Improvement in aspects of sleep with etanercept and optional adjunctive topical therapy in patients with moderate-to-severe psoriasis: results from the PRISTINE trial

BACKGROUND

Impaired sleep in patients with moderate-to-severe psoriasis and improvement on therapy has not been widely studied.

OBJECTIVE

Quantify baseline aspects of sleep and improvement in patients with psoriasis receiving etanercept (ETN) when allowed concomitant topical medications (PRISTINE study).

METHODS

Patients with moderate-to-severe psoriasis were randomized to 50 mg ETN once weekly (QW/QW) or 50 mg ETN twice weekly (BIW/QW) for weeks 1-12, followed by 50 mg QW for weeks 13-24; a broad range of topical therapies were permitted during weeks 13-24. Sleep impairment was measured by the Medical Outcomes Study (MOS) sleep questionnaire Index II (population norm = 25.8; minimum clinically important difference = 5.1); quality of life (QoL) measures included Dermatology Life Quality Index (DLQI), EuroQoL 5 Dimension (EQ-5D) Utility Index and Visual Analogue Scale (VAS) and Functional Activity in Chronic Therapy-Fatigue (FACIT-Fatigue). ancova and Fisher's exact test or chi-squared tests were used for between-group testing.

RESULTS

Mean baseline MOS-Sleep scores were 34.0 for both groups indicating impairment (N = 270; QW/QW n = 137; BIW/QW n = 133, approximately 64% had impaired sleep). At week 12 of treatment, MOS-Sleep scores improved to 30.8 and 30.1, and at week 24, to 28.4 and 28.2 respectively. Poor sleep was significantly associated with clinically important problems in EQ-5D utility, VAS and FACIT-Fatigue; sleep improvement was associated with improved EQ-5D utility and FACIT-Fatigue (P < 0.001).

CONCLUSION

This study confirms that most patients with moderate-to-severe psoriasis have impaired sleep which is associated with impaired QoL. Treatment with etanercept significantly improved sleep, with most improvement occurring before a broad range of topicals were allowed. Sleep improvement was associated with improved QoL.

Definition of treatment goals for moderate to severe psoriasis: a European consensus

Patients with moderate to severe psoriasis are undertreated. To solve this persistent problem, the consensus programme was performed to define goals for treatment of plaque psoriasis with systemic therapy and to improve patient care. An expert consensus meeting and a collaborative Delphi procedure were carried out. Nineteen dermatologists from different European countries met for a face-to-face discussion and defined items through a four-round Delphi process. Severity of plaque psoriasis was graded into mild and moderate to severe disease. Mild disease was defined as body surface area (BSA) ≤10 and psoriasis area and severity index (PASI) ≤10 and dermatology life quality index (DLQI) ≤10 and moderate to severe psoriasis as (BSA > 10 or PASI > 10) and DLQI > 10. Special clinical situations may change mild psoriasis to moderate to severe including involvement of visible areas or severe nail involvement. For systemic therapy of plaque psoriasis two treatment phases were defined: (1) induction phase as the treatment period until week 16; however, depending on the type of drug and dose regimen used, this phase may be extended until week 24 and (2) maintenance phase for all drugs was defined as the treatment period after the induction phase. For the definition of treatment goals in plaque psoriasis, the change of PASI from baseline until the time of evaluation (ΔPASI) and the absolute DLQI were used. After induction and during maintenance therapy, treatment can be continued if reduction in PASI is ≥75%. The treatment regimen should be modified if improvement of PASI is <50%. In a situation where the therapeutic response improved ≥50% but <75%, as assessed by PASI, therapy should be modified if the DLQI is >5 but can be continued if the DLQI is ≤5. This programme defines the severity of plaque psoriasis for the first time using a formal consensus of 19 European experts. In addition, treatment goals for moderate to severe disease were established. Implementation of treatment goals in the daily management of psoriasis will improve patient care and mitigate the problem of undertreatment. It is planned to evaluate the implementation of these treatment goals in a subsequent programme involving patients and physicians.

German evidence-based guidelines for the treatment of Psoriasis vulgaris (short version)

Psoriasis vulgaris is a common and chronic inflammatory skin disease which has the potential to significantly reduce the quality of life in severely affected patients. The incidence of psoriasis in Western industrialized countries ranges from 1.5 to 2%. Despite the large variety of treatment options available, patient surveys have revealed insufficient satisfaction with the efficacy of available treatments and a high rate of medication non-compliance. To optimize the treatment of psoriasis in Germany, the Deutsche Dermatologische Gesellschaft and the Berufsverband Deutscher Dermatologen (BVDD) have initiated a project to develop evidence-based guidelines for the management of psoriasis. The guidelines focus on induction therapy in cases of mild, moderate, and severe plaque-type psoriasis in adults. The short version of the guidelines reported here consist of a series of therapeutic recommendations that are based on a systematic literature search and subsequent discussion with experts in the field; they have been approved by a team of dermatology experts. In addition to the therapeutic recommendations provided in this short version, the full version of the guidelines includes information on contraindications, adverse events, drug interactions, practicality, and costs as well as detailed information on how best to apply the treatments described (for full version, please see Nast et al., JDDG, Suppl 2:S1-S126, 2006; or http://www.psoriasis-leitlinie.de ).

Towards defining the pathogenesis of the hairless phenotype

Mutation of the hairless (hr) gene in mice causes severe abnormalities during the first hair follicle regression (catagen), resulting in complete baldness. Here, we further characterize how hairlessness develops in HRS/J hairless mouse skin (hr) by histology, histochemistry, immunohistology, and in situ hybridization. We show that, in hr skin, only two defined epithelial cell populations in the distal outer root sheath (ORS) retain their integrity, whereas the rest of the ORS disintegrates. The surviving distal ORS forms the characteristic utriculi, whereas the remnants of the bulge get isolated from other epithelial compartments, but retain the capacity to proliferate and to produce either columnar epithelial outgrowths or selected dermal cysts. Normal dermal papilla structures get lost during the development of hairlessness. Based on the patterns of keratin 17 mRNA and neural cell adhesion molecule antigen expression, and on the distribution of alkaline phosphatase activity, we propose that dermal cysts in hr skin arise from (i) the central ORS, (ii) bulge-derived cells, or (iii) the disintegrating proximal ORS under the influence of dermal papilla remnants. The hr mutation seems to disrupt the integrity of key functional tissue units in the hair follicle, possibly due to a dysregulation of normal, catagen-associated apoptosis and/or an impairment of cell adhesion, whereas the distal follicle epithelium (including its stem cell region) seems to be largely protected from this. Thus, hairless mice offer a unique model for dissecting the as yet obscure functional properties of the hr gene product in maintaining follicle integrity during normal catagen.

Membrane translocation of 15-lipoxygenase in hematopoietic cells is calcium-dependent and activates the oxygenase activity of the enzyme

Mammalian 15-lipoxygenases, which have been implicated in the differentiation of hematopoietic cells are commonly regarded as cytosolic enzymes. Studying the interaction of the purified rabbit reticulocyte 15-lipoxygenase with various types of biomembranes, we found that the enzyme binds to biomembranes when calcium is present in the incubation mixture. Under these conditions, an oxidation of the membrane lipids was observed. The membrane binding was reversible and led to an increase in the fatty acid oxygenase activity of the enzyme. To find out whether such a membrane binding also occurs in vivo, we investigated the intracellular localization of the enzyme in stimulated and resting hematopoietic cells by immunoelectron microscopy, cell fractionation studies and activity assays. In rabbit reticulocytes, the 15-lipoxygenase was localized in the cytosol, but also bound to intracellular membranes. This membrane binding was also reversible and the detection of specific lipoxygenase products in the membrane lipids indicated the in vivo activity of the enzyme on endogenous substrates. Immunoelectron microscopy showed that in interleukin-4 -treated monocytes, the 15-lipoxygenase was localized in the cytosol, but also at the inner side of the plasma membrane and at the cytosolic side of intracellular vesicles. Here again, cell fractionation studies confirmed the in vivo membrane binding of the enzyme. In human eosinophils, which constitutively express the 15-lipoxygenase, the membrane bound share of the enzyme was augmented when the cells were stimulated with calcium ionophore. Only under these conditions, specific lipoxygenase products were detected in the membrane lipids. These data suggest that in hematopoietic cells the cytosolic 15-lipoxygenase translocates reversibly to the cellular membranes. This translocation, which increases the fatty acid oxygenase activity of the enzyme, is calcium-dependent, but may not require a special docking protein.

Role of p53 in UVB-induced apoptosis in human HaCaT keratinocytes

Apoptosis represents an active form of cell death that is involved in the control of tissue homeostasis and in the deletion of DNA-damaged cells. Because the product of the tumor suppressor gene p53 has been demonstrated to be crucial for the induction of apoptosis in certain cell types, the present study was aimed at elucidating its role in ultraviolet-induced apoptosis in HaCaT keratinocytes. After in vitro ultraviolet B irradiation, p53 protein levels were noted to increase prior to the induction of apoptosis in a time- and concentration-dependent fashion. This increase could not be inhibited by the protein synthesis inhibitor cycloheximide. Because HaCaT keratinocytes are known to bear two p53 point mutations and because it is unclear whether p53 in HaCaT cells is still functional regarding induction of apoptosis, HaCaT cells were stably transfected with wild-type p53 cDNA inserted into the expression vector pCMV-Neo-Bam in sense (pC53-SN3) and anti-sense (pC53-ASN) direction. After selection with geniticin, growing colonies were screened for the presence of the transfected cDNA constructs by polymerase chain reaction. Cell clones bearing the anti-sense product were further analyzed for p53 expression by western blotting. Clones showing reduced p53 protein levels were irradiated with ultraviolet B light, and there was a clear reduction of apoptosis in the pC53-ASN bearing cell clones compared with the parental HaCaT cells. These studies demonstrate that blocking mutated p53 can partially block apoptosis in HaCaT keratinocytes and furthermore can confirm the key role for p53 in ultraviolet-induced apoptosis in human keratinocytes. Moreover, HaCaT keratinocytes and their p53-transfectants provide a convenient model that allows for further detailed analyses of apoptosis-associated biochemical and molecular events in human keratinocytes.

The promoter of the HaCaT keratinocyte differentiation-related gene keratin 4 contains a functional AP-2 binding site

The nuclear transcription factor AP-2 appears to be a key regulator mediating programmed gene expression during embryonic morphogenesis and adult cell differentiation. AP-2 has also been considered to be involved in epidermal gene regulation, but its precise role is not yet defined. The level of AP-2 transcripts increases during culturing of HaCaT keratinocytes preceding the expression of the differentiation-related gene keratin 4 (K4). The current study was aimed at investigating whether AP-2 transactivates K4 transcription. We cloned and sequenced the promoter region of K4 and found, in addition to canonical sequences, an AP-2 consensus site in the vicinity of the transcriptional start. In order to provide functional evidence for a regulation of K4 transcription by AP-2, we cloned various parts, which did or did not contain the AP-2 site of the K4 upstream sequence, into Cat reporter plasmids. These constructs were ballistically transfected into differentiating HaCaT keratinocytes. The determination of the resulting Cat activity revealed that the AP-2 site in the vicinity of the transcriptional start was functional for K4 transcription. Thus, the role of AP-2 in the process of keratinocyte differentiation appears to be considerable. In addition, further regulatory elements were found to be necessary for full transcription of K4.

Retinoic acid attenuates phospholipase C-mediated signaling in HaCaT keratinocytes

Release of inositol(1,4,5)trisphosphate (Ins(1,4,5)P3) generated by phospholipase C (PLC) upon receptor stimulation plays an important role in the regulation of cell growth and differentiation. A second, completely different, signal transduction system involves retinoic acid (RA) and related derivatives. Binding to intracellular receptor sites can modulate keratinocyte growth and inhibits differentiation. The present study was aimed at characterizing possible interactions between the two signalling pathways in HaCaT keratinocytes. As determined by anion exchange chromatography and HPLC analysis, HaCaT keratinocytes treated with 1 microM RA for up to 72 h showed a marked decrease in Ins(1,4,5)P3 release upon stimulation with 10 microM bradykinin or 10 microM ionomycin. Thin-layer chromatography of phosphatidylinositol phosphates, the substrates of PLC, revealed no differences between RA-treated and untreated cells. Western blot analysis of the PLC isozymes present in HaCaT cells, PLC beta 3 and PLC gamma 1, showed no alterations in the expression of these proteins in RA-treated cells as compared to vehicle-treated controls. In addition, expression of the PLC-activating G protein G alpha q was not affected by RA treatment. Our results show that RA downregulates the PLC-mediated signaling system. The point of interference of this signal transduction crosstalk has yet to be elucidated. Our results suggest, furthermore, that RA-induced attenuation of keratinocyte differentiation might be mediated at least in part by the downregulation of Ins(1,4,5)P3 release.

Phospholipase C-mediated signaling is altered during HaCaT cell proliferation and differentiation

To elucidate the signaling mechanisms associated with keratinocyte differentiation, we studied in vitro phospholipase C-mediated signal transduction, which results in the generation of inositol phosphates, comparing proliferating versus differentiated HaCaT cells, a human keratinocyte line. Bradykinin- or A23187-induced formation of inositol 1,4,5-trisphosphate, inositol 1,4-bisphosphate, and inositol monophosphates, as determined by anion exchange high performance liquid chromatography, were found to be highest in the early logarithmic growth phase of the cells. In more highly differentiated HaCaT cells, which expressed maximal amounts of the differentiation marker involucrin, inositol phosphate formation was reduced to about one third of that in proliferating cells. Thin layer chromatography of membrane phosphatidylinositol phosphates revealed that this reduction was associated with a steady decrease in phospholipase C substrates. Immunoblot analysis of phospholipase C isozymes, however, and of expression of Gq alpha, the G protein subunit that activates phospholipase C beta, revealed no decrease during the differentiation phase. The results suggest that the inositol-phospholipid signal transduction pathway is involved in keratinocyte proliferation and in the induction of differentiation, with attenuated signal transduction activity via phospholipase C-coupled receptors in more differentiated keratinocytes.

Keratin 17 gene expression during the murine hair cycle

Keratin 17 (K17) expression is currently considered to be associated with hyperplastic or malignant growth of epithelial cells. The functions of this keratin in normal skin physiology and the regulation of its gene expression, however, are still unclear. As one possible approach to further explore K17 functions, we have studied the differential patterns of mouse K17 (MK17) transcription during the murine hair cycle by means of in situ hybridization, using a digoxigenin-labeled riboprobe. Cycling hair follicles in the skin of C57BL/6 mice were found to be the only skin structures expressing MK17 under physiologic conditions. MK17 transcripts were constantly observed throughout all hair cycle stages in the suprainfundibular outer root sheath (ORS). The MK17 expression was also evident in the isthmus part of the ORS, where it was expressed weakly and was spatially restricted during telogen, with an increase in early anagen and stable expression during mid- and late anagen, localizing to the zone of so-called trichilemmal keratinization. In addition, in early anagen, a group of epithelial cells in or next to the bulge region stained weakly for MK17. With progressing anagen development, MK17 expression in this region increased and was consistently localized to keratinocytes at the advancing front of the emerging epithelial hair bulb. In mid- and late anagen, this zone of MK17 expression spread along the proximal ORS, with a maximal level of expression in the innermost cell layer of the ORS. Overall, these findings provide data on the MK17 expression profile of normal murine skin and demonstrate hair-cycle-dependent regulation of MK17 expression.

2,3,7,8-tetrachlorodibenzo-p-dioxin (TCCD) affects keratin 1 and keratin 17 gene expression and differentially induces keratinization in hairless mouse skin

The environmental pollutant 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) causes chloracne in humans by mechanisms that are as yet poorly understood. Because TCDD is known to affect keratinocyte differentiation in vitro, we have studied TCDD-dependent morphologic changes and the expression of murine keratin 1 (MK1; differentiation associated) and keratin 17 (MK17; presumably hyperproliferation associated) in HRS/J hr/hr hairless mouse skin. TCDD (0.2 microg in acetone) applied topically to the dorsal skin caused epidermal acanthosis and hyperkeratosis of the dermal cysts as well as an involution of the utricles and the sebaceous glands. By means of in situ hybridization with digoxigenin-labeled riboprobes of sections from untreated and vehicle (control)-treated skin, we localized MK1 mRNA to the epidermal spinous cell compartment. MK17 transcripts were detected only in the derivatives of the hair follicle-utricle epithelium and dermal cysts. No spatial overlap was observed between MK1 and MK17 expression. After TCDD application, MK17 was newly expressed in the upper spinous cell layers of the interfollicular epidermis, although it was suppressed in the involuting utricles. In contrast, MK1 expression in the interfollicular epidermis was not affected by TCDD. Furthermore, MK1 expression was induced in the epithelium of the utricle remnants and in some dermal cysts. These data suggest that increased keratinization of the part of the follicular epithelium corresponding to the dermal cyst epithelium of hairless mice most probably explains the pathogenesis of TCDD-induced chloracne. The results demonstrate, furthermore, that TCDD can differentially affect keratinocyte differentiation in vivo as well as in vitro.

Treatment of melanoma cells with the synthetic retinoid CD437 induces apoptosis via activation of AP-1 in vitro, and causes growth inhibition in xenografts in vivo

Human malignant melanoma is notoriously resistant to pharmacological modulation. We describe here for the first time that the synthetic retinoid CD437 has a strong dose-dependent antiproliferative effect on human melanoma cells (IC50: 5 x 10(-6) M) via the induction of programmed cell death, as judged by analysis of cell morphology, electron microscopical features, and DNA fragmentation. Programmed cell death was preceded by a strong activation of the AP-1 complex in CD437-treated cells as demonstrated by gel retardation and chloramphenicol transferase (CAT) assays. Northern blot analysis showed a time-dependent increase in the expression of c-fos and c-jun encoding components of AP-1, whereas bcl-2 and p53 mRNA levels remained constant. CD437 also exhibited a strong growth inhibitory effect on MeWo melanoma cells in a xenograft model. In tissue sections of CD437-treated MeWo tumors from these animals, apoptotic melanoma cells and c-fos overexpressing cells were colocalized by TdT-mediated deoxyuridine triphosphate-digoxigenin nick end labeling (TUNEL) staining and in situ hybridization. Taken together, this report identifies CD437 as a retinoid that activates and upregulates the transcription factor AP-1, leading eventually to programmed cell death of exposed human melanoma cells in vitro and in vivo. Further studies are needed to evaluate whether synthetic retinoids such as CD437 represent a new class of retinoids, which may open up new ways to a more effective therapy of malignant melanoma.

Retinoic acid affects the expression rate of the differentiation-related genes aryl hydrocarbon receptor, ARNT and keratin 4 in proliferative keratinocytes only

The environmental contaminant dioxin exerts most of its effects by activating the aryl hydrocarbon receptor (AhR). The AhR is considered to play not only a role in the regulation of xenobiotic metabolism, but also for development, growth, and differentiation. The transcript levels of the AhR and its associated translocator protein (ARNT) were found to increase with ongoing differentiation in the human keratinocyte cell line HaCaT. Correspondingly, in situ hybridization studies in normal human skin revealed an absence of AhR-expression in proliferating basal cells and increasing transcript levels in upper cell layers, in dependence of keratinocyte differentiation. AhR expression in differentiation-deficient hyperproliferative psoriatic skin was markedly decreased. When keratinocytes were continuously treated with 1 microM retinoic acid (RA), the upregulation of AhR- and ARNT-mRNA levels was inhibited as was keratin 4-expression, a marker of HaCaT-keratinocyte differentiation. In contrast, treatment of already differentiated cells with RA did not down-regulate these transcript levels. The mRNA levels of the prevalent retinoic acid receptors in keratinocytes, RAR gamma and RXR alpha, were not influenced by the process of differentiation or by addition of RA. Our data suggest that the regulation of AhR-, ARNT- and keratin 4-expression by RA is indirect and mediated by a yet to be identified factor.

Induction of apoptosis in human HaCaT keratinocytes

Although cell death by apoptosis has been recognized as an important control mechanism in the maintenance of tissue homeostasis and in the elimination of cells with damaged DNA, information on the induction and characteristics of apoptosis in keratinocytes is rather scarce. Apoptotic mechanisms may play an important role in normal and disturbed homeostasis of the skin. In the present study, we therefore investigated the effects of several potential inducers of apoptosis in the human keratinocyte cell line HaCaT. Apoptosis was assessed with respect to morphological changes by light and electron microscopic examinations and to DNA integrity by a specific ELISA. UVB irradiation induced the morphology and internucleosomal DNA fragmentation characteristic of apoptosis in a dose- and time-dependent manner. Interferon-gamma caused DNA cleavage at the linker regions without producing morphological features consistent with apoptotic cell death. In contrast, treatment with dithranol and NP-40 resulted in necrotic alterations in the keratinocytes. Treatment with the calcium ionophore A23187 caused morphological changes which were similar to the characteristics of 'nonapoptotic programmed cell death'. Dexamethasone, tumor necrosis factor-alpha, transforming growth factor-beta, TPA, retinoic acid, the podophyllin derivative etoposide, the thromboxane A2 analogue U46619, cycloheximide, and the nitric oxide donors sodium nitroprusside and S-nitroso-glutathione, which are all known to induce apoptosis in other cell types, did not affect HaCaT keratinocytes. These results demonstrate that apoptosis can be induced in keratinocytes in vitro but the apoptosis differs from that in other cell types, such as haematopoietic cells, with regard to the type of inducer and/or the sensitivity of the target cells. Since keratinocytes are affected by numerous external and internal stimuli, they might posses several protective mechanisms to prevent apoptosis and to ensure the structural integrity of the outermost barrier of the body.

Release of stem cell factor from a human keratinocyte line, HaCaT, is increased in differentiating versus proliferating cells

Stem cell factor, a recently discovered growth factor for hematopoietic stem cells, mast cells, and melanocytes, was initially reported to be produced by fibroblasts. In this study, we investigated the secretion of this factor from human HaCaT cells during in vitro culture and compared it to synthesis by cells in the skin. Release of stem cell factor from freshly cultured keratinocytes was comparable to that of HaCaT cells and was nearly half that produced by fibroblasts and umbilical vein endothelial cells. No stem cell factor was detectable in culture supernatants of melanocytes. HaCaT cells underwent spontaneous differentiation after a period of proliferation until confluency. Depending on duration of culture, they released increasing amounts of stem cell factor (approximately 150 pg/10(6) cells on day 3 (proliferating cells) vs approximately 450 pg/10(6) cells on day 14 (differentiating cells) measured by enzyme-linked immunosorbent assay. Stimulation for 24 h with the calcium ionophore A 23187 (10(-6) to 10(-8) M) further enhanced release. Western blot analysis of HaCaT cell lysates with a stem cell factor antibody revealed two proteins with the known molecular weights of membrane-bound and soluble stem cell factor. By semiquantitative reverse transcriptase polymerase chain reaction, full-length as well as spliced type stem cell factor mRNA was found to be increased in differentiating versus proliferating HaCaT cells. Keratinocytes are thus potentially important sources of stem cell factor in human skin, and HaCaT cells provide a useful model for further studies of stem cell factor from keratinocytes.

AP-2 gene expression and modulation by retinoic acid during keratinocyte differentiation

The transcription factor AP-2 has been suggested to participate in keratinocyte gene regulation, but its precise role in the processes of keratinocyte proliferation and differentiation is largely unknown. We here report on an increase of AP-2 transcripts in proliferating HaCaT keratinocytes preceding the expression and upregulation of the differentiation-related genes keratin 4 (K4) and Ah-receptor (AhR), but a decrease of AP-2 transcript levels during the process of keratinocyte differentiation. Continuous treatment of the keratinocyte cell cultures with retinoic acid (RA) resulted in a premature downregulation of AP-2 mRNA levels, and the transcripts of K4 and AhR remained at basal levels. Furthermore, addition of RA to already differentiated cells failed to exert any effect on K4- and AhR-mRNA levels. The data suggest a role for AP-2 as an intermediate factor in the pathway of RA action in keratinocyte differentiation, explaining both the downregulation of K4 and AhR transcript levels in proliferative keratinocytes and the loss of RA effects in already differentiated cells. It appears thus that AP-2 plays a pivotal role at the onset of differentiation in still proliferating keratinocytes.

Thrombin and melittin activate phospholipase C in human HaCaT keratinocytes

Following the activation of specific receptors, phospholipase C has been shown to cleave the membrane phospholipid phosphatidylinositol bisphosphate into the 2nd messengers inositol 1,4,5-trisphosphate and diacylglycerol. Both 2nd messengers contribute to the regulation of cellular proliferation. The receptor for bradykinin is coupled to this pathway in keratinocytes, but knowledge about other activators of phospholipase C is limited. Additional mediators and agents were therefore examined regarding their ability to activate phospholipase C in HaCaT keratinocytes. Analysis for 3H-inositol phosphates was performed by anion-exchange HPLC. Thrombin and melittin induced a time- and dose-dependent release of inositol 1,4,5-trisphosphate. Several other mediators examined such as angiotension II, neurotensin, C3a, pituitary adenylate cyclase activating peptide, phenylephrin, and prostaglandin E2, did not induce the formation of inositol phosphates. In view of the mitogenic activity and the increased formation of thrombin after tissue injury, the coupling of the thrombin receptor to phospholipase C in HaCaT keratinocytes suggests a role of this protease in epidermal wound healing.

Expression of 5-lipoxygenase in differentiating human skin keratinocytes

We studied the expression of arachidonate 5-lipoxygenase (5-LO) in a cell line of human keratinocytes (HaCaT) and in normal human skin keratinocytes in tissue culture. In undifferentiated keratinocytes 5-LO gene expression was low or undetectable as determined by 5-LO mRNA, protein, cell-free enzyme activity, and leukotriene production in intact cells. However, after shift to culture conditions that promote conversion of prokeratinocytes into a more differentiated phenotype, 5-LO gene expression was markedly induced in HaCaT cells and, to a lesser extent, in normal keratinocytes. These results show that 5-LO gene expression is an intrinsic property of human skin keratinocytes.

The differentiation-related upregulation of aryl hydrocarbon receptor transcript levels is suppressed by retinoic acid

The environmental contaminant 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) binds to a specific intracellular receptor protein -the Ah-receptor- which acts as a transcription factor. Herein we report on the relative levels of Ah-receptor-mRNA and TCDD-induced cytochrome P450 1A1 (Cyp1A1)-mRNA and their modulation by retinoic acid in the human keratinocyte cell line HaCaT. Ah-receptor-mRNA was already present in proliferating keratinocytes and increased 8-fold in the course of differentiation. Addition of 10 nM TCDD did not alter the level of Ah-receptor transcripts. In contrast, addition of 1 microM RA maintained the amount of Ah-receptor-mRNA at the basal level as observed only in proliferating keratinocytes. The transcription of Cyp1A1 was dependent on TCDD-treatment and increased fivefold in more differentiated cells as compared to proliferating cells. Simultaneous addition of retinoic acid revealed an only twofold increase. These results indicate that the expression of the AhR is dependent on the state of differentiation of keratinocytes and seems to be affected by retinoic acid.

Inositol phosphate formation and release of intracellular free calcium by bradykinin in HaCaT keratinocytes

Phospholipase C-mediated release of inositol trisphosphate, followed by an increase in free intracellular calcium, is an important signal transduction pathway for several membrane receptors. In the present investigation, the coupling of various receptors to phospholipase C was studied in the human keratinocyte line HaCaT. Inositol trisphosphate formation was determined by anion-exchange chromatography, and the release of intracellular calcium was analysed with the fluorescence probe Fura-2 AM. Activation of HaCaT keratinocytes with bradykinin resulted in a time- and dose-dependent release of inositol trisphosphate and intracellular calcium, with an EC50 value of 50 nM for bradykinin-induced inositol trisphosphate formation. The mediators and cytokines IL-1, IL-4, IL-6, IL-8, EGF and TGF alpha, as well as bombesin, prolactin, carbachol, substance P and retinoic acid, did not activate this pathway. The inability of the mediators examined to activate phospholipase C may be due to lack of the respective cognate receptors or to the use of other signal transduction pathways.

Human mast cells produce IL-8

Recruitment of neutrophils is a common feature in diseases that are associated with mast cell activation. The mechanisms that mediate neutrophil activation are not well understood. IL-8 is a recently described potent chemotactic factor that might be pathogenetically involved in this process. We therefore studied the human mast cell line HMCI and human skin mast cells for their ability to produce IL-8 using various stimuli. IL-8-mRNA was expressed in a stimulus- and time-dependent fashion as detected by Northern blot analysis with an IL-8-specific cDNA probe. The molecular mass of HMCI-derived IL-8 was determined to be about 8 kDa by immunoblot analysis. Immunoreactive and biologically active IL-8 protein was measured in the cell culture supernatants of HMCI cells by an ELISA and a chemotaxis assay, respectively. On immunoelectron microscopy of stimulated skin mast cells, IL-8 was found along cytoplasmatic membranes and in intracellular granules. Our data indicate that mast cells may contribute to neutrophil recruitment by secretion of IL-8.

Human mast cells produce IL-8

Recruitment of neutrophils is a common feature in diseases that are associated with mast cell activation. The mechanisms that mediate neutrophil activation are not well understood. IL-8 is a recently described potent chemotactic factor that might be pathogenetically involved in this process. We therefore studied the human mast cell line HMCI and human skin mast cells for their ability to produce IL-8 using various stimuli. IL-8-mRNA was expressed in a stimulus- and time-dependent fashion as detected by Northern blot analysis with an IL-8-specific cDNA probe. The molecular mass of HMCI-derived IL-8 was determined to be about 8 kDa by immunoblot analysis. Immunoreactive and biologically active IL-8 protein was measured in the cell culture supernatants of HMCI cells by an ELISA and a chemotaxis assay, respectively. On immunoelectron microscopy of stimulated skin mast cells, IL-8 was found along cytoplasmatic membranes and in intracellular granules. Our data indicate that mast cells may contribute to neutrophil recruitment by secretion of IL-8.

[Treatment of vitiligo with phenylalanine and UV-A]

Seven patients with generalized vitiligo were treated with 100 mg/kg body weight phenylalanine in combination with UV-A. A 20% repigmentation of the vitiligenous area was achieved in only one patient. Three patients each showed either a sparse follicular repigmentation or no effect at all. Because of the disappointing therapeutic results and possible side effects, we cannot recommend a therapy with phenylalanine and UV-A for vitiligo.

Patterns of cell death: the significance of apoptosis for dermatology

Development, function, remodelling, and senescence of multicellular organisms depend on the coordinated occurrence of physiological, actively induced cell death in two major patterns: terminal differentiation and programmed cell death (apoptosis). Apoptosis is a highly selective form of "cell suicide" with characteristic morphological and biochemical features: chromatin condensation, formation of apoptotic bodies, and DNA fragmentation by activation of endonucleases. Here, we outline the current understanding of apoptosis and its subtypes, discuss their biological functions, and delineate why apoptosis is relevant to the skin and its diseases. We distinguish apoptosis from necrosis, and discuss the regulation of apoptosis by selected genes, hormones, growth factors and cytokines. The epidermis and the regressing hair follicle offer interesting models for studying the as yet ill-understood biology of epithelial cell apoptosis. The selective manipulation of cell death programs may become part of the therapeutic arsenal of clinical dermatology.

[Ammonium bituminosulfonate (Ichthyol). Anti-inflammatory effect and inhibition of the 5-lipoxygenase enzyme]

Ammonium bituminosulphonate (Ichthyol) inhibits 5-lipoxygenase activity in human polymorphonuclear neutrophils. The inhibition is dose-dependent and occurs at non-cytotoxic concentrations of the drug. This results in a decreased release of Leukotriene B4 from polymorphonuclear neutrophils. Furthermore, when applied to the ear skin of AB/Bln mice pretreated with croton oil, Ichthyol reduces the inflammatory reaction.

Signal transduction pathways in keratinocytes

Mammalian cells do not live as isolated organisms, but are instead organized into complex, highly specialized tissue organs composed of a homogeneous or a mixed cell population. In order to maintain tissue homeostasis in physiological and pathophysiological conditions, intercellular communication is an absolute requirement. This review will summarize our current knowledge as to how an extracellular signal is transduced via a specific receptor to the interior of the cell and how this signal will induce special cell functions. Attention will be paid to the major signal transduction pathways known to be active in keratinocytes, namely the adenylate cyclase, guanylate cyclase, tyrosine kinase, and phospholipase C systems. Finally, examples will be given of how interactions between these signal transduction pathways can take place and how 'signal cross-talk' might regulate keratinocyte function.

Inositol phosphate formation in the human squamous cell carcinoma line SCC-12 F: studies with bradykinin, the calcium ionophore A23187, and sodium fluoride

The phospholipase C (PLC)-mediated hydrolysis of membrane phosphoinositides is an important signal transduction pathway coupled to the cell-surface receptors for several hormones and growth factors. In addition, PLC activity can be modulated by changes in intracellular calcium and activation of GTP binding proteins. In this report, differential activation of PLC in the human keratinocyte cell line SCC-12F was studied as judged by specific patterns of inositol phosphate formation. Several hormones and growth factors previously shown to stimulate PLC in a variety of cell types were screened for activity in SCC-12F cells. Only bradykinin was active, stimulating the PLC-dependent generation of inositol (1,4,5) triphosphate (Ins(1,4,5)P3). Ins(1,4,5)P3 was rapidly metabolized to inositol(1,4)biphosphate (Ins(1,4)P2) and inositol(1,3,4,5)tetrakisphosphate (Ins(1,3,4,5)P4), and subsequently degraded to inositol monophosphates. The response elicited by bradykinin was concentration dependent (EC50 value of 50 nM), suggesting involvement of a specific bradykinin receptor. Treatment of these cells with the calcium ionophore A23187 appeared to result in the direct formation of Ins(1,4)P2 without Ins(1,4,5)P3 as precursor. Treatment of the cells with AIF4-, a putative activator of GTP binding proteins, resulted in the generation of inositol monophosphates as the major metabolites in the absence of detectable Ins(1,4,5)P3 formation. Taken together, these observations suggest that the PLC complex present in SCC-12F cells can be differentially activated to yield either Ins(1,4,5)P3, Ins(1,4)P2, or InsP. The observed effects may be due to a direct PLC-dependent hydrolysis of the appropriate membrane phosphoinositide.

In vitro generation of smooth muscle-contracting leukotrienes from isolated epidermal cells

Single-cell suspensions of murine and human epidermal cells were studied for the presence of peptidoleukotrienes (LTs), using in vitro guinea pig ileum contraction as bioassay and a commercial radioimmunoassay. The calcium ionophore A23187 at 5 x 10(-6) M alone or in combination with arachidonic acid at 10(-4) M caused release of LTC4/D4 within 10-30 min and for up to 18 h. LTB4, as was measured in the chemotaxis assay, was released at different levels and with different kinetics from the same cells. Epidermal cells may thus regulate cutaneous inflammation by secreting potent vasoactive and muscle-contracting in addition to chemotactic lipid mediators.

Comparison of eicosanoid generation by highly purified human Langerhans cells and keratinocytes

The present study was conducted to investigate the eicosanoid metabolism of highly enriched human Langerhans cells and keratinocytes. Arachidonic acid (100 microM) was added to the cells which were then stimulated with 1 microM calcium ionophore A 23187 for 10 and 30 min. The supernatants were examined for cyclooxygenase and lipoxygenase products using different chromatographic systems and radioimmunoassays. Compounds were identified by comparison with authentic standards. The major cyclooxygenase product of both cell types was prostaglandin D2, with minor amounts of prostaglandin E2. The main products of the lipoxygenase pathway were 5-hydroxyeicosatetraenoic acid (5-HETE), 12-HETE, 15-HETE, and their corresponding hydroperoxy derivatives, with small amounts of leukotrienes B4 and C4. The major differences in the metabolism of the two cell types were related to faster kinetics of generation of the mediators and a more complete conversion of arachidonic acid by the LC. Because eicosanoids have been implicated to be potent mediators of inflammation and immunomodulators, the present data underline the potential contributory role of epidermal cells to eicosanoid-associated pathologic processes.

Evidence for leukotrienes in animal venoms

To elucidate further the pathomechanisms of cutaneous whealing in response to insect or sea-animal stings, commercial sources of bee and wasp venoms and of sea nettle nematocyst extracts, as well as crude bee and wasp venoms, were examined for the presence of histamine, leukotrienes (LT) C4, LTB4 (radioimmunoassay and reverse-phase high-pressure liquid chromatography), and neutrophil chemotactic activity (NCA). Histamine was present in all samples with the highest levels in the crude insect venoms. The same held for LTC4 with highest quantities in a liquid commercial bee venom extract and in the crude venoms. Relatively large amounts of LTB4 were recovered from the sea nettles with a correspondingly high NCA. Although small levels of LTB4 were found in the other samples, there was no clear correlation to the NCA on a quantitative basis. The demonstration of these mediators offers an explanation for the occurrence of local immediate and persistent wheals at sites of bee, wasp, and sea nettle stings in nonsensitized individuals.

Immunoreactive leukotrienes in nettle plants (Urtica urens)

In order to clarify the mechanisms of urtication after contact with stinging plants, nettle (Urtica urens) hair and whole-plant extracts were examined for the presence of leukotriene (LT) B4 and LTC4 by reverse phase high-pressure liquid chromatography (RP-HPLC) and radioimmunoassay (RIA) and for in vitro neutrophil chemotactic activity and histamine contents. Both hair and plant extracts contained high levels of LTB4 and LTC4 by RIA as well as histamine. The presence of LTB4 was supported by RP-HPLC elution profiles and by in vitro chemotaxis. Nettle hairs therefore resemble insect venoms and cutaneous mast cells with regard to their spectrum of mediators.

From eosinophil chemotactic factor of anaphylaxis to leukotriene B4--chemistry, biology and functional significance of eosinophil chemotactic leukotrienes in dermatology

The present paper examines evidence for the identity of low molecular weight eosinophil chemotactic factor (ECF) and of leukotriene B4 (LTB4) and its metabolites. Total congruity between the two entities is found regarding (1) cells of origin; (2) conditions for in vitro generation and pharmacological modulation; (3) physiochemical properties; (4) in vitro chemotaxis towards human monocytes, fibroblasts and guinea pig eosinophils; (5) in vivo activities in humans, and (6) occurrence of the factors in various dermatological diseases. Quantitative differences were observed only for in vitro neutrophil migration which may be due to neutrophil chemotactic mono-HETEs and possibly platelet activating factor in the ECF preparations. The name ECF should therefore be replaced by LTB4 and its metabolites, as has happened for SRS which is now called LTC4/D4.

Involvement of arachidonate-dependent lipid mediators and platelet-activating factor in experimental murine contact dermatitis

A 5-lipoxygenase inhibitor (5-LPI) and a platelet-activating factor antagonist (PAF-A) were studied in dinitrofluorobenzene (DNFB)-induced allergic and croton-oil-induced irritant murine contact dermatitis. Both inhibitors, at 1 and 5% concentrations, significantly reduced the ear swelling in allergic dermatitis while irritant dermatitis was far less affected. This suggests that 5-lipoxygenase-dependent mediators and PAF are involved in allergic contact dermatitis and that these mediators play only a minor role in irritant dermatitis.

Studies on the role of leukotrienes in murine allergic and irritant contact dermatitis

A specific peptidoleukotriene receptor antagonist, Ro 23-3544, was tested for its efficacy in modulating DNFB-induced allergic and croton oil-induced irritant contact dermatitis in mouse ears. Treatment shortly after elicitation of the dermatitis, and for up to 5 days thereafter, was moderately effective in suppressing DNFB-induced ear swelling in a dose-dependent fashion. Daily pre-treatment of the ears for 1 week caused a more marked reduction of DNFB-induced ear swelling during the first 48 h after elicitation. No reduction, but rather an increase in ear swelling was observed with croton oil-induced dermatitis. These results indicate that peptidoleukotrienes play a role in the early stages of elicitation of murine allergic, but not irritant contact dermatitis and that a specific receptor antagonist can only partially reverse the effect of peptidoleukotrienes once the dermatitis is established.

Comparison of the generation in vitro of chemotactically active LTB4 and its omega-metabolites by human neutrophils and lymphocytes/monocytes

To assess the relative contribution of different leucocyte subpopulations to LTB4 production, peripheral blood leucocytes from human donors were separated into polymorphonuclear neutrophils (PMN) and lymphocytes/monocytes (L/M) and were then stimulated in vitro with the Ca-ionophore A 23187 for different times. The supernatants were analysed for their contents of leukotriene B4 (LTB4) and its omega-metabolites by HPLC-analysis and column fractions were also examined for their chemotactic activities towards eosinophils in vitro. PMN supernatants contained greater quantities of LTB4, 20-OH-LTB4, 20-COOH-LTB4, and chemotactic activities than did L/M supernatants. On the other hand, the time dependent decrease of LTB4 and chemotactic activity and the increase of omega-metabolites were higher in PMN than in L/M. These results would correlate with the greater role of PMN in acute and that of monocytes in chronic inflammation.

Chemotaxis of human neutrophils and eosinophils towards leukotriene B4 and its 20-w-oxidation products in vitro

Peripheral blood neutrophils and eosinophils from 70 patients and controls were studied for their in vitro chemotactic and chemokinetic responses towards synthetic leukotriene B4 (LTB4), 20-OH-LTB4 and 20-COOH-LTB4. All three factors induced chemotaxis and chemokinesis of cells. 20-OH-LTB4 was always less and 20-COOH-LTB4 even less active than the parent compound. Cells from patients with atopic eczema and T cell lymphoma moved less than cells from normal controls or from patients with psoriasis. In the presence of LTB4, 20-OH-LTB4 and buffer alone, more eosinophils than neutrophils moved to the lower side of the filter, while this did not occur with platelet activating factor as chemoattractant. Studies of neutrophil and eosinophil chemotaxis in the presence of LTB4 should therefore always take into account a high variability of the quantitative response which is donor and disease dependent.

Production of LTB4-like chemotactic arachidonate metabolites from human keratinocytes

Keratinocytes have recently been recognized as a source of mediators of cellular immune function. We present here further data on the production of 5-lipoxygenase-dependent arachidonate metabolites from freshly isolated human epidermal cells. Stimulation of cells with arachidonic acid or the calcium ionophore A 23187 alone or together caused a dose- and time-dependent release of chemotactic activity which was maximal during the first 10 min and which continued for up to 18 h. Indomethacin (10(-6) M) enhanced and compound BW 755C (20 micrograms/ml), a lipoxygenase inhibitor, decreased release. The chemotactic activity was heat stable for 30 min at 56 degrees C and was extractable into ether at pH 3.0. Analysis of 15- and 30-min supernatants showed coelution of biologic activity and of leukotriene B4 (LTB4), as measured by radioimmunoassay, at marker positions of LTB4 and of 20-OH-LTB4. Elimination of Langerhans cells did not alter the secretion of chemotactic lipids, suggesting that keratinocytes are the main source of potent, biologically active, lipoxygenase-dependent arachidonate metabolites.

Generation of leukotrienes from normal epidermis and their demonstration in cutaneous disease

In order to evaluate the significance of chemotactic leukotrienes in cutaneous disease, synthetic leukotriene B4 and its metabolites were examined during in vitro chemotaxis. Leukotriene B4, and less so 20-OH-leukotriene B4, were chemotactic for neutrophils and eosinophils, with a preferential attraction of eosinophils. The responsiveness of human monocytes towards leukotriene B4 was relatively low. Normal cells and cells from different patients varied in their quantitative response. Cells from patients with eczema and T-cell lymphoma tended to migrate less than those from patients with other inflammatory diseases. Leukotrienes are generated from several types of peripheral leukocytes. In order to examine whether resident cells of the skin can also produce these factors, isolated human and murine epidermal cells were examined for their ability to generate leukotriene B4 and leukotriene C4 in vitro. Arachidonic acid, and less so the ionophore A 23187, induced the generation of both types of factors, based on the finding in the bioassay, reverse-phase high-pressure liquid chromatography and radioimmunoassays. The same factors were demonstrated by either or all of these methods in skin biopsies, scales, blisters or suction blisters of patients with psoriasis, pitysiasis rubra pilaris, dyshidrosis, bullous pemphigoid, pressure urticaria, urticaria pigmentosa and drug reactions, but not in Sézary syndrome nor in callus and skin biopsies of normal controls. These findings underline the fact that the leukotrienes are potent inflammatory mediators in diverse skin diseases, but that they are not limited to any specific disease. Furthermore, a relationship between leukotrienes and tissue eosinophilia does not exist.

Phototherapy of urticaria pigmentosa: clinical response and changes of cutaneous reactivity, histamine and chemotactic leukotrienes

Ten patients with moderate to very severe urticaria pigmentosa were studied for the therapeutic effect of photochemotherapy (PUVA; six adults) and selective ultraviolet phototherapy (SUP; four adolescents). Despite a high mean PUVA dosage (138.6 +/- 63.4 J/cm2), only two patients had a very good response, while three had a good response and one had a fair response. On the reduction of the frequency of treatments, the symptoms gradually recurred, and several months after the discontinuation of therapy, the clinical status had reached the level prior to PUVA. The results with SUP were even less encouraging. A number of biophysical and biochemical parameters of the skin were studied in five patients before PUVA treatment, immediately after several months of PUVA treatment and again 5 months after the discontinuation of PUVA treatment. Weal and erythema reactions to intracutaneous skin tests remained unchanged after PUVA, while wealing with topically applied dimethylsulfoxide (DMSO) decreased. Transepidermal water loss was markedly reduced over DMSO weals. Histamine levels, which were elevated in lesional but not in normal skin, dropped with PUVA treatment, but after the discontinuation of treatment, they increased again in the lesions. On reverse-phase high-performance liquid chromatography, two main chemotactic factors, leukotriene B4 and 5-HETE, were identified in lesional skin. Chemotactic activity was elevated in both lesional and uninvolved patient skin, reached normal levels at both sites after PUVA and maintained these low levels for several months after the discontinuation of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical, pharmacological and immunological aspects of delayed pressure urticaria

We studied the clinical features of thirty-two patients with delayed pressure urticaria, and special laboratory tests were performed in seven patients. Striking clinical features included a long duration of the disease (mean 6 years) and an elevated erythrocyte sedimentation rate in 71%, dermographism in 63% and a leukocytosis in 33% of the patients. There was prolongation of weals in response to histamine, compound 48/80, concanavalin A and NaCl. In some patients, histamine and chemotactic factor levels were increased in suction blisters over skin test and delayed pressure sites. In extracts from pressure weals, chemotactic activity was found for leukotriene B4, its 20-omega-oxidation products and mono-HETEs. Studies of peripheral blood leukocytes revealed significantly increased intracellular histamine levels and increased release of histamine, and a trend to increased release of chemotactic activity from stimulated cells. The response of leukocytes to mitogens was normal. We conclude that histamine plays a major role in the pathogenesis of PU. Arachidonate-derived chemotactic factors might account for the variably observed leukocytosis and the cellular infiltrate in lesions of pressure urticaria. Additional mediators must be involved in PU in order to explain the unique prolonged wealing response.

Identification of chemotactic lipoxygenase products of arachidonate metabolism in psoriatic skin

Skin biopsies and scale extracts from 22 patients with psoriasis were examined for the presence of chemotactic lipoxygenase products of arachidonate metabolism. Heat-stable leukocyte chemotactic activity in aqueous extracts of 2-mm punch biopsies from involved and uninvolved patient skin was significantly elevated, compared to healed psoriatic skin and to skin of normal controls. Ether extracts (pH 3.0) from 13 mg of psoriatic scales contained a mean chemotactic activity corresponding to that of leukotriene B4, 5 X 10(-8) M. On reverse phase high-pressure liquid chromatography, the main chemotactic lipids in scale extracts were leukotriene B4 and 5-HETE. Since lipoxygenase products are potent mediators of inflammation, they may play an important role in the evolution and maintenance of psoriatic lesions.