[Skin tests for diagnostics of allergic immediate-type reactions. Guideline of the German Society for Allergology and Clinical Immunology]. / Hauttests zur Diagnostik von allergischen Soforttyp-Reaktionen. Leitlinie der Deutschen Gesellschaft für Allergologie und klinischen Immunologie (DGAKI).

Skin tests in patients with IgE-mediated immediate type allergy are performed with the intention to establish a contact between allergens and skin mast cells. The latter carry specific IgE antibodies on their surface. If mast cells get activated, mediators (mainly histamine) are released which induce a visible skin reaction (wheal and erythema).[nl]Skin tests are indicated, if an immediate type allergic disease is suspected. Systemic anaphylactic reactions at skin testing are very rare. However, it is necessary to take them into account and to provide emergency treatment. Relative contraindications comprise skin diseases in the test area, poor general condition and insufficiently treated severe asthma. If tests are used, which have a higher risk for a systemic anaphylactic reaction, pregnancy or beta-blocker therapy, are further contraindications.[nl]Skin test application does not depend on patient age. However, in pre-school age tests are reluctantly performed. It is essential to consider the half-life of drugs which may interfere with the test result, and which have to be discontinued early enough before testing. After anaphylactic reactions there may be a refractory period. Therefore, tests should not be done within the first week after such reactions. Skin prick tests are the procedures of first choice, intradermal tests are more sensitive than prick tests. Skin tests are performed at the flexor side of the forearm. As intradermal tests are more inconvenient, testing can be also done at a less susceptible site of the body (upper back).[nl]It is recommended to use standardized test extracts. However, if standardised extracts are not available or do not yield suitable test results, one may switch to other preparations. If the patient shows a positive reaction to a non-standardized substance, control tests should be performed in healthy subjects in order to exclude an unspecific reaction.[nl]The reaction is read after 15 to 20 min. Skin tests are regarded positive if the mean wheal diameter is ≥ 3 mm at the prick test, and ≥ 5 mm at the intradermal test.[nl]Skin test results may be negative although patients are allergic. If a skin test is positive, one will have to distinguish reactions, which are clinically relevant, from those, which are not. History and/or challenge tests help to clarify the relevance of a sensitization. Usually, a clinically irrelevant sensitization does not lead to practical consequences.

Interleukin-4 promotes the expansion of skin-infiltrating lymphocytes from atopic dermatitis in vitro.

Functional studies of lymphocytes in atopic dermatitis (AD) have so far focused on peripheral blood mononuclear cells (PBMC), whereas cells at the involved site, the skin, have not been examined. Accordingly, we have developed methods to generate lymphocyte cultures from biopsies of inflammatory skin areas. Skin-infiltrating lymphocytes (SIL) were isolated from skin biopsies of 6 patients with severe AD and expanded in vitro in the presence of interleukin-2 (IL-2) without additional antigens. After 6-10 d in culture, outgrowth of mononuclear cells from biopsy tissue was observed in all cases. Phenotypic analysis of skin-derived cells revealed the predominance of CD4+ T-helper/inducer phenotype in SIL populations. Parallel cultures of SIL and PBMC showed an increase and expansion of CD8+ T cells in cultured PBMC, whereas the CD4+ phenotype was predominant in SIL cultures. As indicated by their expression of HLA-DR and CD25 antigens, most of the SIL were activated and the cells mainly expressed T-cell receptors (TCR) composed of alpha and beta chains. Different strategies for expansion of SIL in vitro were examined. High levels of IL-4 (1,000 U/ml) in combination with IL-2 (50 U/ml or 1,000 U/ml) preferentially promoted growth of SIL derived from AD and were much more effective than IL-2 alone. No cells expanded in cultures with IL-4 alone. SIL grown with high concentrations of IL-4 contained a significant proportion of double-positive CD4+8+ cells. No other marked differences were observed in the distribution of T cell subsets in cultures propagated under different conditions for 21 d. Our results demonstrate the feasibility of growing infiltrating T lymphocytes from inflammatory skin of AD patients. The use of high concentrations of IL-2 in combination with high levels of IL-4 allows a large expansion of these cells and thus represents a useful strategy to expand cells for further functional and molecular biologic studies.

In vitro generation of IFN-gamma in relationship to in vivo concentration of IgE and IgG subclasses and Fc epsilon Rl/CD23 positive circulating lymphocytes in patients with severe atopic dermatitis (AD).

In fifteen patients with severe atopic dermatitis (AD) and ten healthy controls we investigated the in vitro generation of IFN-gamma and analysed the number of Fc epsilon RL/CD23 (low affinity Fc receptor for IgE) positive lymphocytes. We found a significantly impaired capacity to secrete IFN-gamma after PHA-stimulation compared to controls in a significant proportion of patients. Serum IgG4 levels in patients were higher compared to controls. A significant portion of lymphocytes bearing the low affinity Fc receptor for IgE (CD23) was observed with the moab Tü1 in patients. Lymphocytes from healthy donors were completely negative or less than 2% positive for Tü1. Despite small numbers of patients a significant correlation was found between IFN-gamma generation in vitro and IgE serum concentration in patients, whereas the IFN-gamma generation and IgG4 concentration were negatively correlated in the patient group. The number of Fc epsilon RL/CD23 positive lymphocytes in patients was positive correlated with the serum IgG4 and IgE concentration and negative correlated with IFN-gamma generation in vitro. Our data suggest that a possible dysregulation of IFN-gamma, Interleukin 4 or other lymphokine production may be related to increased IgE and IgG4 production.

[Socio-legal evaluation of UV-induced skin tumors]. / Sozialrechtliche Bewertung UV-induzierter Hauttumoren.

The present work deals with insurance and legal issues on the prevention of UV-induced skin tumors. We are convinced that squamous cell carcinoma of the skin fulfils the socio-legally required conditions according to paragraph 9 Abs. 2 SGB VII for approval as an occupational disease. In malignant melanoma evidence also exists for its induction through UV exposure and increased risk for occupational UV exposure, thus, making approval as an occupational disease possible in individual cases. According to the currently available medical knowledge on basal cell carcinoma and malignant melanoma, there is no sufficient basis for the approval of these as occupational disorders. Therefore, significant actions should not only be taken in the context of primary disease prevention, but also within the framework of secondary and tertiary disease prevention in occupational UV exposure.

[Evidence-based evaluation of the effect of Type IV Allergies on the reduction of fitness for work. Survey of occupational skin diseases]. / Evidenzbasierte Beurteilung der Auswirkung von Typ-IV-Allergien bei der Minderung der Erwerbsfähigkeit. Begutachtung berufsbedingter Hautkrankheiten.

Evidence-based guidelines about the distribution of type IV allergens of the European standard series in different professions and its occupational relevance are missing. Based on published data, epidemiological investigations, work related knowledge about industrial processes, and allergen specific properties, recommendations are given about the clinical impact in the working environment for the following allergens: acrylates/methacrylates, epoxy resins, dichromate, cobalt, nickel, formaldehyde, (chlor-)methylisothiazolone, p-phenylendiamine, colophony, thiurame, mercaptobenzothiazole, dithiocarbamate, n-isopropyl-n'-phenyl-p-phenylendiamine, fragrance mix, composite mix, and neomycinsulfate. These recommendations might improve the clearance rate and allergological evaluation of the occupational relevance of different delayed type sensitizations or allergens.

[Clinical and immune-modulating effects of the treatment with unsaturated fatty acids in atopic dermatitis]. / Klinische und immunmodulatorische Effekte einer Behandlung mit ungesättigten Fettsäuren bei atopischer Dermatitis.

The metabolism of essential unsaturated fatty acids seems to show changes in patients with atopic dermatitis (AD). A defect or a deficiency of a Delta-6-Desaturase, which transforms cis-linoleic acid into gamma-linolenic-acid will be discussed. We examined the influence of a treatment with unsaturated fatty acids on clinical phenotype and the surface antigens of lymphocytes in peripheral blood. Prolonged recurrence free intervals as well as a faster ability to control relapse were established. Dysbalance in the lymphocytic system was able to be positively influenced. We found an increase of Leu 2 a-antigen carrying T-suppressor-lymphocytes and of the Leu 3+8+- antigen carrying subpopulation of T-helper-lymphocytes, which are responsible for activation of precursor T-suppressor cells into.

[The Papillon-Lefevre syndrome (keratosis palmoplantaris with periodontopathy). Treatment with etretinate]. / Papillon-Lefèvre-Syndrom (Keratosis palmoplantaris mit Periodontopathie). Behandlung mit Etretinat.

The Papillon-Lefèvre syndrome is an autosomal recessive gene defect characterized by transgredient palmoplantar hyperkeratosis and periodontopathia leading to loss of the teeth. The syndrome is described in a 28-year-old man who had lost all of his teeth at the age of 10 years. Treatment with etretinate resulted in a marked improvement of the palmar and plantar skin lesions.

[Deficit of natural killer cells (NK cells) in the peripheral blood of patients with atopic dermatitis]. / Defizit natürlicher Killerzellen (NK-Zellen) im peripheren Blut bei atopischer Dermatitis.

Immunoregulatory T-cell subsets of the peripheral blood were measured using monoclonal antibodies (Leu series) in a group of 30 patients with atopic dermatitis and 20 healthy control persons. A highly significant reduction (P less than 0.001) in the percentage of Leu 11a+ (NK) and Leu 7+ (K/NK) cells was found in the peripheral blood of patients with atopic dermatitis. The proportion of Leu 2a+ cells (cytotoxic/suppressor) was significantly (P less than 0.001) lower in the patient group. The immunoregulatory ratio of Leu 3a+/Leu 2a+ T cells (helper/suppressor) was significantly (P less than 0.001) higher in the patient group (4.3 +/- 0.3) than in the blood of control persons (2.2 +/- 0.1). The percentage of Leu 11a+ cells was positively correlated with the percentage of Leu 2a+ cells (r = 0.67) and negatively correlated with the ratio of Leu 3a+/Leu 2a+ T cells (r = -0.63).

Reaction of human keratinocytes with the monoclonal antibody anti-Leu-11: an immunohistologic study.

Biopsy specimens from skin of 99 patients with 26 different dermatoses and 17 specimens from normal skin were labeled with regard to the reactivity of keratinocytes with the monoclonal natural killer-associated antibody anti-Leu-11b by means of the avidin-biotin-peroxidase complex method. Reactivity occurred in 64.7% of the preparations from normal skin and in 84.8% of the preparations from diseased skin. The membranes of the subcorneal keratinocyte layers were labeled regularly. In some of the preparations cytoplasmic reactivity and labeling of the basement membrane zone occurred in addition. Most labeled preparations and the highest labeling intensities were shown in the skin tumors and in the infectious dermatoses. The biologic significance of this finding is discussed.

Anti-Leu 19 monoclonal antibody detects an antigen on autonomic nerves in human skin.

The monoclonal antibody anti-Leu 19 recognizes the NKH-1 antigen of active natural killer cells. In immunohistological preparations of the skin, the antibody reacts with cutaneous nerves and labels nerve fibers in the region of the sweat glands, the blood vessels and the hair arrector muscles. This staining pattern corresponds to the distribution of the autonomic sympathetic nervous system of the skin. On the other hand, anti-Leu 7 labels a myelin-associated glycoprotein which is to be found in the myelin sheath of sensory cutaneous nerves. The reactivity of neural structures of the skin can thus be differentiated. Anti-Leu 7 labels the myelinated sensory nervous system, whereas anti-Leu 19 seems to constitute a new marker for the autonomic nervous system of the skin.

Evidence that defective interferon-gamma production in atopic dermatitis patients is due to intrinsic abnormalities.

The in vitro production of interferon-gamma (IFN-gamma) in 19 atopic dermatitis (AD) patients was compared with that of 12 controls. IFN-gamma production by phytohaemagglutinin (PHA) stimulated peripheral blood mononuclear cells (PBMC) was profoundly diminished in AD patients, whereas the proliferative response was similar to that of control PBMC. The addition of 40 U/ml of interleukin-2 (IL-2) to the cultures failed to restore IFN-gamma production. Similarly, removal of adherent cells also had no effect. Reduced IFN-gamma secretion was observed after stimulation with the CD3 monoclonal antibody OKT3, ionomycin + 12-O-tetradecanoyl-phorbol-13-acetate (TPA) or with high levels of IL-2 (200 U/ml). There were increased proportions of CD4+ T helper/inducer cells and decreased proportions of CD8+ T cytotoxic-/suppressor cells and CD16+ natural killer (NK) cells in AD patients. This resulted in an increased CD4/CD8 ratio as compared with controls, but no correlation was observed between numbers of T cell subpopulations and IFN-gamma generation. However, a significant correlation was found between IFN-gamma generation in vitro and IgE serum concentration in AD patients. The data suggest that the decreased production of IFN-gamma by AD patients is due to intrinsic differences in capacity to produce this cytokine and is not the result of differences in regulatory cell interactions. Moreover, the findings indicate that decreased production of IFN-gamma may be an important factor in the pathogenesis of this disease.

[GnRH test in disorders of testicular function. Studies of the methodology and value in normogonadotropic oligozoospermia]. / Gn-RH-Test bei Hodenfunktionsstörungen. Untersuchungen zur Methodik und Aussagekraft bei normogonadotroper Oligozoospermie.

In 42 men suffering from normogonadotropic oligospermia, the response of follicle-stimulating hormone (FSH) to 50 micrograms of intravenously administered gonadotropin-releasing hormone (GnRH) was determined after 15, 30, 60, 90 and 120 minutes. In most patients, the release of FSH rapidly increased during the first 30 minutes following GnRH administration, and there was little change after the maximum level of FSH (FSH max) had been achieved. FSH max was noticed after 30 minutes in 45,2% and after 60 or 90 minutes in other 45.3% of the patients; so every GnRH test should include the determination after 60 minutes. Hypergonadotropic response in GnRH test at normal basal levels of FSH may be diagnosed at sperm densities below 5 mill./ml. We regard a difference between basal and maximum level of FSH of more than 3 mU/ml to be a hypergonadotropic response. The GnRH test should not be confined to hypogonadotropic oligospermia; it may also be applied in endocrinological investigation of severe normogonadotropic oligo- and azoospermia.

Immunoglobulin E and immunoglobulin G subclass distribution in vivo and relationship to in vitro generation of interferon-gamma and neopterin in patients with severe atopic dermatitis.

In vitro interferon-gamma (IFN gamma) and neopterin generation by peripheral blood mononuclear cells (PBMC) from 15 patients with severe atopic dermatitis (AD) and 10 healthy controls was investigated. A significant proportion of patients had an impaired capacity to secrete IFN gamma after phytohemagglutinin (PHA) stimulation in vitro and therefore IFN gamma production was significantly lower compared to controls. Neopterin generation in vitro did not differ significantly from that of controls and no correlation between in vitro IFN gamma and neopterin production could be observed in either group. Analysis of serum IgG subclass distribution showed that patients with AD. had increased IgG4 serum concentrations while IgG1, IgG2 and IgG3 levels did not differ significantly from those of controls. Surface marker analysis revealed increased numbers of CD23+ lymphocytes in patients with AD which was positively correlated with the serum IgG4 and IgE concentration. Furthermore, a significant correlation was found between IFN gamma generation in vitro and IgE and IgG4 concentration in vivo in AD. The data suggest that a possible dysregulation of IFN gamma, interleukin-4 or other lymphokine interleukin-4 or other lymphokine production may be related to increased IgE and IgG4 production and seems to be an important factor in the pathogenesis of AD.

Selective alterations in natural killer cell subsets in patients with atopic dermatitis.

We examined the immunophenotypic characteristics of natural killer (NK) cell subsets in patients with severe atopic dermatitis (AD), rhinitis allergica (RA) and in healthy controls. Expression of CD16, CD56 and CD57 antigens on peripheral blood lymphocytes was evaluated by simultaneous double immunocytofluorometry. Our results showed significantly lower percentages of cells with CD16, CD56 and CD57 surface antigens in patients with AD. Furthermore subdivision of the AD group into two subgroups, AD1 and AD0 (with and without antigen-specific IgE antibodies against potent inhalative allergens, i.e. mite, grass, rye, birch, cat) revealed that patients of subgroup AD1 showed a more prominent decrease compared to that of subgroup AD0. Moreover, we found a significant negative correlation between the percentage of CD56 + CD16 + NK cells and total IgE levels in serum, which were significantly higher in patients of subgroup AD1 than in AD0. NK cell activity was deficient in patients with AD but there was no difference between both subgroups. These data indicate that considerable heterogeneity in immunologic regulation may exist in patients with AD with regard to their NK cell subsets.

Cytokine release from cultured peripheral blood mononuclear cells of patients with severe atopic dermatitis.

Peripheral blood mononuclear cells (PBMC) from 14 patients with severe atopic dermatitis (AD) and 11 healthy donors were tested for their capacity to produce tumour necrosis factor-alpha (TNF-alpha) after PHA stimulation and compared with their in vitro production of interferon-gamma (IFN-gamma). The mean TNF-alpha production in AD patients did not differ vis-à-vis controls. However, a significant portion of patients with AD which was defective in generating IFN-gamma in vitro showed in addition significantly a decreased production of TNF-alpha. No correlation could be found between TNF-alpha and neopterin production in either group, whereas there was a close overall correlation between the amount of TNF-alpha and IFN-gamma detectable in culture supernatants of patients and controls. Furthermore, a significant correlation was found between TNF-alpha and IFN-gamma generation in vitro and serum IgE concentration in AD. Based on cytokine production in vitro and IgE concentration in vivo, patients with severe AD could be divided into two groups. Furthermore, 3 AD patients with normal IFN-gamma generation and low serum IgE concentration but suffering from eczema herpeticum formed a subgroup which showed an increased TNF-alpha production in vitro. The data suggest alterations in cytokine production in a subgroup of patients with AD which bear a reciprocal relationship to abnormal IgE regulation.

Role of activated T lymphocytes in mycosis fungoides.

A patient with mycosis fungoides was treated effectively with the immunosuppressant cyclosporine A. Excretion of urinary neopterin, a marker of activation of the cellular immune system, fell immediately at the start of therapy. This result argues in support of a central role of activated T lymphocytes in this disease as has already been proposed by other authors.