Specific sweat metabolite profile in ocular Behcet's disease.

BACKGROUND: Behcet's disease (BD) is an autoimmune disorder with the serious possibility of blindness, calling for further research on its pathogenesis. Our aim was to study the metabolite composition of sweat in BD and to identify possible biomarkers. METHODS: Metabolomics analysis was performed on sweat samples from 20 BD patients and 18 normal controls by liquid chromatography tandem mass spectrometry. RESULTS: A significantly different metabolic profile of sweat was observed when BD patients were compared with healthy controls. The result of the orthogonal partial least squared-discrimination analysis (OPLS-DA) showed that these two comparison groups could be separated with a relatively satisfactory fitting degree (R2Y = 0.995 and Q2 = 0.817 in positive ion mode; R2Y = 0.991 and Q2 = 0.721 in negative ion mode). Based on OPLS-DA, a panel of metabolites was selected as candidate biomarkers, including l-citrulline, l-pyroglutamic acid, urocanic acid, 2-oxoadipic acid, cholesterol 3-sulfate, and pentadecanoic acid. CONCLUSION: This is the first report on the metabolite profile of sweat in BD. Our results demonstrated a significantly different metabolite composition of sweat in BD compared to that of healthy controls.

Direct and indirect action modes of acetylcholine in cholinergic urticaria.

Cholinergic urticaria (CholU) manifests small, itchy and/or painful wheals occurring upon perspiration and mechanically involving acetylcholine (Ach). Although a considerable number of studies have been conducted, the pathomechanisms underlying perspiration-associated release of histamine remain to be elucidated. We have proposed that CholU can be categorized into two major subtypes: Ach-indirectly induced, sweat allergic type and Ach-directly induced, depressed sweating type. In the former type, Ach evokes perspiration, and some sweat antigen(s) leaking from the sweat ducts to the dermis may stimulate mast cells to release histamine. In this scenario, the ducts might be damaged or obstructed for sweat leakage, and patients frequently exhibit positive autologous sweat skin test, representing "sweat allergy (hypersensitivity)". On the other hand, the latter Ach-mast cell directly interacting type, typically seen as "CholU with anhidrosis and/or hypohidrosis (CUAH)", eccrine sweat gland epithelial cells lack cholinergic receptor M3 expression. The expression of cholinergic receptors is completely absent in the anhidrotic areas and only slightly expressed in the hypohidrotic areas. In the hypohidrotic area, where pinpoint wheal occurs, it is hypothesized that released Ach cannot be completely trapped by cholinergic receptors of eccrine glands and overflows to the adjacent mast cells, leading to wheal formation. Thus, sweat allergy is not a requirement in this depressed sweating type. Although some additional complications, such as angioedema, anaphylaxis, and cold urticaria, have been documented, these two types represent the modes of action of Ach in this enigmatic urticaria.

Palmoplantar pustulosis: Current understanding of disease definition and pathomechanism.

Pustulosis palmaris et plantaris, or palmoplantar pustulosis (PPP), is a chronic pustular dermatitis involving the palms and soles and is characterized by vesicles, pustules, erythema, lichenification, and abnormal desquamation. It is one of the most common skin diseases in Japan but its pathomechanism is unclear and the disease remains poorly defined. Consequently, adequate treatment for PPP is lacking. As a localized type of pustular psoriasis, PPP has long been treated with the conventional therapies used for plaque-type psoriasis, especially in Western countries. However, PPP may be a distinct entity, with a much lower prevalence in Western countries than in Japan. Furthermore, while treatment has yielded insights into the underlying pathology in plaque-type psoriasis, the pathogenesis of PPP has yet to be elucidated. In 2018, Gulselkumab, a monoclonal antibody against interleukin (IL)-23, was certified for use in Japan and is the first biologic effective in PPP both in Japanese and other patients. In this review, we summarize the current understanding of PPP, including the revised definition and possible pathomechanism. The information presented herein provides a more complete picture of PPP and may facilitate the development of improved treatment options.

Clinical utility of the basophil activation test in the diagnosis of sweat allergy.

BACKGROUND: Many patients with atopic dermatitis and cholinergic urticaria display an immediate-type allergy to autologous sweat. Although the histamine release test (HRT) using semi-purified sweat antigen (QR) was available for the detection of immediate sweat allergy, the existence of HRT low responders could not be disregarded. Furthermore, it has not been established whether the results of the HRT are consistent with the autologous sweat skin test (ASwST). We aimed to compare the HRT and basophil activation test (BAT) for the diagnosis of immediate sweat allergy. METHODS: The HRT and BAT were performed on 47 subjects (35 ASwST positive, 12 negative) whose symptoms had worsened on sweating. For the BAT, blood was incubated with QR or crude sweat and CD203c upregulation was assessed. A commercial HRT was performed and histamine release induced by QR was quantified. RESULTS: When excluding non-responders for anti-IgE antibody, the BAT using QR and the HRT had a sensitivity of 100% and 44% and specificity of 75% and 100%, respectively. The BAT and HRT had a positive predictive value of 91.3% and 100% and negative predictive value of 100% and 30%, respectively. The BAT detected 0% non-responders, whereas the HRT identified 22.5%. When using crude sweat for the BAT, the false-positives observed when using QR were not detected. CONCLUSIONS: The BAT using QR displayed a higher sensitivity and negative predictive value and a lower number of non-responders compared with the HRT. Furthermore, the BAT using crude sweat can also be an alternative tool for the ASwST.

Sweat in the pathogenesis of atopic dermatitis.

Sweat is a transparent hypotonic body fluid made from eccrine sweat glands. Various ingredients contained in sweat are involved in a broad sense in skin homeostasis including temperature regulation, skin moisture, and immune functions. Thus, sweat plays a major role in maintaining skin homeostasis. Therefore, abnormal sweating easily compromises human health. For example, in atopic dermatitis (AD), perspiration stagnation accompanying sweat tube or sweat pore blockage, leakage of perspiration from the sweat gland to the outside tissue, and impaired secretion of sweat from the sweat gland are confirmed. In recent years, the hypothesis that atopic dermatitis is a sweat stasis syndrome has been clarified by the establishment of a sweat and sweat gland dynamic analysis technique. Secretion of sweat and leakage into tissues is caused by dermatitis and is thought to promote itching. Furthermore, from the metabolomic analysis of sweat of patients with atopic dermatitis, it was confirmed that the glucose concentration in AD sweat increased according to severity and skin phenotype, suggesting that elevated glucose affected the homeostasis of the skin. Multifaceted analyses of sweat from subjects with AD have revealed new aspects of the pathology, and appropriate measures to treat sweat can be expected to contribute to long-term control of AD.

Sweat allergy.

Sweat allergy is defined as a type I hypersensitivity against the contents of sweat, and is specifically observed in patients with atopic dermatitis (AD) and cholinergic urticaria (CholU). The allergic reaction is clinically revealed by positive reactions in the intradermal skin test and the basophil histamine release assay by sweat. A major histamine-releasing antigen in sweat, MGL_1304, has been identified. MGL_1304 is produced at a size of 29 kDa by Malassezia (M.) globosa and secreted into sweat after being processed and converted into the mature form of 17 kDa. It induces significant histamine release from basophils of patients with AD and/or CholU with MGL_1304-specific IgE, which is detected in their sera. Patients with AD also show cross-reactivity to MGL_1304-homologs in Malassezia restricta and Malassezia sympodialis, but MGL_1304 does not share cross antigenicity with human intrinsic proteins. Malassezia or its components may penetrate the damaged epidermis of AD lesions and interact with the skin immune system, resulting in the sensitization and reaction to the fungal antigen. As well as the improvement of impaired barrier functions by topical interventions, approaches such as anti-microbial treatment, the induction of tolerance and antibody/substance neutralizing the sweat antigen may be beneficial for the patients with intractable AD or CholU due to sweat allergy. The identification of antigens other than MGL_1304 in sweat should be the scope for future studies, which may lead to better understanding of sweat allergy and therapeutic innovations.

Proteomic Profiling of Sweat Exosome Suggests its Involvement in Skin Immunity.

Healthy human skin sustains an effective immune defense mechanism, formed by a complex physical and chemical epidermal barrier that coordinates with different cellular components of the skin immune system. However, the mechanism by which skin cells regulate local immune homeostasis in health and disease contexts is not well known. To investigate whether exosomes exist in sweat, sweat samples from healthy individuals were collected after aerobic exercise. Sweat exosome was isolated via differential ultracentrifugation, observed under transmission electron microscopy, measured by dynamic light scattering, and confirmed by immunoblot. Further, shotgun liquid chromatography (LC)-mass spectrometry (MS)/MS analysis was conducted to investigate the proteomic profiling of sweat exosome. Secreted exosome was detected in human sweat. A total of 1,062 proteins were identified in sweat exosome, including 997 different proteins compared with sweat proteomics and 896 unique proteins compared with urine, saliva, and plasma exosomes. Diverse antimicrobial peptides and immunological factors were found in sweat exosome, suggesting the involvement of exosome in skin immunity. This study provides direct evidence that secreted exosomes exist in human sweat. The proteomic profiling of sweat exosome provides insight into sweat features and the potential physiological significance of exosomes in immune homeostasis.

Sweat allergy: Extrinsic or intrinsic?

Sweat is an exacerbation factor in atopic dermatitis (AD) in all age groups. A body core temperature elevation with sweating triggers cholinergic urticaria (CholU). We recently reported that AD symptoms are improved by tannic acid-containing spray, which suppresses the basophil histamine release induced by semi-purified sweat antigen in vitro, and by showering, which removes antigens in sweat from the skin surface. Sweat contains small amount of proteins including proteases, protease inhibitors, and anti-microbial peptides. We finally identified MGL_1304 secreted by Malassezia (M.) globosa as a major histamine - releasing antigen in human sweat. MGL_1304 is a 17-kDa protein in sweat that elicits almost the highest histamine - release activity from basophils of patients with AD and CholU among antigens derived from Malassezia species. Moreover, serum levels of anti-MGL_1304 IgE were significantly higher in patients with AD and CholU than in normal controls. The recombinant protein produced by Pichia pastoris possessed comparable allergenicity to native MGL_1304. We found a monoclonal IgE antibody against MGL_1304 which did not elicit histamine release from sensitized mast cells. Desensitization therapy using autologous sweat, or MGL_1304 purified from culture of M. globosa or its cognates might be beneficial for patients with intractable CholU due to sweat allergy.

Hypohidrosis and metal allergy: Trigger factors for unilateral lichen planus.

Unilateral lichen planus (LP) is a rare clinical variant of LP. The etiology of unilateral LP has not been clarified, although various causes have been reported because of the characteristic distribution. We focused on the contribution of metal allergy and sweating in the development of unilateral LP in this case. To confirm the presence of metal allergy, patch tests with metal allergens were performed. To investigate the cause of the unilateral distribution in unilateral LP, the function of sweating and sweat leaking in the dermis was assessed by a thermoregulatory sweat test and immunohistochemical staining of dermcidin. The patch tests with SnCl2 , H2 PtCl6 , ZnCl2 and MnCl2 were positive. The thermoregulatory sweat test using the starch-iodine method (Minor test) with sweating provoked by heat stimulation revealed hypohidrosis of the affected area, whereas no skin lesions were observed on the dorsal hand and wrist where sweating was normal. Histopathological examination showed keratin plugging of the acrosyringium and lymphocytic infiltrations in the papillary and subpapillary dermis around the intraepidermal and intradermal eccrine duct in the affected area. The immunohistochemical staining of dermcidin confirmed sweat leakage in the subpapillary dermis in the affected area. The symptoms refractory to the topical steroids were markedly improved after removal of the dental metals. The coexistence of metal allergy and sweat leakage in the hypohidrotic area may be involved in the development of unilateral LP.

Sweat as an Efficient Natural Moisturizer.

Although recent research on the pathogenesis of allergic skin diseases such as atopic dermatitis has focused on defects in skin genes important for maintaining skin barrier function, the fact that excreted sweat has an overwhelmingly great capacity to increase skin surface hydration and contains moisturizing factors has long been ignored: the increase in water loss induced by these gene defects could theoretically be compensated fully by a significant increase in sweating. In this review, the dogma postulating the detrimental role of sweat in these diseases has been challenged on the basis of recent findings on the physiological functions of sweat, newly recognized sweat gland-/duct-related skin diseases, and therapeutic approaches to the management of these diseases. We are now beginning to appreciate that sweat glands/ducts are a sophisticated regulatory system. Furthermore, depending on their anatomical location and the degree of the impairment, this system might have a different function: sweating responses in sweat glands/ducts located at the folds in hairy skin such as on the trunk and extremities could function as natural regulators that maintain skin hydration under quiescent basal conditions, in addition to the better-studied thermoregulatory functions, which can be mainly mediated by those at the ridges. The normal functioning of sweat could be disturbed in various inflammatory skin diseases. Thus, we should recognize sweating disturbance as an etiologic factor in the development of these diseases.

Histamine Modulates Sweating and Affects Clinical Manifestations of Atopic Dermatitis.

Many factors such as food or environmental allergens, bacteria, fungi, and mental stress aggravate the condition of atopic dermatitis (AD) eczema. Sweating can also exacerbate AD, and patients are aware of that. In the past, it has been reported that contamination of skin surface antigens by sweat induces acute allergic reactions and that sweating functions of AD patients via axonal reflexes are decreased. Histamine demonstrably inhibits acetylcholine-induced sweating in both mice and humans via histamine H1 receptor-mediated signaling. In sweat glands, acetylcholine inactivates glycogen synthase kinase 3ß (GSK3ß), a kinase involved in endocytosis and secretion, whereas simultaneous stimulation with histamine activates GSK3ß and inhibits sweat secretion. Thus, histamine might be involved in the mechanism of abnormal skin dryness in patients with AD via decreasing sweat secretion. On another front, some patients secrete sweat normally. Patients with regular sweating are prone to develop skin disorders such as papules or erythema by residual sweat left on the skin surface. Patients with decreased sweating are prone to develop disorders characterized by xerosis, lichenoid changes, prurigo by elevated skin temperature, skin dryness, and compromised skin conditions. Careful inspection of skin manifestations provides a good indication of a patient's ability to sweat.

New Etiology of Cholinergic Urticaria.

Cholinergic urticaria (CholU) is characterized by pinpoint-sized, highly pruritic wheals occurring upon sweating. Both direct and indirect theories in the interaction of acetylcholine (ACh) with mast cells have been put forward in the sweating-associated histamine release from mast cells. In the mechanism of indirect involvement of ACh, patients are hypersensitive to sweat antigen(s) and develop wheals in response to sweat substances leaking from the syringeal ducts to the dermis, possibly by obstruction of the ducts. Some patients with CholU exhibit a positive reaction to intradermal injection of their own diluted sweat, representing 'sweat allergy (hypersensitivity)'. Regarding the direct interaction theory between ACh and mast cells, we found that CholU with anhidrosis and hypohidrosis lacks cholinergic receptor M3 (CHRM3) expression in eccrine sweat gland epithelial cells. The expression of CHRM3 is completely absent in the anhidrotic areas and lowly expressed in the hypohidrotic areas. In the hypohidrotic area, where CholU occurs, it is hypothesized that ACh released from nerves cannot be completely trapped by cholinergic receptors of eccrine glands and overflows to the adjacent mast cells, leading to wheals.

Sweat Allergy.

For many years, sweat has been recognized as an exacerbation factor in all age groups of atopic dermatitis (AD) and a trigger of cholinergic urticaria (CholU). Recently, we reported the improvement of AD symptoms by spray with tannic acid, which suppresses basophil histamine release by semipurified sweat antigens in vitro, and showering that removes antigens in sweat from the skin surface. We finally identified MGL_1304 secreted by Malassezia globosa as a major histamine-releasing antigen in human sweat. MGL_1304 is detected as a 17-kDa protein in sweat and exhibits almost the highest histamine-release ability from basophils of patients with AD and CholU among antigens derived from Malassezia species. Moreover, serum levels of anti-MGL_1304 IgE of patients with AD and CholU were significantly higher than those of normal controls. Desensitization therapy using autologous sweat or MGL_1304 purified from culture of M. globosa or its cognates might be beneficial for patients with intractable CholU due to sweat allergy.

Immediate Wheal Reactivity to Autologous Sweat in Atopic Dermatitis Is Associated with Clinical Severity, Serum Total and Specific IgE and Sweat Tryptase Activity.

BACKGROUND: Sweating can worsen atopic dermatitis (AD). The purpose of this work was to study the associations between reactivity to autologous sweat and the clinical severity of AD as well as investigate the possible wheal-inducing factors of sweat. METHODS: Intracutaneous skin tests with autologous sweat were performed on 50 AD patients and 24 control subjects. In skin biopsies, tryptase and PAR-2 were enzyme and immunohistochemically stained. The associations between skin test reactivity and sweat histamine concentration, tryptase or chymase activity levels, tryptase or PAR-2 expression and AD clinical severity or IgE levels were investigated. RESULTS: The wheal reactions in the intracutaneous tests with autologous sweat were positive, weakly positive and negative in 38, 34 and 28% of the AD patients, respectively, and in 4, 46 and 50% of the healthy controls, respectively (p = 0.008). In AD, the wheal reaction was associated significantly with clinical severity, serum total and specific IgE levels and sweat tryptase activity, but not with sweat histamine and chymase. In nonlesional AD skin, the percentage of PAR-2+ mast cells (MCs) or the number of tryptase+ MCs did not differ significantly between the intracutaneous test reactivity groups. CONCLUSION: Reactivity to autologous sweat correlates with the clinical severity of AD, and tryptase may be one of the factors involved in the sweat-induced wheal.