Studying the effect of adding growth factors to the autologous melanocyte keratinocyte suspension in segmental vitiligo.

Addition of different growth factors to the medium used in autologous melanocyte-keratinocyte transplantation procedure (MKTP) was reported in the literature. The aim of the current study was comparison of response to MKTP in segmental vitiligo (SV) with and without adding growth factors to the suspension medium. Eighteen cases with SV were randomly divided into two groups. In group A: Ham F12 medium was used for suspension and in group B: 5 ng/mL recombinant basic fibroblast growth factor (bFGF) and 25 mg/500 mL 3'5' cyclic adenosine monophosphate (cAMP) were added to the medium. All cases received NB-UVB twice weekly for 24 weeks. The area of vitiligo lesions was measured before and after therapy by point-counting technique and complications were recorded. Excellent response (90%-100% repigmentation) occurred in 5/9 cases (56%) in group A and 7/9 cases (78%) in group B (with growth factors). A significant decrease in the area of treated lesions before and after therapy was found in both groups A and B (P = .0012 and .0004, respectively), however, a higher percentage of reduction in area of vitiligo was seen in group B cases (70% in group A vs 90% in group B; P value: .028). Marginal halo was seen in five cases in group A and six in group B. In conclusion addition of bFGF and cAMP to MKTP medium improved the results of the procedure. It could be considered if economically feasible.

Evaluation of the expression of the stromal cell-derived factor-1 alpha (CXCL 12) in psoriatic patients after treatment with Methotrexate.

BACKGROUND: CXCL12 has an important role in skin homeostasis and inflammation. OBJECTIVE: In this work, the expression of CXCL12 was evaluated in psoriasis vulgaris, psoriatic arthritis (PsA) patients in relation to disease activity and methotrexate (MTX) therapy. METHODS: Skin biopsies were obtained from 10 psoriasis vulgaris patients, 10 PsA patients, and 20 controls. The biopsies were repeated 6 weeks after MTX therapy. The biopsies were stained immunohistochemically by stromal dermal factor 1 alpha (CXCL 12) antibody. RESULTS: Psoriatic arthritis showed significantly more expression of CXCL 12 than psoriasis vulgaris patients before treatment but not after treatment. There was significant decrease in CXCL 12 expression in the keratinocytes of psoriasis vulgaris patients after MTX therapy than before treatment, P-value was 0.009. There was no significant difference between pre- and post-treatment in the CXCL 12 expression of keratinocytes of PsA patients, P-value was 0.093. The percentage decrease of PASI score after treatment showed a moderate correlation with the percentage decrease of CXCL12 expression of the keratinocytes of the total psoriasis patients, r = 0.484, P-value was 0.015. CONCLUSION: CXCL12 might be involved in the progression of psoriasis vulgaris to PsA. MTX therapy downregulated the expression of CXCL12 of the keratinocytes of psoriasis patients. This downregulation was paralleled by decrease in the PASI score. CXCL12 can be used as a biological marker of disease severity of psoriasis patients.

Effect of Procedural-Related Variables on Melanocyte-Keratinocyte Suspension Transplantation in Nonsegmental Stable Vitiligo: A Clinical and Immunocytochemical Study.

BACKGROUND: Melanocyte-keratinocyte suspension (M-K susp) is gaining popularity for vitiligo treatment. Few studies have addressed procedure-related variables. OBJECTIVE: To assess the effect of different M-K susp procedure-related variables on the clinical outcome in stable vitiligo. METHODS: This prospective multicenter comparative study included 40 cases with nonsegmental stable vitiligo. Donor site was either a skin graft in noncultured epidermal cell suspension (NCECS) or hair follicle units in outer root sheath hair follicle suspension (ORSHFS). Recipient site was prepared by either cryoblebbing or CO2 laser resurfacing. Cell counts and viability were recorded in the cell suspensions. Tissue melanocytes and keratinocytes were examined by melan-A and cytokeratin, respectively. Assessment of repigmentation was performed 18 months after the procedure. RESULTS: Thirty-seven subjects completed the study. Cell count was significantly lower in the ORSHFS compared with NCECS with no significant difference in the repigmentation outcome. On comparing techniques of recipient site preparation, homogenicity was better in the CO2 group. Elbows and knees responded better to CO2 resurfacing, whereas distal fingers responded better to combination of cryoblebbing with NCECS. CONCLUSION: Using different techniques in M-K susp produces comparable results. However, the distal fingers showed better results using combination of donor NCECS and recipient cryoblebs.

Cathelicidin (LL-37) level in the scalp hair of patients with tinea capitis.

Antimicrobial peptides (AMPs) are considered an important first line of defense against pathogens. Cathelicidin LL-37 was upregulated in response to fungal infection. In this work we aimed to evaluate cathelicidin LL-37 in the hair of tinea capitis and compare it to normal controls. Hair samples were collected from 30 children and 30 controls aged from 2 to10 years old, and the level of cathelicidin LL-37 in the hair was detected by quantitative real-time PCR. The 30 patients were further subdivided into three subgroups according to their clinical type. Ten patients were scaly type, 10 patients were black dots type, and 10 patients were kerion type. Cathelicidin level in patients ranged from 6.0 to 17.5 with mean ± SD (11.3 ± 2.3) and in control ranged from 1.02 to 6.2, with mean ± SD (2.8 ± 1.5). There was a significant difference between the patients and controls regarding the cathelicidin level; P value was 0. The mean cathelicidin level was lowest in the kerion type10.73 ± 2.6 and highest in the black dot type 12.05 ± 2.76. However, there was no significant difference between the cathelicidin level of the different clinical types of tinea capitis; P value was 0.58. In conclusion, the level of cathelicidin LL-37 in hair specimens of human tinea capitis was significantly higher than controls.

Dermoscopy could be useful in differentiating sarcoidosis from necrobiotic granulomas even after treatment with systemic steroids.

BACKGROUND: Diagnosing cutaneous sarcoidosis and necrobiotic granulomas is challenging. OBJECTIVE: Assessing the value of dermoscopy in differentiating cutaneous sarcoidosis from necrobiotic granulomas and evaluating whether their dermoscopic features will be altered after treatment. METHODS: Nineteen cutaneous sarcoidosis and 11 necrobiotic granuloma patients (2 necrobiosis lipoidica, 4 granuloma annulare and 5 rheumatoid nodule) were included in this study. The diagnosis was confirmed by skin biopsy. The lesions were examined using non-contact polarized dermoscope (Dermlite 2 HR-Pro; 3Gen, San Juan Capistrano, CA). RESULTS: Ten out of 19 cutaneous sarcoidosis patients and 7/11 necrobiotic cases group were receiving treatments (topical, intralesional or systemic steroids ± chloroquine) but still have cutaneous lesions. Treatment duration in the sarcoidosis group ranged from 2 months to 10 years (median 3 years) and in the necrobiotic cases group ranged from 3 months to 16 years (median 2 years). Pink homogenous background, translucent orange areas, white scar-like depigmentation and fine white scales were significantly associated with the cutaneous sarcoidosis compared to necrobiotic cases group. On the other hand mixed pink, white and yellowish background was significantly associated with the necrobiotic cases group. No significant difference in the dermoscopic findings was detected between treated and non-treated patients. CONCLUSION: Some dermoscopic findings are shared between the cutaneous sarcoidosis group and the necrobiotic cases group, yet dermoscopy could be a useful aid in differentiating them even after treatment.

Assessment of tissue levels of dickkopf-1 in androgenetic alopecia and alopecia areata.

BACKGROUND: Androgenetic alopecia (AGA) is the commonest form of hair loss in men. Alopecia areata (AA) is an organ-specific autoimmune disease. Studies revealed that Dickkopf 1 (DKK-1), a powerful suppressor of the Wnt/ß-catenin signaling pathway, induced anagen-to-catagen transition in mice. Moreover, in vitro studies suggested that DKK-1 played a role in dihydrotestosterone (DHT)-induced balding. AIM: To evaluate the tissue levels of DKK-1 in patients with AGA and AA, to assess its possible role as a pathogenetic mechanism in both disorders. METHODS: This study included 24 patients with AGA, 31 patients with AA, and 33 healthy controls. Scalp biopsies were taken from all participants for the detection of tissue DKK-1 levels. RESULTS: Tissue DKK-1 levels were significantly higher in patients with AGA than in controls (P = 0.000) as well as in patients with AA than in controls (P = 0.001). In addition, they were significantly higher in patients with AGA than in patients with AA (P = 0.000). DKK-1 was higher in male than in female patients with AGA. DKK-1 was negatively correlated with disease duration in AGA. CONCLUSION: In conclusion, this study suggests an important role for DKK-1 in the pathogenesis of AGA and AA through documenting higher tissue DKK-1 levels in patients with both hair disorders compared to controls and suggests that DKK-1 may be a promising therapeutic target for these hair diseases.

Low pathogenicity of anti-desmoglein 3 immunoglobulin G autoantibodies contributes to the atypical clinical phenotypes in pemphigus.

The clinical phenotypes of pemphigus can be explained by the desmoglein (Dsg) compensation theory. However, some atypical cases such as cutaneous pemphigus vulgaris (cPV), in which patients have anti-Dsg3 antibodies without oral erosions, do not conform to this theory. To explain the discrepancy between clinical phenotypes and anti-Dsg antibody profiles, the pathogenic strength of immunoglobulin (Ig)G autoantibodies against Dsg3 must be taken into consideration. We analyzed the epitopes and blister-inducing pathogenic strength of the sera from three patients having IgG against Dsg3 without oral erosions with domain-swapped recombinant proteins and dissociation assay using cultured normal human epidermal keratinocytes. The results showed that all sera contained IgG directed against the amino terminal EC1 domain of Dsg3, as is found in most PV sera. However, dissociation assays revealed that the pathogenic strength of the anti-Dsg3 antibodies in all three cases was extremely lower than that of typical PV cases with mucosal involvement. In conclusion, when anti-Dsg3 IgG antibodies are not sufficient to inhibit the expression of Dsg3 in the oral mucosa, but can inhibit the expression in the skin, skin blisters can result. Therefore, the pathogenicity of anti-Dsg3 antibodies should be regarded as a key factor contributing to the clinical phenotype in pemphigus patients with conflicting antibody profiles.

Pemphigus in the Arab world.

The Arab world lies geographically between the Atlantic coasts of northern Africa and the Arabian Gulf. This area has wide latitudinal differences as well as variable environmental conditions ranging from deserts to forests. Approximately 370 million individuals who share the Arabic language live in this area. Pemphigus vulgaris (PV) and pemphigus foliaceus (PF) are the main subtypes of the pemphigus disease. Both pemphigus subtypes are present in many Arab countries; however, there is variation in the predominant subtype among countries. PV is the most common subtype in Egypt, Sudan, Morocco, Syria, Kuwait, Saudi Arabia and Yemen. On the other hand, PF is more prevalent in Libya and is endemic in Tunisia. Interestingly, there is variation in the dominant subtype in some cities within Morocco. For example, PF is more common in Marrakech which is the second largest city. The presence of anti-desmoglein 1 antibodies in the sera of normal Tunisians and the presence of anti-desmoglein 3 in normal Egyptians' sera suggested that environmental factors played a role in the disease pathogenesis in those areas. Further researches detected that traditional cosmetics were among the risk factors in Tunisia. Moreover, farming was suggested as a risk factor in Egypt, Tunisia and Sudan. Because there is no consensus for pemphigus treatment among the Arab countries, there is diversity in their pemphigus treatment regimens. Studying the demographic characteristics and the environmental conditions which caused the variations in the prevailing clinical phenotype will help us fill the gaps to understand the pathogenesis of the pemphigus disease.

Do normal Egyptians possess anti-desmoglein 3 antibodies?

BACKGROUND: Pemphigus is a group of autoimmune blistering diseases targeting the cell-cell adhesion molecules, desmogleins (Dsgs). Anti-Dsg antibodies, the hallmark of the disease, were not detected in normal individuals in many populations. In spite of the rarity of pemphigus vulgaris (PV) disease in many parts of the world, PV is not rare in Egypt. The purpose of the present study is to investigate the presence of anti-Dsg3 antibodies in normal Egyptians aiming to determine the reason for the increase in number of patients in Egypt with pemphigus. METHODS: Anti-Dsg3 antibodies were evaluated in 200 normal human sera, 20 first-degree relatives with PV in comparison with 10 patients with PV as controls using the enzyme-linked immunosorbent assay technique. RESULTS: Fourteen of 200 (7%) normal individuals and two of 20 (10%) first-degree relatives with PV had anti-Dsg3 antibodies using enzyme-linked immunosorbent assay technique, and 11 of 16 were still positive after confirmation by indirect immunofluorescence. The sera were positive for IgG1, IgG3, and IgG4 subclasses. The presence of IgG4 subclass in normal individuals is suggestive that they may be in the preclinical stage and therefore are at higher risk to develop the PV disease. CONCLUSION: The study proved the presence of anti-Dsg3 antibodies in normal Egyptians with significant relation to some environmental factors. Follow-up of those individuals is necessary to determine who will develop the disease and the triggering factors.

Anti-type VII collagen autoantibodies, detected by enzyme-linked immunosorbent assay, fluctuate in parallel with clinical severity in patients with epidermolysis bullosa acquisita.

Epidermolysis bullosa acquisita (EBA) is an autoimmune subepidermal blistering disease caused by autoantibodies against type VII collagen. An enzyme-linked immunosorbent assay (ELISA) is currently available to detect autoantibodies in EBA. There have been reports suggesting generically that ELISA indices reflect EBA disease severity; however, there is, as yet, no conclusion as to whether ELISA indices fluctuate with disease activity over time in each EBA patient. This study aimed to investigate whether ELISA titers fluctuate with EBA disease activity and to validate the clinical significance of checking ELISA values in EBA by monitoring type VII collagen ELISA titers and disease severity, evaluated in terms of numbers of blisters and erosions as a clinical score, over time in three Japanese patients with EBA. All three cases in this study, which were treated successfully, showed titers of anti-type VII collagen autoantibodies detected by ELISA that fluctuated in parallel with disease activity. Especially in case 1, we could determine that the expanding erosions were not due to flare-ups of EBA because the ELISA indices stayed low, although new lesions continued to appear. In fact, control of infection and nutrition helped the lesions to become epithelialized. In conclusion, we found that repeated ELISA measurements are useful in monitoring disease activity and making decisions in EBA treatment plans.

Pathogenic anti-desmoglein 3 mAbs cloned from a paraneoplastic pemphigus patient by phage display.

Paraneoplastic pemphigus (PNP) is an autoimmune blistering disease associated with lymphoproliferative neoplasms and characterized by antibodies against plakins and desmoglein 3 (Dsg3). Anti-Dsg3 antibodies have a primary role in blister formation in PNP. In this study, we used phage display to clone monoclonal anti-Dsg3 antibodies from a PNP patient to further characterize their pathogenicity. We isolated 20 unique Dsg3-reactive mAbs, which we classified into four groups according to the heavy-chain complementarity-determining region 3 (CDR3) region. Genetic analyses demonstrated that three antibody groups used the VH1-46 gene (18 clones) and one group used the VH1-02 gene (2 clones). The results of an in vitro keratinocyte dissociation assay and a human skin organ culture injection assay showed that three antibodies displayed pathogenic activity in blister formation with different potencies. Epitope mapping using domain-swapped Dsg3/Dsg2 showed that these pathogenic mAbs bound Ca(2+)-dependent conformational epitopes in the middle portion of the extracellular region of Dsg3 (EC2 and EC3 domains), in contrast to most previously characterized pathogenic pemphigus vulgaris antibodies, which bound to the EC1 domain of Dsg3. These mAbs reflect the unique polyclonal nature of anti-Dsg3 antibodies in PNP and represent an important tool for detailing the pathophysiological mechanisms of blister formation in PNP.