Characterization of Amino Acid Substitutions and Deletions in Kindlin-1 FERM Domain: Relevance for Precision Medicine.

Kindler epidermolysis bullosa is a genodermatosis that manifests with cutaneous and mucosal fragility and with photosensitivity. No cure is available to date. Kindlin-1, a deficient protein, binds to ß-integrin and is required for its activation. Using a previously established experimental workflow, we addressed the consequences of three naturally occurring pathogenic variants, leading either to single amino acid substitutions p.Y293D and p.W559R or to a single amino acid deletion p.I623del in kindlin-1. We show that p.Y293D disrupts kindlin-1 localization to focal adhesions and cell spreading. Although treatment with a chemical chaperone increases the amount of mutant protein, spreading does not improve, and cellular stress increases, whereas the variants p.W559R and p.I623del do not interfere with kindlin-1 localization to focal adhesions and support cell adhesion and survival. These mutants are also responsive to the treatment with a chemical chaperone, and the increased mutant proteins improve cell spreading. These findings suggest that low levels of mutant kindlins p.W559R and p.I623del are able to rescue some important cellular functions. Patients carrying these mutations could benefit from treatment with promotors of proteostasis. Our results show that each pathogenic variant must be individually tested on genetic, molecular, and cellular levels to tailor personalized treatments for patients.

Initial validation of the epidermolysis bullosa-specific module of the Infants and Toddlers Dermatology Quality of Life questionnaire.

Children with epidermolysis bullosa (EB) experienced the highest quality of life impact among several skin conditions and have problems which had not been reported by parents of children with other skin diseases. The EB-specific module of the Infants and Toddlers Dermatology Quality of Life (InToDermQoL) questionnaire was recently developed to measure the impact of disease-specific aspects in children from birth to the age of 4 years. The aim of this study was initial validation of the InToDermQoL-EB questionnaire. Parents of 44 children with EB from seven countries completed the InToDermQoL-EB questionnaire. Cronbach's alpha was .86, .89 and .91 for three age-specific versions. Differences between severity levels were all significant except for that between moderate and severe level in the version for 3- to 4-year-old children. All items of the three versions of the InToDermQoL-EB showed very high levels of relevance except "problems with defecation" in children younger than 1 year and "rejection by other children" in 3- to 4-year-old children. The three versions of the InToDermQoL-EB instrument showed good internal consistency and discriminated well between different severity levels. All InToDermQoL-EB items were confirmed as being of high relevance and the questionnaire may be used in practice and clinical trials.

Activography reveals aberrant proteolysis in desquamating diseases of differing backgrounds.

The role of epidermal proteolysis in overdesquamation was revealed in Netherton syndrome, a rare ichthyosis due to genetic deficiency of the LEKTI inhibitor of serine proteases. Recently, we developed activography, a new histochemical method, to spatially localize and semiquantitatively assess proteolytic activities using activity-based probes. Activography provides specificity and versatility compared to in situ zymography, the only available method to determine enzymatic activities in tissue biopsies. Here, activography was validated in skin biopsies obtained from an array of distinct disorders and compared with in situ zymography. Activography provides a methodological advancement due to its simplicity and specificity and can be readily adapted as a routine diagnostic assay. Interestingly, the levels of epidermal proteolysis correlated with the degree of desquamation independent of skin pathology. Thus, deregulated epidermal proteolysis likely represents a universal mechanism underlying aberrant desquamation.

Successful management of cryopyrin-associated periodic syndrome with canakinumab in infancy.

Neonatal onset multisystem inflammatory disease (NOMID)/chronic infantile neurologic cutaneous and articular (CINCA) syndrome is a rare, early-onset autoinflammatory disorder and the most severe form of cryopyrin-associated periodic syndrome, which is associated with overproduction of interleukin (IL)-1ß. This is a case report of a 70-day-old boy, who was diagnosed with NOMID/CINCA syndrome and who has been treated with anti-IL-1ß monoclonal antibody (canakinumab) since then, despite his early infancy. The patient presented with fever, aseptic meningitis, and rash. The clinical manifestations combined with the elevated acute-phase reactants strengthened the suspicion of the diagnosis of NOMID/CINCA syndrome. Specific immunologic workup revealed high levels of serum amyloid A and IL-6. The clinical diagnosis was confirmed by the detection of a de novo mutation of the CIAS1/NLR3 gene (p.Thr348Met), and canakinumab was started at a dose of 4 mg/kg, higher than the recommended dose for older age. White blood cell, serum amyloid A, C-reactive protein, and IL-6 levels quickly decreased and became normal within a month, and the clinical condition of the patient improved significantly. The infant remains without recurrence of disease or further complications and with satisfactory mental development with anti-IL-1ß monoclonal antibody treatment for >2 years. This report indicates the importance of early diagnosis of NOMID/CINCA syndrome and medication with IL-1 blockers as soon as possible for the improvement of the prognosis of cryopyrin-associated periodic syndrome and of a better patient outcome.

Targeting epidermal lipids for treatment of Mendelian disorders of cornification.

BACKGROUND: Inherited ichthyoses or Mendelian disorders of cornification (MeDOC) are clinically heterogeneous disorders with high unmet therapeutic needs, which are characterized by skin hyperkeratosis and scaling. Some MeDOC types are associated with defects of the epidermal lipid metabolism, resulting in perturbed barrier permeability and subsequent epidermal hyperplasia, hyperkeratosis and inflammation. An example is the CHILD (congenital hemidysplasia with ichthyosiform nevus and limb defects) syndrome, an X-linked dominant multisystem MeDOC caused by mutations in the NSDHL (NAD(P)H steroid dehydrogenase-like protein) gene, which is involved in the distal cholesterol biosynthetic pathway. The skin manifestations of the CHILD syndrome have been attributed to two major mechanisms: deficiency of cholesterol, probably influencing the proper corneocyte membrane formation, and toxic accumulation of aberrant steroid precursors. METHODS: Here we addressed the efficacy of an ointment containing cholesterol and simvastatin, an agent inhibiting endogenous cholesterol synthesis in a compassionate-use treatment of three patients with CHILD syndrome. To test the specificity of this therapeutic approach, we applied the same topical treatment to two patients with other types of MeDOC with disturbed skin lipid metabolism. RESULTS: The therapy with simvastatin and cholesterol was highly effective and well-tolerated by the CHILD syndrome patients; only lesions in the body folds represented a therapeutic challenge. No improvement was noted in the patients with other types of MeDOC. CONCLUSIONS: This therapy is inexpensive and accessible to every patient with CHILD syndrome, because both simvastatin and cholesterol are available worldwide. Our data provide initial evidence of the specificity of the therapeutic effect of the simvastatin-cholesterol ointment in CHILD syndrome in comparison to other types of MeDOC.

Clinical expression and new SPINK5 splicing defects in Netherton syndrome: unmasking a frequent founder synonymous mutation and unconventional intronic mutations.

Netherton syndrome (NS) is a severe skin disease caused by loss-of-function mutations in SPINK5 (serine protease inhibitor Kazal-type 5) encoding the serine protease inhibitor LEKTI (lympho-epithelial Kazal type-related inhibitor). Here, we disclose new SPINK5 defects in 12 patients, who presented a clinical triad suggestive of NS with variations in inter- and intra-familial disease expression. We identified a new and frequent synonymous mutation c.891C>T (p.Cys297Cys) in exon 11 of the 12 NS patients. This mutation disrupts an exonic splicing enhancer sequence and causes out-of-frame skipping of exon 11. Haplotype analysis indicates that this mutation is a founder mutation in Greece. Two other new deep intronic mutations, c.283-12T>A in intron 4 and c.1820+53G>A in intron 19, induced partial intronic sequence retention. A new nonsense c.2557C>T (p.Arg853X) mutation was also identified. All mutations led to a premature termination codon resulting in no detectable LEKTI on skin sections. Two patients with deep intronic mutations showed residual LEKTI fragments in cultured keratinocytes. These fragments retained some functional activity, and could therefore, together with other determinants, contribute to modulate the disease phenotype. This new founder mutation, the most frequent mutation described in European populations so far, and these unusual intronic mutations, widen the clinical and molecular spectrum of NS and offer new diagnostic perspectives for NS patients.

Condylomata acuminata in children.

We describe a study on 38 children from 1 to 11 years of age, with anogenital warts, 25 were girls. The disease was primarily perianal. Sexual abuse was confirmed in one 9-year-old boy. Most responded to monotherapy with podophyllotoxin, imiquimod 5%, or cryotherapy in a 3-month follow-up period.

A rare case of neonatal systemic xanthogranulomatosis with severe hepatic disease and metachronous skin involvement.

Juvenile xanthogranuloma (JXG) is a rare benign disorder of unknown pathogenesis, usually a self-limited condition. Extracutaneous systematic involvement is infrequent. We report one of the few documented cases of congenital systemic JXG, presenting with fever, jaundice, hepatosplenomegaly, ascites, pancytopenia, and delayed skin involvement. Liver biopsy established the diagnosis and JXG was not demonstrated in the bone marrow. Rapid deterioration of liver disease and pancytopenia, prompted us to administer immunosuppressive treatment (Langerhans cell histiocytosis-II Protocol). The patient's clinical condition improved and visceral and skin lesions showed gradual involution. The patient is still free of disease 4 years after the initial presentation.

Cases of Tinea capitis due to pale isolates of Trichophyton violaceum (Trichophyton glabrum) in South-East Europe. A challenge to the clinical laboratory.

Two recent indigenous cases of tinea capitis in children due to pale isolates of Trichophyton violaceum are reported herein for the first time from South-East Europe (Greece). Pale isolates of Trichophyton violaceum, reported in the past as Trichophyton glabrum, are thus far sporadically reported only from African or Asian countries. The cases reported herein raise the awareness of its existence in the community, assigning special importance to its accurate identification in the clinical laboratory.

Parental attitudes towards head lice infestation in Greece.

BACKGROUND: Pediculosis capitis constitutes a growing problem worldwide and is usually considered as an inconvenience. Parents often handle this infestation on their own initiative. OBJECTIVE: We conducted a survey in order to depict the parental attitudes towards head lice infestation in Greece. METHODS: Parents of children aged 3-14 years, attending a dermatology outpatient clinic at a children's hospital, were given a questionnaire regarding head lice. Demographic data, management, and prevention strategies were included in the questionnaire. RESULTS: Three-hundred and seventy-two complete questionnaires were analyzed (response rate: 89%). Pediculosis capitis was more prevalent in the age groups 3-5 years and 6-8 years. The percentage of parents of infested children who sought advice on treatment from the pharmacist was 73%, and only 15% consulted their doctor. Chemical agents to treat head lice were used by 59% of them, products containing natural oils by 38%, and wet combing in parallel was employed by 79% of them. Preventive measures were employed by 66% of the respondents, and 54% applied botanical and synthetic products commercially available for this purpose. CONCLUSION: There is a trend towards the use of natural oils for either prevention or treatment. More needs to be done to promote public education and rational use of either pediculicides or non-pharmacological agents for pediculosis capitis infestation.

Incontinentia pigmenti revisited. A novel nonsense mutation of the IKBKG gene.

AIM: To describe and evaluate the clinical and molecular findings of patients with incontinentia pigmenti (IP) in Greece. METHODS: We examined 12 female patients, initially aged 2 weeks to 7 months with clinical diagnosis of IP. Standard tests were performed including skin biopsies and ocular, dental and neurologic examinations. Molecular analysis was carried out on 8 out of 12 cases. RESULTS: The initial clinical examination was stage 1 (vesicular lesions), stage 2 (verrucous lesions) or stage 3 (hyperpigmented linear lesions of the trunk/limbs). At the final clinical examination, 10 of our patients had typical vesicular, verrucous or mixed hyper-hypopigmented skin lesions which had persisted from the neonatal period; seven had delayed dentition or conical teeth; two had developmental delay; one had microcephaly and strabismus and two had scarring alopecia. In seven patients, deletion of exons 4-10 of the IKBKG gene was found. In one patient, skewed X-inactivation was demonstrated and a novel mutation p.Gln332X was found. The mothers' DNA analyses were all normal. CONCLUSION: In our sample, all the cases were sporadic and the diagnosis of IP was based mainly on clinical features and confirmed with skin histology. Molecular analysis was used to find the mutations, in some cases to confirm diagnosis and to identify the carriers, which are crucial for prenatal and preimplantation diagnosis.

Histological and immunohistochemical study of granuloma annulare and subcutaneous granuloma annulare in children.

BACKGROUND: The aim of this study was to investigate the histological and immunohistochemical features of granuloma annulare (GA) in comparison to deep granuloma annulare (DGA) and granulomatous dermatoses (GDs). METHODS: Our material comprised 13 GA, 8 DGA and 1 atypical granuloma annulare (AGA) in a child with primary immunodeficiency, 10 cases of nonspecific GDs and 1 case of sarcoidosis with cutaneous involvement. The immunohistochemical streptavidin-biotin-Horseradish peroxidase (HRP) analysis was performed on paraffin sections for the detection of CD68/KP-1, CD68/anti-human CD68 clone PGM1 (PGM1), lysozyme, S-100 protein, CD1a, CD3, CD20/L-26, CD4 and CD8. RESULTS: All 13 GA were characterized by typical palisading and interstitial granulomas. In 6 cases, the lesion extended to the subcutaneous fat, while a considerable perivascular lymphocytic infiltrate without any signs of vasculitis was observed in 10 cases. The DGA were located to the deep dermis and subcutaneous fat, showing palisading granulomas with central necrobiosis. Immunohistochemistry revealed a broad intense expression of CD68/PGM1 in the histiocytic population in all cases, a constant but fainter detection of CD68/KP-1 and a variable one of lysozyme. T-cell markers (CD3, CD4 and CD8) were mainly detected in the perivascular lymphocytic infiltrate of GA and DGA, with CD4+ T lymphocytes predominating over CD8+ in GA and DGA, while CD8+ T lymphocytes was the predominant population in AGA. CONCLUSIONS: CD68/PGM1 is a sensitive and reliable histiocytic marker in confirming the histiocytic nature of equivocal GA and DGA, but the histiocytic immunoprofile is of no particular usefulness in differentiating GA from other GD.