Characterization of the facial microbiome in twins discordant for rosacea.

Previously, we determined that genetic and environmental factors contributed equally towards rosacea in twins. To assess an environmental factor, we characterized the malar cheek bacterial microbiome from twins discordant for rosacea. We found no significant difference in facial microbiome alpha and beta diversity between related twins discordant for rosacea. However, the relative percentage abundance of Gordonia and Geobacillus, low-abundant genera, was positively and negatively associated with rosacea severity, respectively. Our data demonstrate a significant correlation between facial microbiome and severity of rosacea in genetically matched twins and importantly that overall microbiome composition is largely unchanged.

Use of 16S rRNA sequencing and quantitative PCR to correlate venous leg ulcer bacterial bioburden dynamics with wound expansion, antibiotic therapy, and healing.

Clinical diagnosis of infection in chronic wounds is currently limited to subjective clinical signs and culture-based methods that underestimate the complexity of wound microbial bioburden as revealed by DNA-based microbial identification methods. Here, we use 16S rRNA next generation sequencing and quantitative polymerase chain reaction to characterize weekly changes in bacterial load, community structure, and diversity associated with a chronic venous leg ulcer over the 15-week course of treatment and healing. Our DNA-based methods and detailed sampling scheme reveal that the bacterial bioburden of the wound is unexpectedly dynamic, including changes in the bacterial load and community structure that correlate with wound expansion, antibiotic therapy, and healing. We demonstrate that these multidimensional changes in bacterial bioburden can be summarized using swabs taken prior to debridement, and therefore, can be more easily collected serially than debridement or biopsy samples. Overall, this case illustrates the importance of detailed clinical indicators and longitudinal sampling to determine the pathogenic significance of chronic wound microbial dynamics and guide best use of antimicrobials for improvement of healing outcomes.

Characterization of bacterial communities in venous insufficiency wounds by use of conventional culture and molecular diagnostic methods.

Microbial infections delay wound healing, but the effect of the composition of the wound microbiome on healing parameters is unknown. To better understand bacterial communities in chronic wounds, we analyzed debridement samples from lower-extremity venous insufficiency ulcers using the following: conventional anaerobic and aerobic bacterial cultures; the Ibis T5000 universal biosensor (Abbott Molecular); and 16S 454 FLX titanium series pyrosequencing (Roche). Wound debridement samples were obtained from 10 patients monitored clinically for at least 6 months, at which point 5 of the 10 sampled wounds had healed. Pyrosequencing data revealed significantly higher bacterial abundance and diversity in wounds that had not healed at 6 months. Additionally, Actinomycetales was increased in wounds that had not healed, and Pseudomonadaceae was increased in wounds that had healed by the 6-month follow-up. Baseline wound surface area, duration, or analysis by Ibis or conventional culture did not reveal significant differences between wounds that healed after 6 months and those that did not. Thus, pyrosequencing identified distinctive baseline characteristics of wounds that did not heal by the 6-month follow-up, furthering our understanding of potentially unique microbiome characteristics of chronic wounds.

A case of multiple skin cancers in a patient on combination immunosuppressive therapy for Behcet's disease.

Skin cancer risk from the use of immunosuppressive medications used to treat inflammatory conditions is not well understood, though studies clearly establish an exaggerated risk of skin cancer in solid organ transplant recipients (SOTRs) receiving these medications. The authors report a patient with Behcet's disease treated with combination immunosuppressive therapy and common variable immunodeficiency developing multiple squamous cell carcinomas (SCCs) of the skin, necessitating adjustment of her immunosuppressive regimen. As more patients are treated with immunosuppressive medications for chronic inflammatory diseases, clinicians must be aware of the possible increased risk of skin cancers associated with these medications. Skin cancer risk assessment, screening for sub-clinical malignancies and frequent skin exams of high risk patients may represent strategies to improve the safety of these medications.

Perforating folliculitis in a patient with cystic fibrosis.

We report a case of a young man with perforating folliculitis and cystic fibrosis with complications including chronic obstructive pulmonary disease, insulin dependent diabetes mellitus, and liver cirrhosis. We demonstrate increased TGF-ß1 immunohistochemical staining in the perforating folliculitis lesions of our patient and discuss the possible associations between cystic fibrosis and perforating folliculitis.

Pseudocarcinomatous hyperplasia with follicular differentiation overlying basal cell carcinoma.

We present a series of 25 cases of basal cell carcinoma (BCC) with overlying cytologically bland epidermal hyperplasia and cyst formation. Eight of the BCCs were nodular and 11 were infiltrative. Immunohistochemical staining for Ki-67 and cytokeratin 17 (CK17) was performed to evaluate the proliferative and differentiation characteristics of the hyperplastic epithelium compared with the adjacent BCC and normal epidermis. Fourteen of the 25 cases had sufficient tissue to evaluate the staining patterns. In the majority of cases, Ki-67 expression was prominent throughout the BCCs, but only expressed in the basal and suprabasal layers of the adjacent hyperplastic epithelium, which was equivalent to normal epidermis. CK17 expression was prominent throughout the BCC and surrounding incident hair follicles. CK17 was expressed to a lesser extent in the central more keratinized portions of the hyperplastic epithelium, but rarely in normal epidermis. The morphologic characteristics and immunohistochemical staining patterns in these tumors suggest that the epidermal hyperplasia represents pseudocarcinomatous hyperplasia with follicular differentiation. Recognizing this pattern of epidermal change should alert the pathologist to the possibility of an associated BCC in cases in which the biopsy specimen or sectioning is initially too superficial to reveal the underlying malignancy.

Association Between Microbial Bioburden and Healing Outcomes in Venous Leg Ulcers: A Review of the Evidence.

Significance: Venous leg ulcers (VLUs) are susceptible to microbial invasion, and serious complications can result without the timely control of infection. Diagnosis of wound infection is primarily based on subjective clinical characteristics and patient-reported symptoms, and the treatment with antimicrobials has not consistently shown improvement in healing outcomes. This is a review of studies using bacterial cultures and/or new molecular-based methods associating microbial bioburden with healing outcomes in VLU patients, with the goal of guiding future studies to better determine significant patterns of microbial involvement in chronic wounds. Recent Advances: Studies reviewed here use cultivation-based identification of bacteria and next-generation sequencing of the bacterial 16S rRNA gene to gain insight into microbial bioburden in VLUs. Further application of sophisticated DNA sequencing and bioinformatic analyses has the potential to revolutionize our ability to further discern, with high resolution, complex microbial communities in chronic wounds. Critical Issues: Few previous studies of microbial bioburden in VLUs have incorporated the knowledge of clinical treatments, which includes close monitoring of patients' symptoms and responses to therapy. Thus, wound care practitioners are currently without evidence-based guidance for the diagnosis and treatment of wound infections. Future Directions: Clinically relevant breakthroughs are possible by combining advanced microbial detection techniques with improved study designs that reflect clinical practices. Well-designed longitudinal studies have great potential to lead to better evidence-based diagnosis of chronic wounds. A greater understanding of microbial bioburden in chronic wounds is likely to lead to better therapies that speed healing and prevent wound infection without risking the development of antimicrobial resistance.

Genetic vs Environmental Factors That Correlate With Rosacea: A Cohort-Based Survey of Twins.

IMPORTANCE: To our knowledge, this is the first study on rosacea to formally define genetic and environmental contributions. OBJECTIVES: To study a cohort of identical and fraternal twins to determine whether genetic factors contribute to rosacea development and, if genetic factors are present, quantitatively estimate the genetic contribution, as well as to identify environmental factors that correlate with rosacea by controlling for genetic susceptibility. DESIGN, SETTING, AND PARTICIPANTS: Identical and fraternal twins were surveyed regarding risk factors implicated in rosacea. Faculty dermatologists determined a rosacea score for each twin participant according to the National Rosacea Society (NRS) grading system. Data were collected at the annual Twins Days Festival in Twinsburg, Ohio, on August 4-5, 2012, and August 2-3, 2013. Analysis was conducted for several months after each meeting. A cohort of 550 twin individuals, with most from Ohio, Pennsylvania, and the northeastern United States, participated. MAIN OUTCOMES AND MEASURES: The NRS score and rosacea subtype were assessed using the NRS grading system and physical examination by board-certified dermatologists. RESULTS: Among the 275 twin pairs (550 individuals), there were 233 identical twin pairs with a mean rosacea score of 2.46 and 42 fraternal twin pairs with a mean rosacea score of 0.75. We observed a higher association of NRS scores between identical vs fraternal twins (r = 0.69 vs r = 0.46; P = .04), demonstrating a genetic contribution. Using the ACE model (proportion of variance in a trait heritable secondary to additive genetics [A] vs the proportions due to a common environment [C] and unique environment [E]), we calculated this genetic contribution to be 46%. A higher NRS score was also significantly associated with the following factors: age (r = 0.38; P < .001) and lifetime UV radiation exposure (r = 0.26; P < .001). These associations remained after use of propensity score matching to adjust for multicollinearity. Other correlated variables included body mass index (r = 0.21; P < .001), smoking (r = 0.10; P < .02), alcohol consumption (r = 0.11; P = .01), cardiovascular comorbidity (r = 0.17; P < .001), and skin cancer comorbidity (r = 0.19; P < .001). CONCLUSIONS AND RELEVANCE: The study of twins allows us to separate genetic susceptibility and the influence of environmental factors affecting rosacea. We found that approximately half of the contribution to the NRS score could be accounted for by genetics and the other half by environment. We identified correlations between rosacea and UV radiation exposure, alcohol, smoking, skin cancer history, cardiac comorbidity, and age. These findings may help improve current management and expectations of individuals affected by rosacea.

Hepcidin regulates cellular iron efflux by binding to ferroportin and inducing its internalization.

Hepcidin is a peptide hormone secreted by the liver in response to iron loading and inflammation. Decreased hepcidin leads to tissue iron overload, whereas hepcidin overproduction leads to hypoferremia and the anemia of inflammation. Ferroportin is an iron exporter present on the surface of absorptive enterocytes, macrophages, hepatocytes, and placental cells. Here we report that hepcidin bound to ferroportin in tissue culture cells. After binding, ferroportin was internalized and degraded, leading to decreased export of cellular iron. The posttranslational regulation of ferroportin by hepcidin may thus complete a homeostatic loop: Iron regulates the secretion of hepcidin, which in turn controls the concentration of ferroportin on the cell surface.