Upregulation of N-acetylglucosaminyltransferase-V by heparin-binding EGF-like growth factor induces keratinocyte proliferation and epidermal hyperplasia.

Oligosaccharide modification by N-acetylglucosaminyltransferase-V (GnT-V), a glycosyltransferase encoded by the Mgat5 gene that catalyses the formation of ß1,6 GlcNAc (N-acetylglucosamine) branches on N-glycans, is thought to be associated with cancer growth and metastasis. Overexpression of GnT-V in cancer cells enhances the signalling of growth factors such as epidermal growth factor (EGF) and transforming growth factor-ß by increasing galectin-3 binding to polylactosamine structures on receptor N-glycans. We previously demonstrated that transgenic mice overexpressing GnT-V fail to develop spontaneous tumors in any organs, but phenotypes reminiscent of epithelial-to-mesenchymal transition were observed in their skin. However, the biological function of GnT-V in normal skin remained unknown. In this study, we examined the role of GnT-V in keratinocyte proliferation using GnT-V-deficient mice. Proliferation of human keratinocytes was suppressed by treatment with GnT-V siRNA. Mgat5(-/-) mouse keratinocytes also showed impaired cell proliferation through the reduction in EGF receptors on the cell surface. Although the skin of Mgat5(-/-) mice appeared normal, epidermal hyperplasia and proliferation of keratinocytes induced by the phorbol ester 12-O-tetradecanoyl phorbol-13-acetate (TPA) were downregulated in these mutants. Moreover, a dramatic increase in GnT-V expression was observed by treatment with TPA or heparin-binding EGF-like growth factor (HB-EGF) in normal human epidermal keratinocytes. This increase was inhibited by an EGF receptor inhibitor. These results indicate that a high expression of GnT-V in keratinocytes contributes to HB-EGF-mediated epidermal hyperproliferation by inhibiting endocytosis of EGF receptors bearing ß1,6 GlcNAc on their N-glycans. Our findings demonstrate a novel role for GnT-V in epidermal homoeostasis, particularly in hyperproliferative conditions.

A phase 3, multicenter, randomized, double-blind, vehicle-controlled, parallel-group study of 5% sofpironium bromide (BBI-4000) gel in Japanese patients with primary axillary hyperhidrosis.

A phase 3 study was conducted to verify the efficacy and safety of 5% sofpironium bromide (BBI-4000) gel (hereinafter referred to as sofpironium) administrated for 6 weeks in Japanese patients with primary axillary hyperhidrosis. The primary efficacy end-point was the proportion of patients who satisfied both criteria of a Hyperhidrosis Disease Severity Score (HDSS) of 1 or 2 at the end of 6-week treatment and a 50% or more reduction in total gravimetric weight of sweat at the end of treatment relative to baseline. A total of 281 patients were randomized to receive 5% sofpironium (141 patients) or vehicle (140 patients), and all patients were included in the full analysis set (FAS). In the FAS, 70.1% of patients were female, and the median age was 35.0 years. The proportion of patients who achieved the primary efficacy end-point was 53.9% in the sofpironium group and 36.4% in the vehicle group, with a statistically significant difference of 17.5% (95% confidence interval, 6.02-28.93) between these two groups (P = 0.003). The incidence of adverse events was 44.0% in the sofpironium group and 30.7% in the vehicle group, and the incidence of adverse drug reactions was 16.3% in the sofpironium group and 5.0% in the vehicle group. Reported adverse events were generally mild or moderate in severity. In the sofpironium group, common events (incidence, ≥5%) were nasopharyngitis (14.2%) and dermatitis/erythema at the application site (8.5%/5.7%), with no serious adverse events reported. This study demonstrated the efficacy and safety of 5% sofpironium.

A phase III, 52-week, open-label study to evaluate the safety and efficacy of 5% sofpironium bromide (BBI-4000) gel in Japanese patients with primary axillary hyperhidrosis.

A long-term study was conducted in Japanese patients with primary axillary hyperhidrosis who completed the preceding 6-week phase III, confirmatory study of 5% sofpironium bromide gel (hereinafter referred to as sofpironium) to evaluate the safety and efficacy of 52-week treatment with sofpironium. In the long-term study, 185 patients who completed the confirmatory study (94 and 91 patients in the vehicle and sofpironium groups, respectively) started to receive sofpironium (switching and extension groups, respectively), and all these patients were included in both the full analysis set (FAS) and the safety analysis set (SAF). In the FAS, there were more females than males (73.0% vs. 27.0%), and median age was 38.0 years. A total of 161 patients (86 and 75 patients in the switching and extension groups, respectively) completed the study at week 52. The proportions of patients with hyperhidrosis disease severity score of 1 or 2 and a 50% or more reduction in total gravimetric weight of sweat were 57.4% in the switching group and 58.2% in the extension group at week 52. The proportions of patients who achieved this efficacy end-point in the long-term study were similar to that (53.9%) in the sofpironium group in the confirmatory study. In the SAF, the incidences of adverse events (AEs) were 80.9% in the switching group and 83.5% in the extension group, and the incidences of adverse drug reactions were 39.4% and 45.1%, respectively. AEs that occurred in at least 20% of patients in both treatment groups were application site dermatitis (25.5% and 33.0%, respectively) and nasopharyngitis (31.9% and 23.1%, respectively). Reported AEs were generally mild, and there were no deaths. Serious AEs occurred in three patients, but none were considered related to the study drug. In this study, the efficacy of sofpironium was maintained during 52-week treatment, and no new safety risk was observed.

Intractable wounds caused by arteriosclerosis obliterans with end-stage renal disease treated by aggressive debridement and epidermal grafting.

BACKGROUND: Patients receiving hemodialysis (HD) need to avoid skin laceration; amputation is common because of intractability of wounds and complications with other diseases, including diabetes mellitus. We have reported the usefulness of aggressive debridement deep enough to expose bone marrow cells, occlusive dressing, and epidermal grafting for diabetic foot ulcers and wounds from rheumatic diseases. OBJECTIVE: To test whether this experimental protocol is effective to treat intractable wounds in a patient receiving HD accompanied with arteriosclerosis obliterans (ASO). METHODS AND RESULTS: A 78-year-old patient with chronic renal failure and arteriosclerosis obliterans suffered a wound with exposed bone on the left great toe. Aggressive combination therapy was effective despite methicillin-resistant Staphylococcus aureus infection, and the wound healed in 13 weeks. LIMITATIONS: This study, reporting a single case, limits the interpretation of results. CONCLUSION: Aggressive debridement exposing bone marrow cells is useful in preparing a healthy wound bed and epidermal sheet grafting may be accepted more advantageously in an ischemic environment and adopt a site-specific phenotype via mesenchymal-epithelial interactions.

Intractable wounds caused by calcific uremic arteriolopathy treated with bisphosphonates.

BACKGROUND: Calcific uremic arteriolopathy (calciphylaxis) is a calcification syndrome that predominantly affects relatively small vessels and is a life-threatening entity usually seen in patients with end-stage renal disease. Intractable skin necrosis sometimes causes lethal sepsis because it progresses rapidly as a result of mechanical stress. OBJECTIVE: We sought to investigate the efficacy of etidronate disodium (bisphosphonates) in treating intractable ulcers occurred in a patient on hemodialysis accompanied with calcific uremic arteriolopathy. METHODS AND RESULTS: A 53-year-old patient receiving hemodialysis with chronic renal failure accompanied with calciphylaxis had bilateral leg ulcers caused by minor trauma. The aggressive debridement worsened his skin condition as is usually seen in pyoderma gangrenosum. It eventually healed by lowering calcium-phosphorus levels with the administration of bisphosphonates and with the continuous use of sevelamer hydrochloride. LIMITATIONS: This study reporting a single case limits the interpretation of results. CONCLUSION: Bisphosphonates may be effective in treating calciphylaxis and arteriosclerosis obliterans by reducing the formation of ectopic calcification around blood vessels.

Infliximab-Induced Aseptic Meningitis during the Treatment of Psoriatic Arthritis.

A 42-year-old Japanese man presented with persistent headache during treatment for psoriatic arthritis (PsA) with infliximab. Treatment with infliximab was initiated 3 years before and the psoriatic skin lesions with arthritis were well controlled. However, after 21 doses of infliximab, the skin lesions and joint pain exacerbated and became intractable. Ten days after the dosage of infliximab was increased, the patient experienced headache and nausea with high fever. He had scaly, well-circumscribed erythemas on his trunk, extremities, and deformed nails. He also had swelling and pain in multiple joints. His complete blood and differential leukocyte counts were normal. The level of C-reactive protein was 16.66 mg/dL, whereas anti-infliximab antibodies were absent. Nuchal rigidity was absent and there were no abnormal neurological findings; however, jolt test results were positive. Results from magnetic resonance imaging were normal, whereas those from cerebrospinal fluid (CSF) examination were almost normal. The CSF contained mononuclear cells and was negative for bacteriological cultures, India ink staining, and polymerase chain reaction amplification of herpesvirus group DNA. Headache and nausea improved 2 months after infliximab was discontinued. The patient failed to respond to infliximab treatment for PsA, and we diagnosed infliximab-induced aseptic meningitis. Infliximab was discontinued and treatment with ustekinumab and methotrexate was initiated. Thereafter, the psoriatic skin lesion and joint pain gradually improved. Infliximab-induced aseptic meningitis may be a differential diagnosis when symptoms of meningitis develop during infliximab administration.

Novel interferon-γ enzyme-linked immunoSpot assay using activated cells for identifying hypersensitivity-inducing drug culprits.

BACKGROUND: The drug-induced lymphocyte stimulation test (DLST), also referred to as lymphocyte transformation test (LTT), is used to identify the culprit drug in cases of cutaneous adverse drug reactions (cADR). Although DLST is a widely used in vitro test, its sensitivity and specificity are unsatisfactory. Recent reports suggest that the detection of drug-induced interferon (IFN)-γ production using enzyme-linked immunoSpot (ELISpot) assay (conventional IFN-γ ELISpot) is useful for identifying culprit drugs in cADR cases. OBJECTIVE: The aim of this study was to establish a novel method for identifying culprit drugs in patients with cADR by efficiently detecting drug-specific IFN-γ production using activated cells. METHODS: Sixteen patients with cADR, including drug-induced hypersensitivity syndrome, erythema multiforme-like eruption, maculopapular exanthema, Stevens-Johnson syndrome, and toxic epidermal necrolysis, caused by clinically convincing culprit drugs were enrolled in this study. In some cases, the blood samples were obtained at two or three different time points. Peripheral blood mononuclear cells (PBMCs) from total 20 samples were analyzed using both the DLST and drug-induced conventional IFN-γ ELISpot. In addition, drug-induced IFN-γ ELISpot was performed using PBMCs, which were stimulated with anti-cluster of differentiation (CD)-3/CD28 antibody-coated microbeads and interleukin (IL)-2 for 7 days before exposure to the culprit drugs (modified IFN-γ ELISpot). RESULTS: Among the culprit drugs tested in each patient, the modified IFN-γ ELISpot was positive in 17 samples (13 patients) while DLST and conventional IFN-γ ELISpot were positive in eight and four samples (six and three patients), respectively. CONCLUSION: The modified IFN-γ ELISpot using activated PBMCs was more sensitive than the conventional IFN-γ ELISpot was for detecting drug-induced IFN-γ production, which could be a useful in vitro tool for identifying culprit drugs in cADR cases.

Intractable Postoperative Wounds Caused by Self-Inflicted Trauma in a Patient with Cutaneous Munchausen Syndrome Presenting as a Pyoderma Gangrenosum-Like Lesion.

A 50-year-old Japanese woman consulted the emergency department of our hospital for bleeding due to an intractable postoperative wound on the lower abdomen; the postoperative wound was owing to a laparoscopic cholecystectomy performed 1 year previously for acute cholecystitis. She presented with a painful ulcer on her right lower abdomen. She also presented with multiple scars, skin grafts on the extremities, and a missing left lower leg, the causes for all of which were unexplained. The results of her blood test were normal, except for the hemoglobin level. Histology of the skin biopsy specimen from the ulcer did not show any specific findings. The previous surgeon who had performed the laparoscopic cholecystectomy revealed that surgical wound dehiscence had occurred during her admission. After a body restraint had been applied, the ulcer improved. Medical records indicated that she had been admitted to the department of plastic surgery at our hospital for skin grafting of a leg ulcer. During that admission, she refused to consult with the department of psychiatry, al-though the staff suspected mental disorders. Therefore, we diagnosed her with cutaneous Munchausen syndrome. After vacuum-assisted closure (VAC) therapy had been performed to prevent her from traumatizing the ulcer again, it rapidly became granulated and reepithelialized. Munchausen syndrome is characterized by feigning physical symptoms to seek attention. Patients self-inflict numerous lesions, keep getting admitted to different hospitals, and feign acute illness, usually spectacular diseases. VAC therapy may be effective for preventing patients with cutaneous Munchausen syndrome from traumatizing their wounds.

Bazex Syndrome in Lung Squamous Cell Carcinoma: High Expression of Epidermal Growth Factor Receptor in Lesional Keratinocytes with Th2 Immune Shift.

An 82-year-old Japanese man was referred for detailed examination of hyperkeratotic erythematous plaques on his palms and soles for 6 months. Two weeks before his first visit, he had undergone lung lobectomy for right lung squamous cell carcinoma (SCC). Laboratory findings showed elevations of eosinophil counts, serum IgE, thymus and activation-regulated chemokine, SCC antigen, and soluble interleukin-2 receptor levels. Histological results of a skin biopsy involving the left palm showed psoriasiform dermatitis. Before lung lobectomy, the hyperkeratotic erythematous plaques on the palms and soles and the erythemas on the trunk and extremities were difficult to treat with topical steroids. After lobectomy, the skin symptoms dramatically and rapidly subsided with topical steroids. Therefore, we diagnosed Bazex syndrome (BS), also known as acrokeratosis paraneoplastica, as a paraneoplastic cutaneous disease in lung SCC. The mild eosinophilia subsided and levels of SCC antigen, IgE, and soluble interleukin-2 receptor were reduced. BS is a paraneoplastic cutaneous disease characterized by acral psoriasiform lesions associated with an underlying neoplasm. In a previous report, a shift to the Th2 immune condition was found in patients with non-small cell lung cancer, as shown in our patient. Epidermal growth factor receptor (EGFR) is also known as tumor growth factor-α receptor; it is increased in psoriatic keratinocytes. In our case, EGFR expression increased in lesional keratinocytes 2 weeks after surgery and decreased 4 weeks after surgery. We speculate that a shift to Th2 immune reactions in lung SCC may be the pathogenesis of BS, whereby lesional keratinocytes highly express EGFR in parallel with disease activity.

B-1 B cell progenitors transiently and partially express keratin 5 during differentiation in bone marrow.

BACKGROUND: Keratin 5 (K5) is a cytoskeletal tissue-specific protein expressed in the epithelial cells of skin and esophagus and ectopic K5 expression in lymphocytes has never been reported. OBJECTIVE: Here we demonstrate an ectopic epidermal self-protein expression in B-1 B cell by fate mapping of K5-expressing cells. METHODS: K5-Cre×CAG-CAT-loxP-EGFP double Tg (K5×GFP) mice that express enhanced GFP under the control of the K5 promoter were employed. RESULTS: Unexpectedly, B220(+)GFP(+) cells were found in LN, spleen, peripheral blood and peritoneal cavity. These cells were IgM(+)IgD(low)CD23(-)CD43(+)CD19(+)CD93(-), indicating that they were B-1 B cells. The number of B220(+)GFP(+) cells was significantly larger in spleen than in the other tissues tested. Although GFP(+) B-1 cells did not express K5 in the periphery, Lin(-)CD93(+)B220(low-neg)CD19(+) B-1 B cell progenitors expressed GFP and B220(+)CD93(+) progenitor cells expressed K5 and MHC-class II in BM, indicating that GFP(+) B-1 cells transiently expressed K5 and the progenitor cells were potential APC. GFP(+) B-1 cells in the periphery continued expressing MHC class II and had exogenous antigen-presenting capacity comparable to non-follicular B cells. GFP(+) B-1 cells spontaneously secreted more IgM than GFP(-) B-1 cells in vitro. CONCLUSION: These results indicate that B-1 B cells transiently and partially express K5 in BM and are potent for both natural antibody production and antigen presentation.

Clinical study and stability assessment of a novel transcutaneous influenza vaccination using a dissolving microneedle patch.

Transcutaneous immunization (TCI) is an attractive vaccination method compared with conventional injectable vaccines because it is easier to administer without pain. We developed a dissolving microneedle patch (MicroHyala, MH) made of hyaluronic acid and showed that transcutaneous vaccination using MH induced a strong immune response against various antigens in mice. In the present study, we investigated the clinical safety and efficacy of a novel transcutaneous influenza vaccine using MH (flu-MH), which contains trivalent influenza hemagglutinins (15 µg each). Subjects of the TCI group were treated transcutaneously with flu-MH, and were compared with subjects who received subcutaneous injections of a solution containing 15 µg of each influenza antigen (SCI group). No severe local or systemic adverse events were detected in either group and immune responses against A/H1N1 and A/H3N2 strains were induced equally in the TCI and SCI groups. Moreover, the efficacy of the vaccine against the B strain in the TCI group was stronger than that in the SCI group. Influenza vaccination using MH is promising for practical use as an easy and effective method to replace conventional injections systems.

[Function of Aire in central and peripheral immune tolerance].

Negative selection induces central tolerance in which self-reactive T cells are deleted by medullary thymic epithelial cells (mTECs) to prevent autoimmunity. The transcriptional factor, autoimmune regulator (Aire), controls the expression of tissue-specific antigens (TSAs) by mTECs for negative selection. The mechanisms by which Aire targets loci which encode TSAs are unknown in detail; recently, however, the ATF7ip-MBD1 complex was identified as an Aire-interacting transcriptional protein complex required for its targeting the loci. Lineage tracing of Aire(+) mTECs identified that mTECs have a post-Aire stage during the development, where they lost maturation markers but maintained intermediate TSA expression, and Aire is required for the terminal differentiation of mTEC's. Extrathymic Aire-expressing cells (eTACs) are identified in murine and human secondary lymphoid organs. eTACs express major histocompatibility complex class II(hi), CD80(lo), CD86(lo), epithelial cell adhesion molecule(hi), CD45(lo) bone marrow-derived peripheral antigen-presenting cell population, which is distinct from mTECs and dendritic cells. They can induce activation-induced cell death of self-reactive CD8(+) T cells and unresponsiveness of self-reactive CD4(+) T cells through a mechanism that does not require regulatory T cells, suggesting that peripheral Aire plays a complementary role for central tolerance.