Community validation of the U.K. diagnostic criteria for atopic dermatitis in Japanese elementary schoolchildren.

BACKGROUND: A simple list of diagnostic criteria for atopic dermatitis for use in epidemiological studies was developed by a U.K. working party. This list served well for both hospital patients with skin diseases and in general population within the U.K. OBJECTIVES: To validate the U.K. diagnostic criteria in Japanese elementary schoolchildren, we collected the questionnaires on regular health checkups, which had been completed by parents of schoolchildren in 2001/2002 and 2004/2005. METHODS: Elementary schoolchildren were examined by dermatologists in eight areas (16,152 children) in 2001/2002 and in three areas (3849 children) in 2004/2005. The questionnaire was distributed to the parents 2 weeks before the skin examination, completed by the parents and collected after the survey. RESULTS: In 2002/2002 comparing the U.K. diagnostic criteria with the findings on clinical examination used as the reference standard, the U.K. criteria (1-year prevalence measure) showed a sensitivity of 71.8%, specificity of 89.3% and positive predictive value of 44.7%. In 2004/2005 we confirmed that the U.K. criteria for a point prevalence measure showed a higher positive predictive value (59.9%) compared with that for 1-year prevalence measure (49.3%). CONCLUSION: Now that we know the sensitivity and specificity of the U.K. criteria in the population examined in this study, we will be able in the near future to estimate the prevalence of atopic dermatitis in a similar population with reverse operation by questionnaires alone using these criteria without examination by dermatologists. Therefore, the validation study of U.K. criteria could be useful for future epidemiologic surveys.

Properties and histochemical application of a novel antibody against trichohyalin granules.

We obtained an antibody, anti-inner root sheath cells antibody (anti-IRSC Ab), that reacted with the inner root sheath (IRS) cells especially trichohyalin granules (THG). In order to compare the properties of anti-IRSC Ab and AE15, which is a specific monoclonal antibody against THG, histochemical and biochemical examinations were performed. In vivo localization with anti-IRSC Ab and AE15 indicated that both antibodies reacted with THG, but anti-IRSC Ab reacted with THG in the suprabulbar region of the Huxley layer, whereas AE15 reacted with THG in the suprabulbar region and upper bulbar portion of the Huxley layer, as shown by immunohistochemical and immunoelectron microscopic analyses. The results of immunoblot analysis showed that anti-IRSC Ab reacted with a protein spot at 45 kDa, pI 6.5, but AE15 reacted with high molecular weight proteins at pI 5.5. Furthermore, anti-IRSC Ab reacted with specimens of squamous cell carcinoma (SCC) but did not react with those of basal cell carcinoma (BCC). In contrast, AE15 reacted with neither SCC nor BCC. These findings suggest that anti-IRSC Ab and AE 15 recognized different component proteins in THG, and therefore indicated that THG, like as keratohyalin granules, might consist of several proteins. It is the novel finding that the anti-IRSC Ab positive substance in THG in the normal hair and SCC cells.

The presence of tryptase-positive and bikunin-negative mast cells in psoriatic skin lesions.

Human mast cells are well known to produce a serine protease, tryptase, which appears to play a pathogenic role in various skin inflammations. It was previously reported that a rat homologue of bikunin may inhibit tryptase activity. Various type of cells (i.e. keratinocytes) are able to produce this protein inhibitor, it still remains unclear if bikunin is present in dermal inflammatory milieu, in which mast cells, through secretion of tryptase, play an inflammatory role. Therefore, the purpose of the present study was to exploit expression and production of bikunin in dermis and dermal constituents. We first compared the dermal mast cells in psoriatic lesions with those in lesional skin of atopic dermatitis or of chronic eczema by use of immunoelectron microscopy and immunohistochemical analyses using antibodies to bikunin and tryptase. Then, we tested what kinds of cytokines may regulate the de novo synthesis of bikunin. To do so, RNA was extracted from a human mastocytic cell line, HMC-1, reverse-transcribed, and semiquantitative RT-PCR was performed using primers specific for bikunin. With immunoelectron microscopy, bikunin was found to localize on the cell membrane, while tryptase was in the secretary granules of the mast cells. In psoriatic lesions, around 70% of dermal mast cells were positive for both tryptase and bikunin, and the remaining was mostly positive for tryptase, but the expression of bikunin was under the detection limit of the experimental setting. This observation was seen in only psoriatic lesions, even in almost cured lesions, while in atopic dermatitis or chronic eczema only mast cells doubly positive for bikunin and tryptase were seen. In HMC-1, bikunin was constitutively expressed at an mRNA level, which was upregulated by stimulation with interleukine-4, but was suppressed by interferon-gamma. Bearing in mind the concept that in psoriasis local cytokine milieu is shifted toward a Th1 pattern (predominant secretion of interferon-gamma), tryptase-positive, bikunin-negative mast cells may be induced.

The receptor for erythropoietin is present on cutaneous mast cells.

Skin samples from patients with extra-mammary Paget disease, Bowen's disease, atopic dermatitis, psoriasis and non-lesional skin of nevus pigmentosus were immunohistochemically examined with an anti-soluble erythropoietin receptor antibody (anti-sEPOR antibody), and only the dermal mast cells positively stained in all skin samples were examined. These positively stained dermal cells were proved to be mast cells by double staining with anti-sEPOR antibody and either with anti-bikunin antibody or anti-tryptase antibody. Immunoelectron microscopically these EPOR were found in the secretory granules of the dermal mast cells. Further, EPOR in the mast cells may be consisting of only the extracellular domain of erythropoietin receptor molecule as the mast cells were immunohistochemically not reacted with an antibody to the C-terminal peptide of EPOR. Human mast cell line, HMC-1 cells has immunohistochemically the erythropoietin receptor, which was consisting of a 43 kDa major protein and a 20 kDa minor protein in the immunoelectrophoresis. These data may indicate that EPOR in the mast cells may not be the whole molecule, but probably the soluble one of EPOR.

Terfenadine antagonism against interleukin-4-modulated gene expression of T cell cytokines.

Here, we investigated whether an anti-allergy drug, terfenadine, affects interleukin-4-modulated cytokine expression in peripheral T cells. Peripheral blood T cells were first stimulated with recombinant interleukin-4 and then tested for modulation of the mRNA of a panel of cytokines using the reverse transcription-polymerase chain reaction followed by Southern blot analysis. It was found that T cells constitutively expressed mRNA specific to T helper 1 cytokines (interleukin-2, interferon-gamma, tumor necrosis factor-alpha), which was markedly downregulated upon stimulation with interleukin-4, whereas mRNA for T helper 2 cytokines such as interleukins 4, 5, and 6 was induced in response to interleukin-4. Interestingly, the interleukin-4-induced expression of all T helper 2 cytokines examined was markedly downregulated by terfenadine. Among T helper 1 cytokines, interleukin-4-mediated suppression of tumor necrosis factor-alpha was not affected by terfenadine, which, however, markedly restored mRNA expression of interferon-gamma or interleukin-2. Electrophoretic mobility shift assays using [32P]-labeled synthetic oligonucleotides encoding the consensus binding motif of activator protein-1 demonstrated that interleukin-4-induced binding of activator protein-1 composed of JunB was interfered by terfenadine. This study indicates that terfenadine, at least partially, interferes with interleukin-4-activated signaling, leading to terfenadine antagonism against the modulatory impact of interleukin-4 on T cell cytokines.

Characterization of Kdap, a protein secreted by keratinocytes.

Using a signal sequence-trap we identified a human gene encoding a polypeptide of 99 amino acids with a putative signal sequence. The gene was identical to keratinocyte differentiation-associated protein (Kdap), which was reported previously by Oomizu et al (Gene 256: 19-27, 2000) to be expressed in embryonal rat epidermis at the mRNA level. In humans, we found Kdap mRNA expression to be restricted to epithelial tissue at high levels. The 12.5 kDa protein was detected in culture supernatant of keratinocytes and those transfected adenovirally with the Kdap gene. In normal skin, Kdap protein was found exclusively within lamellar granules of granular keratinocytes and in the intercellular space of the stratum corneum. By contrast, in lesional skin of patients with psoriasis, Kdap was expressed more widely throughout suprabasal keratinocytes. When induced to differentiate in vitro, keratinocytes showed marked upregulation of Kdap mRNA expression similar to that of involucrin mRNA, but with differing kinetics. Finally, a spliced variant of Kdap mRNA was generated by alternative splicing mechanisms. Our studies indicate that human Kdap resembles rat Kdap with respect to tissue and cell expression at the mRNA level and that Kdap is a low-molecular-weight protein secreted by keratinocytes. Thus Kdap may serve as a soluble regulator of keratinocyte differentiation.

Acne phototherapy with a high-intensity, enhanced, narrow-band, blue light source: an open study and in vitro investigation.

The purpose of this study was to investigate the efficacy of phototherapy with a newly-developed high-intensity, enhanced, narrow-band, blue light source in patients with mild to moderate acne. An open study was performed in acne patients who were treated twice a week up to 5 weeks. Acne lesions were reduced by 64%. Two patients experienced dryness. No patient discontinued treatment due to adverse effects. In vitro investigation revealed that irradiation from this light source reduced the number of Propionibacterium acnes (P. acnes), but not Staphylococcus epidermidis that were isolated from the acne patients. Phototherapy using this blue light source was effective and well tolerated in acne patients and had an ability to decrease numbers of P. acnes in vitro, suggesting that this phototherapy may be a new modality for the treatment of acne.

Overactivation of IL-4-induced activator protein-1 in atopic dermatitis.

Atopic dermatitis is regarded as mediated by Th2-type immunity. In fact, it frequently coincides with the elevation of immunoglobulin (Ig)-E in patients' sera. Due to the pivotal role of interleukin (IL)-4 in regulation of IgE, we hypothesized if atopic dermatitis represents a hyper-reactive condition in response to IL-4 when it coincides the higher serum level of IgE. To address this possibility, peripheral blood mononuclear cells (PBMC) isolated from patients with atopic dermatitis with the high serum IgE level, from those with psoriasis or from healthy volunteers were stimulated with recombinant IL-4 and analyzed for activation of transcription factors including activator protein (AP)-1 or signal transducers and activators of transcription (STAT)-6 by employing electrophoretic mobility shift assays. Although no significant difference between atopy patients and other groups was observed in the STAT-6 binding activity in IL-4-stimulated PBMC, it over-activated the binding of AP-1 in PBMC of the patients with atopic dermatitis. The AP-1 binding was interfered by the use of an antibody directed against JunB. This is the indication that IL-4-overactivated AP-1 is composed of JunB. Furthermore, semi-quantitative RT-PCR analyses revealed marked down-modulation of a Th1 cytokine, interferon (IFN)-gamma, in IL-4-stimulated PBMC derived from atopy patients, but not that from healthy individuals. Together, our present study indicates that AP-1 is over-activated by IL-4 in PBMC of the atopic patients with the higher IgE level, thereby implying that IL-4-induced over-activation of AP-1 might be one of pathogenic factors in atopic dermatitis.

Videomicroscopic and histopathological investigation of intense pulsed light therapy for solar lentigines.

A noncoherent, broadband, intense pulsed light source has been effective for symptoms of photoaging skin as a nonablative method. The purpose of this study was to investigate the mechanism of efficacy of intense pulsed light for solar lentigines, a symptom of photoaging skin, with videomicroscopy and histopathology. Skin lesions of patients with solar lentigines who received one treatment of intense pulsed light were examined. Sixteen of 20 patients showed tiny crusts clinically. These tiny crusts were confirmed to be micro-crust formation after epidermal injury with sequential observation using videomicroscope and histopathology. Drop-off of micro-crusts with ample melanin pigments lead to clinical improvement of skin lesions. Intense pulsed light with absorption spectrum for melanin induced injury of melanin-containing epidermal cells via photothermal effects, suggesting that intense pulsed light may be a new modality for solar lentigines.

A new approach to the evaluation of whitening effect of a cosmetic using computer analysis of video-captured image.

Whitening effects of cosmetics have been evaluated with change of skin reflectance of the colorimeter. However, skin color implies Hue (H) and Saturation (S) as well as skin reflectance (Value). We have developed a new evaluation method of change of skin color using computer analysis of the video-captured digital image. We have also investigated whitening effects of a new whitening cosmetic essence, 'Concentre anti-tache nuit' (CAN; Parfums Christian Dior, France), which contained 3% magnesium l-ascorbyl 2-phosphate, on skin color of the face in 15 healthy Japanese females. Measurement was performed after 6 weeks application. Whitening effects were also evaluated with the combination of observation and photographs. CAN showed significant improvement in Saturation of the forehead and left cheek and Value of the forehead. CAN showed greater whitening effects both on the forehead and left cheek in eight (53%) of 15 subjects with the combination of observation and photographs. These results indicated that CAN may have a whitening effect on skin of the face after 6 weeks application. This method may be useful to evaluate the whitening effect of cosmetics and color change of cutaneous disorders.

A survey of psoriasis patients in Japan from 1982 to 2001.

BACKGROUND: The Japanese Society for Psoriasis Research has conducted an annual survey of psoriasis patients in Japan from 1982 to 2001. OBJECTIVE: To perform the epidemiological study about a survey of psoriasis patients conducted in Japan for twenty years. METHODS: A sample of 28628 cases was collected from 148 dermatology centers throughout Japan. The reports from each center were analyzed. RESULTS: Males (65.8%) were predominant over females (34.2%) in number. The vast majority of cases (86.0%) had plaque-form of psoriasis vulgaris, and 812 cases (2.8%) showed guttate psoriasis. Psoriatic erythroderma (0.8%), generalized pustular psoriasis (0.9%), and localized pustular psoriasis (0.5%) were rare. Three hundred of the patients (1.0%) manifested psoriatic arthritis. Local corticosteroids (67.8%) were the most used modalities, whereas local vitamin D(3) preparations (2.4%) were rarely used. For photo-therapeutic treatments, topical (12.1%) and systemic (7.5%) PUVA were predominant over UVB therapy (0.5%). In systemic treatments, drugs from the herbal medicine was the first (14.2%), followed by etretinate (7.6%), nonsteroidal anti-inflammatory drugs (4.4%), oral corticosteroids (4.1%), methotrexate (2.8%), cyclosporine (1.6%), and anti-cancer drugs (1.4%). CONCLUSION: This survey was the first epidemiological study throughout Japan.

The content of free amino acids in the stratum corneum is increased in senile xerosis.

Xerosis is one of the characteristics of aged skin. Xerosis may be caused by a decrease in the stratum corneum free amino acids which are natural moisturizing factors derived from filaggrin. In aged skin, filaggrin is immunohistochemically decreased compared with the levels in young skin. However, the differences in stratum corneum amino acids between aged and young skin have not been analyzed quantitatively. Therefore, in this study we determined the stratum corneum amino acids per 1000 stratum corneum cells in aged and young skin by high-performance liquid chromatography. The amount of filaggrin mRNA in the epidermis was also compared between aged and young skin using RT-PCR. The total amount of amino acids in the stratum corneum was larger in aged senile xerosis skin than in young skin. Only a few amino acids were found in the stratum corneum of ichthyosis vulgaris patients (control skin). The expression of filaggrin mRNA in aged skin was, however, similar to that in young skin. These findings suggest that the immunohistochemical decrease in filaggrin in aged skin may be caused by promotion of filaggrin proteolysis in the upper layers of the stratum spinulosum.

Quantitative analysis of bikunin-laden mast cells in follicular eruptions and chronic skin lesions of atopic dermatitis.

Bikunin, an inhibitor of serine proteases, is widely distributed in human tissues, including the skin, and may inhibit tryptase and modulate allergic inflammation. The purpose of the present study was to compare follicular eruptions (FE), so-called atopic skin or perifollicular accentuation, with atopic dermatitis (AD) lesions (ADL) by immunohistochemical analysis using antibodies to bikunin and tryptase. Immunohistochemically, bikunin was colocalized with tryptase in dermal mast cells, and a small quantity of bikunin was also deposited in the intercellular spaces in FE and ADL. The number of bikunin-laden mast cells per 0.78 mm(2) of skin was 78.1+/-7.1 (mean+/-SEM, n=14) in FE, 25.4+/-2.3 (n=10) in normal skin from children and infants, 91.3+/-11.8 (n=10) in ADL, 25.6+/-4.8 (n=5) in nonlesional skin of AD, and 27.8+/-2.0 (n=13) in normal adult skin. The difference between FE and normal control skin from children and infants, between FE and nonlesional skin of AD, and between lesional and nonlesional skin of AD were significant. Based on the above findings and the occasional presence of spongiosis and lymphocyte infiltration, in FE moderate inflammation is apparent histopathologically even though little inflammation is apparent clinically.

Clinical and pharmacokinetic studies of continuous itraconazole for the treatment of onychomycosis.

Itraconazole, a triazole antifungal agent, has been widely used for onychomycosis with high cure rates. Unchanged itraconazole and a major metabolite hydroxy-itraconazole reach the nail with a strong affinity for keratin. The aim of this study was to elucidate clinical effectiveness and pharmacokinetic profiles of a 6-month continuous itraconazole treatment at a daily dose of 100 mg. Nail growth, the decrease in nail turbidity, and the nail concentrations of unchanged- and hydroxy-itraconazole were investigated. The affected nails we examined demonstrated nail growth proportional to the decrease in turbidity and a quick increase in drug concentration with a long duration of a high concentration after cessation. Our results support the hypothesis that this continuous therapy is a good modality for onychomycosis.

Basal cell carcinoma on the right hallux.

Basal cell carcinomas (BCCs) usually develop in sun-exposed areas. The finger, toe, and nail unit are very rare sites of BCC. We describe a patient with BCC on the right hallux. Clinically, it appeared as a brown-colored small plaque with an irregular border on the nail fold and dorsum of the right hallux. Histopathological findings were consistent with the superficial type of BCC.

Successful treatment of pulmonary metastasis and local recurrence of angiosarcoma with docetaxel.

Angiosarcoma of the face and scalp of the elderly frequently recurs locally, metastasizes early despite various treatments, and has a poor prognosis. We describe a patient who had angiosarcoma of the scalp with pulmonary metastasis. Local recurrence occurred after excision and local and arterial administration of IL-2. A weekly administration method of docetaxel was therefore selected, resulting in complete remission of the pulmonary metastasis and a partial response of the local recurrence. This favorable clinical outcome in our case suggests that docetaxel therapy may be an option for the treatment of angiosarcoma of the scalp with pulmonary metastasis.

A case of herpetiform pemphigus with anti-desmoglein 3 IgG autoantibodies.

Herpetiform pemphigus (HP) is a rare variant of pemphigus characterized by a unique clinical phenotype of erythematous or urticarial plaques and vesicles that present in a herpetiform arrangement. Most HP cases have circulating anti-desmoglein 1 (Dsg1) IgG autoantibodies, but some HP cases have anti-desmoglein 3 (Dsg3) IgG. A 92-year-old Japanese woman presented with severely pruritic annular erythema and vesicles in a herpetiform arrangement on the trunk. No oral mucosal lesions were present. Histopathologically, these vesicles showed eosinophilic spongiosis as well as suprabasilar acantholysis. Direct immunofluorescence showed in vivo IgG deposition on keratinocyte cell surfaces, and indirect immunofluorescence showed circulating IgG autoantibodies against keratinocyte cell surfaces at a titer of 1:30. Enzyme-linked immunosorbent assay using recombinant Dsg1 and Dsg3 revealed the presence of anti-Dsg3 IgG but no anti-Dsg1 IgG autoantibodies. The lack of oral mucosal involvement and the unique clinical features favored the diagnosis of HP. It remains to be clarified why the anti-Dsg3 IgG autoantibodies in this patient induced this unique features of HP, rather than the mucosal dominant type of pemphigus vulgaris.

Hematoxylin-stainability of keratohyalin granules is due to the novel component, fibrinogen γ-chain protein.

Hematoxylin-stainability of keratohyalin granules (KHG) using biochemical and immunohistochemical techniques is due to the presence of a fibrinogen γ-chain protein. A protein with a molecular weight of 100 kDa was stained with anti-Ted-H-1 monoclonal antibody and hematoxylin solution (hematoxylin-stainable protein). Since the amino acid sequence of the hematoxylin-stainable protein was to that of fibrinogen γ-chain protein, a peptide was synthesized and an antibody against the peptide was produced. This antibody reacted with the hematoxylin-stainable protein and fibrinogen γ-chain protein on immunoblot analysis and with KHG on immunohistochemical examination. Furthermore, a commercial anti-fibrinogen γ-chain protein antibody (Ab) also reacted with the hematoxylin-stainable protein as well as fibrinogen. In contrast, anti-fibrinogen ß-chain protein Ab did not react with the hematoxylin-stainable protein. The fibrinogen γ-chain protein also stained with hematoxylin. These findings suggested that fibrinogen γ-chain protein may be a novel component protein of KHG and may induce the hematoxylin-stainability of KHG.

Presence of bactericidal/permeability-increasing protein in human and rat skin.

To examine the presence of bactericidal/permeability-increasing protein (BPI) in skin, which is an antibacterial protein, has cytotoxicity toward Gram-negative bacteria, and may have an important role against bacterial infection in the skin, immunohistochemical and biochemical analyses were performed. Anti-BPI/KLH Ab reacted with the cytoplasm of the inner root sheath cells of both human and rat hair follicles by immunohistochemical examination. A protein band in 10-M alkaline urea extracts of human scalp skin or 7-day-old rat skin reacted with an antibody against BPI conjugated with KLH (anti-BPI/KLH Ab). Purified skin BPI (sBPI) from rat was a single protein spot and reacted with both anti-BPI/KLH Ab and a commercially available monoclonal antibody against BPI (anti-BPI MoAb). Moreover, sBPI possessed inhibitory activity against LPS. Bactericidal/permeability-increasing protein mRNA was expressed not only in leukocytes but also in human scalp skin and cultured keratinocytes. These findings suggest that sBPI could exist in the inner root sheath cells of human and rat hair follicles, and might play a role as a barrier against anaerobic bacteria in the isthmus of hair follicles.