Role of acrylates in the development of contact dermatitis in diabetic patients-A Polish dermatology tertiary centre experience

BACKGROUND

In recent years, an increasing number of contact dermatitis cases triggered by acrylates contained in diabetes medical devices have been reported. Acrylates seem to play a major role in the development of irritant contact dermatitis and allergic contact dermatitis (ACD) in diabetic patients.

OBJECTIVES

To study a group of patients with contact dermatitis caused by diabetes medical devices with a focus on acrylates as possible allergens responsible for contact dermatitis.

PATIENTS AND METHODS

Fifteen patients with diabetes mellitus type 1 and contact dermatitis from diabetic devices were patch tested to 25 acrylate allergens.

RESULTS

Three patients (20%) reacted to the following allergens: three patients reacted to isobornyl acrylate (IBOA) and one of them additionally to 2-hydroxyethyl acrylate (2-HEA); results were of clinical relevance. All three patients were using insulin pumps and glucose sensors (GS)-in one patient contact dermatitis was towards the insulin pump and the GS, in one patient only towards the insulin pump and in one patient only towards the GS. Twelve patients (80%) did not show any skin reaction towards the allergens tested.

CONCLUSION

A majority of diabetic patients showed no reactions towards any acrylate allergen tested; yet, the presence of untested allergens must be kept in mind. IBOA proved to be a cause of ACD in diabetes patients. 2-HEA might be another culprit allergen, but its presence in the devices must first be confirmed.

Gastrointestinal Comorbidities Associated with Atopic Dermatitis-A Narrative Review

The current understanding of atopic dermatitis (AD) seems to be extending beyond a skin-confined condition frequently associated with allergic comorbidities, as in a number of epidemiological studies, the prevalence rate of a range of illnesses has been determined to be greater in patients with AD, or inversely. In most cases, the reasons for this are vague. A subset of these conditions are gastrointestinal disorders, including food sensitization (FS) and food allergy (FA), eosinophilic esophagitis (EoE) (it is of mixed background, both IgE-dependent and independent), food protein-induced enterocolitis syndrome (FPIES) (it exemplifies an IgE-independent food allergy), Crohn's disease (CD), colitis ulcerosa (CU), celiac disease, irritable bowel syndrome (IBS), and gastroesophageal reflux disease (GERD). In this review, we performed a comprehensive search of the literature using the PubMed database. We addressed the epidemiology of the increased co-occurrence of these diseases with AD and discussed potential causes for this subject. Multiple gastroenterological comorbidities appear to be more common in patients with AD, according to our review. The mechanisms that underlie this phenomenon are largely unknown, highlighting the need for further study in this field.

Differences in the detection of circulating Hsp90 alpha between patients with atopic dermatitis and dermatitis herpetiformis

Heat shock protein 90 alpha (Hsp90α) is one of the key intra- and extracellular chaperones responsible for the biological activity of various signaling molecules that are involved in (auto)immune-mediated inflammatory diseases. Recent epidemiologic data suggest that patients with atopic dermatitis (AD) are at risk for several autoimmune diseases, including dermatitis herpetiformis (DH), an extraintestinal manifestation of celiac disease (CD). In addition, pruritic diseases such as AD may be confused clinically with DH. In this study, we aimed to determine the role of circulating Hsp90α in patients with AD in relation to patients with DH, CD, and healthy controls. Using an enzyme-linked immunosorbent assay, levels of circulating Hsp90α were determined in serum samples derived from patients with AD (n = 31), DH (n = 26), CD (n = 15), and healthy controls (n = 55). Although serum concentrations of Hsp90α were similar between patients with DH, CD, and healthy controls, we found that serum levels of Hsp90α were significantly higher (mean value of 5.08-fold; p < 0.0001) in patients with AD when compared to patients with DH. A cutoff value calculated as 2 × standard deviation above the mean concentration of Hsp90α in DH patients revealed that 83.9% (26/31) of AD patients were Hsp90α positive, whereas none of the DH patients (0/26) displayed such a positivity. This preliminary study suggests a distinct role for extracellular Hsp90α in the pathogenesis of AD compared to DH and its potential use in distinguishing AD from DH. Nevertheless, the potential role of the evaluation of extracellular Hsp90α for distinguishing between AD and DH is at present speculative and requires further and careful observations.

Altered Gene Expression of IL-35 and IL-36α in the Skin of Patients with Atopic Dermatitis

A comprehensive understanding of atopic dermatitis (AD) pathogenesis is desired, especially in the current era of novel biologics and small molecule drugs. In recent years, new cytokines have emerged that may play a significant role in the pathogenesis of AD. Using the tape stripping (TS) method, this study analyzed the gene expression of IL-35 and IL-36α in lesional and nonlesional AD skin compared with healthy skin and their association with the clinical features of AD among the Polish population. Ten AD patients and seven healthy individuals were enrolled. The lesional skin of the AD patients showed significantly higher expression levels of IL-35 compared to healthy skin (p = 0.0001). The expression level of IL-36α was significantly higher in lesional AD skin than in nonlesional AD skin (p = 0.0039) and healthy skin (p = 0.0045). There was a significant negative correlation between AD severity and the expression level of IL-35 in both lesional (R = -0.66, p = 0.048) and nonlesional skin (R = -0.9, p = 0.0016). In summary, both IL-35 and IL-36α appear to play a role in the pathogenesis of AD. Furthermore, it might be speculated that IL-35 and IL-36α may be potential candidates for disease biomarkers. However, further studies are needed to verify these assumptions and comprehensively elucidate their importance in the pathogenesis of AD.

Potential Role of IL-37 in Atopic Dermatitis

Interleukin 37 (IL-37) is a recently discovered member of the IL-1 cytokine family that appears to have anti-inflammatory and immunosuppressive effects in various diseases. IL-37 acts as a dual-function cytokine, exerting its effect extracellularly by forming a complex with the receptors IL-18 α (IL-18Rα) and IL-1R8 and transmitting anti-inflammatory signals, as well as intracellularly by interacting with Smad3, entering the nucleus, and inhibiting the transcription of pro-inflammatory genes. Consequently, IL-37 is linked to IL-18, which plays a role in the pathogenesis of atopic dermatitis (AD), consistent with our studies. Some isoforms of IL-37 are expressed by keratinocytes, monocytes, and other skin immune cells. IL-37 has been found to modulate the skewed T helper 2 (Th2) inflammation that is fundamental to the pathogenesis of AD. This review provides an up-to-date summary of the function of IL-37 in modulating the immune system and analyses its potential role in the pathogenesis of AD. Moreover, it speculates on IL-37's hypothetical value as a therapeutic target in the treatment of AD.

Dupilumab for the treatment of moderate and severe atopic dermatitis: real-life experience

Introduction

Atopic dermatitis is a relapsing, chronic, inflammatory dermatosis. So far, treatment options for more severe forms of the disease have been limited. The prospect has changed with the advent of biological drug registrations. Dupilumab is a monoclonal antibody targeting the a subunit of the IL-4 receptor and is responsible for blocking the signalling of interleukin (IL) 4 (IL-4) and IL-13. Clinical trials conducted for over 10 years have confirmed the efficacy and safety of dupilumab's treatment for atopic dermatitis.

Aim

Evaluating the efficacy of dupilumab treatment in patients with moderate and severe atopic dermatitis in real life.

Material and methods

We retrospectively evaluated medical records of patients treated with dupilumab for atopic dermatitis at the Department of Dermatology, Venereology and Allergology in Gdansk.

Results

Ten patients in total were studied. They received dupilumab with standard dosing. The mean percentage reduction in SCORAD score was 52.16% in 8 weeks. Dupilumab was generally well tolerated and did not cause serious side effects. The most common adverse event was conjunctivitis.

Conclusions

Dupilumab is an effective disease-modifying drug for patients with moderate to severe atopic dermatitis. The effects of treatment in real life are consistent with those demonstrated in clinical trials.

Erythrodermic Presentation of Atopic Dermatitis in a Patient with Secondary Adrenal Insufficiency Caused by Oral Glucocorticosteroid Abuse

Dear Editor, A 41-year-old man presented to the Department of Dermatology for the first time due to an exacerbation of atopic dermatitis (AD) in the form of erythroderma. The patient had a history of atopic diseases, with being AD active from infancy. On clinical examination, generalized erythematous skin lesions causing acute pruritus and accompanied by severe skin exfoliation and dryness were present. On closer examination, the patient had a collection of signs and symptoms characterizing Cushing syndrome that included a round and full face (''moon face''), supraclavicular fat pads, and proximal muscle atrophy. The patient stated that AD had exacerbated six years earlier. He had received systemic treatment consisting of methotrexate followed by cyclosporine in another medical facility. However, both medications had proven ineffective and caused malaise. Only oral glucocorticosteroids had proven successful. The patient had been satisfied with the quick and observable effects, and, as he stated, he refrained from regular dermatological visits for six years. During that time, he consistently took 4 mg of methylprednisolone twice daily. Laboratory tests showed undetectably low levels of cortisol, triacylglycerols (TAG) at 288 mg/dL, and total cholesterol levels (CHC) of 81 mg/dL. Based on laboratory findings, clinical presentation, and histopathological evaluation of the skin biopsy, the diagnoses were secondary adrenal insufficiency caused by oral glucocorticosteroid abuse and AD in the form of erythroderma. The endocrinologist suggested a progressive reduction of the dose of methylprednisolone, starting at 2 mg twice daily. Total and sudden drug withdrawal was unacceptable, as it could cause an adrenal crisis. Methylprednisolone was eventually discontinued after being administered for 5 months while the blood levels of ACTH, cortisol, ionized sodium, and ionized potassium were monitored every 4 weeks. 25 mg of hydroxycortisol in divided doses was the actual treatment for adrenal insufficiency, with plans to also gradually reduce the dose. Since the commencement of endocrinological treatment, the dose was reduced to 15 mg after 5 months and to 10 mg after 7 months. Following an 8-month period, the patient began taking 10 mg as needed, usually a few times each month. Calcium carbonate in a dose of 1000 mg taken once daily before a meal for 5 months and vitamin D3 protected the patient from osteoporosis, another manifestation of Cushing syndrome. An initial dose of 4000 IU was prescribed. It is vital to emphasize that all dose adjustments in the endocrinological treatment of Cushing syndrome were a direct consequence of laboratory testing that was performed. In terms of erythrodermic AD management, the patient was treated with cyclosporin, which was once again ineffective. The patient was then prepared for the introduction of dupilumab. A 300 mg dose of the medication was subcutaneously administered every 2 weeks for over a year with positive outcomes, with an initial dose of 600 mg. The patient developed gynecomastia at the beginning of the treatment, initially categorized as another manifestation of Cushing syndrome. However, due to its unilateral nature, it was later identified a benign adverse event of dupilumab, as described in the literature (1). Due to a decline in effectiveness, the treatment was recently switched from dupilumab to baricitinib, with positive outcomes. Erythroderma, which the patient presented in our case, is an acute condition characterized by erythema and scaling that involves more than 90% of the skin's surface area (2,3). It can be potentially fatal due to electrolyte imbalance, fluid loss from capillary dilation, and significant heat dissipation (3). According to estimates, erythroderma is relatively rare, affecting approximately 1-2 patients for every 100,000 people per year, with AD comprising 8.7% of all cases of erythroderma (2,4). Despite growing therapeutic possibilities for AD, corticosteroids remain the drug of choice in severe exacerbations, including erythroderma, when we cannot afford to wait for the effects of therapy. Oral glucocorticosteroids can be an effective treatment for acute flares of AD (5). However, there is a lack of evidence for the long-term efficacy and safety of oral glucocorticosteroids in the treatment of AD (5). Reported side-effects include endocrine disturbances, gastric ulcers, cardiovascular disorders (arterial hypertension, atherosclerotic disease), osteoporosis, glaucoma, cataracts, and an increased risk of infections. Corticosteroids also have an undesired action on the skin that can result in steroid acne, skin atrophy, striae, telangiectasias, hypertrichosis, and impaired wound healing. The psychological adverse effects of steroid treatment can be quite severe and include depression and psychosis (6), The therapy should only be applied in the short-term, not exceeding one week, due to the occurrence of the abovementioned side-effects, which presented in as Cushing syndrome our patient (5). However, glucocorticoids are one of the most commonly used drugs in clinical dermatology practice, raising concerns about the risk of their misuse, which can lead to secondary adrenal insufficiency, among other complications (7). When no other treatment options are available, it should be noted that many of the side-effects of oral glucocorticosteroids can be mitigated through close monitoring and the implementation of appropriate preventive measures (7).

Impact of the COVID-19 Pandemic on Adult Patients with Atopic Dermatitis

Atopic dermatitis (AD) is a chronic, inflammatory, itchy dermatosis with periods of remissions and exacerbations. Social isolation and lockdown measures may cause increased stress which in turn may affect the skin condition of patients with AD. We aimed to investigate the impact of the COVID-19 pandemic on the course of AD and the mental health of adult patients with AD. The study was based on an anonymous online questionnaire. A total of 91 adult patients with AD participated in this survey. The study population consisted of 77 (84.6%) female and 14 (15.4%) male patients. The average age of patients was 28.3 years. Fifty-four respondents out of 91 (59.3%) noticed a worsening in the course of AD. Patients with worsened AD most often indicated exacerbating itching of the skin (92.6% of 54). Only 54 (59.3%) patients continued treatment as directed by the attending physician. Of those that did not, 13 (14.3%) took or applied fewer medications and 24 (26.4%) stopped taking or applying medications altogether. Of all respondents, 60 (65.9%) believed that their mental health had deteriorated and 11 (12.1%) patients developed suicidal thoughts during the COVID-19 pandemic. The results indicate that the COVID-19 pandemic had a negative impact on the course of AD among adult patients. Forced life changes, increased stress, and poor adherence to treatment may have been contributing factors. Increased stress may have also worsened the mental health of patients with AD, which in turn may have exacerbated AD.

Contact Dermatitis to Diabetes Medical Devices

Skin adverse reactions to diabetes medical devices have been reported frequently over recent years. Adhesives attaching glucose sensors and continuous insulin infusion sets to the skin are proven to cause both allergic contact dermatitis and irritant contact dermatitis in patients with diabetes mellitus. Several allergens contained in adhesives and/or parts of medical devices are documented to cause allergic contact dermatitis, with acrylate chemicals being the most common culprit-especially isobornyl acrylate (IBOA), but also 2,2'-methylenebis(6-tert-butyl-4-methylphenol) monoacrylate or cyanoacrylates. Epoxy resin, colophonium and nickel were also identified as causative allergens. However, repetitive occlusion, maceration of the skin and resulting disruption of the skin barrier seem to have an impact on the development of skin lesions as well. The purpose of this study is to highlight the burden of contact dermatitis triggered by diabetes medical devices and to show possible mechanisms responsible for the development of contact dermatitis in a group of diabetic patients.

Excess filaggrin in keratinocytes is removed by extracellular vesicles to prevent premature death and this mechanism can be hijacked by Staphylococcus aureus in a TLR2-dependent fashion

Filaggrin (FLG) protein is indispensable for multiple aspects of the epidermal barrier function but its accumulation in a monomeric filaggrin form may initiate premature keratinocytes death; it is unclear how filaggrin levels are controlled before the formation of storing keratohyalin granules. Here we show that keratinocyte-secreted small extracellular vesicles (sEVs) may contain filaggrin-related cargo providing a route of eliminating excess filaggrin from keratinocytes; blocking of sEV release has cytotoxic effects on those cells. Filaggrin-containing sEVs are found in plasma in both healthy individuals and atopic dermatitis patients. Staphylococcus aureus (S. aureus) enhances packaging and secretion of filaggrin-relevant products within the sEVs for enhanced export via a TLR2-mediated mechanism which is also linked to the ubiquitination process. This filaggrin removal system, preventing premature keratinocyte death and epidermal barrier dysfunction, is exploited by S. aureus which promotes filaggrin elimination from the skin that could help safeguard bacterial growth.

Regnase-1 plays an essential role in maintaining skin immune homeostasis via regulation of chemokine expression

Regnase-1 is an endoribonuclease that regulates the stability of target genes. Here, we investigated whether Regnase-1 plays a regulatory role in the pathophysiology of atopic dermatitis, a chronic inflammatory skin disease. Regnase-1 levels were decreased in skin and serum of atopic dermatitis patients and mice. Regnase-1^+/- mice exhibited more severe atopic dermatitis symptoms than wild-type mice in a house dust mite allergen-induced atopic dermatitis model. Regnase-1 deficiency led to the global changes in gene expression related with innate immune and inflammatory responses, in particular chemokines. The skin Regnase-1 level had an inverse relationship with chemokine expression when we analyzed samples of atopic dermatitis patients and Regnase-1-deficient mice, suggesting that potentiated chemokine production contributes to the augmented inflammation at lesion sites. Subcutaneous administration of recombinant Regnase-1 to mice significantly ameliorated atopic dermatitis-like skin inflammation with reduced chemokine production in a house dust mite-induced atopic dermatitis NC/Nga mouse model. These results indicate that Regnase-1 plays an essential role in maintaining skin immune homeostasis as a regulator of chemokine expression. Modulating Regnase-1 activity may be an efficient therapeutic strategy for treating chronic inflammatory diseases, including atopic dermatitis.

How to Understand Personalized Medicine in Atopic Dermatitis Nowadays?

Atopic dermatitis (AD) is a heterogeneous disease in terms of its phenotypical, barrier, and immunological presentation. Emerging therapies are undoubtedly contributing to a new chapter in the treatment of AD, bringing an excellent possibility of individualization, and thereby creating a tailored approach. The two most promising substance groups are biological drugs (dupilumab, tralokinumab, lebrikizumab, nemolizumab) and Janus kinase inhibitors (JAKis) (baricitinib, upadacitinib, and abrocitinib). The vision that certain well-defined phenotypes and endotypes, as well as personal preferences, may guide the future treatment of AD is both tempting and appealing, but not yet reality. The accessibility of new drugs such as biologics and small molecules has opened up the discussion regarding personalized medicine, referring to the complex nature of AD as well as the experiences from clinical trials and real-world evidence. We have now reached the point of creating new strategies and AD treatment goals by increasing the amount of new information concerning the efficacy and safety of new drugs. This article has reviewed the novel treatment options for AD in the light of the heterogeneity of this disease and proposes a broader vision on the strategy of personalized treatment of AD.

The Associations of Single Nucleotide Polymorphisms of the COL3A1, COL6A5, and COL8A1 Genes with Atopic Dermatitis

The pathophysiology of atopic dermatitis (AD) is complex, multifactorial, and not fully understood. Genes encoding collagens, the most abundant proteins in the extracellular matrix (ECM), may play a potential role in the pathogenesis of AD. Our study aimed to estimate the associations between Col3A1/rs1800255, Col6A5 /29rs12488457, and Col8A1/rs13081855 polymorphisms and the occurrence, course, and features of AD in the Polish population. Blood samples were collected from 157 patients with AD and 111 healthy volunteers. The genotype distribution of the investigated collagens genes did not differ significantly between the AD and control subjects (p > 0.05). The AA genotype of Col3A1/rs1800255 was significantly associated with the occurrence of mild SCORAD (OR = 0.16; 95% Cl: 0.03-0.78; p = 0.02) and mild pruritus (OR = 18.5; 95% Cl: 3.48-98.40; p = 0.0006), while the GG genotype was significantly associated with severe SCORAD (OR = 6.6; 95% Cl: 1.23-32.35; p = 0.03). Regarding Col6A5/29rs12488457 polymorphism, the average SCORAD score was significantly lower in the group of patients with genotype AA than in patients with the AC genotype (39.8 vs. 53.4; p = 0.04). Nevertheless, both average SCORAD scores were high, and represent the moderate and severe grades of the diseases, respectively. The single nucleotide polymorphisms (SNPs) of COL3A1/ rs1800255 and Col6A5/29rs12488457 seem to be associated with AD courses and symptoms, suggesting new disease biomarkers. The modulation of collagens, the major component of the ECM, may serve as a therapeutic target of AD in the future.

Characterization of Chronic Urticaria and Associated Conditions - A Web-Based Survey

INTRODUCTION

Chronic urticaria is a common disease, characterized by the development of wheals, angioedema, or both, which can be associated with several comorbidities. Most of the available studies have focused on specific common comorbidities and their association with CU, but have seldom reported the overall burden of comorbidities.

OBJECTIVES

This study aimed to investigate and analyze self-reported comorbidities in Polish patients with CU.

METHODS

An anonymous online survey consisting of 20 questions was conducted on members of an Urticaria group on the social media platform Facebook. A total of 102 people took part in this survey. The results were analyzed in Microsoft Excel 2016.

RESULTS

In the group, 95.1% were females and 4.9% males, with a mean age of 33.8 years. The most common diagnosed type of urticaria was spontaneous (52.9%). Angioedema accompanied urticaria in 68.6% of the respondents, mainly those with delayed pressure urticaria (86.4%). 85.3% of respondents reported comorbidities, most often atopic diseases and allergies (49%), chronic inflammation and infections (36.3%), thyroid (36.3%) and psychiatric disorders (25.5%). Moreover, in 30.4% of patients, at least one autoimmune disease was noted. As compared to the patients without autoimmune urticaria, many more with autoimmune urticaria had a coexisting autoimmune disease (50% vs. 23.7%). Family history of autoimmune diseases was positive in 42.2%, and the familial history of urticaria and atopy was positive in 7.8% and 25.5%, respectively.

CONCLUSIONS

The knowledge of comorbidities of chronic urticaria may support clinicians to manage and treat patients with this common condition.

Current Insight into the Role of IL-35 and Its Potential Involvement in the Pathogenesis and Therapy of Atopic Dermatitis

Interleukin 35 (IL-35), a new member of the IL-12 family of heterodimeric cytokines, could induce two different types of regulatory cells including regulatory T and B cells such as IL-35-induced regulatory T cells and IL-10-producing regulatory B cells (IL-10+Bregs), and IL-35-producing regulatory B cells (IL-35+Bregs). These cells appear to play an important role in modulating the immune system in numerous diseases. Several findings suggested that the expression of IL-35 is dysregulated in many autoimmune, inflammatory, and allergic diseases. Due to the functions of IL-35, it seems that this cytokine may act as an efficient therapeutic strategy for numerous conditions including atopic dermatitis (AD). We aimed to provide a comprehensive overview of the role of IL-35 in modulating the immune system. Additionally, we highlight IL-35 as a specific immunological target, discuss its possible involvement in the pathogenesis of AD, and hypothesize that IL-35 may become a novel target for the treatment of AD. However, further studies are required to evaluate this hypothesis.

The role of sodium hypochlorite in atopic dermatitis therapy: a narrative review

Atopic dermatitis (AD) is a common skin disorder, especially in the pediatric population. Genetic and immunological factors, epidermal barrier defect, as well as skin microbiota imbalance with increased colonization by Staphylococcus aureus (SA) are involved in the pathogenesis of the disease. One of the AD topical treatments is sodium hypochlorite (NaOCl) as a 0.005% water bath solution. This substance has been used for years as an antiseptic preparation. Studies show that NaOCl has an antimicrobial effect but probably at higher concentrations than those used in AD treatment. Nevertheless, many research studies confirm the anti-inflammatory and anti-itching effects of NaOCl, which contributes to clinical improvement in AD patients as well as reducing the need for local steroids and antibiotics. Bleach baths seem to be a well tolerated, cheap, and easily available therapy. However, research still should be continued to evaluate its antibacterial efficacy, anti-inflammatory effects, and safety.

Safety and Danger Considerations of Novel Treatments for Atopic Dermatitis in Context of Primary Cutaneous Lymphomas

The impact of new and emerging therapies on the microenvironment of primary cutaneous lymphomas (PCLs) has been recently raised in the literature. Concomitantly, novel treatments are already used or registered (dupilumab, upadacitinib) and others seem to be added to the armamentarium against atopic dermatitis. Our aim was to review the literature on interleukins 4, 13, 22, and 31, and JAK/STAT pathways in PCLs to elucidate the safety of using biologics (dupilumab, tralokinumab, fezakinumab, nemolizumab) and small molecule inhibitors (upadacitinib, baricitinib, abrocitinib, ruxolitinib, tofacitinib) in the treatment of atopic dermatitis. We summarized the current state of knowledge on this topic based on the search of the PubMed database and related references published before 21 October 2021. Our analysis suggests that some of the mentioned agents (dupilumab, ruxolitinib) and others may have a direct impact on the progression of cutaneous lymphomas. This issue requires further study and meticulous monitoring of patients receiving these drugs to ensure their safety, especially in light of the FDA warning on tofacitinib. In conclusion, in the case of the rapid progression of atopic dermatitis/eczema, especially in patients older than 40 years old, there is a necessity to perform a biopsy followed by a very careful pathological examination.

Circulating heat shock protein 90 (Hsp90) and autoantibodies to Hsp90 are increased in patients with atopic dermatitis

Atopic dermatitis (AD) is one of the most common chronic inflammatory dermatoses characterized by persistent itching and recurrent eczematous lesions. While the primary events and key drivers of AD are topics of ongoing debate, cutaneous inflammation due to inappropriate IgE (auto)antibody-related immune reactions is frequently considered. Highly conserved and immunogenic heat shock protein 90 (Hsp90), a key intra- and extracellular chaperone, can activate the immune response driving the generation of circulating anti-Hsp90 autoantibodies that are found to be elevated in several autoimmune disorders. Here, for the first time, we observed that serum levels of Hsp90 and anti-Hsp90 IgE autoantibodies are significantly elevated (p < 0.0001) in AD patients (n = 29) when compared to age- and gender-matched healthy controls (n = 70). We revealed a positive correlation (0.378, p = 0.042) between serum levels of Hsp90 and the severity of AD assessed by Scoring Atopic Dermatitis (SCORAD). In addition, seropositivity for anti-Hsp90 IgE has been found in 48.27% of AD patients and in 2.85% of healthy controls. Although further studies on a larger group of patients are needed to confirm presented data, our results suggest that extracellular Hsp90 and autoantibodies to Hsp90 deserve attention in the study of the mechanisms that promote the development and/or maintenance of atopic dermatitis.

Atopic dermatitis. Interdisciplinary diagnostic and therapeutic recommendations of the Polish Dermatological Society, Polish Society of Allergology, Polish Pediatric Society and Polish Society of Family Medicine. Part I. Prophylaxis, topical treatment and phototherapy

Atopic dermatitis is a chronic and recurrent inflammatory dermatosis with concomitant intensive pruritus, and is diagnosed both in children and adults. Atopic dermatitis-patients are predisposed to have bacterial, viral and fungal skin infections; they also suffer from an increased risk of developing food allergies (especially, at an infantile age), allergic rhinitis, or bronchial asthma (a so-called atopic march). Currently, an increasing atopic dermatitis incidence constitutes a serious medical problem that regards not only dermatology and allergology, but also paediatrics, and family medicine. The basis for atopic dermatitis treatment and prophylaxis is restoration of epidermal barrier functions by means of tailored emollients. Atopic dermatitis therapies should effectively eliminate clinical symptoms of the disease, prevent exacerbations as well as complications, and improve patients' quality of life.

European task force on atopic dermatitis position paper: treatment of parental atopic dermatitis during preconception, pregnancy and lactation period

Atopic dermatitis (AD) is a common inflammatory skin disease that affects both children and adults, including a large number of adults of reproductive age. Several guidelines for the treatment of AD exist, yet specific recommendations for the treatment of pregnant or lactating women and for adults planning to have a child are often lacking. This position paper from the European Task force on Atopic Dermatitis (ETFAD) is based on up-to-date scientific literature on treating pregnant and lactating women as wells as adults with AD planning to have a child. It is based on the expert opinions of members of the ETFAD and on existing safety data on the proposed treatments, many of which are derived from patients with other inflammatory diseases or from transplantation medicine. For treating future parents, as well as pregnant and lactating women with AD, the use of topical treatments including moisturizers, topical corticosteroids, tacrolimus, antiseptics such as chlorhexidine, octenidine, potassium permanganate and sodium hypochlorite (bleach) is deemed to be safe. Ultraviolet (UV) therapy may also be used. Systemic treatment should be prescribed only after careful consideration. According to the opinion of the ETFAD, treatment should be restricted to systemic corticosteroids and cyclosporine A, and, in selected cases, azathioprine.

Validation of the dermatology-specific proxy instrument the Infants and Toddlers Dermatology Quality of Life

BACKGROUND

The first dermatology-specific proxy health-related quality of life (HRQoL) instrument for children 0-4 years old with skin diseases, the Infants and Toddlers Dermatology Quality of Life (InToDermQoL), was recently developed. In order to avoid the problem of cross-cultural inequivalence focus groups work and pilot tests were organized simultaneously in all national centres of the project. The InToDermQoL showed good comprehensibility, clarity and acceptance.

OBJECTIVE

To validate the InToDermQoL questionnaire during international field tests.

METHODS

Internal consistency, test-retest reliability, convergent and discriminant validity of the InToDermQoL questionnaire were checked during international field tests.

RESULTS

Parents of 473 children with skin diseases filled in the national language versions of the InToDermQoL questionnaire. All three age-specific versions of the InToDermQoL questionnaire with 10, 12 and 15 items, respectively, showed high internal consistency (Cronbach's α 0.90-0.93), good test-retest reliability (correlation coefficients > 0.9), significant correlations with the most widely used atopic dermatitis-specific proxy instrument, the Infants Dermatitis Quality of Life Index (correlation coefficients 0.68-0.79). The InToDermQoL versions for children <3 years old well correlated with the atopic dermatis severity measure Scoring of Atopic Dermatitis (correlation coefficients 0.66 and 0.86 for 10 and 12 items versions, respectively). The InToDermQoL questionnaire discriminated well among different diagnoses and disease severity levels.

CONCLUSION

Our field tests confirmed internal consistency, test-retest reliability, convergent and discriminant validity of the InToDermQoL questionnaire. Development and validation of the InToDermQoL questionnaire make it possible to assess dermatology-specific aspects of HRQoL in youngest children with skin diseases. There are many reasons to assess HRQoL in dermatologic clinical practice, and we hope that our new instrument will be used internationally in paediatric dermatology for research and practical needs.

Rural-urban differences in children’s musculosceletal injuries in north-eastern Poland

OBJECTIVE

To investigate rural-urban differences in severity of injuries, by means of age, sex and duration of hospitalization of injured children in northeastern Poland.

METHODS

The study included children admitted to the Department of Pediatric Orthopaedics and Traumatology in between 2002-2005 (1322 patients) and 2012-2013 (1725 patients) due to injury. We applied the rural-urban division on the base of number of inhabitants (rural – below, urban – over 25000). We divided injuries into four categories based on severity. Statistical analysis was performed to compare the risk of hospitalization due to different types of injuries among children in different age and sex groups, living in rural and urban areas

RESULTS

Children from urban areas have a higher risk of hospitalization compared to their peers living in rural areas due to two least severe categories of injuries. Children from rural areas had much higher risk of hospitalization due to most severe injuries. Results were consistent for both time intervals.. The average duration of hospitalization was significantly longer among rural populations. However, in both rural and urban areas the mean length of stay has been shortened in comparison with the years 2002-2005. The average age of urban patients has been reduced over the years and remained stable among rural population. In both groups boys comprised the majority of patients with all kinds of injuries.

CONCLUSIONS

Analysis of the risk of hospitalization among children from rural and urban areas brings constructive conclusions only after applying the division based on severity of injuries. Children living in rural areas and small towns are at a higher risk of suffering severe injuries that pose a risk of permanent disability, and of longer hospitalization because of them, compared to children living in larger cities.

A data mining paradigm for identifying key factors in biological processes using gene expression data

A large volume of biological data is being generated for studying mechanisms of various biological processes. These precious data enable large-scale computational analyses to gain biological insights. However, it remains a challenge to mine the data efficiently for knowledge discovery. The heterogeneity of these data makes it difficult to consistently integrate them, slowing down the process of biological discovery. We introduce a data processing paradigm to identify key factors in biological processes via systematic collection of gene expression datasets, primary analysis of data, and evaluation of consistent signals. To demonstrate its effectiveness, our paradigm was applied to epidermal development and identified many genes that play a potential role in this process. Besides the known epidermal development genes, a substantial proportion of the identified genes are still not supported by gain- or loss-of-function studies, yielding many novel genes for future studies. Among them, we selected a top gene for loss-of-function experimental validation and confirmed its function in epidermal differentiation, proving the ability of this paradigm to identify new factors in biological processes. In addition, this paradigm revealed many key genes in cold-induced thermogenesis using data from cold-challenged tissues, demonstrating its generalizability. This paradigm can lead to fruitful results for studying molecular mechanisms in an era of explosive accumulation of publicly available biological data.

Use of calibrated automated thrombinography ± thrombomodulin to recognise the prothrombotic phenotype

There is currently no validated method to detect a prothrombotic phenotype. The question remains, can tissue factor (TF) induced thrombin generation (TG), as measured with the calibrated automated thrombinography (CAT) technique, according to Hemker et al., recognise a prothrombotic state either as such, or when the activated proteinC (APC)-system is boosted with thrombomodulin (TM)? We determined the normal range of CAT-TG ± TM in a group of 71 healthy blood donors, in 11 healthy women using oral contraceptives (OC), and in 89 patients with a history of venous thromboembolism (VTE), divided into a group of 50 in whicha prothrombotic risk factor could be found (VTEprf+) and 39 others (VTEprf-). The endogenous thrombin potential (ETP) in the OC, VTEprf+ and VTEprf-group was significantly higher than for the controls. In the presence of TM, the differences were significantly higher than in its absence. The VTEprf+ group had a higher ETP, ± TM than the VTEprf group. In conclusion,TG, measured with the CAT technique in the presence of TM is capable of detecting the prothrombotic phenotype with a high sensitivity of 0.93 (95% confidence limits 0.82–0.99).

Topical corticosteroid phobia in atopic dermatitis: International feasibility study of the TOPICOP score

BACKGROUND

Adherence to topical corticosteroids (TCS) is essential for the effective treatment of atopic dermatitis but can be limited by concerns about their use. This study examined the feasibility of applying the validated TOPICOP score for assessing TCS phobia across different countries.

METHODS

This was a prospective multicentre feasibility study conducted in 21 hospitals in 17 countries. Patients >3 months of age with atopic dermatitis or their parents or legal representatives completed a validated translation of the TOPICOP questionnaire in the country's native language. Respondents also completed questionnaires collecting opinions about the feasibility and acceptability of the TOPICOP questionnaire.

RESULTS

A total of 1564 participants in 15 countries were included in the analysis. 81% of respondents considered the questions clear or very clear, and 79% reported that it took less than 5 minutes to complete. Each of the individual items in the TOPICOP questionnaire was considered to be not at all difficult to answer by 49% to 74% of participants. The mean global TOPICOP score was 44.7%±20.5. Mean TOPICOP subscores were 37.0±22.8% for knowledge and beliefs, 54.7±27.8% for fears and 50.1±29.1% for behaviours. Global scores and subscores differed between countries, although the subscores did not always vary in parallel, suggesting different levels of TCS phobia and different drivers for each country.

CONCLUSIONS

The TOPICOP score can be feasibly applied across countries and may therefore be useful for obtaining qualitative and quantitative data from international studies and for adapting patient education and treatment.

Altered Expression of Genes Encoding Cornulin and Repetin in Atopic Dermatitis

BACKGROUND

It is assumed that beside alterations in the filaggrin gene (FLG), disturbances within genes encoding other cornified envelope proteins are also involved in atopic dermatitis (AD). To identify new potential markers of AD, we studied the polymorphisms of genes encoding repetin (RPTN), cornulin (CRNN), and their expression in the skin of AD patients.

METHODS

Polymorphisms in CRNN (rs941934), RPTN (rs284544, rs28441202, rs3001978, and rs12117644), and FLG mutations (R2447X, S3247X) were analyzed by TaqMan genotyping assay and by PCR-RFLP in the blood samples of 159 AD patients and 108 healthy subjects. The expression levels of CRNN and RPTN were determined by qRT-PCR in 34 AD skin samples (17 lesional and 17 nonlesional) and in 27 skin biopsies from healthy volunteers. The AD patients were recruited from the clinic of the university hospital between 2012 and 2014.

RESULTS

CRNN rs941934 (A allele) was associated with AD (OR 2.095, p = 0.008), a severe course of disease (p = 0.041), elevated IgE levels (p = 0.047), eosinophilia (p = 0.018), and concomitant asthma (p = 0.004). The mRNA level of CRNN was decreased in the AD skin (p = 0.041). In the AD patients without FLG mutations, the CC genotype of RPTN rs3001978 was associated with AD (OR 0.39, p = 0.037), early age at onset (p = 0.033), pruritus (p = 0.021), severity of AD (p = 0.045), and concomitant asthma (p = 0.041). The elevated mRNA levels of RPTN in lesional (p < 0.001) and nonlesional (p = 0.017) AD skin were observed.

CONCLUSIONS

The single-nucleotide polymorphisms of CRNN (rs941934) and RPTN (rs3001978, rs28441202) may contribute to AD development, but further studies on a larger group of AD patients are needed to verify this assumption.

Expression of Cornified Envelope Proteins in Skin and Its Relationship with Atopic Dermatitis Phenotype

Changes in the expression of cornified envelope (CE) proteins are thought to affect the development and course of atopic dermatitis (AD). The aim of this study was to examine the expression level of CE proteins in order to identify new molecular markers of the AD phenotype. Expression levels of CE proteins were evaluated in the skin of patients with AD (38 biopsies) and healthy subjects (26 biopsies). Levels of FLG, FLG2 and SPRR3 mRNAs and proteins were reduced in AD skin. Levels of LELP-1 and SPRR1A transcripts and proteins were significantly increased in AD skin. SPRR3v2 mRNA level in non-lesional AD skin correlated with severity of AD, and SPRR3 protein level in non-lesional AD skin correlated inversely with pruritus. FLG protein level in AD skin correlated inversely with severity of AD. These results point to SPRR3 as an important factor in AD and itch.

Association of a Single Nucleotide Polymorphism in a Late Cornified Envelope-like Proline-rich 1 Gene (LELP1) with Atopic Dermatitis

There is some evidence that genes involved in the pathogenesis of atopic dermatitis, in addition to the filaggrin (FLG) gene, may be located at chromosome region 1q21. The aim of this study was to examine the association of single nucleotide polymorphisms in the region of the late cornified envelope-like proline-rich 1 (LELP1), hornerin (HRNR) and FLG genes with the course and risk of atopic dermatitis. Single nucleotide polymorphisms and mutations were genotyped by PCR restriction fragment length polymorphism and real-time PCR in a group of 152 patients with atopic dermatitis and 104 healthy volunteers. CC genotype and C-allele of LELP1 rs7534334 were found in patients with atopic dermatitis and were associated with elevated levels of serum immunoglobulin E, severity of atopic dermatitis and concomitant asthma. LELP1 rs7534334 enhanced the risk of atopic dermatitis nearly 2.5-fold. This pilot study suggests that rs7534334 SNP, located in the LELP1 region, may be a potential genetic marker for the risk and course of atopic dermatitis.

The frequencies of haplotypes defined by three polymorphisms of the IL-31 gene: -1066, -2057, and IVS2+12 in Polish patients with atopic dermatitis

BACKGROUND

Severe pruritus is one of the cardinal symptoms of atopic dermatitis (AD). Recently, the interleukin (IL)-31 cytokine has been implicated in the induction and maintenance of severe pruritus and chronic skin inflammation in several pruritic skin diseases, including AD.

OBJECTIVE

We aimed to investigate the association of the IL-31 gene haplotypes with pruritus and severity of AD, as well as their correlation to the serum IL-31 levels.

METHODS

A total of 127 patients with AD and 96 healthy controls were analyzed for polymorphic variants of the IL-31 gene using an amplification refractory mutation system-polymerase chain reaction method. IL-31 haplotype frequencies were estimated with the use of tagging single nucleotide polymorphisms, expectation-maximization, and Excoffier-Laval-Balding algorithms. Serum IL-31 levels were measured using a standard enzyme-linked immunosorbent assay kit.

RESULTS

The frequency of AAG, AGA, AGG, and GAA haplotypes of the IL-31 gene was higher in patients with AD than in controls. The mean IL-31 levels in serum were lower in controls than in the patients (P < 0.00001) and were higher in those with severe vs. mild AD (P = 0.008). No correlation was found between IL-31 and the severity of pruritus. The haplotype AAA was associated with a high IL-31 serum level (P = 0.008) and with severe AD (high SCORing Atopic Dermatitis index) (P = 0.013). The haplotype GAA was associated with a severe form of pruritus (P = 0.016) and the haplotype GGG with the mild one (P = 0.07).

CONCLUSION

The results of this study suggest that the severity of AD in a Polish population is associated with some specific haplotypes of the IL-31 gene, which can indicate their prognostic role also renews the questions concerning the role of IL-31 in pruritus in AD.

Interleukin-13 promoter gene polymorphism -1112 C/T is associated with atopic dermatitis in Polish patients

Interleukin 13 (IL-13) is one of the major cytokines involved in the IgE synthesis in patients with atopic dermatitis (AD). IL-13 gene has been mapped on chromosome 5q31-33 region associated with atopic conditions, where several polymorphisms are described. The aims of the study were to establish the frequency of the IL-13 gene polymorphism and its relation to serum IgE and IL-13 levels and SCORAD. In 180 AD patients and 167 healthy volunteers, the -1112 C/T IL-13 gene polymorphism was genotyped using allele-specific PCR method. Serum total IgE (tIgE) level was measured by Uni-CAP 100 and IL-13 level using ELISA standard kit. The -1112T allele frequency was significantly higher in AD patients compared to controls (P=0.00001). The TT and CT genotypes were correlated with increased serum tIgE concentration (P=0.0004). The TT genotype was associated with severe, CT genotype with moderate and CC genotype with mild course of AD (P=0.0008). Both CT and TT genotypes predominated in cases of AD with concomitant asthma, while CC genotype was not found in any case in this group (P=0.03). The mean levels of serum IL-13 and tIgE were significantly higher in AD with concomitant asthma than in cases without asthma (IL-13 P=0.03 and tIgE P=0.0001). There was positive correlation between serum concentration of IL-13 (P=0.0005) and tIgE (P=0.0000001) and severity of AD as assessed by SCORAD index. Our results confirmed the significant role of -1112 C/T IL-13 gene polymorphism in the pathogenesis of AD.

Diffuse cutaneous mastocytosis: analysis of 10 cases and a brief review of the literature

BACKGROUND

Diffuse cutaneous mastocytosis (DCM) is an extremely rare disease characterized by mast cell (MCs) infiltration of the entire skin. Little is known about the natural course of DCM.

OBJECTIVES

We decided to characterize clinical manifestations, the frequency of MCs mediator-related symptoms and anaphylaxis, risk of systemic mastocytosis (SM) and prognosis, based on 10 cases of DCM, the largest series published to date.

METHODS

Diffuse cutaneous mastocytosis, DCM was confirmed by histopathological examination of skin samples in all cases. SCORing Mastocytosis (SCORMA) Index was used to assess the intensity of DCM. The analysis of clinical symptoms and laboratory tests, including serum tryptase levels was performed. Bone marrow biopsy was done only in selected cases.

RESULTS

Large haemorrhagic bullous variant of DCM (five cases) and infiltrative small vesicular variant (five cases) were identified. The skin symptoms appeared in age-dependent manner; blistering predominated in infancy, whereas grain-leather appearance of the skin and pseudoxanthomatous presentation developed with time. SM was not recognized in any of the patients. Mast cell mediator-related symptoms were present in all cases. Anaphylactic shock occurred in three patients. Follow-up performed in seven cases revealed slight improvement of skin symptoms, reflected by decrease of SCORMA Index in all of them. Serum tryptase levels declined with time in six cases.

CONCLUSIONS

Diffuse cutaneous mastocytosis, DCM is a heterogeneous, severe, cutaneous disease, associated with mediator-related symptoms and risk of anaphylactic shock. Although our results suggest generally favourable prognosis, the review of the literature indicate that SM may occur. Therefore, more guarded prognosis should be given in DCM patients.

Atopic dermatitis-like pre-Sézary syndrome: role of immunosuppression

We describe here 4 patients with Sézary syndrome masquerading as adult-onset atopic dermatitis. The patients presented with a clinical picture compatible with wide-spread atopic dermatitis and did not fulfil the criteria for Sézary syndrome (lack of lymphoadenopathy and blood involvement, skin histology without presence of atypical cells). In our patients, overt Sézary syndrome developed after immunosuppressive treatment (including cyclosporine). These cases support the validity of the concept of pre-Sézary syndrome, which is a long-lasting, pre-malignant condition, and which may develop to true malignancy in a state of immunosuppression.

Relationship between serum levels of interleukin-18, IgE and disease severity in patients with atopic dermatitis

BACKGROUND

Interleukin (IL)-18 is a pleiotropic cytokine. Synergistically with IL-12, IL-18 promotes immune responses of the T helper type, by enhancing synthesis of interferon-γ and inhibiting IgE production. IL-18 can also enhance production of IL-4 and IL-13 production, and stimulate synthesis of IgE. Moreover, in the presence of IL-3, IL-18 can directly stimulate basophils and mast cells to produce their mediators in an IgE-independent manner. These results indicate a role for IL-18 in the pathogenesis of atopic dermatitis (AD).

AIM

To examine the association of serum IL-18 with IgE levels and disease severity in patients with AD.

METHODS

ELISA was used to measure IL-18 and total IgE levels in the sera of 67 patients with AD and 50 healthy volunteers. The SCORing Atopic Dermatitis (SCORAD) tool was used to determine the severity of this disease.

RESULTS

The mean serum level of IL-18 in study group (155.68 pg/mL) was significantly higher than that of controls. IL-18 was also significantly higher in the sera of the patients with severe AD than in those with milder disease. There was a correlation with IgE and IL-18 levels, as patients who had high IgE levels also had high IL-18 levels, compared with controls.

CONCLUSION

IL-18 seems to play an important role in the pathogenesis of AD, but this requires further study. IL-18 could be a useful clinical marker of disease severity in AD.

2-Chlorodeoxyadenosine treatment for cutaneous T-cell lymphoma

The primary cutaneous lymphomas are often indolent but difficult to treat. In the early stages psoralen and ultraviolet-A therapy is the standard treatment whereas at the tumor stage chemotherapy (e.g. pegylated doxorubicin) is often used for debulking. The purine analog 2-chlorodeoxyadenosine (2CdA) acts in non-Hodgkin’s lymphoma and has been used in our center for the treatment of advanced primary cutaneous T-cell lyphomas (CTCL). Here, we report on the efficacy and side effects of 2CdA in six patients with CTCL. One patient died owing to myelosuppression. Partial responses were seen in four cases but full remission was observed in only one case. We concluded that 2CdA has a limited usefulness in the management of advanced CTCL.