Cholesteatoma: a morphologic study of stratum corneum lipids.

Two different lipid-retaining fixation techniques permitted electron microscopic visualization of both intra- and extracellular lipids in cholesteatoma epithelium obtained from 25 patients. An increased number of intracellular lipid-containing Odland bodies was demonstrated, with a maximum in the basal layer of the stratum granulosum, while the superior layer contained substantially fewer organelles than are found in normal skin. At the stratum granulosum/stratum corneum interface lipids secreted from Odland bodies were found in sac-like invaginations along the cell membrane but premature exocytosis was also frequently observed. In the intercellular spaces of the stratum corneum, multiple long sheets of lamellar structures interrupted by slits or pores enclosed the keratinized corneocytes. The intercellular spaces seemed narrow and an extracellular barrier was not found until well above the stratum granulosum/stratum corneum interface. A similar distribution of Odland bodies and structure of intercellular lipids can occur in several dermatoses, where the formation and maintenance of the cutaneous permeability barrier are defective.

Diagnostic value of PCR for detection of Borrelia burgdorferi DNA in clinical specimens from patients with erythema migrans and Lyme neuroborreliosis.

BACKGROUND: The aim of the study is to evaluate the diagnostic sensitivity of a 16S ribosomal RNA-based PCR on clinical specimens from patients with erythema migrans (EM) and neuroborreliosis and to compare the sensitivities with those obtained by in vitro culture and serological testing. A semiquantitative detection system, representing the input amount of specific DNA and thus the density of spirochetes in clinical specimens, indicated the preferred clinical sample to obtain for PCR testing. METHODS AND RESULTS: Skin biopsy and urine samples from 31 patients with EM and cerebrospinal fluid (CSF) and urine samples from 30 patients with neuroborreliosis were investigated. Borrelia burgdorferi DNA was detected in 71% of the skin biopsy specimens and 13% of the urine samples from patients with EM. Forty-one percent of the patients with EM were found to have B burgdorferi-specific antibodies in serum, and B burgdorferi was cultured in 29% of the EM specimens. For patients with neuroborreliosis, the diagnostic sensitivities in CSF and urine samples were 17% and 7%, respectively. Specific intrathecal antibody production was found in 90% of the patients, and 87% showed elevated B burgdorferi antibodies in serum. In general, PCR of skin biopsy samples yielded very high amounts of amplicons versus low amounts for CSF and urine samples. CONCLUSIONS: PCR of skin biopsy specimens is currently the most sensitive and specific test for the diagnosis of patients with EM, superior to culture and serological testing. For B burgdorferi-specific CSF disgnosis in patients with neuroborreliosis, the measurement of specific intrathecal antibody synthesis is superior to PCR. However, in patients with a short duration of disease (<14 days), PCR may be a useful diagnostic supplement. PCR of urine samples cannot be recommended at the present time for routine diagnosis of patients with EM or neuroborreliosis.

Stratum corneum barrier lipids in cholesteatoma.

Specimens from primary cholesteatomas were examined under the electron microscope using a lipid-retaining method that is best suited for intracellular lipids and a method that is best for intercellular lipids. In the stratum granulosum of the squamous epithelium, a large number of Odland bodies emerged. When the corneocyte reaches the transitional stage to the stratum corneum, the Odland bodies accumulate near the cell membrane and discharge their contents of lipid and enzymes. The lipids are reorganized into multiple long sheets of lamellar structures that embrace the keratinized corneocytes, as seen in the formation and maintenance of the cutaneous permeability barrier. In this study we draw the attention to the facts that the cholesteatoma epithelium is capable of producing not only cholesterol, but also several lipids, and that the lipid molecules are organized in multilamellar structures in the intercellular space. In theory, the failure to desquamate seen in cholesteatomas could be caused by partial or total failure of Odland body delivery to the intercellular region, or to local breakdown of the permeability barrier.

Long-term serological follow-up of patients treated for chronic cutaneous borreliosis or culture-positive erythema migrans.

The kinetics of antibodies to Borrelia burgdorferi following successful treatment of early and late cutaneous borreliosis were analysed in consecutive serum samples by an enzyme-linked immunosorbent assay (ELISA) technique. Twenty-three patients with culture positive erythema migrans were followed for 23+/-14 months: 41% stayed seronegative, 35% showed an isolated immunoglobulin M (IgM) response, 8% an isolated IgG response and 16% a combined IgM and IgG responses. In general, antibody levels peaked within the first 3 months of symptom onset, whereafter a gradual decline was observed within 1 year. Twenty-two patients with chronic cutaneous borreliosis were followed for 23+/-11 months and all patients stayed IgG positive. Nearly three-quarters showed a clear decline in IgG levels over the years, while the rest did not. After 9+/-1 years 88% of 16 patients examined were still IgG positive. In conclusion, treatment of erythema migrans should be initiated on clinical appearance as a substantial number of patients stayed seronegative. Treatment success may in part be monitored serologically for both seropositive erythema migrans and chronic cutaneous borreliosis as most patients show declining titres after successful treatment. However, continuously high titres do not necessarily indicate treatment failure.

Oral iloprost in Raynaud's phenomenon secondary to systemic sclerosis: a multicentre, placebo-controlled, dose-comparison study.

OBJECTIVE: To identify the optimal dose of oral iloprost on the basis of efficacy and tolerability in patients with Raynaud's phenomenon secondary to systemic sclerosis. DESIGN: Multicentre, randomized, parallel-group comparison of two different doses of oral iloprost and placebo. SETTING: European university hospitals. PATIENTS: A total of 103 patients with Raynaud's phenomenon secondary to systemic sclerosis. INTERVENTION: Patients received one of three treatments for 6 weeks: placebo, oral iloprost 50 microg or oral iloprost 100 microg. Each treatment was taken twice daily, giving total daily doses of iloprost of 100 and 200 microg. MEASUREMENTS: The frequency, total daily duration and severity of Raynaud's attacks were recorded in a specially designed patient diary; physician's global assessment and adverse events were recorded at visits to the clinic. Analysis was performed on an intention-to-treat population. RESULTS: A total of 103 patients were recruited, 89 completed the assessments throughout the treatment period and 82 completed an additional 6 weeks of follow-up after treatment. Thirty-five patients received placebo, 33 received iloprost 50 microg and 35 received iloprost 100 microg. The mean percentage reductions in the frequency, total daily duration and severity of Raynaud's attacks were numerically greater in the iloprost groups at the end of treatment and at the end of follow-up. At the end of treatment (6 weeks), there were significant treatment differences in the total daily duration of attacks (P = 0.03), but not in the severity (P = 0.07) or the frequency of attacks (P = 0.37). At the end of follow-up (12 weeks), there were significant treatment differences in the total daily duration of attacks (P = 0.001) and in the severity of attacks (P = 0.007), but not in the frequency of attacks (P = 0.07). Percentages of patients improved at the end of treatment as assessed by the physician were 44% placebo, 57% iloprost 50 microg and 64% iloprost 100 microg (not significant). Side-effects were reported by 80% of patients on placebo, 85% on oral iloprost 50 microg and 97% on oral iloprost 100 microg. Premature discontinuations of treatment in each group were 9, 30 and 51%, respectively, with 6, 27 and 51% being due to adverse events. CONCLUSION: The results on the daily duration of Raynaud's attacks suggest that both 50 and 100 microg oral iloprost twice daily may be effective in the treatment of Raynaud's phenomenon secondary to systemic sclerosis. The 50 microg iloprost dose was better tolerated in this patient group.

Occupational skin diseases: reliability and utility of the data in the various registers; the course from notification to compensation and the costs. A case study from Denmark.

Occupational diseases affect many people and may have serious social and economic consequences. In 1984, the National Labour Inspection Service established the Register of Occupational Diseases (ROD). The purpose of the central register was to provide information about injury-causing factors and risk groups, etc., changes in risk factors (ongoing monitoring and warning system), and to document the effects of preventive activities. However, we are dealing with several uncertain factors (i.e., whether the number of notified cases is too high or too low), and although the ROD contains a lot of information, it basically represents only notified (suspected) cases, until otherwise proven. Therefore, the utility and reliability of the data in the ROD may be questionable. The National Board of Industrial Injuries and the insurance companies represent recognized and compensated (genuine) cases, but their registers in general contain little information on variables. Thus, it is difficult to obtain exact information of occupational diseases (i.e., the real frequency and causes). What is known, is the number of cases that are notified, recognized and compensated, and the costs. Clearly, the higher the frequency of recognition, the more representative the data in the ROD of the recognized (genuine) cases. Therefore, the course from notification to recognition, and from recognition to compensation was calculated, and, for each step, the importance of skin diseases was considered. Only in the case of skin diseases, was the frequency of recognition high (2/3), and the data in the ROD were considered in more detail, and, where possible, compared with recognized and compensated cases. The various registers concurrently showed that nearly all occupational skin diseases were eczematous in nature (98%), most cases belonged to the younger age group (2/3), women (2/3) predominated over men, and the dominant type of occupational eczema was irritant (2/3). It has not been possible to get further information about exposure sources, occupations and trades from the other registers. However, considering the high frequency of recognition for skin diseases (eczemas), it is likely that the information in the ROD is also to some extent representative of the recognized (genuine) cases. As regards the importance of various disease categories, skin diseases (eczemas) ranked 1st (numerically) among both recognized and compensated cases, and were the most expensive. Therefore preventive activities are mandatory, and because of the high frequency of recognition, the data in the ROD may provide a basis for establishment of the most relevant preventive activities. For other disease categories, the frequency of recognition was low, and the utility and reliability of the data in ROD is in questionable. Therefore, in general, an improvement in the notification system is desirable, but a system that takes into account the many uncertain factors is extremely difficult to set up. Linking of the registers is in progress, and this will be useful during everyday situations.

Structural and biochemical basis for the UVB-induced alterations in epidermal barrier function.

Ultraviolet light (UVR) induces a myriad of cutaneous changes, including delayed disruption of the permeability barrier with higher doses. To investigate the basis for the UVB-induced barrier alteration, we assessed the epidermal lamellar body secretory system at various time points before and after barrier disruption with a single high dose of UVB (7.5 MED) to murine epidermis. Morphological data were correlated with changes in epidermal proliferation and lipid synthesis, indicative of lamellar body generation. Twenty-four hours following UVB, the stratum corneum (SC) is normal, but a layer of abnormal, vacuolated, and lamellar body (LB)-deficient cells is present, immediately beneath the stratum granulosum (SG)/SC interface. Immediately subjacent to this band of damaged cells, normal keratinocytes that contain intact LBs are present. By 72 h, concomitant with the appearance of a barrier abnormality, extensively damaged cells persist at the SC/SG interface, and abnormal lamellar membrane structures appear in the lower SC. Upper stratum spinosum (SS) and lower SG cells appear normal, with increased numbers of LBs. A barrier abnormality is still present at 96 h, in association with membrane abnormalities in the lower SC interstices, but up to four normal appearing, subjacent SG cell layers are present. By 120 h, accelerated LB formation and precocious LB extrusion occur throughout the thickened SG; normal lamellar membranes are present in the lower SC; and barrier recovery is almost complete. Whereas, epidermal synthesis of the major barrier lipid species (i.e., cholesterol, fatty acids, and ceramides, including acylceramides) is reduced or unchanged at 24 and 48 h, it increases significantly 72 h after exposure to UVB. Therefore, the delayed disruption of the permeability barrier following acute UVB exposure results from the arrival of a band of lamellar body-incompetent (i.e., damaged) cells at the SG/SC interface. The subsequent, rapid recovery of the barrier, in turn, results from compensatory hyperplasia of subjacent, undamaged SS/SG cells, generating increased numbers and contents of LB. These results underscore the critical role of the stratum compactum in mediating barrier function, and suggest that beneficial therapeutic effects of UV exposure may be due to enhanced lipid production and barrier regeneration.

The efficacy of different moisturizers on barrier recovery in hairless mice evaluated by non-invasive bioengineering methods. A model to select the potentially most effective product.

Moisturizers (emollients) are used frequently on normal and diseased skin. However, only few studies have examined their effects in dynamic situations and in more clinically relevant settings. We evaluated the effect of 4 commonly used products in a hairless mice model after acute skin barrier perturbation with acetone. The efficacy was evaluated by measurement of the transepidermal water loss (TEWL) and electrical conductance at various time intervals during barrier repair. The test products were compared with acetone-treated air-exposed controls allowed to recover otherwise normally and with a known irritant product, chlorhexidine cream 1%. Locobase was the most effective product in correcting barrier function and significantly improved barrier function during early stages of barrier recovery (< 6 h) without interfering with late stages of barrier recovery (> 6 h). The irritant control product, chlorhexidine cream 1%, delayed barrier recovery in the late stages. The model makes it possible to evaluate the combined effects of exogenous and endogenous components on barrier repair and to select the potentially most effective products before performing more cumbersome and time-consuming field studies.

[Occupational systemic sclerosis in men]. / Arbejdsbetinget systemisk sklerodermi hos maend.

An analysis of the history of 28 men suffering from systemic sclerosis, diagnosed at our department during the last 25 years, showed that 21 (75%) had been subject to exposures previously suggested to be of importance in occupational scleroderma. The exposures were revealed by patient files, reports to health authorities, interviews and/or answers to questionnaires. Organic solvents being the most frequent exposure. This was found in thirteen of the patients (46%). A significant difference was found between scleroderma patients and control patients not suffering from connective tissue diseases in relation to total number of subjects exposed to one or several of the agents in question.

Analysis of the human antibody response to outer surface protein C (OspC) of Borrelia burgdorferi sensu stricto, B. garinii, and B. afzelii.

The aim of this study was to determine by Western blotting (WB) the prevalence of anti-outer surface protein C (OspC) IgM and IgG antibodies in patients with Lyme borreliosis according to each of the three genospecies of Borrelia burgdorferi sensu lato. Strains of B. burgdorferi sensu stricto (MUL), B. garinii (DK 6), and B. afzelii (DK 26) served as antigen, all of which expressed abundant OspC. We examined sera from 117 patients with untreated early and late Lyme borreliosis, as well as from 100 blood donors and 29 patients with syphilis. WB results were compared with the B. burgdorferi flagellum enzyme-linked immunosorbent assay (ELISA) data. OspC from B. burgdorferi sensu stricto showed the lowest diagnostic sensitivity. OspC from B. garinii and B. afzelii performed almost identically in erythema migrans, with an IgM positive rate of 36% versus 34%, whereas OspC from B. garinii performed best in neuroborreliosis (60% versus 44%). The anti-OspC IgG response was less prominent than the IgM response and was infrequent in the late stages of the disease (0-20%). The benefit of combining the evaluation of anti-OspC responses with all three species was limited. The overall diagnostic sensitivity of WB anti-B. garinii OspC evaluation was, in the early stages of the disease, comparable to the results obtained using the flagellum ELISA. In erythema migrans and neuroborreliosis, the addition of anti-OspC IgM to the flagellum ELISA increased the sensitivity by 15% and 10%, respectively. It can, therefore, be concluded that OspC from B. garinii is a suitable OspC test antigen, and that supplementary use of OspC from other species adds little to the overall diagnostic sensitivity. An ELISA based on B. garinii OspC and native flagella seems currently the most promising concept for a future antibody test in early Lyme borreliosis.

Treatment of ischaemic digital ulcers and prevention of gangrene with intravenous iloprost in systemic sclerosis.

Twelve patients with systemic sclerosis were treated with intravenous infusions of the prostacyclin-stable analogue iloprost 0.5-2.0 ng/kg/min for 6 h from 8 to 13 days. Imminent gangrene was stopped in 2 patients and followed by healing. In 4 of 6 patients iloprost led to complete healing of ischaemic ulcers and in the remaining 2 patients to partial healing. One patient with severe Raynaud's phenomenon discontinued the study after 3 days due to severe headache. The 2 remaining patients with Raynaud's phenomenon as an indication improved, while no improvement was recorded in a patient with vasculitis of the lower leg. Side-effects such as headache, nausea and flushing were the reason that only 5 patients reached the maximum infusion rate. No statistical differences were recorded in digital bloodflow before and after the study or in plasma endothelin in the 9 patients investigated. Three of the 6 patients with healing ulcers, however, showed a pronounced decrease in plasma endothelin. Iloprost appears useful as a treatment of imminent gangrene and ischaemic ulcers in systemic sclerosis. This reparatory capacity could also be of a more general importance in therapy of this disease.

The use of serologic markers for collagen synthesis and degradation in systemic sclerosis.

BACKGROUND: Systemic sclerosis is characterized by excessive accumulation of collagen in all involved organs. Serum markers of collagen synthesis and degradation, the aminoterminal propeptide of type III procollagen (PIIINP), the carboxyterminal propeptide of type I procollagen (PICP), and the crosslinked telopeptide of type I collagen (ICTP), can be measured. OBJECTIVE: Our purpose was to investigate these markers in different subgroups of untreated patients with systemic sclerosis and in patients before and after various types of therapy. PIIINP and PICP were also investigated in blister fluid from involved and uninvolved skin. METHODS: Sera from 97 patients and suction blister fluid from 13 patients were radioimmunoassayed. RESULTS: The highest levels of PIIINP and PICP were found in blister fluid from involved skin. Patients with systemic sclerosis had higher serum levels of PIIINP than control subjects. The highest levels were found in patients with diffuse cutaneous systemic (type III) sclerosis; increased serum PIIINP was also characteristic of type II limited cutaneous systemic sclerosis. Most patients with limited cutaneous type I systemic sclerosis had normal levels. Serum PICP was within normal limits in all three types of systemic sclerosis. Variations in ICTP type I collagen degradation in general followed PICP. Immunosuppressive drugs significantly reduced PIIINP, whereas no significant decrease was found after photopheresis. PICP and ICTP also diminished after treatment with D-penicillamine and cyclophosphamide given together with prednisone. CONCLUSION: PIIINP can be recommended for monitoring collagen synthesis in systemic sclerosis. Our data support the use of immunosuppressive therapy for this disease.

Cutaneous barrier function after cold exposure in hairless mice: a model to demonstrate how cold interferes with barrier homeostasis among workers in the fish-processing industry.

Dry skin and eczema only seldomly occur in workers in the Danish fish-processing industry (FPI) during work, when their fingers and palms have a low skin surface temperature, low transepidermal water loss (TEWL), and a high capacitance. However, shortly after work, when the skin temperature has become normal, TEWL levels increase to above normal, and capacitance decreases to below normal, followed by the development of dry skin or chapping, which subsequently revert to normal over a period of hours. These observations suggest that workers in the FPI may have a defect in skin barrier function, which is, however, masked by a low skin temperature, resulting in misleadingly low TEWL levels during work. To test this hypothesis, we disrupted the permeability barrier in hairless mice with topical acetone, and exposed the treated skin to ice for 3.5 h. Although TEWL rates immediately after cold exposure were low, suggesting normal barrier recovery, TEWL increased to levels slightly above pre-cold exposure levels (i.e. levels just after the barrier was disrupted with acetone) when the skin temperature reverted to normal (> or = 15 min). The changes in TEWL were paralleled by equivalent changes in percutaneous penetration of the electron-dense tracer lanthanum nitrate. This indicates that cold masks a defective barrier, and inhibits barrier repair. After a few hours at ambient temperatures, normal barrier recovery was observed. Electron microscopy revealed empty or partially empty lamellar bodies during the first 30 min post-cold exposure. After 1 h the majority of nascent LBs displayed normal morphology. Moreover, histochemical studies showed a delayed reappearance of stratum corneum intercellular lipids following cold exposure. These results demonstrate that cold exposure prevents barrier recovery after acetone disruption, and provide an explanation for the occupational dermatosis observed in the fish-processing industry and related occupations.

Skin scoring in systemic sclerosis: a modification--relations to subtypes and the aminoterminal propeptide of type III procollagen (PIIINP).

Forty-one patients with systemic sclerosis were investigated with a new and simple skin score method measuring the degree of thickening and pliability in seven regions together with area involvement in each region. The highest values were, as expected, found in diffuse cutaneous systemic sclerosis (type III SS) and the lowest in limited cutaneous systemic sclerosis (type I SS) with no lesions extending above wrists and ancles. A positive correlation was found to the aminoterminal propeptide of type III procollagen, a serological marker for synthesis of type III collagen. The skin score is considered simpler than previous methods and is recommended for more general use.

Plasma endothelin and the aminoterminal propeptide of type III procollagen (PIIINP) in systemic sclerosis.

Forty-four patients with systemic sclerosis and 3 patients with localized scleroderma were investigated for plasma endothelin and aminoterminal propeptide of type III procollagen (PIIINP). Although there was an overlap between plasma levels of endothelin in patients with systemic sclerosis and healthy controls, the mean value of the patients was significantly higher than in controls. Plasma endothelin was normal in all 3 patients with localized scleroderma. The highest levels of plasma endothelin were found in patients with type II and III systemic sclerosis with the largest cutaneous involvement, and in patients with the scleroderma-specific antibodies Scl-70 and anticentromere antibodies. Extremely high values were found in a patient who experienced a renal crisis and in a patient who had her lower leg amputated due to severe vasculitis. A positive correlation was found between plasma endothelin and serum PIIINP. This, together with the fact that in systemic sclerosis the vascular lesions are the earliest, would seem to support the theory that endothelial cell damage could lead to increased secretion of endothelin and subsequent fibrosis in this disease.

Nickel patch test reactivity and the menstrual cycle.

Premenstrual exacerbation of allergic contact dermatitis and varying allergic patch test responses have been reported at different points of the period. Using a dilution series of nickel sulphate, we studied the variation in patch test reactivity in nickel allergic women in relation to the menstrual cycle. Twenty women with regular periods were tested on day 7-10 and on day 20-24. Ten nickel patch tests with different concentrations were applied using the TRUE test assay, and the threshold concentration of nickel sulphate eliciting an erythematous reaction was determined. Half of the women were tested first on day 7-10 and the other half first on day 20-24. There was no difference in the degree of patch test reactivity, when the results from day 7-10 and day 20-24 were compared (p > 0.4). However, when we compared the patch test results from the first and second test procedure, we found an increased nickel sensitivity at the second patch test (0.02 < p < 0.05), suggesting a booster effect from the first patch test procedure. In conclusion, we could not demonstrate an increased sensitivity to nickel sulphate patch tests premenstrually in 20 nickel allergic women, but we found that elicitation of positive patch tests led to an increased skin reactivity towards the same allergen, when the patients were retested weeks later.

The efficacy of a moisturizer (Locobase) among cleaners and kitchen assistants during everyday exposure to water and detergents.

Workers exposed to various irritants are widely advised to use moisturizers. To evaluate the efficacy of a moisturizer (Locobase), we studied 111 cleaners and kitchen workers during everyday exposure to water and detergents. All took part in a standardized interview. After randomization, 1/2 the workers (n = 56) used Locobase during a period of 2 weeks (period L), followed by a period without any emollient (period C), or vice versa (n = 55). Clinical assessment and measurements of the skin surface temperature, electrical capacitance and transepidermal water loss (TEWL) were performed on the fingers, hands and arms on entry to the study, after 2 weeks and 4 weeks, or at drop out. The final evaluation showed that 70 (63%) were able to complete the study; 23 (21%) completed period L, but withdrew from period C after a mean of 6 days because of progressive dryness of the skin and eczema; and 12 (11%) were excluded because they used topical corticosteroids or emollients. The remaining 6 (5%) participants were lost to follow-up. Clinically, we observed a significant increase in dryness (p < 0.001) during periods of no treatment (period C), and normalization of the skin texture during use of Locobase. Clinical observations were confirmed by statistically significant differences (p < 0.001) in the electrical capacitance (epidermal hydration), which decreased during period C and increased to pre-study values during period L. No significant differences were found in skin temperatures and TEWL rates.(ABSTRACT TRUNCATED AT 250 WORDS)