Histocompatibility alloantigens in psoriasis and psoriatic arthritis. Evidence for the influence of multiple genes in the major histocompatibility complex.

The frequency of HLA-A, B, and Cw antigens as well as the antigens expressed preferentially on B cells and monocytes (DRw and Ia-like) was examined in a normal population and two related disease populations, psoriasis and psoriatic arthritis. HLA antigens distinguishing the two disease populations were found. Psoriatic patients demonstrated an increase in frequency of HLA-A1, B17, and B13. Patients with psoriatic arthritis demonstrated an increased frequency of HLA-A26, B38, and DRw4. Antigens showing a common increase in frequency in the two disease populations were HLA-Cw6, DRw7, and Ia744. These results demonstrate genetic differences as well as similarities in the two populations of patients with the common clinical feature of psoriasis. In addition to the above analysis, we examined the association of individual alloantigens elevated in frequency in the diseased population. These same alloantigens were examined for association in the normal population. This analysis revealed HLA antigen associations in the two disease groups that differed from the association of several antigens in the normal population. The results suggest that at least two genetic factors, one mapping in the HLA-A, C-B region and one mapping in the HLA-B-DRw region are associated with the disease states. Thus, multiple factors controlled by genes in the major histocompatibility complex appear to contribute to the disease entities under investigation.

Quantitative determination by bioassay of photoactive 8-methoxypsoralen in serum.

Photoactive 8-methoxypsoralen (8-MOP) levels in human and animal sera were determined by bioassay with Staphylcoccus aureus serving as the test organism. 8-MOP was extracted from sera with as 9:1 (V/V) ethyl acetate-n-hexane mixture and reconstituted in an aqueous medium following evaporation of the extractant. Bacterial suspensions containing extracted 8-MOP were irradiated for predetermined intervals with longwave ultraviolet light (UVA) at an intensity of 2.1 mw/cm2. Cultures containing known amounts of 8-MOP were used as standards and cytotoxicity (i.e., drug levels) determined by colony counts. The detection limit for 8-MOP was 5 ng/ml with an accuracy of +/- 10% above 10 ng/ml. Concomitant determinations of 8-MOP levels by high pressure liquid chromatography (HPLC) were in excellent agreement with the bioassay results.

Elevation of serum triglyceride levels from oral isotretinoin in disorders of keratinization.

Ten patients with disorders of keratinization were treated with oral isotretinoin (13-cis-retinoic acid) on an investigational protocol to test the efficacy, safety, and optimal dosage schedule for using the drug in these rare disorders. Elevations of serum triglyceride levels above the highest normal levels developed in seven of the ten patients, while they maintained normal levels of serum cholesterol. This effect was found to be dose and/or time related and reversible. Moderate elevations of serum triglyceride levels have not been clearly established as a risk factor for the development of coronary artery disease. High levels, however, may precipitate acute pancreatitis. For this reason, the conditions of patients receiving retinoids must be carefully monitored for triglyceride abnormalities throughout their courses of treatment.

Topical tretinoin for treatment of photodamaged skin. A multicenter study.

The clinical and histologic effects of a new emollient cream formulation of topical tretinoin at concentrations of 0.05% and 0.01% were examined in 251 subjects with mild to moderate photodamaged facial skin in a randomized, double-blind, vehicle-controlled, multicenter study. Seventy-nine percent of the subjects who received 0.05% tretinoin for 24 weeks showed overall improvement in photodamaged skin compared with improvement in 48% of the vehicle-treated control subjects. Significant reductions were found in fine wrinkling, mottled hyperpigmentation, roughness, and laxity after 0.05% tretinoin therapy when compared with controls. In addition, histologic changes of increased epidermal thickness, decreased melanin content, and stratum corneum compaction provide independent evidence supporting clinical improvement. Side effects of erythema, peeling, and stinging were usually mild and well tolerated.

Kinetics of [14C-5] 8-methoxypsoralen distribution in rabbits.

Distribution, kinetics and localization of 8-methoxypsoralen (8-MOP) was determined in rabbits over 24 h following i.v. administration of [14C-5] labeled and carrier 8-MOP at respective concentration of 50 muCi and 5 mg/kg. Peak levels were reached by kidneys at 1 h (18,500 ng/g) at 2 h by liver (2,470 ng/g) and at 8 h by bile (64,000 ng/g). Muscles, lymphatic tissues and brain showed low drug uptake (800 ng/g). Endocrine organs also had low drug concentration. In gastrointestinal tract the maximum level of 8-MOP was 1,500 mg/g at 1 h in jejunum. Plasma 8-MOP concentration was 3,700 ng/ml at 5 min post injection with 100 ng/ml still detectable at 24 h. Urine label concentration peaked at 1 h (4 x 10(5) cpm/ml) and was 2 x 10(2) cpm/ml at 24 h. The intact skin concentration was at the maximum during the first 30 min (1,958 ng/g) declining progressively thereafter to 155 ng/g at 24 h. The UVA irradiated skin (320-380 nm at the rate of 14.2 mW/cm2 x s-1 for 1 h) had a higher 8-MOP concentration (2,834 ng/g at 1 h and 280 ng/g at 24 h).

Hydroxylysine-deficient skin collagen in a patient with a form of the Ehlers-Danlos syndrome.

Two sibs with the Ehlers-Danlos syndrome, one of whom was shown to have hydroxylysine-deficient collagen, are described. In addition to the usual features of the Ehlers-Danlos syndrome (loose-jointedness and excessively stretchable, fragile, and bruisable skin), these patients had severe scoliosis and fragility of ocular tissues leading to rupture of the globe or retinal detachment. This combination of symptoms was tentatively classified as Ehlers-Danlos syndrome, Type VI. The condition is inherited as an autosomal recessive. The activity of lysyl hydroxylase was present at a reduced level in fibroblasts cultured from the patient's skin.

Photochemotherapy and the eye: photoprotective factors.

The photosensitizer, 8-Methoxypsoralen, binds reversibly to a greater extent to human serum albumin than to human lens in the absence of UVA irradiation. Since experimental and clinical evidence suggests that peak levels in skin exceed those in plasma, which in turn exceed those in the lens, 5 to 10 fold more UVA is required to induce lenticular injury than to produce a threshold skin effect. To prevent the potential photoactivation of residual of 8-MOP in the lens, UVA opaque wraparound sunglasses should be worn for 24 hours after drug ingestion. Glasses with limited UVA transmission but good visible transmission should be worn after the 24 hour period following drug ingestion or indoors during the first 24 hours as a substitute for the wraparound. Every effort should be made to insure complete compliance in the wearing of UVA photoprotective lenses by all psoralen photosensitized patients.

Esophageal acanthosis nigricans in association with adenocarcinoma from an unknown primary site.

A case of acanthosis nigricans with esophageal involvement is presented. Six months after the patient's initial examination, metastatic adenocarcinoma from an unknown primary site was discovered. This represents the ninth reported case of esophageal acanthosis nigricans; six of the eight previously described cases were in association with malignancy localized to the gastrointestinal tract. Esophageal acanthosis nigricans may be a more specific marker for associated malignancy than cutaneous or oral mucosal manifestations. If present, esophageal acanthosis nigricans may serve as an indication for an extensive search for occult malignancy.

Psoralens and ocular effects in humans.

The safety of psoralen photochemotherapy (PUVA) in relation to the eye has been an area of research at the Washington Hospital Center for the last 6 years. Our studies indicate that, with proper shielding of the eye, safety for acute lenticular damage can be established. However, the potential for cataract formation from low-dose, long-term ambient UVA exposure is not known. The guidelines for proper shielding of the eye with PUVA therapy have been established and are enumerated in the text. Our studies on 68 patients for an average length of 4 years and 7 months while they received PUVA have established that the rate in the development of cataracts in treated patients had not increased as compared with the Framingham Eye Study.

Subacute cutaneous lupus erythematosus during PUVA therapy for psoriasis: case report and review of the literature.

Lesions typical of subacute cutaneous lupus erythematosus developed in an elderly woman after 6 months of PUVA (8-methoxypsoralen and longwave ultraviolet light) therapy for psoriasis. Pancytopenia, antibodies to double-stranded DNA, and hypocomplementemia developed concurrently with the appearance of the cutaneous lesions. With discontinuation of photochemotherapy, the cutaneous lesions disappeared and the pancytopenia improved.

A new skin manifestation of progressive systemic sclerosis.

This paper describes a pigmentary abnormality found in three patients with progressive systemic sclerosis. This consists of pigment retention over superficial blood vessels in an area of depigmentation. Sequential clinical observations demonstrated the dynamic nature of this abnormality, and on the basis of thermographic examination in one patient, we suggest that local thermal mechanisms may affect its development. This abnormality has been seen only in patients with progressive systemic sclerosis.

Kinetics of [14C-5] 8-methoxypsoralen uptake by UVA irradiated and non-irradiated rabbit eye tissues.

Total 8-methoxypsoralen (8-MOP) in intact and UVA irradiated rabbit eye tissues and its unaltered fraction in aqueous and eye lenses were determined over the 24 hours after i.v. injection of [14-C-5] and carrier 8-MOP at the concentration of 50 microCi and 5 mg/kg. No 8-MOP was detected at the end of 24 hours in intact and irradiated aqueous, vitreous and retina in contrast to one hour when the respective levels were congruent to 220, greater than 0 and congruent to 160 ng/g. Eye-plasma drug concentration ratios were less than 0.5 initially, but increased thereafter. While the average lens 8-MOP levels of congruent to 140 ng/g remained unchanged for 24 hours, no unaltered drug was detected beyond eight hours. Measurable amounts of label at the end of 24 hours also persisted in the cornea, iris, sclera and conjunctiva.

N1N8-bis(gamma-glutamyl)spermidine cross-linking in epidermal-cell envelopes. Comparison of cross-link levels in normal and psoriatic cell envelopes.

N1N8-Bis(gamma-glutamyl)spermidine was found in exhaustive proteolytic digests of isolated cell envelopes from human epidermis at levels comparable with those of epsilon-(gamma-glutamyl)lysine. Significantly higher than normal amounts of these compounds, particularly the bis(gamma-glutamyl)polyamine, were observed in envelopes from afflicted areas (scales) of psoriatic patients. These findings support the notions that N1N8-bis(gamma-glutamyl)spermidine, like epsilon-(gamma-glutamyl)lysine, functions in cell envelopes as an enzyme-generated protein cross-link and stabilizing force and that individuals with the chronic, recurrent skin disease, psoriasis, exhibit in involved epidermis abnormal cell-envelope-protein cross-linking.

Vesicular pemphigoid vs dermatitis herpetiformis.

We describe a patient with clinical features of dermatitis herpetiformis (DH) and histopathologic features suggestive of both DH and bullous pemphigoid (BP). Immunofluorescent (IF) studies of skin biopsy revealed IgG and C3 deposits along the basement membrane zone (BMZ) in a linear pattern and circulating BMZ antibodies in the serum consistent with BP. The patient's condition evolved over 5 years into a typical case of DH characterized by histologic findings of papillary edema and neutrophilic infiltrates and evidence by IF findings of granular IgA deposits in the dermal papillae and the presence of antigliadin antibodies in the serum.