Microenvironmental network of clonal CXCL13+CD4+ T cells and Tregs in pemphigus chronic blisters.

BACKGROUNDPemphigus, a rare autoimmune bullous disease mediated by antidesmoglein autoantibodies, can be controlled with systemic medication like rituximab and high-dose systemic corticosteroids combined with immunosuppressants. However, some patients continue to experience chronically recurrent blisters in a specific area and require long-term maintenance systemic therapy.METHODSSkin with chronic blisters was obtained from patients with pemphigus. Immunologic properties of the skin were analyzed by immunofluorescence staining, bulk and single-cell RNA and TCR sequencing, and a highly multiplex imaging technique known as CO-Detection by indEXing (CODEX). Functional analyses were performed by flow cytometry and bulk RNA-Seq using peripheral blood from healthy donors. Intralesional corticosteroid was injected into patient skin, and changes in chronically recurrent blisters were observed.RESULTSWe demonstrated the presence of skin tertiary lymphoid structures (TLSs) with desmoglein-specific B cells in chronic blisters from patients with pemphigus. In the skin TLSs, CD4+ T cells predominantly produced CXCL13. These clonally expanded CXCL13+CD4+ T cells exhibited features of activated Th1-like cells and downregulated genes associated with T cell receptor-mediated signaling. Tregs are in direct contact with CXCL13+CD4+ memory T cells and increased CXCL13 production of CD4+ T cells through IL-2 consumption and TGF-ß stimulation. Finally, intralesional corticosteroid injection improved chronic blisters and reduced skin TLSs in patients with pemphigus.CONCLUSIONThrough this study we conclude that skin TLSs are associated with the persistence of chronically recurrent blisters in patients with pemphigus, and the microenvironmental network involving CXCL13+CD4+ T cells and Tregs within these structures plays an important role in CXCL13 production.TRIAL REGISTRATIONClinicalTrials.gov NCT04509570.FUNDINGThis work was supported by National Research Foundation of South Korea (NRF-2021R1C1C1007179) and Korea Drug Development Fund, which is funded by Ministry of Science and ICT; Ministry of Trade, Industry, and Energy; and Ministry of Health and Welfare (grant RS-2022-00165917).

Clinical impact and a prognostic marker of early rituximab treatment after rituximab reimbursement in Korean pemphigus patients.

Pemphigus is an autoimmune mucocutaneous blistering disease caused by autoantibodies against desmogleins. Rituximab effectively treats pemphigus by inducing remission and rapidly reducing corticosteroid dosage. In Korea, the high cost of rituximab had been a burden until the National Health Insurance began to cover 90% of rituximab costs via reimbursement for severe pemphigus patients. We analyzed 214 patients with pemphigus who were treated with their first round of rituximab. The time to initiate rituximab and the time to partial remission under minimal therapy (PRMT) were both significantly shorter after the rituximab reimbursement policy. The total steroid intake for PRMT and complete remission (CR) was less in patients who were diagnosed after the reimbursement. The interrupted time series (ITS) model, a novel analysis method to evaluate the effects of an intervention, showed a decrease in total systemic corticosteroid intake until PRMT after reimbursement began. In peripheral blood mononuclear cells from patients with pemphigus vulgaris, the relative frequencies of desmoglein 3-specific CD11c+CD27-IgD- atypical memory B cells positively correlated with the periods from disease onset to rituximab treatment and to PRMT and the total systemic corticosteroid intake until PRMT. We found that early rituximab therapy, induced by the reimbursement policy, shortened the disease course and reduced the total corticosteroid use by pemphigus patients. The decreased frequency of circulating desmoglein-specific atypical memory B cells can be used as a surrogate marker for a good prognosis after rituximab.

A Novel Method of Steroid Delivery to Improve the Efficacy of Intralesional Injection in Keloid Treatment.

BACKGROUND: Keloids are a chronic disease and cause pain, pruritus, and limitation of motion. Intralesional corticosteroid injection is the first-line treatment, but its effects can be limited, even with repeated injections. OBJECTIVE: To investigate the efficacy and safety of a tunneling method of corticosteroid injection compared with conventional intralesional injection. MATERIALS AND METHODS: A retrospective review was conducted of keloid patients treated with intralesional corticosteroid injection by conventional and tunneling methods. RESULTS: A total of 119 cases of keloid were included in the study. Among 78 patients treated with 20 mg/mL triamcinolone, the Investigators' Global Assessment effectiveness score and Observer Scar Assessment Scale (OSAS) score were significantly higher in the tunneling group than the conventional group at 1 month. At 6 months, the tunneling group showed significantly higher effectiveness in the OSAS score than the conventional group. In the tunneling group, the interval between treatments was significantly longer than in the conventional group. The occurrence of side effects was lower in the tunneling method group than in the conventional method group. CONCLUSION: This study reveals the benefits of the tunneling method over the conventional method for therapeutic effect and side effects in keloid treatment.

Immunopathology and Immunotherapy of Inflammatory Skin Diseases.

Recently, there have been impressive advancements in understanding of the immune mechanisms underlying cutaneous inflammatory diseases. To understand these diseases on a deeper level and clarify the therapeutic targets more precisely, numerous studies including in vitro experiments, animal models, and clinical trials have been conducted. This has resulted in a paradigm shift from non-specific suppression of the immune system to selective, targeted immunotherapies. These approaches target the molecular pathways and cytokines responsible for generating inflammatory conditions and reinforcing feedback mechanisms to aggravate inflammation. Among the numerous types of skin inflammation, psoriasis and atopic dermatitis (AD) are common chronic cutaneous inflammatory diseases. Psoriasis is a IL-17-mediated disease driven by IL-23, while AD is predominantly mediated by Th2 immunity. Autoimmune bullous diseases are autoantibody-mediated blistering disorders, including pemphigus and bullous pemphigoid. Alopecia areata is an organ-specific autoimmune disease mediated by CD8+ T-cells that targets hair follicles. This review will give an updated, comprehensive summary of the pathophysiology and immune mechanisms of inflammatory skin diseases. Moreover, the therapeutic potential of current and upcoming immunotherapies will be discussed.

Environmental and dietary exposure of perfluorooctanoic acid and perfluorooctanesulfonic acid in the Nakdong River, Korea.

This study performed the first environmental and dietary exposure assessment to explore plant uptake of perfluorooctanoic acid (PFOA) and perfluorooctanesulfonic acid (PFOS) from agricultural soil and irrigation water in the Nakdong River delta, South Korea. Annual average concentrations of total PFOA and PFOS ranged from 0.026 to 0.112 µg L-1 (irrigation water), and from 0.818 to 1.364 µg kg-1 (soil), respectively. PFOA and PFOS hotspots were identified downstream of the Nakdong River and were influenced by seasonal climatic variations. The observed average biennial concentration of the sum of PFOA and PFOS decreased in irrigation water, from 0.112 µg L-1 in 2013 to 0.026 µg L-1 in 2015, suggests that the 2013 Persistent Organic Pollutants Control Act may have helped to reduce levels of PFAS at this location. This study calculated some of the highest plant uptake factors reported to date, with values ranging from 0.962 in green onions to < 0.004 in plums. Leafy vegetables and rice are important components of the Korean diet; these groups had the largest contribution to the estimated dietary intake of PFOA and PFOS, which was calculated at 0.449 and 0.140 ng kg bw -1 day-1, respectively. This corresponded to 66.4% for PFOA and 7.9% for PFOS of the EFSA reference dose (RfD). The dietary intake of PFOA and PFOS from crops alone did not exceed the RfD. However, when the estimated daily intake (EDI) from other sources such as tap water, meat, fish, dairy, and beverages was included in the exposure risk assessment, both of the EDIs to PFOA and PFOS exceeded the RfDs, indicating that there may be a risk to human health. This study concludes that consumption of crops might, therefore, be a significant and underappreciated pathway for human exposure to PFAS.