenia Hopps
- Dipartimento Biomedico di Medicina Interna eSpecialistica, Università di Palermo, Italy
| |
Collapse
|
7
|
Toyama T, Asano Y, Miyagawa T, Nakamura K, Hirabayashi M, Yamashita T, Saigusa R, Miura S, Ichimura Y, Takahashi T, Taniguchi T, Yoshizaki A, Sato S. The impact of transcription factor Fli1 deficiency on the regulation of angiogenesis. Exp Dermatol 2017; 26:912-918. [PMID: 28370536 DOI: 10.1111/exd.13341] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2017] [Indexed: 12/18/2022]
Abstract
The insufficiency of Friend leukaemia virus integration 1 (Fli1), a member of the Ets family transcription factors, is implicated in the pathogenesis of vasculopathy associated with systemic sclerosis (SSc). Fli1 deficiency accelerates early steps of angiogenesis, including detachment of pre-existing pericytes and extracellular matrix degradation by endothelial proteinases, but the impact of Fli1 deficiency on the other steps of angiogenesis has not been investigated. Therefore, we evaluated the effect of Fli1 deficiency on migration, proliferation, cell survival and tube formation of human dermal microvascular endothelial cells (HDMECs). HDMECs transfected with FLI1 siRNA exhibited a greater migratory property in scratch assay and transwell migration assay and a higher proliferation rate in BrdU assay than HDMECs transfected with non-silencing scrambled RNA. In flow cytometry-based apoptosis assay, FLI1 siRNA-transduced HDMECs revealed the decreased number of annexin and propidium iodide-double-positive apoptotic cells compared with control cells, reflecting the promotion of cell survival. On the other hand, tubulogenic activity on Matrigel was remarkably suppressed in Fli1-deficient HDMECs relative to control cells. These results indicate that Fli1 deficiency promotes migration, proliferation and cell survival, while abating tube formation of endothelial cells, suggesting that Fli1 deficiency is potentially attributable to the development of both proliferative obliterative vasculopathy (occlusion of arterioles and small arteries) and destructive vasculopathy (loss of small vessels) characteristic of SSc vasculopathy.
Collapse
Affiliation(s)
- Tetsuo Toyama
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Yoshihide Asano
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Takuya Miyagawa
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Kouki Nakamura
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Megumi Hirabayashi
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Takashi Yamashita
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Ryosuke Saigusa
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Shunsuke Miura
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Yohei Ichimura
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Takehiro Takahashi
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Takashi Taniguchi
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Ayumi Yoshizaki
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Shinichi Sato
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| |
Collapse
|
8
|
Caimi G, Carlisi M, Urso C, Lo Presti R, Hopps E. Clinical disorders responsible for plasma hyperviscosity and skin complications. Eur J Intern Med 2017; 42:24-28. [PMID: 28390781 DOI: 10.1016/j.ejim.2017.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 03/30/2017] [Accepted: 04/03/2017] [Indexed: 12/17/2022]
Abstract
In this brief review, we have examined some clinical disorders which are associated to an altered hemorheological profile and at times accompanied by skin ulcers. This skin condition may be, in fact, observed in patients with primary plasma hyperviscosity such as multiple myeloma, Waldenstrom macroglobulinemia, cryoglobulinemia, cryofibrinogenemia, dysfibrinogenemia and connective tissue diseases. It must be underlined that the altered hemorheological pattern is not the only responsible for this skin complication but, as it worsens the microcirculatory flow, it contributes to determine the occurrence of the skin ulcers.
Collapse
Affiliation(s)
- Gregorio Caimi
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Italy.
| | - Melania Carlisi
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Italy
| | - Caterina Urso
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Italy
| | - Rosalia Lo Presti
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Italy
| | - Eugenia Hopps
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Italy
| |
Collapse
|
9
|
Takahashi T, Asano Y, Nakamura K, Yamashita T, Saigusa R, Ichimura Y, Toyama T, Taniguchi T, Yoshizaki A, Tamaki Z, Tada Y, Sugaya M, Kadono T, Sato S. A potential contribution of antimicrobial peptide LL-37 to tissue fibrosis and vasculopathy in systemic sclerosis. Br J Dermatol 2016; 175:1195-1203. [PMID: 27105895 DOI: 10.1111/bjd.14699] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND LL-37 is an antimicrobial peptide with pleiotropic effects on the immune system, angiogenesis and tissue remodelling. These are cardinal pathological events in systemic sclerosis (SSc). OBJECTIVES To elucidate the potential role of LL-37 in SSc. METHODS The expression of target molecules was evaluated by immunostaining and quantitative reverse-transcription real-time polymerase chain reaction in human and murine skin. The mechanisms regulating LL-37 expression in endothelial cells were examined by gene silencing and chromatin immunoprecipitation. Serum LL-37 levels were determined by enzyme-linked immunosorbent assay. RESULTS In SSc lesional skin, LL-37 expression was increased in dermal fibroblasts, perivascular inflammatory cells, keratinocytes and, particularly, dermal small vessels. Expression positively correlated with interferon-α expression, possibly reflecting LL-37-dependent induction of interferon-α. In SSc animal models, bleomycin-treated skin exhibited the expression pattern of CRAMP, a murine homologue of LL-37, similar to that of LL-37 in SSc lesional skin. Furthermore, Fli1+/- mice showed upregulated expression of CRAMP in dermal small vessels. Fli1 binding to the CAMP (LL-37 gene) promoter and Fli1 deficiency-dependent induction of LL-37 were also confirmed in human dermal microvascular endothelial cells. In the analysis of sera, patients with SSc had serum LL-37 levels significantly higher than in healthy controls. Furthermore, serum LL-37 levels positively correlated with skin score and the activity of alveolitis and were significantly elevated in patients with digital ulcers compared with those without. CONCLUSIONS LL-37 upregulation, induced by Fli1 deficiency at least in endothelial cells, potentially contributes to the development of skin sclerosis, interstitial lung disease and digital ulcers in SSc.
Collapse
Affiliation(s)
- T Takahashi
- Department of Dermatology, University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Y Asano
- Department of Dermatology, University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - K Nakamura
- Department of Dermatology, University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - T Yamashita
- Department of Dermatology, University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - R Saigusa
- Department of Dermatology, University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Y Ichimura
- Department of Dermatology, University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - T Toyama
- Department of Dermatology, University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - T Taniguchi
- Department of Dermatology, University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - A Yoshizaki
- Department of Dermatology, University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Z Tamaki
- Department of Dermatology, University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Y Tada
- Department of Dermatology, University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - M Sugaya
- Department of Dermatology, University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - T Kadono
- Department of Dermatology, University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - S Sato
- Department of Dermatology, University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| |
Collapse
|
10
|
De Cata A, Inglese M, Molinaro F, De Cosmo S, Rubino R, Bernal M, Mazzoccoli G. Digital ulcers in scleroderma patients: A retrospective observational study. Int J Immunopathol Pharmacol 2015; 29:180-7. [PMID: 26684622 DOI: 10.1177/0394632015606846] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 08/26/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The guidelines for digital ulcers (DUs) management in systemic sclerosis (SSc) indicate the use of iloprost to induce wound healing and bosentan to prevent the onset of new DU. The aim of our study was to evaluate whether the combination treatment may surmount the effect of the single drug. METHODS We analyzed data regarding 34 patients with SSc and at least one active DU persisting despite 6 months of iloprost therapy, and treated for other 6 months with a combination therapy, i.e. iloprost plus bosentan. RESULTS Overall, patients initially presented 69 DUs (58 on the fingers and 11 on the legs). At the end of the study 34 (49.3%) DUs were completely healed (responding, R), 18 (26.1%) started the healing process (partially responding, PR), and 17 (24.6%) did not respond (NR) to therapy. No new DU was recorded and the ulcers localized on the legs did not respond to the combination therapy. Finally, data have been analyzed by dividing the patients in two groups according to the fibrosis level on the finger. In the group with mild fibrosis, 83.4% of DUs resulted with showing complete healing while, in the group with severe fibrosis, only 18% of DUs were healed (P = 0.024). CONCLUSION The treatment with iloprost plus bosentan is effective in determining healing of DUs in SSc patients with mild digital skin fibrosis. Conversely, the severity of skin fibrosis strongly influences the healing process of DUs. The study confirmed the efficacy of bosentan to prevent onset of new DUs.
Collapse
Affiliation(s)
- A De Cata
- Department of Medical Sciences, Division of Internal Medicine and Rheumatology Unit, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG), Italy
| | - M Inglese
- Department of Medical Sciences, Division of Internal Medicine and Rheumatology Unit, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG), Italy
| | - F Molinaro
- Department of Medical Sciences, Division of Internal Medicine and Rheumatology Unit, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG), Italy
| | - S De Cosmo
- Department of Medical Sciences, Division of Internal Medicine and Rheumatology Unit, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG), Italy
| | - R Rubino
- Department of Medical Sciences, Division of Internal Medicine and Rheumatology Unit, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG), Italy
| | - M Bernal
- Department of Medical Sciences, Division of Internal Medicine and Rheumatology Unit, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG), Italy
| | - G Mazzoccoli
- Department of Medical Sciences, Division of Internal Medicine and Rheumatology Unit, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG), Italy
| |
Collapse
|
11
|
Viswanath V, Phiske MM, Gopalani VV. Systemic sclerosis: current concepts in pathogenesis and therapeutic aspects of dermatological manifestations. Indian J Dermatol 2013; 58:255-68. [PMID: 23918994 PMCID: PMC3726870 DOI: 10.4103/0019-5154.113930] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Systemic sclerosis (SSc) is a chronic, multisystem connective tissue disease with protean clinical manifestations. Recent advances in understanding the pathogenic mechanisms have led to development of target-oriented and vasomodulatory drugs which play a pivotal role in treating various dermatological manifestations. An exhaustive literature search was done using Medline, Embase, and Cochrane library to review the recent concepts regarding pathogenesis and evidence-based treatment of salient dermatological manifestations. The concept of shared genetic risk factors for the development of autoimmune diseases is seen in SSc. It is divided into fibroproliferative and inflammatory groups based on genome-wide molecular profiling. Genetic, infectious, and environmental factors play a key role; vascular injury, fibrosis, and immune activation are the chief pathogenic factors. Vitamin D deficiency has been documented in SSc and correlates with the severity of skin involvement. Skin sclerosis, Raynaud's phenomenon (RP) with digital vasculopathies, pigmentation, calcinosis, and leg ulcers affect the patient's quality of life. Immunosuppressives, biologicals, and hematopoietic stem cell transplantation are efficacious in skin sclerosis. Endothelin A receptor antagonists, calcium-channel blockers, angiotensin receptor inhibitors, prostacyclin analogs, and phosphodiesterase type 5 (PDE-5) inhibitors are the mainstay in RP and digital vasculopathies. Pigmentation in SSc has been attributed to melanogenic potential of endothelin-1 (ET-1); the role of ET 1 antagonists and vitamin D analogs needs to be investigated. Sexual dysfunction in both male and female patients has been attributed to vasculopathy and fibrosis, wherein PDE-5 inhibitors are found to be useful. The future concepts of treating SSc may be based on the gene expression signature.
Collapse
Affiliation(s)
- Vishalakshi Viswanath
- Department of Dermatology, Rajiv Gandhi Medical College and CSM Hospital, Kalwa, Thane Municipal Corporation, India
| | | | | |
Collapse
|
12
|
Chrobak I, Lenna S, Stawski L, Trojanowska M. Interferon-γ promotes vascular remodeling in human microvascular endothelial cells by upregulating endothelin (ET)-1 and transforming growth factor (TGF) β2. J Cell Physiol 2013; 228:1774-83. [PMID: 23359533 DOI: 10.1002/jcp.24337] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Accepted: 01/18/2013] [Indexed: 12/17/2022]
Abstract
Systemic sclerosis (SSc) is a complex disease characterized by vascular alterations, activation of the immune system and tissue fibrosis. Previous studies have implicated activation of the interferon pathways in the pathogenesis of SSc. The goal of this study was to determine whether interferon type I and/or type II could play a pathogenic role in SSc vasculopathy. Human dermal microvascular endothelial cells (HDMVECs) and fibroblasts were obtained from foreskins of healthy newborns. The RT Profiler PCR Array System was utilized to screen for EndoMT genes. Treatment with IFN-α or IFN-γ downregulated Fli1 and VE-cadherin. In contrast, IFN-α and IFN-γ exerted opposite effects on the expression of α-SMA, CTGF, ET-1, and TGFβ2, with IFN-α downregulating and IFN-γ upregulating this set of genes. Blockade of TGFβ signaling normalized IFN-γ-mediated changes in Fli1, VE-cadherin, CTGF, and ET-1 levels, whereas upregulation of α-SMA and TGFβ2 was not affected. Bosentan treatment was more effective than TGFβ blockade in reversing the actions of IFN-γ, including downregulation of α-SMA and TGFβ2, suggesting that activation of the ET-1 pathway plays a main role in the IFN-γ responses in HDMECs. IFN-γ induced expression of selected genes related to endothelial-to-mesenchymal transition (EndoMT), including Snail1, FN1, PAI1, TWIST1, STAT3, RGS2, and components of the WNT pathway. The effect of IFN-γ on EndoMT was mediated via TGFβ2 and ET-1 signaling pathways. This study demonstrates distinct effects of IFN-α and IFN-γ on the biology of vascular endothelial cells. IFN-γ may contribute to abnormal vascular remodeling and fibrogenesis in SSc, partially via induction of EndoMT.
Collapse
Affiliation(s)
- Izabela Chrobak
- Boston University School of Medicine, Arthritis Center, Boston, Massachusetts 02118, USA
| | | | | | | |
Collapse
|
13
|
Abstract
This review focuses on new findings and developments relevant to the clinician caring for patients with primary and secondary [especially systemic sclerosis (SSc)-related] Raynaud phenomenon (RP). In the last 18 months, several clinical trials and observational studies of RP and of SSc-related digital ulceration have been published, reflecting increased awareness of disease burden and increased interest by pharmaceutical companies: new insights into pathophysiology are driving new approaches to treatment. Key developments are the increased use of phosphodiesterase type V inhibitors in severe RP, and of bosentan (an endothelin-1 receptor antagonist) for prevention of recurrent SSc-related digital ulcers. Other treatments being researched include topical glyceryl trinitrate (applied locally to the digits), botulinum toxin (for severe digital ischemia/ulceration), and several other drugs including oral prostanoids. Increased availability and interest in nailfold capillaroscopy, by facilitating early diagnosis of SSc, should pave the way for studies of early intervention and vascular protection.
Collapse
Affiliation(s)
- Ariane L Herrick
- Centre for Musculoskeletal Research, Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, University of Manchester, Salford M6 8HD, UK.
| |
Collapse
|
14
|
Abstract
Pathogenic processes that underlie the development and progression of systemic sclerosis (SSc) are being defined in preclinical, clinical and genetic studies. Important evidence of interplay between the vasculature, connective tissue and specialized epithelial structures is emerging, and abnormalities of both the innate and adaptive immune systems have been identified. In this context, information regarding pivotal mediators, pathways or cell types that could be targets for therapeutic intervention, and that might offer potential for true disease modification, is accruing. Precedent for the regression of some aspects of the pathology has been set in clinical studies showing that potential exists to improve tissue structure and function as well as to prevent disease progression. This article reviews the concept of targeted therapies and considers potential pathways and processes that might be attenuated by therapeutic intervention in SSc. As well as improving outcomes, such approaches will undoubtedly provide information about pathogenesis. The concept of translational medicine is especially relevant in SSc, and we anticipate that the elusive goal of an effective antifibrotic treatment will emerge from one of the several clinical trials currently underway or planned in this disease. Therapeutic advances in SSc would have implications and potential beyond autoimmune rheumatic diseases.
Collapse
Affiliation(s)
- Christopher P Denton
- Centre for Rheumatology and Connective Tissue Disease, UCL Medical School, Royal Free Hospital, London NW3 2QG, UK.
| | | |
Collapse
|
15
|
Successful treatment with bosentan of lower extremity ulcers in a scleroderma patient. Case Rep Med 2013; 2013:690591. [PMID: 23653656 PMCID: PMC3638571 DOI: 10.1155/2013/690591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 03/14/2013] [Indexed: 11/17/2022] Open
Abstract
Digital ulcers are a well-known problem in patients with systemic sclerosis. Lower extremity ulcers are less prevalent but are also a challenging and underestimated complication of the disease causing important pain and morbidity. Bosentan, an oral dual endothelin receptor antagonist, has been shown to be effective in preventing digital ulcers in patients with systemic sclerosis. A few recent observations showed the efficacy of bosentan for accelerating the healing of nondigital ulcers in scleroderma patients. This report deals with a 48-year-old patient with systemic sclerosis who developed painful ulcers on the left ankle and hallux. The ulcers were refractory to a combination of vasodilator therapy with a calcium antagonist and several courses of intravenous prostanoids, low molecular weight heparin, aspirin, simvastatin, and intensive local treatment. Bosentan treatment showed spectacular healing of the ulcers already after 4 months of therapy. This case supports the previous few observations of accelerating wound healing of lower extremity ulcers in systemic sclerosis patients with bosentan treatment.
Collapse
|
16
|
Frech TM, Smith G, Reily M, Chamberlain J, Murtaugh MA, Penrod J, Battistone MJ, Stults BM. Peripheral neuropathy: a complication of systemic sclerosis. Clin Rheumatol 2013; 32:885-8. [PMID: 23404236 DOI: 10.1007/s10067-013-2206-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 01/22/2013] [Accepted: 01/29/2013] [Indexed: 10/27/2022]
Abstract
We performed bedside testing for peripheral neuropathy in our systemic sclerosis (SSc) population to determine whether foot care guidelines should be developed for SSc. Twenty consecutive SSc patients and 20 healthy control (HC) patients were evaluated for peripheral neuropathy in both feet using the 10-g Semmes-Weinstein monofilament examination (SWME) and 128 Hz vibration sensation using the on-off method. Independent, blinded, vibratory sensation, and SWME evaluations were performed on each subject by two investigators who had completed a training session to standardize each exam. An additional consecutive 20 patients with type 2 diabetes mellitus (DM) were examined by a diabetologist to compare with peripheral neuropathy prevalence in SSc patients. We examined the inter-rater variability using Cohen's kappa. We compared SWME and vibratory sensation in SSc to HC using Fisher's exact. The t test was used to compare duration of disease and modified Rodnan skin score (mRSS) for those with abnormal SWME or vibratory sensation. Two of 20 SSc patients reported sensory foot symptoms consistent with peripheral neuropathy prior to the examination. Inter-rater agreement for both SWME and vibratory sensation was strong (kappa: 0.72 and 0.83, respectively). Two HC and 12 SSc patients demonstrated abnormal vibratory sense (one-sided Fishers' exact, p < 0.002). No HC and four SSc patients had abnormal monofilament exams (one-sided Fisher's exact, p = 0.053). Neither mRSS (p = 0.28) nor duration of non-Raynauds (p = 0.07) symptoms differed between those with peripheral neuropathy and those without. Duration of Raynaud's symptoms were clinically significantly associated with presence of peripheral neuropathy (p = 0.04). The prevalence of sensory loss to monofilament in SSc was identical to DM patients (4/20). SSc patients have a considerable prevalence of pedal peripheral neuropathy as detected by loss of vibratory sensation or inability to sense the 10-g SWME. Further studies are indicated to determine if routine screening for neuropathy and subsequent podiatric care for SSc patients with abnormalities can reduce pedal complications.
Collapse
Affiliation(s)
- Tracy M Frech
- Division of Rheumatology, Department of Internal Medicine, University of Utah, 4B200 SOM 30 N 1900 E, Salt Lake City, UT 84132, USA.
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Quoi de neuf en médecine interne ? Ann Dermatol Venereol 2012; 139 Suppl 5:S194-201. [DOI: 10.1016/s0151-9638(12)70134-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
18
|
Nitsche A. Raynaud, úlceras digitales y calcinosis en esclerodermia. ACTA ACUST UNITED AC 2012; 8:270-7. [DOI: 10.1016/j.reuma.2012.02.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Revised: 02/23/2012] [Accepted: 02/29/2012] [Indexed: 12/17/2022]
|