Atopic dermatitis: A global health perspective

The International Society of AD (ISAD) organized a roundtable on global aspects of AD at the WCD 2023 in Singapore. According to the Global Burden of Disease (GBD) consortium, at least 171 million individuals were affected with AD in 2019, corresponding to 2.23% of the world population, with age-standardized prevalence and incidence rates that were relatively stable from 1990 to 2019. Based on the panel experience, most AD cases are mild-to-moderate. Without parallel data on disease prevalence and severity, the GBD data are difficult to interpret in many regions. This gap is particularly important in countries with limited medical infrastructure, but indirect evidence suggests a significant burden of AD in low-and-medium resource settings, especially urban areas. The Singapore roundtable was an opportunity to compare experiences in World Bank category 1 (Madagascar and Mali), 3 (Brazil, China) and 4 (Australia, Germany, Qatar, USA, Singapore, Japan) countries. The panel concluded that current AD guidelines are not adapted for low resource settings and a more pragmatic approach, as developed by WHO for skin NTDs, would be advisable for minimal access to moisturizers and topical corticosteroids. The panel also recommended prioritizing prevention studies, regardless of the level of existing resources. For disease long-term control in World Bank category 3 and most category 4 countries, the main problem is not access to drugs for most mild-to-moderate cases, but rather poor compliance due to insufficient time at visits. Collaboration with WHO, patient advocacy groups and industry may promote global change, improve capacity training and fight current inequalities. Finally, optimizing management of AD and its comorbidities needs more action at the primary care level, because reaching specialist care is merely aspirational in most settings. Primary care empowerment with store and forward telemedicine and algorithms based on augmented intelligence is a future goal.

Exploiting transcription factors to target EMT and cancer stem cells for tumor modulation and therapy

Transcription factors (TFs) are essential in controlling gene regulatory networks that determine cellular fate during embryogenesis and tumor development. TFs are the major players in promoting cancer stemness by regulating the function of cancer stem cells (CSCs). Understanding how TFs interact with their downstream targets for determining cell fate during embryogenesis and tumor development is a critical area of research. CSCs are increasingly recognized for their significance in tumorigenesis and patient prognosis, as they play a significant role in cancer initiation, progression, metastasis, and treatment resistance. However, traditional therapies have limited effectiveness in eliminating this subset of cells, allowing CSCs to persist and potentially form secondary tumors. Recent studies have revealed that cancer cells and tumors with CSC-like features also exhibit genes related to the epithelial-to-mesenchymal transition (EMT). EMT-associated transcription factors (EMT-TFs) like TWIST and Snail/Slug can upregulate EMT-related genes and reprogram cancer cells into a stem-like phenotype. Importantly, the regulation of EMT-TFs, particularly through post-translational modifications (PTMs), plays a significant role in cancer metastasis and the acquisition of stem cell-like features. PTMs, including phosphorylation, ubiquitination, and SUMOylation, can alter the stability, localization, and activity of EMT-TFs, thereby modulating their ability to drive EMT and stemness properties in cancer cells. Although targeting EMT-TFs holds potential in tackling CSCs, current pharmacological approaches to do so directly are unavailable. Therefore, this review aims to explore the role of EMT- and CSC-TFs, their connection and impact in cellular development and cancer, emphasizing the potential of TF networks as targets for therapeutic intervention.

The cross-talk between miRNAs and JAK/STAT pathway in cutaneous T cell lymphoma: Emphasis on therapeutic opportunities

Mycosis Fungoides (MF) and Sézary Syndrome (SS) belong to a wide spectrum of T cell lymphoproliferative disorders collectively termed cutaneous T cell lymphomas (CTCL). CTCLs represent an archetype of heterogeneous and dynamically variable lymphoproliferative neoplasms typified by distinct clinical, histological, immunophenotypic, and genetic features. Owing to its complex dynamics, the pathogenesis of CTCL remains elusive. However, in recent years, progress in CTCL classification combined with next-generation sequencing analyses has broadened the genetic and epigenetic spectrum of clearly defined CTCL entities such as MF and SS. Several large-scale genome studies have identified the polygenic nature of CTCL and unveiled an idiosyncratic mutational landscape involving genetic aberrations, epigenetic alterations, cell cycle dysregulation, apoptosis, and the constitutive activation of T cell/NF-κB/JAK-STAT signaling pathways. In this review, we summarize the evolving insights on how the intrinsic epigenetic events driven by dysregulated miRNAs, including the oncogenic and tumor-suppressive miRNAs, influence the pathogenesis of MF and SS. We also focus on the interplay between the JAK/STAT pathway and miRNAs in CTCL as well as the significance of the miRNA/STAT axis as a relevant pathogenetic mechanism underlying CTCL initiation and progression. Based on these biologic insights, the current status and recent progress on novel therapies with a strong biological rationale, including miRNA-targeted molecules and JAK/STAT-targeted therapy for CTCL management, are discussed.

Epigenetic control of inflammation in Atopic Dermatitis

Atopic dermatitis (AD), also known as atopic eczema, is a common but also complex chronic, itchy skin condition with underlying inflammation of the skin. This skin ailment is prevalent worldwide and affects people of all ages, particularly children below five years of age. The itching and resulting rashes in AD patients are often the result of inflammatory signals, thus necessitating a closer look at the inflammation-regulating mechanisms for putative relief, care and therapy. Several chemical- as well as genetically-induced animal models have established the importance of targeting pro-inflammatory AD microenvironment. Epigenetic mechanisms are gaining attention towards a better understanding of the onset as well as the progression of inflammation. Several physiological processes with implications in pathophysiology of AD, such as, barrier dysfunction either due to reduced filaggrin / human β-defensins or altered microbiome, reprograming of Fc receptors with resulting overexpression of high affinity IgE receptors, elevated eosinophil numbers or the elevated IL-22 production by CD4 + T cells have underlying epigenetic mechanisms that include differential promoter methylation and/or regulation by non-coding RNAs. Reversing these epigenetic changes has been verified to reduce inflammatory burden through altered secretion of cytokines IL-6, IL-4, IL-13, IL-17, IL-22 etc, with benefit against AD progression in experimental models. A thorough understanding of epigenetic remodeling of inflammation in AD has the potential of opening avenues for novel diagnostic, prognostic and therapeutic options.

Neuronal BST2: A Pruritic Mediator alongside Protease-Activated Receptor 2 in the IL-27-Driven Itch Pathway

Chronic itch is a common and complex symptom often associated with skin diseases such as atopic dermatitis (AD). Although IL-27 is linked to AD, its role and clinical significance in itch remain undefined. We sought to investigate IL-27 function in itch using tissue-specific transgenic mice, various itch models, behavior scoring, RNA sequencing, and cytokine/kinase array. Our findings show that IL-27 receptors were overexpressed in human AD skin. Intradermal IL-27 injection failed to directly induce itch in mice but upregulated skin protease-activated receptor 2 (PAR2) transcripts, a key factor in itch and AD. IL-27 activated human keratinocytes, increasing PAR2 transcription and activity. Coinjection of SLIGRL (PAR2 agonist) and IL-27 in mice heightened PAR2-mediated itch. In addition, IL-27 boosted BST2 transcription in sensory neurons and keratinocytes. BST2 was upregulated in AD skin, and its injection in mice induced itch-like response. BST2 colocalized with sensory nerve branches in AD skin from both human and murine models. Sensory neurons released BST2, and mice with sensory neuron-specific BST2 knockout displayed reduced itch responses. Overall, this study provides evidence that skin IL-27/PAR2 and neuronal IL-27/BST2 axes are implicated in cutaneous inflammation and pruritus. The discovery of neuronal BST2 in pruritus shed light on BST2 in the itch cascade.

Emerging Role of the IL-36/IL-36R Axis in Multiple Inflammatory Skin Diseases

IL-36 is a most recent member of the IL-1 cytokine family, primarily expressed at barrier sites of the body such as the skin, lungs, and intestine. It plays a vital role in inflammation and is implicated in the development of various cutaneous; intestinal; and pulmonary disorders, including psoriasis, inflammatory bowel disease, and chronic obstructive pulmonary disease. IL-36 comprises 4 isoforms: the proinflammatory IL-36α, IL-36β, and IL-36γ and the anti-inflammatory IL-36R antagonist. An imbalance between proinflammatory and anti-inflammatory IL-36 isoforms can contribute to the inflammatory fate of cells and tissues. IL-36 cytokines signal through an IL-36R heterodimer mediating their function through canonical signaling cacade, including the NF-B pathway. Prominent for its role in psoriasis, IL-36 has recently been associated with disease mechanisms in atopic dermatitis, hidradenitis suppurativa, neutrophilic dermatoses, autoimmune blistering disease, and Netherton syndrome. The major cutaneous source of IL-36 cytokines is keratinocytes, pointing to its role in the communication between the epidermis, innate (neutrophils, dendritic cells) immune system, and adaptive (T helper [Th]1 cells, Th17) immune system. Thus, cutaneous IL-36 signaling is crucial for the immunopathological outcome of various skin diseases. Consequently, the IL-36/IL-36R axis has recently been recognized as a promising drug target for the treatment of inflammatory disorders beyond psoriasis. This review summarizes the current update on IL-36 cytokines in inflammatory skin diseases.

Sanguinarine Triggers Apoptosis in Cutaneous Squamous Cell Carcinoma Cells through Reactive Oxygen Species-Dependent c-Jun N-Terminal Kinase Signaling Pathway

BACKGROUND

The benzophenanthridine Sanguinarine (Sng) is one of the most abundant root alkaloids with a long history of investigation and pharmaceutical applications. The cytotoxicity of Sng against various tumor cells is well-established; however, its antiproliferative and apoptotic potential against the cutaneous squamous cell carcinoma (cSCC) cells remains unknown. In the present study, we investigated the anti-cancer potential of Sng against cSCC cells and elucidated the underlying mechanisms relevant to the drug action.

METHODS

The inhibitory effect of Sng on cSCC cells was evaluated by analyzing cell viability, colony-forming ability and multi-caspase activity. Apoptosis was quantified through Annexin-V/Propidium iodide flow cytometric assay and antagonized by pan-caspase inhibitor z-VAD-FMK. Mitochondrial membrane potential (ΔΨm) dysfunction was analyzed by JC-1 staining, whereas reactive oxygen species (ROS) generation was confirmed by pretreatment with N-acetylcysteine (NAC) and fluorogenic probe-based flow cytometric detection. The expression of cell cycle regulatory proteins, apoptotic proteins and MAPK signaling molecules was determined by Western blotting. Involvement of JNK, p38-MAPK and MEK/ERK in ROS-mediated apoptosis was investigated by pretreatment with SP600125 (JNK inhibitor), SB203580 (p38 inhibitor) and U0126 (ERK1/2 inhibitor), respectively. The stemness-targeting potential of Sng was assessed in tumor cell-derived spheroids.

RESULTS

Treatment with Sng decreased cell viability and colony formation in primary (A431) and metastatic (A388) cSCC cells in a time- and dose-dependent manner. Sng significantly inhibited cell proliferation by inducing sub-G0/G1 cell-cycle arrest and apoptosis in cSCC cells. Sng evoked ROS generation, intracellular glutathione (GSH) depletion, ΔΨm depolarization and the activation of JNK pathway as well as that of caspase-3, -8, -9, and PARP. Antioxidant NAC inhibited ROS production, replenished GSH levels, and abolished apoptosis induced by Sng by downregulating JNK. Pretreatment with z-VAD-FMK inhibited Sng-mediated apoptosis. The pharmacological inhibition of JNK by SP600125 mitigated Sng-induced apoptosis in metastatic cSCC cells. Finally, Sng ablated the stemness of metastatic cSCC cell-derived spheroids.

CONCLUSION

Our results indicate that Sng exerts a potent cytotoxic effect against cSCC cells that is underscored by a mechanism involving multiple levels of cooperation, including cell-cycle sub-G0/G1 arrest and apoptosis induction through ROS-dependent activation of the JNK signaling pathway. This study provides insight into the potential therapeutic application of Sng targeting cSCC.

Deregulated transcription factors in the emerging cancer hallmarks

Cancer progression is a multifaceted process that entails several stages and demands the persistent expression or activation of transcription factors (TFs) to facilitate growth and survival. TFs are a cluster of proteins with DNA-binding domains that attach to promoter or enhancer DNA strands to start the transcription of genes by collaborating with RNA polymerase and other supporting proteins. They are generally acknowledged as the major regulatory molecules that coordinate biological homeostasis and the appropriate functioning of cellular components, subsequently contributing to human physiology. TFs proteins are crucial for controlling transcription during the embryonic stage and development, and the stability of different cell types depends on how they function in different cell types. The development and progression of cancer cells and tumors might be triggered by any anomaly in transcription factor function. It has long been acknowledged that cancer development is accompanied by the dysregulated activity of TF alterations which might result in faulty gene expression. Recent studies have suggested that dysregulated transcription factors play a major role in developing various human malignancies by altering and rewiring metabolic processes, modifying the immune response, and triggering oncogenic signaling cascades. This review emphasizes the interplay between TFs involved in metabolic and epigenetic reprogramming, evading immune attacks, cellular senescence, and the maintenance of cancer stemness in cancerous cells. The insights presented herein will facilitate the development of innovative therapeutic modalities to tackle the dysregulated transcription factors underlying cancer.

Effects of probiotic supplementation in adult with atopic dermatitis: a systematic review with meta-analysis

BACKGROUND

Atopic dermatitis (AD) is one of the most common chronic inflammatory skin diseases. The effect of probiotic administration on the severity of AD in adults has shown inconsistent results.

OBJECTIVES

To determine the effectiveness of probiotic supplementation as a therapeutic tool for adult AD.

METHODS

PubMed, Scopus and Embase were systematically searched to collect data from studies in which probiotics were administered to treat adult AD.

RESULTS

Out of 413 publications, 9 papers were included in the meta-analysis. Significant differences in the ScORing Atopic Dermatitis tool favouring probiotics were observed [relative risk (RR) -5.93, 95% confidence interval (CI) -8.43 to -3.43]. Lactobacillus salivarius presented with largest effect size (RR -9.79, 95% CI -13.04 to -6.54), followed by L. acidophilus (RR -5.77, 95% CI -10.82 to -0.72) and L. plantarum (RR -3.76, 95% CI -6.36 to -1.16). No benefit was observed with L. fermentum. Based on the severity of AD, probiotics showed better results in people with moderate-to-severe AD (RR -9.12, 95% CI -12.17 to -6.08) than in individuals with mild disease (RR -2.67, 95% CI -4.67 to -0.66). Serum levels of IgE and eosinophil count remained significantly unchanged after the probiotic intervention (RR 0.25, 95% CI -0.10 to 0.60; RR -0.27, 95% CI -0.68 to 0.13, respectively).

CONCLUSIONS

Current evidence supports a role for some probiotics as a therapeutic tool for the treatment of adult AD, particularly in patients with severe AD. The efficacy of probiotics is strain specific, with L. salivarius and L. acidophilus having the largest clinical benefit. Such benefit is apparently independent of IgE levels and eosinophil count. Despite these encouraging results, the decrease in AD severity did not translate into a clinically meaningful better quality of life as assessed by the Dermatology Life Quality Index. There currently is not enough reliable data to reach conclusions about the optimal dose and duration for probiotic treatment.

Embelin inhibits viability of cutaneous T cell lymphoma cell lines HuT78 and H9 by targeting inhibitors of apoptosis

Cutaneous T cell lymphoma (CTCL) is a varied group of neoplasms that affects the skin. Acquired resistance against chemotherapeutic drugs and associated toxic side effects are limitations that warrant search for novel drugs against CTCL. Embelin (EMB) is a naturally occurring benzoquinone derivative that has gained attention owing to its anticancer pharmacological actions and nontoxic nature. We assessed the anticancer activity of EMB against CTCL cell lines, HuT78, and H9. EMB inhibited viability of CTCL cells in a dose-dependent manner. EMB activated extrinsic and intrinsic pathways of apoptosis as shown by the activation of initiator and executioner caspases. EMB-induced apoptosis also involved suppression of inhibitors of apoptosis, XIAP, cIAP1, and cIAP2. PARP cleavage and upregulation of pH2AX indicated DNA damage induced by EMB. In conclusion, we characterized a novel apoptosis-inducing activity of EMB against CTCL cells, implicating EMB as a potential therapeutic agent against CTCL.

Expert opinion on management of moderate-to-severe atopic dermatitis in Qatar

Atopic dermatitis (AD), a chronic-relapsing inflammatory skin disorder, manifests with intense itching and eczematous lesions impairing quality of life. A heterogeneous population, and regional clinical practices for treating AD warrant the development of guidelines in Qatar. Therefore, guidelines for the management of moderate-to-severe AD in Qatar have been developed and discussed. Experts, including dermatologists and immunologists, used the Delphi technique for developing guidelines. Consensus was defined as ≥75% agreement or disagreement. AD is highly prevalent in primary and tertiary dermatology centers. AD-associated foot eczema and psoriasiform eczema are more frequent in Qatar than in Europe or USA. SCORing Atopic Dermatitis Index quantifies disease severity and itch. Dermatology Life Quality Index assesses the quality of life. Atopic Dermatitis Control Tool assesses long-term disease control. Moderate-severe AD benefits from new topicals like Janus-kinase-inhibitors or PDE4-inhibitors combined with phototherapy. Currently approved systemic agents are dupilumab, baricitinib, abrocitinib, and upadacitinib. New anti-IL-13 and anti-IL-31 therapies will soon be available. Patient education, allergy testing, and comorbidity consideration are critical in the management of AD. The expert panel established a comprehensive and pragmatic approach to managing moderate-to-severe AD, thereby assisting clinical decision-making for healthcare professionals in Qatar.

Efficacy of Dupilumab in severe Atopic Dermatitis (AD) using the AD Control Tool (ADCT) Score in the population of Qatar

Atopic Dermatitis (AD) is a high-burden disease that affects approximately 2-5% of adults. AD patients experience intense pruritus and often report sleep and mental health disturbances accompanied by a diminished quality of life. The patients' perceptions of their treatment benefits are becoming increasingly important in the benefit/risk assessment of therapeutics such as the gold standard in AD therapy, Dupilumab. A survey questionnaire (ADCT) has been recently developed to assess the control of AD symptoms using subjective patient-based reporting only. This study aimed to investigate the self-reported efficacy of Dupilumab in Qatari patients with severe AD using the new ADCT evaluation tool. Methods: 30 patients completed a baseline survey before starting Dupilumab, and ADCT was assessed at four weeks post-therapy initiation. ADCT evaluates six AD symptoms in a severity grading from 0 to 3 (max. 24 points). The impact is assessed over the past week, including overall severity of symptoms, days with intense episodes of itching, the intensity of bother, problems with sleep, impact on daily activities, and impact on mood or emotions. In addition, itch severity was also assessed using a numeric rating scale (NRS11) ranging from 0 to 10. Results: The overall mean ADCT score at baseline was 17.6, and at week 4, it was reduced to 4.1. Patients reported a dramatic change in the overall symptoms already in this early phase. The parried t-test showed a significant difference in ADCT Score before and after therapy. There was a substantial decline in experiencing the associated AD symptoms: overall severity of symptoms (mean baseline =3.1, Dupilumab week 4 =0.9 (3.1/0.9), days with intense episodes of itching (3.2/0.7), the intensity of bother (3.2/0.8), the problem with sleep (2.7/0.4), impact on daily activities (2.5/0.6), and impact on mood or emotions (2.9/0.6). The itch score also reduced from 8/10 at baseline to 0-3 at week 4. Conclusion: Treatment of adult Asian/Arabic patients with severe AD treated with Dupilumab with or without topical steroids was highly effective and significantly improved overall well-being and pruritus as early as after 4 weeks of treatment.

Epidemiology of Geriatric-Dermatology virtual clinic: Teledermatology-Based care for elderly patients with skin diseases in Qatar

Background: The 'GeriDerm' (geriatric dermatology) clinic, is a new dermatology-based service at Hamad Medical Corporation (HMC), accommodating the needs of our elderly population living in the State of Qatar. Due to the global demographic transition towards an elderly population (≥65 years of age), incidences of chronic diseases, including dermatologic conditions, rise in parallel. Patients of older age are at higher risk of using multiple medications, seeing multiple care providers, often receiving multiple diverging pieces of information, and feeling lost within the system. Taking into consideration the elderly unique characteristics, the Geriatric Dermatology telemedicine clinic is a novel approach to meeting the many challenges our elderly patients face via providing quick, accurate assessments of cognition, functional status, frailty screening, and assessment for polypharmacy. Methods: Data of 1080 elderly patients with various skin disorders from June 2020 to July 2021 was received from the Dermatology Geriatric clinic, and then reviewed. Results: There were 521(48.2%) new cases and 559(51.8%) follow-up cases who attended the clinic either virtually or face to face consultation. A total of 587(54.4%) female and 493(45.6%) male elderly patients attended the clinic. The mean age was 74.6, with a minimum age of 60 and a maximum age of 106 years. 57.9%(625) of GeriDerm patients were Qatari, followed by Palestinian 75(6.9%), Syrian 51(4.7%), Egyptian 46(4.3%), and Indian 44(4.1%); while other nationalities constituted 239(22.1%). The majority of the cases were Contact Dermatitis 146(13%), Bullous Pemphigoid 107 (10%), and Pruritis 101(9.4%). Conclusion: The 'GeriDerm' service at HMC aimed to achieve the best healthcare standards for the elderly population of Qatar during COVID-19 pandemic, and is now established as a continuous advanced technology-based framework facilitating caring for older patients with skin disease via providing a clear pathway for adequate triaging, identification of severe conditions (red flag) requiring in-person clinic visits, while managing non-life threatening dermatoses via a teledermatology based approach.

Inhibition of T-cell activity in alopecia areata: recent developments and new directions

Alopecia areata (AA) is an autoimmune disease that has a complex underlying immunopathogenesis characterized by nonscarring hair loss ranging from small bald patches to complete loss of scalp, face, and/or body hair. Although the etiopathogenesis of AA has not yet been fully characterized, immune privilege collapse at the hair follicle (HF) followed by T-cell receptor recognition of exposed HF autoantigens by autoreactive cytotoxic CD8+ T cells is now understood to play a central role. Few treatment options are available, with the Janus kinase (JAK) 1/2 inhibitor baricitinib (2022) and the selective JAK3/tyrosine kinase expressed in hepatocellular carcinoma (TEC) inhibitor ritlecitinib (2023) being the only US Food and Drug Administration-approved systemic medications thus far for severe AA. Several other treatments are used off-label with limited efficacy and/or suboptimal safety and tolerability. With an increased understanding of the T-cell-mediated autoimmune and inflammatory pathogenesis of AA, additional therapeutic pathways beyond JAK inhibition are currently under investigation for the development of AA therapies. This narrative review presents a detailed overview about the role of T cells and T-cell-signaling pathways in the pathogenesis of AA, with a focus on those pathways targeted by drugs in clinical development for the treatment of AA. A detailed summary of new drugs targeting these pathways with expert commentary on future directions for AA drug development and the importance of targeting multiple T-cell-signaling pathways is also provided in this review.

In vitro evaluation of Neosetophomone B inducing apoptosis in cutaneous T cell lymphoma by targeting the FOXM1 signaling pathway

BACKGROUND

Cutaneous T cell lymphoma (CTCL) is a T cell-derived non-Hodgkin lymphoma primarily affecting the skin, with treatment posing a significant challenge and low survival rates.

OBJECTIVE

In this study, we investigated the anti-cancer potential of Neosetophomone B (NSP-B), a fungal-derived secondary metabolite, on CTCL cell lines H9 and HH.

METHODS

Cell viability was measured using Cell counting Kit-8 (CCK8) assays. Apoptosis was measured by annexin V/PI dual staining. Immunoblotting was performed to examine the expression of proteins. Applied Biosystems' high-resolution Human Transcriptome Array 2.0 was used to examine gene expression.

RESULTS

NSP-B induced apoptosis in CTCL cells by activating mitochondrial signaling pathways and caspases. We observed downregulated expression of BUB1B, Aurora Kinases A and B, cyclin-dependent kinases (CDKs) 4 and 6, and polo-like kinase 1 (PLK1) in NSP-B treated cells, which was further corroborated by Western blot analysis. Notably, higher expression levels of these genes showed reduced overall and progression-free survival in the CTCL patient cohort. FOXM1 and BUB1B expression exhibited a dose-dependent reduction in NSP-B-treated CTCL cells.FOXM1 silencing decreased cell viability and increased apoptosis via BUB1B downregulation. Moreover, NSP-B suppressed FOXM1-regulated genes, such as Aurora Kinases A and B, CDKs 4 and 6, and PLK1. The combined treatment of Bortezomib and NSP-B showed greater efficacy in reducing CTCL cell viability and promoting apoptosis compared to either treatment alone.

CONCLUSION

Our findings suggest that targeting the FOXM1 pathway may provide a promising therapeutic strategy for CTCL management, with NSP-B offering significant potential as a novel treatment option.

Azithromycin downregulates ICOS (CD278) and OX40 (CD134) expression and mTOR activity of TCR-activated T cells to inhibit proliferation

The precise mechanism of macrolide antibiotic azithromycin (AZM) mediated CD4+ T cell suppression is not fully understood. Given the crucial role of co-stimulatory signaling in T-lymphocyte function, we tested in vitro effects of AZM on two of the most extensively investigated costimulatory molecules, ICOS and OX40 in context to CD4+ T cell proliferation. Using multi-color flow cytometry approach on TCR-activated healthy donor peripheral blood mononuclear cells, we observed a marked reduction in the frequencies and surface expression of ICOS and OX40 receptors following AZM treatment. Functionally, in contrast to ICOS- and OX40- CD3+ CD4+ T cells, AZM treated ICOS+ and OX40+ displayed profound reduction in cell proliferation. Furthermore, AZM treated T cells displaying reduced levels of ICOS and OX40 found to be associated with suppressed mTOR activity as detected by phosphorylation levels of S6 ribosomal protein. This study provides new insights on potential mechanism of AZM mediated inhibition of T cell proliferation by targeting costimulatory pathways.

Epigenetic m6A RNA Modification Reader YTHDF1 in Merkel Cell Carcinoma

Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine cutaneous malignancy that commonly affects older individuals with a high mortality rate [...].

Metaanalyse zu präventiven und therapeutischen Effekten probiotischer Supplementierung bei Kindern mit atopischer Dermatitis

Trotz zahlreicher wissenschaftlicher Untersuchungen gibt es zur Wirkung von Probiotika auf die Inzidenz und Schwere der atopischen Dermatitis (AD) widersprüchliche Ergebnisse. Wir untersuchten, ob die Supplementierung mit Probiotika diese Parameter verringern. Dazu wurden drei Datenbanken systematisch durchsucht. In der Probiotika‐Gruppe war die AD‐Inzidenz um 22% geringer. Bei Verabreichung der Probiotika an schwangere und stillende Mütter betrug die Verringerung der Inzidenz 49% und bei Verabreichung an schwangere Mütter und Kinder 27%. Bei Verabreichung an schwangere und stillende Mütter sowie Kinder wurde eine 39%ige Verringerung der AD‐Inzidenz erreicht. Es wurden signifikante Unterschiede beim SCORAD (SCORing Atopic Dermatitis) zugunsten der Probiotika beobachtet, die IDLQI blieb jedoch unverändert. Lactobacillus (L.) rhamnosus war der am häufigsten dokumentierte Stamm, erwies sich jedoch bezüglich der Verringerung des SCORAD als unwirksam. Im Gegensatz dazu zeigte sich bei L. paracasei und L. sakei eine signifikante Verringerung des SCORAD. Während Probiotika bei der Prävention einer AD effektiv sind, ist die Wirkung bei der Behandlung einer AD weniger eindeutig, insbesondere bei Kindern <1 Jahr. Die Einnahme von Probiotika durch stillende Mütter ist eine wichtige Maßnahme und kann eine neue prophylaktische Strategie darstellen. Der präventive Effekt von Probiotika bei AD ist nicht mit dem familiären Hintergrund oder dem AD‐Risiko assoziiert. Bei L. paracasei und L. sakei zeigte sich die größte Verringerung des SCORAD.

Meta-analysis on preventive and therapeutic effects of probiotic supplementation in infant atopic dermatitis

Despite a large body of research, the effect of probiotic administration on the incidence and severity of atopic dermatitis (AD) shows conflicting results. We aimed to investigate whether probiotic supplementation reduces the incidence and severity of AD. Three databases were systematically searched. A 22% lower incidence of AD was found in the probiotic group. The reduction in incidence was 49% when probiotics were given to pregnant and lactating mothers, and 27% when they were given to pregnant mothers and infants. A 39% reduction of AD incidence was achieved when administered to pregnant-breastfeeding mothers and infants. Significant differences in SCORAD (SCORing Atopic Dermatitis) favoring probiotics were observed, but the IDLQI remained unchanged. Lactobacillus (L.) rhamnosus was the most documented strain, but it turned out to be ineffective in reducing SCORAD. Conversely, L. paracasei and L. sakei showed a significant decrease in SCORAD. Probiotics are effective in the prevention of AD, but the effect is less conclusive for the treatment of AD, especially in infants <1 year. The intake of probiotics by breastfeeding mothers is an important measure and may become a novel preventive strategy. The preventive effect of probiotics against AD is not associated with family background or AD risk. L. paracasei and L. sakei show the greatest reduction in SCORAD.

Fc Epsilon RI-Neuroimmune Interplay in Pruritus Triggered by Particulate Matter in Atopic Dermatitis Patients

Atopic dermatitis (AD) is the most common chronic relapsing neuroinflammatory skin disease that is characterized by a complex and multifactorial pathophysiology. It reflects a profound interplay between genetic and environmental factors, and a recently disclosed neuroimmune dysregulation that drives skin barrier disruption, pruritus, and microbial imbalance. In terms of the key external environmental players that impact AD, air quality and itch severity linkage have been thoroughly researched. The impact of ambient air pollutants including particulate matter (PM) and AD pruritic exacerbation has been recorded despite reductions in air pollution levels in in developed countries. The developing countries have, on the contrary, experienced significant urbanization and industrialization with limited environmental protection standards in the past decades. This unprecedented construction, petrochemical industry utilization, and increment in population counts has been paired with consistent exposure to outdoor PM. This may present a key cause of AD pruritic exacerbation supported by the fact that AD prevalence has intensified globally in the past 50 years, indicating that environmental exposure may act as a trigger that could flare up itch in vulnerable persons. At the molecular level, the impact of PM on severe pruritus in AD could be interpreted by the toxic effects on the complex neuroimmune pathways that govern this disease. AD has been recently viewed as a manifestation of the disruption of both the immune and neurological systems. In light of these facts, this current review aims to introduce the basic concepts of itch sensory circuits in the neuroimmune system. In addition, it describes the impact of PM on the potential neuroimmune pathways in AD pathogenesis with a special focus on the Fc Epsilon RI pathway. Finally, the review proposes potential treatment lines that could be targeted to alleviate pruritus based on immune mediators involved in the Fc Epsilon signaling map.

Non-coding RNAs in the epigenetic landscape of cutaneous T-cell lymphoma

Cutaneous T-cell lymphoma (CTCL) is a type of cancer that affects skin, and is characterized by abnormal T-cells in the skin. Epigenetic changes have been found to play a significant role in the development and progression of CTCL. Recently, non-coding RNAs (ncRNAs), such as microRNAs and long non-coding RNAs, have been identified as key players in the regulation of gene expression in CTCL. These ncRNAs can alter the expression of genes involved in cell growth, differentiation, and apoptosis, leading to the development and progression of CTCL. In this review, we summarize the current understanding of the role of ncRNAs in CTCL, including their involvement in DNA methylation, and other biological processes. We also discuss the types of ncRNAs, their role as oncogenic or tumor suppressive, and their putative use as diagnostic and prognostic biomarkers, based on the emerging evidence from laboratory-based as well as patients-based studies. Moreover, we also present the potential targets and pathways affected by ncRNAs. A better understanding of the complex epigenetic landscape of CTCL, including the role of ncRNAs, has the potential to lead to the development of novel targeted therapies for this disease.

Epigenetic programing of cancer stemness by transcription factors-non-coding RNAs interactions

Cancer 'stemness' is fundamental to cancer existence. It defines the ability of cancer cells to indefinitely perpetuate as well as differentiate. Cancer stem cell populations within a growing tumor also help evade the inhibitory effects of chemo- as well as radiation-therapies, in addition to playing an important role in cancer metastases. NF-κB and STAT-3 are representative transcription factors (TFs) that have long been associated with cancer stemness, thus presenting as attractive targets for cancer therapy. The growing interest in non-coding RNAs (ncRNAs) in the recent years has provided further insight into the mechanisms by which TFs influence cancer stem cell characteristics. There is evidence for a direct regulation of TFs by ncRNAs, such as, microRNAs (miRNAs), long non-coding RNAs (lncRNAs) as well as circular RNAs (circRNAs), and vice versa. Additionally, the TF-ncRNAs regulations are often indirect, involving ncRNA-target genes or the sponging of other ncRNA species by individual ncRNAs. The information is rapidly evolving and this review provides a comprehensive review of TF-ncRNAs interactions with implications on cancer stemness and in response to therapies. Such knowledge will help uncover the many levels of tight regulations that control cancer stemness, providing novel opportunities and targets for therapy in the process.

Successful Treatment of Rare Linear Lichen Planopilaris with Ixekizumab

Lichen planopilaris (LPP) is a lymphocytic primary cicatricial alopecia characterized by perifollicular erythema, follicular hyperkeratosis and scaring, resulting in permanent hair loss.¹ Current treatment modalities, both topical and systemic, fail to achieve satisfactory and consistent results.^2-4 As therapies fail to halt the inflammatory process, patients with LPP may face long-term disfigurement and significant psychological burden.⁵ Thus, efficacious, safe and targeted therapies are a high priority in preventing disfiguring alopecia in patients with LPP. Here, we report on a case of rare LPP in linear distribution (LLPP) involving the scalp and forehead achieving complete hair regrowth after 12 weeks of treatment with an anti-psoriatic, anti-interleukin (IL)-17A/F antibody (Taltz, Ixekizumab, Lilly). The present case underlines the viability of ixekizumab as a possible first-line, targeted therapy for LPP and its variants with sustained efficacy.

Quality of life measurement in rosacea. Position statement of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient Oriented Outcomes and Acne, Rosacea and Hidradenitis Suppurativa

The European Academy of Dermatology and Venereology (EADV) Task Forces (TFs) on Quality of Life (QoL) and Patient-Oriented Outcomes and Acne, Rosacea and Hidradenitis Suppurativa (ARHS) do not recommend the use of any generic instrument as a single method of Health Related (HR) QoL assessment in rosacea, except when comparing quimp (quality of life impairment) in rosacea patients with that in other non-dermatologic skin diseases and/or healthy controls. The EADV TFs on QoL and Patient-Oriented Outcomes and ARHS recommend the use of the dermatology-specific HRQoL instrument the Dermatology Life Quality Index (DLQI) and the rosacea-specific HRQoL instrument RosaQoL in rosacea patients. The DLQI minimal clinically important difference may be used as a marker of clinical efficacy of the treatment and DLQI score banding of 0 or 1 corresponding to no effect on patients' HRQoL could be an important treatment goal. This information may be added to consensuses and guidelines for rosacea.

CAR-cell therapy in the era of solid tumor treatment: current challenges and emerging therapeutic advances

In the last decade, Chimeric Antigen Receptor (CAR)-T cell therapy has emerged as a promising immunotherapeutic approach to fight cancers. This approach consists of genetically engineered immune cells expressing a surface receptor, called CAR, that specifically targets antigens expressed on the surface of tumor cells. In hematological malignancies like leukemias, myeloma, and non-Hodgkin B-cell lymphomas, adoptive CAR-T cell therapy has shown efficacy in treating chemotherapy refractory patients. However, the value of this therapy remains inconclusive in the context of solid tumors and is restrained by several obstacles including limited tumor trafficking and infiltration, the presence of an immunosuppressive tumor microenvironment, as well as adverse events associated with such therapy. Recently, CAR-Natural Killer (CAR-NK) and CAR-macrophages (CAR-M) were introduced as a complement/alternative to CAR-T cell therapy for solid tumors. CAR-NK cells could be a favorable substitute for CAR-T cells since they do not require HLA compatibility and have limited toxicity. Additionally, CAR-NK cells might be generated in large scale from several sources which would suggest them as promising off-the-shelf product. CAR-M immunotherapy with its capabilities of phagocytosis, tumor-antigen presentation, and broad tumor infiltration, is currently being investigated. Here, we discuss the emerging role of CAR-T, CAR-NK, and CAR-M cells in solid tumors. We also highlight the advantages and drawbacks of CAR-NK and CAR-M cells compared to CAR-T cells. Finally, we suggest prospective solutions such as potential combination therapies to enhance the efficacy of CAR-cells immunotherapy.

Real-world experience and long-term evaluation of tofacitinib in refractory alopecia areata: A prospective, open-label, single-center study in Asian Arab population

Tofacitinib is a pan-janus kinase inhibitor (JAK) which has been tested off-label in alopecia areata (AA) with promising results. However, evidence of tofacitinib in real-life setting is still poor. We evaluated long-term efficacy and safety of tofacitinib for refractory AA. This is a prospective, open-label, observational, single-center cohort study conducted between January 2018 and December 2020. Primary end-point was the percent change in Severity of Alopecia Tool (SALT) at the basal visit and at the most recent follow-up visit. Three categories of treatment response were analyzed. Data on 47 participants of Arab-Asian heritage were analyzed. A complete and partial regrowth was observed in 18 patients (41.86%) and 11 patients (25.58%), respectively. In 12 patients (27.9%), no response was obtained. Most of the non-responders belonged to the alopecia universalis group (66.67%). No statistical differences were observed in rates of regrowth between pediatric and adult individuals (p = 0.52), nor between women and men. Significant differences in the average duration of tofacitinib treatment were obtained among the three categories of regrowth (p < 0.003), notably duration of AA did not impact the clinical regrowth (p = 0.62). To the best of our knowledge, this is the first prospective, observational, long-term study using tofacitinib in refractory AA. Rates of regrowth and side effects are analogous to previous works. Length of tofacinitib therapy should last for 12 months before considering any discontinuation or change, since early cessation can lead to treatment failures or incomplete regrowth. Maintenance therapy after complete regrowth has demonstrated to be safe and effective to prevent recurrences of hair loss.

Targeting oncogenic transcription factors in skin malignancies: An update on cancer stemness and therapeutic outcomes

The skin is the largest organ of the human body and prone to various diseases, including cancer; thus, provides the first line of defense against exogenous biological and non-biological agents. Skin cancer, a complex and heterogenic process, with steep incidence rate often metastasizes due to poor understanding of the underlying mechanisms of pathogenesis and clinical challenges. Indeed, accumulating evidence indicates that deregulation of transcription factors (TFs) due to genetic, epigenetic and signaling distortions plays essential role in the development of cutaneous malignancies and therapeutic challenges including cancer stemness features and reprogramming. This review highlights the recent developments exploring underlying mechanisms how deregulated TFs (e.g., NF-κB, AP-1, STAT etc.,) orchestrates cutaneous onco-pathogenesis, reprogramming, stemness and poor clinical outcomes. Along this line, bioactive drugs, and their derivatives from natural and or synthetic origin has gained attention due to their multitargeting potential, potentially safer and effective therapeutic outcome for human malignancies. We also discussed therapeutic importance of targeting aberrantly expressed TFs in skin cancers with bioactive natural products and or synthetic agents.

Humanistic and Economic Burden of Atopic Dermatitis for Adults and Adolescents in the Middle East and Africa Region

INTRODUCTION

Atopic dermatitis (AD) is a chronic skin disease that poses a significant burden on both patients and the society. AD causes the highest loss in disability-adjusted life years compared with other skin diseases. This study aimed to estimate the economic and humanistic burden of AD in adults and adolescents in seven countries in the Middle East and Africa region (Egypt, Lebanon, Saudi Arabia, Kuwait, Algeria, South Africa, and United Arab Emirates).

METHODS

We conducted a literature review to identify country-specific data on this disease. Subsequently, meetings were organized with experts from each country to complete the missing data. The data were aggregated and calculation models were created to estimate the value of the humanistic and economic burden of the disease in each country. Finally, we conducted meetings with local experts to validate the results, and the necessary adjustments were made.

RESULTS

On average, a patient with AD loses 0.19 quality-adjusted life years (QALYs) annually owing to this disease. The average annual healthcare cost per patient is highest in the United Arab Emirates, with an estimated value of US $3569 and a population-level indirect cost of US $112.5 million. The included countries allocated a range of 0.20-0.77% of their healthcare expenditure to AD-related healthcare services and technologies. The indirect cost of AD represents approximately 67% of the total disease cost and, on average, approximately 0.043% (range 0.022-0.059%) of the gross domestic product (GDP) of each country.

CONCLUSION

Although the humanistic and economic burdens differ from country to country, AD carries a significant socioeconomic burden in all countries. The quality of life is severely affected by the disease. If AD is controlled, the costs, especially indirect costs, could decrease and the disease burden could be alleviated significantly.

S2k guideline: Rosacea

This updated and upgraded S2k guideline deals with the diagnosis and treatment of rosacea, which is a common, chronic inflammatory skin disease mostly affecting the face. Initially, rosacea is characterized by recurrent erythema, telangiectasia and flushing. Later, the inflammatory component predominates, with persistent erythema with follicular papules, papulopustules and pustules. The development of phyma, which usually occurs on the acral localizations, is the most severe manifestation. For the treatment of rosacea, the interdisciplinary guideline committee, with representatives of the German Dermatological Society (DDG), the Professional Association of German Dermatologists (BVDD), the German Opthalmological Society (DOG), the Society for Dermopharmacy (GD), the Swiss Society for Dermatology and Venereology (SGDV) and the German Rosacea Aid e. V., recommends the avoidance of trigger factors and topical applications of metronidazole, azelaic acid or ivermectin. For symptomatic treatment of persistent centrofacial erythema, the topical vasoconstrictors brimonidine or oxymetazoline can also be used. Systemic therapy is recommended for therapy-resistant and severe forms of rosacea papulopustulosa. The drug of choice is low-dose doxycycline. Alternatively, low-dose isotretinoin can be recommended. Ocular rosacea should be treated with lid margin hygiene. For topical treatment, ciclosporin eye drops, azithromycin, ivermectin or metronidazole are suggested.

Bullous pemphigoid induced by biologic drugs in psoriasis: a systematic review

INTRODUCTION

Several therapies for psoriasis have been described as triggers of biologic-induced bullous pemphigoid (BIBP). The real incidence of BIBP in psoriatic patients is still unknown. Hence, we compilated and analyzed current literature to identify the frequency and burden of this adverse event for psoriasis patients treated with biologics.

MATERIAL AND METHOD

We systematically searched literature records involving psoriatic patients developing BIBP. Electronic searches were conducted in Pubmed, EMBASE and Scopus in April 2021. To assess the causal relationship between BP and the biologic drug, we applied the Naranjo adverse reaction probability scale and the Karch-Lasagna algorithm.

RESULTS

Our systematic review identified 586 records through the three electronic databases. We identified 15 case reports of BIBP. These cases implicated two cases induced by adalimumab, three by efalizumab, three by etanercept, six by ustekinumab, and one case by secukinumab. Mean period of latency until the BIBP developed was time 5.12 ± 3.44 weeks for TNF-α blockers, and 28.66 ± 26.27 weeks for ustekinumab (p = .09). Most of the cases were assessed as "probable" consistently in both the Naranjo scale and the Karch-Lasagna algorithm.

CONCLUSION

This work presents an accurate estimation on the frequency and burden of BIBP. Ustekinumab presents with the largest evidence of BIBP, especially in patients with previous failure to TNF-α agents. Distinct patterns in the cytokinic pathways and clinical course exist between the BP induced by TNF-α blockers and ustekinumab. A close monitoring of skin condition is highly advisable in patients receiving biologic therapies for psoriasis. Knowledge of BIBP is of great importance to determine the preventive measures and select optimal treatment options.What's already known about this topic?The widespread use of biologic drugs has led dermatologists to encounter increasing situations of biologic-induced BP (BIBP).A lack of data exists on the real incidence of BIBP in psoriatic patients.BIBP is an important adverse event to know when managing patients with psoriasis using biologics.What does this study add?This work presents an accurate estimation on the raised burden of BIBP.Ustekinumab presents with the largest evidence of BIBP, especially in patients with previous failure to TNF-α agents.Mean period of latency until the BIBP developed was time 5.12 ± 3.44 weeks for TNF-α blockers, and 28.66 ± 26.27 weeks for ustekinumab.Distinct patterns in the cytokine pathways and clinical course exist between the BP induced by TNF-α blockers and ustekinumab.A careful screening of previous history of bullous diseases and a baseline immunologic study in psoriatic patients should be advisable prior to commencing any biologic therapy.A close monitoring of skin condition is highly advisable in patients receiving biologic therapies for psoriasis.

The PLAUR signaling promotes chronic pruritus

Chronic itch is a complex sensation of the skin frequently associated with skin diseases, such as atopic dermatitis (AD) and psoriasis. Although Serpin E1 is implicated in chronic itch, its receptor and signaling pathways involved in itch are not known. In this study, the clinical relevance of a putative Serpin E1 receptor PLAUR to chronic itch, and the neuro‐cutaneous Serpin E1‐PLAUR signaling are explored. We found that PLAUR is overexpressed in skin specimens of human lesional AD and lesional psoriasis, and sensory neurons innervating MC903‐induced AD‐like murine skin. Murine PLAUR⁺ sensory neurons responded to Serpin E1, resulting in enrichment of numerous itch‐ and inflammation‐related genes and their protein release. PLAUR resides in TLR2⁺ neurons and Serpin E1 stimulus led to transcriptional upregulation of TLR2 and its co‐signaling proteins. Agonists of TLR2 propagated itch‐related gene transcription including BNP, OSM, and PAR2. OSM induced acute itch in mice and promoted G‐CSF and IL‐8 release from human keratinocytes. Serpin E1 inhibitor reduced MC903‐induced itch, epidermal hyperplasia, immunocyte infiltration, and resulted in lower transcription/expression levels of Serpin E1 and OSM. Taken together, the PLAUR‐TLR2‐OSM signaling promotes skin‐nerve communication, cutaneous inflammation, and itch, all feeding into an aggravation of AD and exaggerated itch circuits.

Molecular and cellular mechanisms of itch and pain in atopic dermatitis and implications for novel therapeutics

Atopic dermatitis is a chronic inflammatory skin disease. Patients with atopic dermatitis experience inflammatory lesions associated with intense itch and pain, which lead to sleep disturbance and poor mental health and quality of life. We review the molecular mechanisms underlying itch and pain symptoms in atopic dermatitis and discuss the current clinical development of treatments for moderate‐to‐severe atopic dermatitis. The molecular pathology of atopic dermatitis includes aberrant immune activation involving significant cross‐talk among the skin and immune and neuronal cells. Exogenous and endogenous triggers modulate stimulation of mediators including cytokine/chemokine expression/release by the skin and immune cells, which causes inflammation, skin barrier disruption, activation and growth of sensory neurons, itch and pain. These complex interactions among cell types are mediated primarily by cytokines, but also involve chemokines, neurotransmitters, lipids, proteases, antimicrobial peptides, agonists of ion channels or various G protein–coupled receptors. Patients with atopic dermatitis have a cytokine profile characterised by abnormal levels of interleukins 4, 12, 13, 18, 22, 31 and 33; thymic stromal lymphopoietin; and interferon gamma. Cytokine receptors mainly signal through the Janus kinase/signal transducer and activator of transcription pathway. Among emerging novel therapeutics, several Janus kinase inhibitors are being developed for topical or systemic treatment of moderate‐to‐severe atopic dermatitis because of their potential to modulate cytokine expression and release. Janus kinase inhibitors lead to changes in gene expression that have favourable effects on local and systemic cytokine release, and probably other mediators, thus successfully modulating molecular mechanisms responsible for itch and pain in atopic dermatitis.

IL-20 promotes cutaneous inflammation and peripheral itch sensation in atopic dermatitis

Atopic dermatitis (AD) is a chronic skin disease, which is associated with intense itch, skin barrier dysfunction and eczematous lesions. Aberrant IL‐20 expression has been implicated in numerous inflammatory diseases, including psoriasis. However, the role of IL‐20 in AD remains unknown. Here, RNA‐seq, Q‐PCR, and immunocytochemistry were utilized to examine disease‐driven changes of IL‐20 and its cognate receptor subunits in skin from healthy human subjects, AD patients and murine AD‐models. Calcium imaging, knockdown and cytokine array were used to investigate IL‐20‐evoked responses in keratinocytes and sensory neurons. The murine cheek model and behavioral scoring were employed to evaluate IL‐20‐elicited sensations in vivo. We found that transcripts and protein of IL‐20 were upregulated in skin from human AD and murine AD‐like models. Topical MC903 treatment in mice ear enhanced IL‐20R1 expression in the trigeminal sensory ganglia, suggesting a lesion‐associated and epidermal‐driven mechanism for sensitization of sensory IL‐20 signaling. IL‐20 triggered calcium influx in both keratinocytes and sensory neurons, and promoted their AD‐related molecule release and transcription of itch‐related genes. In sensory neurons, IL‐20 application increased TLR2 transcripts, implicating a link between innate immune response and IL‐20. In a murine cheek model of acute itch, intradermal injection IL‐20 and IL‐13 elicited significant itch‐like behavior, though only when co‐injected. Our findings provide novel insights into IL‐20 function in peripheral (skin‐derived) itch and clinically relevant intercellular neuron‐epidermal communication, highlighting a role of IL‐20 signaling in the pathophysiology of AD, thus forming a new basis for the development of a novel antipruritic strategy via interrupting IL‐20 epidermal pathways.

Epigenetic Regulation of CXCR4 Signaling in Cancer Pathogenesis and Progression

Signaling involving chemokine receptor CXCR4 and its ligand SDF-1/CXL12 has been investigated for many years for its possible role in cancer progression and pathogenesis. Evidence emerging from clinical studies in recent years has further established diagnostic as well as prognostic importance of CXCR4 signaling. CXCR4 and SDF-1 are routinely reported to be elevated in tumors, distant metastases, which correlates with poor survival of patients. These findings have kindled interest in the mechanisms that regulate CXCR4/SDF-1 expression. Of note, there is a particular interest in the epigenetic regulation of CXCR4 signaling that may be responsible for upregulated CXCR4 in primary as well as metastatic cancers. This review first lists the clinical evidence supporting CXCR4 signaling as putative cancer diagnostic and/or prognostic biomarker, followed by a discussion on reported epigenetic mechanisms that affect CXCR4 expression. These mechanisms include regulation by non-coding RNAs, such as, microRNAs, long non-coding RNAs and circular RNAs. Additionally, we also discuss the regulation of CXCR4 expression through methylation and acetylation. Better understanding and appreciation of epigenetic regulation of CXCR4 signaling can invariably lead to identification of novel therapeutic targets as well as therapies to regulate this oncogenic signaling.

Neuro-immune communication regulating pruritus in atopic dermatitis

Atopic dermatitis (AD) is a common, chronic-relapsing inflammatory skin disease with significant disease burden. Genetic and environmental trigger factors contribute to AD, activating two of our largest organs, the nervous and immune system. Dysregulation of neuro-immune circuits plays a key role in the pathophysiology of AD causing inflammation, pruritus, pain, and barrier dysfunction. Sensory nerves can be activated by environmental or endogenous trigger factors transmitting itch stimuli to the brain. Upon stimulation, sensory nerve endings also release neuromediators into the skin contributing again to inflammation, barrier dysfunction and itch. Additionally, dysfunctional peripheral and central neuronal structures contribute to neuroinflammation, sensitization, nerve elongation, neuropathic itch, thus chronification and therapy-resistance. Consequently, neuro-immune circuits in skin and central nervous system may be targets to treat pruritus in AD. Cytokines, chemokines, proteases, lipids, opioids, ions excite/sensitize sensory nerve endings not only induce itch but further aggravate/perpetuate inflammation, skin barrier disruption, and pruritus. Thus, targeted therapies for neuro-immune circuits as well as pathway inhibitors (e.g., kinase inhibitors) may be beneficial to control pruritus in AD either in systemic and/or topical form. Understanding neuro-immune circuits and neuronal signaling will optimize our approach to control all pathological mechanisms in AD, inflammation, barrier dysfunction and pruritus.

Recalcitrant erythrodermic ichthyosis with atopic dermatitis successfully treated with Dupilumab in combination with Guselkumab

Background

Autosomal recessive congenital ichthyosis refers to a group of rare inherited disorders of keratinization and defective epidermal barrier resulting in varying clinical presentations and severities ranging from harlequin ichthyosis to congenital ichthyosiform erythroderma (CIE). Secondary atopic dermatitis (AD) can aggravate the disease state for CIE patients leading to recalcitrant CIE/AD with potentially unfavourable side effects and low tolerability.

Aims

Here, we report about a 38‐year‐old male patient with severe CIE as well as AD over the last 30 years.

Materials and Methods

The patients suffered from severe inflammation, pruritus and recurrent infections for decades without disease control and intolerable adverse events of previous therapies.

Results

Dupilumab (targeting IL‐4Ra, 300 mg q2w) partially controlled pruritus, but only the combination of Dupilumab with Guselkumab (anti‐IL23p19) controlled both CIE and AD with markedly reduced inflammation, itch and recurrent infections. Guselkumab alone was not sufficient to treat the severe CIE/AD.

Discussion

Further studies are required to assess the efficacy and safety of targeted therapies like Dupilumab/Guselkumab combination therapy in severe CIE/AD.

Innate immune regulates cutaneous sensory IL-13 receptor alpha 2 to promote atopic dermatitis

The clinical significance and regulators of IL-13Rα2 in itch and atopic dermatitis (AD) remain unclear. To identify disease-driven regulatory circuits of IL-13Rα2, transcriptomic/pathological analysis was performed in skin from patients with AD, psoriasis, healthy subjects, and murine AD model. Functionality was investigated in sensory neurons, keratinocytes and animal model, by using knockdown (KD), calcium imaging, RNA-seq, cytokine arrays, pharmacological assays, and behavioural investigations. In our study, an upregulated IL-13Rα2 expression was revealed in skin of AD patients, but not psoriasis, in a disease activity-dependent manner. In cultured human keratinocytes, IL-13 increased IL-13Rα2 transcription levels, and this were downregulated by IL-13Rα1KD. IL-13Rα2KD reduced transcription levels of EDNRA, CCL20, CCL26. In contrast, sensory neuron-derived IL-13Rα2 was upregulated by TLR2 heterodimer agonists, Pam3CSK4 and FSL-1. In a mouse cheek model, pre-administration of Pam3CSK4 and FSL-1 enhanced IL-13-elicited scratching behaviour. Consistently, in cultured sensory neurons Pam3CSK4 enhanced IL-13-elicted calcium transients, increased number of responders, and orchestrated chemerin, CCL17 and CCL22 release. These release was inhibited by IL-13Rα2KD. Collectively, IL-13 regulates keratinocyte-derived IL-13Rα2 and TLR2 to modulate neuronal IL-13Rα2, thereby promoting neurogenic inflammation and exacerbating AD and itch. Thus, the cutaneous IL-13-IL-13Rα2 and neuronal TLR2-IL-13Rα2 pathway represent important targets to treat AD and itch.

Interleukin-31: The "itchy" cytokine in inflammation and therapy

The cytokine interleukin-31 has been implicated in the pathophysiology of multiple atopic disorders such as atopic dermatitis (AD), allergic rhinitis, and airway hyper-reactivity. In AD, IL-31 has been identified as one of the main "drivers" of its cardinal symptom, pruritus. Here, we summarize the mechanisms by which IL-31 modulates inflammatory and allergic diseases. T_H 2 cells play a central role in AD and release high levels of T_H 2-associated cytokines including IL-31, thereby mediating inflammatory responses, initiating immunoregulatory circuits, stimulating itch, and neuronal outgrowth through activation of the heterodimeric receptor IL-31 receptor A (IL31RA)/Oncostatin M receptor (OSMRβ). IL31RA expression is found on human and murine dorsal root ganglia neurons, epithelial cells including keratinocytes and various innate immune cells. IL-31 is a critical cytokine involved in neuroimmune communication, which opens new avenues for cytokine modulation in neuroinflammatory diseases including AD/pruritus, as validated by recent clinical trials using an anti-IL-31 antibody. Accordingly, inhibition of IL-31-downstream signaling may be a beneficial approach for various inflammatory diseases including prurigo. However, as to whether downstream JAK inhibitors directly block IL-31-mediated-signaling needs to be clarified. Targeting the IL-31/IL31RA/OSMRβ axis appears to be a promising approach for inflammatory, neuroinflammatory, and pruritic disorders in the future.

Comparative appraisal with meta-analysis of erbium vs. CO2 lasers for atrophic acne scars

Recent advances in laser technology allowed the development of systems that improve texture, appearance and pliability of skin in acne scars (AS). Currently, comprehensive comparative studies on the efficacy of the most commonly used fractional systems in AS are lacking. Thus, the aim of this work was to appraise and compare the clinical response to erbium versus CO₂ lasers in AS in the form of a meta-analysis. The databases MEDLINE, EMBASE, Cochrane library were searched. Main clinical outcomes were investigator-reported scar improvement and participant-reported scar improvement. Five studies were included in this meta-analysis. Scar improvement was similar for both types of laser in terms of investigator-reported scar improvement (RR: 0.60 95 % CI: 0.35-1.02) and participant-reported scar improvement (RR: 0.99 95 % CI: 0.79-1.25). A sensitivity analysis that excluded studies with high risk of bias found the CO₂ lasers to be superior to the erbium lasers (RR: 0.47 95 % CI: 0.24-0.93): However, the subgroup analysis showed the CO₂ laser not to be significantly different from either the non-ablative erbium (RR: 0.65 95 % CI: 0.34-1.24) or the ablative erbium laser (RR: 0.60 95 % CI: 0.35-1.02). The CO₂ laser produced a slightly greater clinical response compared to the erbium lasers based on the physician's assessment. Overall, the two devices do not differ largely in terms of efficacy but may be complementary, with each resurfacing laser better suited for different clinical tasks.

Efficacy and predictive factors of cyclosporine A in alopecia areata: a systematic review with meta-analysis

INTRODUCTION

Drugs for alopecia areata (AA) can induce hair regrowth, but do not change the disease course. Dual properties of cyclosporine A (CsA) as hypetrichotic and immunosuppressive agent have encouraged use in AA. We aimed to determine the most meaningful efficacy of CsA and reveal features helping enhance its efficacy and reduce relapses.

METHOD

Efficacy of CsA and predictive factors were investigated. Cochrane, MEDLINE, Pubmed and Embase databases were searched.

RESULTS

2,189 papers were retrieved. Based on 344 patients, mean proportion of responders was 73%. CsA monotherapy showed proportion of hair regrowth of 66%, whereas CsA combined with systemic corticosteroids yielded 78%. Overall efficacy in studies with duration of CsA treatment <6 months was: 74% (53-88%), while in those with duration ≥6 months was: 73% (47-89%). Recurrence with CsA monotherapy was 55% (6-96%) whereas when CsA was combined with systemic corticosteroids it was 28% (6-72%).

CONCLUSION

CsA confers a favorable therapeutic effect and concomitant use of steroids slightly enhances efficacy, but it dramatically decreases relapses. Longer treatments seem to lead to less relapse likelihood, but daily dose does not influence recurrence. Optimal CsA dosage is 5 mg/kg/day in single therapy regimen, whereas it is 3 mg/kg/day in the steroid-associated regimen. KEY POINTSWhat is already known about this subject? Most treatments for alopecia areata have not been critically evaluated. Current outcomes about the efficacy and relapse rate of cyclosporine A (CsA) are inconsistent and predictive factors about the clinical response are lacking.What this study adds? CsA confers a favorable therapeutic hair regrowth. Longer treatment seems to lead to less likelihood of relapse of AA, but the daily dose does not exert any effect on the recurrence of the disease. The concomitant use of corticosteroids broadly decreases relapses, and it also enhances efficacy.Impact on clinical practice The combination with corticosteroids is the most predictive feature to prevent relapse of AA, followed by the duration of CsA therapy. The daily dose of CsA is the feature with the least or null impact on the clinical course of AA.