Clinical practice consensus for the diagnosis and management of melanoma in Taiwan.

Melanoma is rare in Taiwan. Asian melanoma is distinct from Western melanoma because acral and mucosal melanoma accounts for the majority of melanoma cases, leading to distinct tumor behaviors and genetic profiling. With consideration of the clinical guidelines in Western countries, Taiwanese experts developed a local clinical practice consensus guideline. This consensus includes diagnosis, staging, and surgical and systemic treatment, based only on clinical evidence, local epidemiology, and available resources evaluated by experts in Taiwan. This consensus emphasizes the importance of surgical management, particularly for sentinel lymph node biopsies. In addition, molecular testing for BRAF is mandatory for patients before systemic treatment. Furthermore, immunotherapy and targeted therapy are prioritized for systemic treatment. This consensus aimed to assist clinicians in Taiwan in diagnosing and treating patients according to available evidence.

Mechanisms and Effects of Isorhamnetin on Imiquimod-Induced Psoriasiform Dermatitis in Mice.

Isorhamnetin (IRh), which has a wide range of pharmacological effects, is one of the most significant active components in the fruits of Hippophae rhamnoides L. and the leaves of Ginkgo biloba L. It protects the heart and brain, in addition to possessing anti-tumor, anti-inflammatory, antioxidant, organ protection, and anti-obesity properties. We sought to assess IRh's anti-psoriatic activity, explore its immunomodulatory properties in reducing the severity of psoriatic symptoms, and evaluate its potential immunotherapeutic effects. We used IRh to treat imiquimod (IMQ)-induced psoriasis in BALB/C mice and examined the underlying mechanisms. The outcomes demonstrated that IRh reduced epidermal hyperplasia, lowered PASI scores, and improved histopathological psoriasiform lesions in IMQ-induced mice. IRh attenuated the accumulation of malondialdehyde (MDA), and also reversed the reduction caused by IMQ of superoxide dismutase (SOD) and catalase (CAT) in skin tissues. Additionally, IRh effectively inhibited IMQ's ability to increase proinflammatory cytokines such as TNF-α, IL-6, IL-17A, and transcription factor NF-κB. Furthermore, IRh significantly reduced the percentage of Th1 and Th17 in the spleens of mice treated with IMQ and suppressed the maturation of splenic dendritic cells. Overall, our research suggests that IRh protects against oxidative stress and inflammation in the pathogenesis of psoriasis, with potential for the development of new and potent medication for the treatment of psoriasis.

Beta2-adrenergic receptor agonist inhibits keratinocyte proliferation by mechanisms involving nitric oxide.

INTRODUCTION: Beta2-adrenoceptors regulate proliferation of keratinocytes. Nitric oxide (NO) produced by keratinocytes through stimulation of nitric oxide synthase (NOS) mediates keratinocyte proliferation. Aim: In this study, the mechanism interaction ß-ARs and NO production on keratinocyte will be explored, and the important for proliferation will be studied. MATERIAL AND METHODS: To understand the relationship among ß2-adrenoceptors, NO production and proliferation in keratinocytes, the experiment is divided to two parts. In the first part of the experiment, keratinocytes are divided into five groups which are treated with 0 M, 10-7 M, 10-6 M, 5 × 10-6 M and 10-5 M isoproterenol, respectively. In the second part of the experiment, the keratinocytes are divided into five groups which are treated with 10-5 M isoproterenol and L-NMMA at doses of 0 M, 10-6 M, 5 × 10-6 M, 10-5 M and 5 × 10-5 M, respectively. We examine NOS expression, NO production, c-AMP level and proliferation in human keratinocytes. RESULTS: The results show that isoproterenol results in iNOS and ncNOS protein raised and the elevation of nitric oxide. L-NMMA can block the increase of iNOS and ncNOS protein expression and the ability to inhibit proliferation caused by isoproterenol. CONCLUSIONS: Beta2-adrenergic receptor agonist mediates nitric oxide synthase to affect keratinocyte proliferation in skin. The physiological and pathological relationship of these discoveries remains to be defined. These results can provide new possibilities in the therapy of integumentary disease conditions linked with the dysfunction of ß-AR-mediated NO production.

NRAS Mutations May Be Involved in the Pathogenesis of Cutaneous Rosai Dorfman Disease: A Pilot Study.

BACKGROUND: Purely cutaneous Rosai-Dorfman disease (RDD) is a rare histiocytic proliferative disorder limited to the skin. To date, its pathogenesis remains unclear. Owing to recent findings of specific mutations in the mitogen-activated protein kinase/extracellular signal-regulated kinase (MAPK/ERK) pathway in histiocytic proliferative disorders, it provides a novel perspective on the pathomechanism of cutaneous RDD. We aim to investigate the genomic mutations in MAPK/ERK pathway in cutaneous RDD. METHODS: We retrospectively recruited all cases of cutaneous RDD from two hospitals in Taiwan from January 2010 to March 2020 with the clinicopathologic features, immunohistochemistry, and treatment. Mutations of neuroblastoma RAS viral oncogene homolog (NRAS), Kirsten rat sarcoma 2 viral oncogene homolog (KRAS), and v-raf murine sarcoma viral oncogene homolog B1 (BRAF) in MAPK/ERK pathway were investigated by the highly sensitive polymerase chain reaction with Sanger sequencing. RESULTS: Seven patients with cutaneous RDD were recruited with nine biopsy specimens. The median age was 46 years (range: 17-62 years). Four of seven patients (57.1%) received tumor excision, while the other three chose oral and/or topical or intralesional steroids. NRAS mutation was detected in 4 of 7 cases (4/7; 51.7%), and NRAS A146T was the most common mutant point (n = 4/7), followed by NRAS G13S (n = 2/7). There is no KRAS or BRAF mutation detected. CONCLUSIONS: We report the NRAS mutation is common in cutaneous RDD, and NRAS A146T was the most frequent mutation in this cohort. Mutations in the NRAS gene can activate the RAS/MAPK signaling and have been reported to be associated with various cancers. It indicates that NRAS mutation in MAPK/ERK pathway may involve the pathogenesis of cutaneous RDD.

Cisplatin-Induced Giant Cells Formation Is Involved in Chemoresistance of Melanoma Cells.

Melanoma is notoriously resistant to current cancer therapy. However, the chemoresistance mechanism of melanoma remains unclear. The present study unveiled that chemotherapy drug cisplatin induced the formation of giant cells, which exhibited enlargement in cell diameter and nucleus in mice and human melanoma cells. Giant cells were positive with melanoma maker S100 and cancer stem cell markers including ABCB5 and CD133 in vitro and in vivo. Moreover, giant cells retained the mitotic ability with expression of proliferation marker Ki-67 and exhibited multiple drug resistance to doxorubicin and actinomycin D. The mitochondria genesis/activities and cellular ATP level were significantly elevated in giant cells, implicating the demand for energy supply. Application of metabolic blockers such as sodium azide or 2-deoxy glucose abolished the cisplatin-induced giant cells formation and expression of cancer stemness markers. The present study unveils a novel chemoresistance mechanism of melanoma cells via size alteration and the anti-neoplastic strategy by targeting giant cells.

Phloretin alleviates dinitrochlorobenzene-induced dermatitis in BALB/c mice.

Atopic dermatitis (AD) is a chronic inflammatory disease of the skin that substantially affects a patient's quality of life. While steroids are the most common therapy used to temporally alleviate the symptoms of AD, effective and nontoxic alternatives are urgently needed. In this study, we utilized a natural, plant-derived phenolic compound, phloretin, to treat allergic contact dermatitis (ACD) on the dorsal skin of mice. In addition, the effectiveness of phloretin was evaluated using a mouse model of ACD triggered by 2,4-dinitrochlorobenzene (DNCB). In our experimental setting, phloretin was orally administered to BALB/c mice for 21 consecutive days, and then, the lesions were examined histologically. Our data revealed that phloretin reduced the process of epidermal thickening and decreased the infiltration of mast cells into the lesion regions, subsequently reducing the levels of histamine and the pro-inflammatory cytokines interleukin (IL)-6, IL-4, thymic stromal lymphopoietin (TSLP), interferon-γ (IFN-γ) and IL-17A in the serum. These changes were associated with lower serum levels after phloretin treatment. In addition, we observed that the mitogen-activated protein kinase (MAPK) and NF-κB pathways in the dermal tissues of the phloretin-treated rodents were suppressed compared to those in the AD-like skin regions. Furthermore, phloretin appeared to limit the overproliferation of splenocytes in response to DNCB stimulation, reducing the number of IFN-γ-, IL-4-, and IL-17A-producing CD4+ T cells in the spleen back to their normal ranges. Taken together, we discovered a new therapeutic role of phloretin using a mouse model of DNCB-induced ACD, as shown by the alleviated AD-like symptoms and the reversed immunopathological effects. Therefore, we believe that phloretin has the potential to be utilized as an alternative therapeutic agent for treating AD.

Topical MTII Therapy Suppresses Melanoma Through PTEN Upregulation and Cyclooxygenase II Inhibition.

Melanotan II (MTII), a synthetic analogue of the alpha-melanocyte stimulating hormone (α-MSH), has been applied for skin tanning in humans. However, the carcinogenic consequence of topical MTII has been equivocal. This study aims to delineate the anti-neoplastic efficacy and mechanism of MTII using the B16-F10 melanoma model in vitro and in vivo. It was found that, despite a lack of influence on proliferation, MTII potently inhibited the migration, invasion, and colony-forming capability of melanoma cells. Moreover, topical MTII application significantly attenuated the tumor progression in mice bearing established melanoma. Histological analysis revealed that MTII therapy induced apoptosis while inhibiting the proliferation and neovaluarization in melanoma tissues. By immunoblot and immunohistochemical analysis, it was found that MTII dose-dependently increased the phosphatase and tensin homolog (PTEN) protein level while reducing PTEN phosphorylation, which resulted in the inhibition of AKT/nuclear factor kappa B (NFκB) signaling. Consistently, MTII treatment inhibited cyclooxygenase II (COX-2) expression and prostaglandin E2 (PGE2) production in melanoma cells. Finally, studies of antibody neutralization suggest that the melanocortin 1 receptor (MC1R) plays a critical role in MTII-induced PTEN upregulation and melanoma suppression. Together, these results indicate that MTII elicits PTEN upregulation via MC1R, thereby suppressing melanoma progression through downregulating COX-2/PGE2 signaling. Hence, topical MTII therapy may facilitate a novel therapeutic strategy against melanoma.

Epidermal growth factor receptor (EGFR) inhibitor induced purpuric drug eruption: Three case reports.

INTRODUCTION: Purpuric drug eruption (PDE) is an uncommon, clinically distinct side effect of epidermal growth factor receptor (EGFR) inhibitors. PATIENT CONCERNS: Unlike acneiform eruption, which arises from hair follicles mainly in the head and neck area, PDE starts from xerosis cutis, primarily in the lower extremities and is not associated with hair follicles. Herein, we report 3 cases of 3 patients who had received EGFR inhibitor and were hospitalized for PDE later. The cases were characterized by painful late-onset palpable purpura with identifiable bacterial pathogens. DIAGNOSIS: The patients were diagnosed with characteristic clinical presentations, that is, late onset, PDE locations mainly in the lower extremities, nonfollicular centricity, and laboratory findings with identifiable bacterial pathogens. INTERVENTIONS: Systemic antibiotics and intensive moisturizer application were prescribed. OUTCOMES: All the patients were successfully treated within 6 to 9 days without discontinuation of EGFR inhibitors. CONCLUSION: Systemic antibiotics, topical emollient, and skin barrier repair should be included in the treatment regimens for PDE.

Sclareol attenuates the development of atopic dermatitis induced by 2,4-dinitrochlorobenzene in mice.

Context: Atopic dermatitis is a common chronic inflammatory skin disease affecting up to 20% of children and 1% of adults worldwide. Treatment of atopic dermatitis include corticosteroids and immunosuppressants, such as calcineurin inhibitors and methotrexate. However, these treatments often bring about adverse effects including skin atrophy, osteoporosis, skin cancer, and metabolic syndrome. Objective: In this study, we evaluated the therapeutic effects and mechanisms of sclareol, a natural diterpene, on atopic dermatitis (AD)-like skin lesions induced by 2,4-dinitrochlorobenzene (DNCB) in mice. Materials and methods: To evaluate the effect of sclareol in vivo model, BALB/c mice were repeatedly injected intraperitoneally with sclareol (50 and 100 mg/kg) in 2,4-dinitrochlorobenzene (DNCB)-induced AD-like murine model. Major assays were enzyme-linked immunosorbent assay, histological analysis, flow cytometry, western blot analysis. Results: Intraperitoneal administration of sclareol (50 and 100 mg/kg) significantly attenuated AD-like symptoms, such as serum IgE levels, epidermal/dermal hyperplasia, and the numbers of infiltrated mast cells. In addition, systemic sclareol treatments reduced local pro-inflammatory cytokine concentrations, including IL-6, IL-1b, TNF-a, IL-4, IFN-g, and IL-17A, on AD-like lesions. Furthermore, we demonstrated that sclareol also suppressed T cell activation and the capability of cytokine productions (IFN-g, IL-4 and IL-17A) in response to DNCB stimulation. By examining the skin homogenate, we found that sclareol inhibited the AD-like severity likely through suppressions of both NF-kB translocation and phosphorylation of the MAP kinase pathway. Discussion and conclusions: Cumulatively, our results indicate that sclareol induced anti-inflammatory effects against the atopic dermatitis elicited by DNCB. Thus, sclareol is worth of being further evaluated for its potential therapeutic benefits for the clinical treatment of AD.

α-Melanocyte-Stimulating Hormone Attenuates Neovascularization by Inducing Nitric Oxide Deficiency via MC-Rs/PKA/NF-κB Signaling.

α-melanocyte-stimulating hormone (α-MSH) has been characterized as a novel angiogenesis inhibitor. The homeostasis of nitric oxide (NO) plays an important role in neovascularization. However, it remains unclear whether α-MSH mitigates angiogenesis through modulation of NO and its signaling pathway. The present study elucidated the function and mechanism of NO signaling in α-MSH-induced angiogenesis inhibition using cultured human umbilical vein endothelial cells (HUVECs), rat aorta rings, and transgenic zebrafish. By Griess reagent assay, it was found α-MSH dose-dependently reduced the NO release in HUVECs. Immunoblotting and immunofluorescence analysis revealed α-MSH potently suppressed endothelial and inducible nitric oxide synthase (eNOS/iNOS) expression, which was accompanied with inhibition of nuclear factor kappa B (NF-κB) activities. Excessive supply of NO donor l-arginine reversed the α-MSH-induced angiogenesis inhibition in vitro and in vivo. By using antibody neutralization and RNA interference, it was delineated that melanocortin-1 receptor (MC1-R) and melanocortin-2 receptor (MC2-R) participated in α-MSH-induced inhibition of NO production and NF-κB/eNOS/iNOS signaling. This was supported by pharmaceutical inhibition of protein kinase A (PKA), the downstream effector of MC-Rs signaling, using H89 abolished the α-MSH-mediated suppression of NO release and eNOS/iNOS protein level. Therefore, α-MSH exerts anti-angiogenic function by perturbing NO bioavailability and eNOS/iNOS expression in endothelial cells.

Autophagic cell death participates in POMC-induced melanoma suppression.

Hypoxia in tumors is known to trigger the pro-survival pathways such as autophagy. Systemic proopiomelanocortin (POMC) gene therapy suppresses melanoma through apoptosis induction and neovascularization blockage. In this study, we investigated the crosstalk between autophagic and apoptotic signaling in POMC-mediated melanoma suppression. By histological and immunoblot analysis, it was shown that POMC-treated melanoma tissues exhibited the prominent LC3 immunostaining, which was correlated with reduced CD31-positive tumor vascularization. Such autophagy induction could be recapitulated in melanoma cells receiving POMC gene delivery and hypoxia-mimicking agent cobalt chloride (CoCl2). We then utilized the POMC-derived peptide α-MSH with CoCl2 to elicit the autophagy as well as apoptosis in cultured melanoma cells. To delineate the role of autophagy during cell death, application of autophagy-inducer rapamycin enhanced, whereas autophagy inhibitor 3-MA attenuated, the α-MSH-induced apoptosis in melanoma cells. Genetic silencing of ATG5, an autophagy regulator, by RNA interference perturbed the α-MSH-induced apoptosis in melanoma cells. Finally, it was delineated that α-MSH stimulated the HIF-1α signaling as well as the expression of BNIP3/BNIP3L, thereby promoting the autophagy and apoptosis in melanoma cells. Therefore, the present study unveiled a unique function of autophagy in promoting cell death during POMC-mediated melanoma suppression via α-MSH/HIF-1α/BNIP3/BNIP3L signaling pathway.

Electrospun Poly(ε-caprolactone) Nanofibrous Mesh for Imiquimod Delivery in Melanoma Therapy.

Drug delivery systems (DDS) are commonly employed to administer drug-loaded composites to their therapeutic targets both in vitro and in vivo. Thus, we herein report the study of imiquimod-poly(ε-caprolactone) (IMQ-PCL) nanofibrous meshes for application in melanoma therapy. The preparation route employed was based on the electrospinning technique, with the melanoma cells being cultured on electrospun nanofibrous meshes to study their biocompatibility. All parameters employed, including the flow rate and polymer solution concentration, were examined to gain an improved understanding of the factors influencing the diameter and morphology of the electrospun fibre. The optimised parameters were employed to produce 12 IMQ-PCL nanofibrous meshes with diameters ranging from 100 to 900 nm to the melanoma cell viability. The relationship between the fibrous diameter and the imiquimod release profile was also determined using UV-Vis spectroscopy. In addition, similar results were obtained for the simulated imiquimod release profile obtained by COMSOL Multiphysics®. The IMQ-PCL nanofibrous meshes were found to decrease cell viability by ≥50%, with the number of cells dropping by ~10% over 48 h. As the cell viability was affected by the release of imiquimod, we believe that IMQ-PCL nanofibrous meshes are a promising drug delivery system for application in melanoma therapy.

Lactobacillus pentosus GMNL-77 inhibits skin lesions in imiquimod-induced psoriasis-like mice.

Psoriasis, which is regarded as a T-cell-mediated chronic inflammatory skin disease, is characterized by hyperproliferation and poor differentiation of epidermal keratinocytes. In this study, we aimed to determine the in vivo effect of a potentially probiotic strain, Lactobacillus pentosus GMNL-77, in imiquimod-induced epidermal hyperplasia and psoriasis-like skin inflammation in BALB/c mice. Oral administration of L. pentosus GMNL-77 significantly decreased erythematous scaling lesions. Real-time polymerase chain reaction showed that treatment with L. pentosus GMNL-77 significantly decreased the mRNA levels of proinflammatory cytokines, including tumor necrosis factor-alpha, interleukin (IL)-6, and the IL-23/IL-17A axis-associated cytokines (IL-23, IL-17A/F, and IL-22) in the skin of imiquimod-treated mice. In addition, we found that L. pentosus GMNL-77 decreased the spleen weights of the imiquimod-treated group and reduced the numbers of IL-17- and IL-22-producing CD4+ T cells in the spleen. In conclusion, the present study provides insight into the potential use of L. pentosus GMNL-77 in the future treatment of psoriasis.

Risk Factors For Radiation-Induced Skin Ulceration in Percutaneous Coronary Interventions of Chronic Total Occluded Lesions: A 2-Year Observational Study.

Relationship between radiation-induced skin ulceration (RSU) and variables in percutaneous coronary interventions (PCI) was rarely reported. RSU is a severe complication in PCIs, especially for chronic total occlusion (CTO) lesions. We investigated the RSUs and their risk factors in patients receiving CTO PCIs over a 2-year period. Data were analyzed using chi-square tests, t-tests and receiver operating characteristic (ROC) curve. Of 238 patients, 11 patients (4.6%) had RSUs all at right upper back. RSUs were significantly associated with use of left anterior oblique (LAO) views (100% vs. 47.1%, p < 0.001), retrograde techniques (36.3% vs. 7.9%, p = 0.012), or a procedure time (PT) defined as a time duration between the first and last angiograms of > 120, 180, or 240 minutes (p < 0.05). ROC analysis showed a long PT was an accurate predictor of RSUs (AUC = 0.88; p < 0.001) at a cut-off of 130 minutes (sensitivity = 0.91, specificity = 0.81). The results showed risk factors for RSUs containing use of large LAO views, retrograde techniques, and prolonged PTs. This study suggests that, to minimize RSU, interventionalists should limit PT to roughly 2 hours in fixed LAO views.

Various UVB doses affect change of raf kinase inhibitor protein, nitric oxide and proliferation in keratinocytes.

UVB is a potent modulator of cell growth and differentiation in the skin. The UVB irradiation has been used in treating hyperproliferative dermatoses. Otherwise, UVB radiation is also the major risk factor for developing skin cancer. Nitric oxide (NO) has been suggested to be a physiological modulator of cell proliferation. Raf-1 kinase inhibitory protein (RKIP) was involved in cell growth, transformation, and differentiation. The purpose of this study was to search for the possible cause of UVB-inhibited hyperplasia and UVB-resulted hyperproliferation. We evaluated various UVB dose whether affect the expression of RKIP, iNOS, NO and proliferation in keratinocyte. Normal human keratinocytes were treated with UVB dose of 40mJ/cm2, 80mJ/cm2, 120mJ/cm2, 160mJ/cm2 and 0mJ/cm2 (control group) respectively. The results showed that RKIP, iNOS and NO of keratinocytes with doses of 40mJ/cm2 and 80mJ/cm2 UVB treatment significantly higher than control group (P<0.01). The proliferation of keratinocyte with doses of 40mJ/cm2 and 80mJ/cm2 UVB treatment was significantly lower than control group (P<0.01). However, RKIP, iNOS and NO of keratinocytes with doses of 120mJ/cm2 and 160mJ/cm2 UVB treatment significantly lower than control group (P<0.01). The proliferation of keratinocyte with doses of 120mJ/cm2 and 160mJ/cm2 UVB treatment was significantly higher than control group (P<0.01). In conclusion, these results showed that the different UVB dosages induced various alteration of RKIP, NO, iNOS and proliferation may provide important information on the therapeutic molecular mechanism of UVB-inhibited hyperplasia and UVB resulted hyperproliferation.

Alopecia syphilitica.

Alopecia syphilitica is a less common manifestation of secondary syphilis. It could present with other mucocutaneous symptoms of secondary syphilis or rarely present as the only symptom of secondary syphilis, the so-called "essential syphilitic alopecia." Herein, we present a case of essential syphilitic alopecia to remind physicians, especially for sexually active patients.

Primary deep cutaneous candidiasis caused by Candida duobushaemulonii in a 68-year-old man: the first case report and literature review.

Superficial candida infections of the skin are common, but deep cutaneous candidiasis, including secondary dissemination to the skin from systemic candidiasis, candidaemia or primary invasion due to skin defects such as trauma, is rare. These patients are usually immunosuppressed, but immunocompetent hosts can be affected as well. Candida albicans is the most common pathogen. However, non-albicans Candida species can cause deep skin invasion in rare circumstances. We report a case of deep cutaneous candidiasis caused by Candida duobushaemulonii in a 68-year-old man. Deep tissue invasion was confirmed by skin histopathology examination. The pathogen was initially identified as C. haemulonii using the VITEK® 2 system for microbial identification, but was later determined to be C. duobushaemulonii based on sequencing of the internal transcribed spacer region of ribosomal DNA and D1/D2 region of 26S rDNA. The patient was successfully treated with amphotericin B, followed by fluconazole and surgical intervention. To the best of our knowledge, this is the first case of deep cutaneous infection by C. duobushaemulonii.