Cross-sectional Neuromuscular Phenotyping Study of Patients With Arhinia With SMCHD1 Variants.

BACKGROUND AND OBJECTIVES: Facioscapulohumeral muscular dystrophy type 2 (FSHD2) and arhinia are 2 distinct disorders caused by pathogenic variants in the same gene: SMCHD1. The mechanism underlying this phenotypic divergence remains unclear. In this study, we characterize the neuromuscular phenotype of individuals with arhinia caused by SMCHD1 variants and analyze their complex genetic and epigenetic criteria to assess their risk for FSHD2. METHODS: Eleven individuals with congenital nasal anomalies, including arhinia, nasal hypoplasia, or anosmia, underwent a neuromuscular examination, genetic testing, muscle ultrasound, and muscle MRI. Risk for FSHD2 was determined by combined genetic and epigenetic analysis of 4q35 haplotype, D4Z4 repeat length, and methylation profile. We also compared expression levels of pathogenic DUX4 mRNA in primary myoblasts or dermal fibroblasts (upon myogenic differentiation or epigenetic transdifferentiation, respectively) in these individuals vs those with confirmed FSHD2. RESULTS: Among the 11 individuals with rare, pathogenic, heterozygous missense variants in exons 3-11 of SMCHD1, only a subset (n = 3/11; 1 male, 2 female; age 25-51 years) met the strict genetic and epigenetic criteria for FSHD2 (D4Z4 repeat unit length <21 in cis with a 4qA haplotype and D4Z4 methylation <30%). None of the 3 individuals had typical clinical manifestations or muscle imaging findings consistent with FSHD2. However, the patients with arhinia meeting the permissive genetic and epigenetic criteria for FSHD2 displayed some DUX4 expression in dermal fibroblasts under the epigenetic de-repression by drug treatment and in the primary myoblasts undergoing myogenic differentiation. DISCUSSION: In this cross-sectional study, we identified patients with arhinia who meet the full genetic and epigenetic criteria for FSHD2 and display the molecular hallmark of FSHD-DUX4 de-repression and expression in vitro-but who do not manifest with the typical clinicopathologic phenotype of FSHD2. The distinct dichotomy between FSHD2 and arhinia phenotypes despite an otherwise poised DUX4 locus implies the presence of novel disease-modifying factors that seem to operate as a switch, resulting in one phenotype and not the other. Identification and further understanding of these disease-modifying factors will provide valuable insight with therapeutic implications for both diseases.

Radiofrequency ablation of facial nerve branches controlling glabellar frowning.

BACKGROUND: Hyperdynamic activity of the corrugator supercilii and procerus muscles causes glabellar furrows. Recently, a novel radiofrequency device has become available that can effectively ablate the efferent nerves controlling corrugator and procerus contraction, producing clinical results that are similar to those of botulinum toxin. OBJECTIVE: To assess the efficacy, longevity of effect, and side effects of the radiofrequency ablation device in the treatment of hyperdynamic glabellar furrows. MATERIALS AND METHODS: Four probe entry points were used to access branches of the temporal and angular nerves. Seven and two ablations, respectively, were delivered to each temporal branch and angular nerve. RESULTS: Twenty-nine patients underwent bilateral radiofrequency ablation of temporal branches of the facial nerve and the angular nerves. Abrogation of glabellar furrowing was achieved in 90% of patients. No major adverse events were observed. All patients developed mild to moderate swelling, and nine patients (31%) developed purpura in the treated areas. Sixty-nine percent of patients had effects that lasted 4 months or longer, 41% had effects that lasted 6 months or longer, and 10% had effects lasting longer than 12 months. CONCLUSION: Radiofrequency ablation of efferent branches of the temporal and angular nerves effectively eliminates corrugator and procerus contraction and concomitant glabellar furrowing.

Advances in plasma skin regeneration.

Plasma skin regeneration (PSR) is a novel method of resurfacing that uses plasma energy to create a thermal effect on the skin. PSR is different from lasers, light sources, and ablative lasers in that it is not chromophore dependent and does not vaporize tissue, but leaves a layer of intact, desiccated epidermis that acts as a natural biologic dressing and promotes wound healing and rapid recovery. Histological studies performed on plasma resurfacing patients have confirmed continued collagen production, reduction of elastosis, and progressive skin rejuvenation beyond 1 year after treatment. PSR has received US Food and Drug Administration 510 (k) clearance for treatment of rhytides of the body, superficial skin lesions, actinic keratoses, viral papillomata, and seborrheic keratoses. PSR also has beneficial effects in the treatment of other conditions including dyschromias, photoaging, skin laxity, and acne scars. The safety profile of PSR is excellent, and there have been no reports of demarcation lines in perioral, periorbital, or jawline areas, as can sometimes be observed following CO2 resurfacing. PSR is effective in improving facial and periorbital rhytides and can be used on nonfacial sites, including the hands, neck, and chest. Numerous treatment protocols with variable energy settings allow for individualized treatments and provide the operator with fine control over the degree of injury and length of subsequent recovery time.

Early improvement in rhytides and skin laxity following treatment with a combination fractional laser emitting two wavelengths sequentially.

BACKGROUND: Carbon dioxide laser resurfacing remains the gold standard for the treatment of photoaged skin. Today, however, fewer patients will tolerate the postoperative downtime associated with the use of this device. Fractional photothermolysis was designed to overcome the disadvantages associated with ablative resurfacing. Prototype fractional lasers (Fraxel, Reliant Technologies Inc.) have required the use of blue tracking dye to give evenly spaced microtreatment zones, and treatments are associated with moderate levels of discomfort because of microtreatment zone depths reaching nearly 1000 microm. Newer technologies have evolved that do not require tracking dye, and are less painful than older prototypes because microtreatment zones are more superficial (100 to 300 microm) than that of the Fraxel laser. Newer devices offer advances in treating facial rhytides and skin laxity through the use of 2 laser wavelengths (1320 nm/1440 nm) emitted sequentially through a specialized diffractive lens array that produces high-intensity microtreatment zones surrounded by deeper low level heating. OBSERVATIONS: One to 3 treatments with this combination fractional laser device were performed on 16 Caucasian females with static periocular rhytides or skin laxity affecting the nasolabial crease. There was a 3-week period between treatments. Improvement was noted in both areas after a small number of treatments. CONCLUSION: The technology behind fractional lasers is rapidly evolving, and new devices offer significant advances over older prototypes.

Reductions in thigh and infraumbilical circumference following treatment with a novel device combining ultrasound, suction, and massage.

Liposuction is the gold standard of body contouring procedures. Many patients, however, will not tolerate the invasiveness and subsequent recovery time associated with this procedure, despite the likelihood of superior results. Consequently, patients opt for minimally invasive forms of body contouring that require several treatments, have fewer associated side effects, and afford more modest improvements. The MedSculpt device is one such modality that combines computerized massage, vacuum suction, and ultrasound with a continuous sinusoidal pulse delivered at a frequency of 3 Hz. The efficacy of this device was assessed in the reduction of thigh and abdominal circumferences. Five patients were included in this pilot study. A total of 12 treatments were performed on a semiweekly basis to 2 abdomens and 3 pairs of thighs. Photographs and circumferential measurements of each area were obtained prior to, and at the conclusion of, the treatment course. The treatments were well tolerated and without side effects. The mean reduction in thigh circumference was 2.25 cm or 4%, with a 5 cm reduction in 1 subject. Although limited improvement was seen in supraumbilical circumference, the mean reduction in infraumbilical circumference was 6.5 cm or 7.3%, with a 10 cm reduction in 1 subject. Mild improvement in skin tone, texture, and the appearance of cellulite was observed in all study participants. The results observed after 12 treatments were similar to or better than those seen with other minimally invasive, body contouring devices.

The prevalence of acne in adults 20 years and older.

BACKGROUND: Acne, one of the most common skin diseases, is often mistakenly thought to affect exclusively the teenaged group. However, a significant number of patients either continue to experience acne or develop new-onset acne after the teenaged years. OBJECTIVE: A survey was designed to assess the prevalence of acne in the teenaged years, and aged 20 to 29 years, 30 to 39 years, 40 to 49 years, and 50 years and older. METHODS: Adults aged 20 years and older were asked to complete surveys distributed at various sites on our university campus and medical complex. RESULTS: Of 1013 participants aged 20 years and older, 73.3% (n = 744) reported ever having acne. After the teenaged years, women were more likely to report having acne than men, with the difference being statistically significant in all age groups. The prevalence of acne reported in women versus men was as follows: 20 to 29 years, 50.9% (n = 276) versus 42.5% (n = 201) (P = .0073); 30 to 39 years, 35.2% (n = 152) versus 20.1% (n = 73) (P < .0001); 40 to 49 years, 26.3% (n = 93) versus 12.0% (n = 36) (P < .0001); and 50 years and older, 15.3% (n = 41) versus 7.3% (n = 18) (P = .0046). LIMITATIONS: Our results are based on the participant's own perception of the presence or absence of acne rather than a clinical evaluation. CONCLUSIONS: Acne continues to be a common skin problem past the teenaged years, with women being affected at higher rates than men in all age groups 20 years or older.

KLF4 and PCNA identify stages of tumor initiation in a conditional model of cutaneous squamous epithelial neoplasia.

KLF4 is induced upon growth-arrest in vitro and during epithelial maturation in vivo, and is essential for proper cell fate specification of post-mitotic cells. In spite of a normal role in post-mitotic cells, expression is upregulated and constitutive in certain tumor types. KLF4 functions as an oncogene in vitro, and enforced expression in basal cells of mouse skin rapidly induces lesions similar to hyperplasia, dysplasia and squamous cell carcinoma (SCC). Here we used conditional expression to characterize early steps in KLF4-mediated tumor initiation. In contrast to SCC-like lesions that result when using a conditional, keratin 14 promoter-dependent strategy, lower conditional expression achieved using a MMTV promoter induced only epidermal cycling within morphologically normal skin, a process we termed occult cell turnover. Surprisingly, KLF4-induced hyperplastic lesions showed increased transgene-derived mRNA and protein in maturing, PCNA-negative cells, a property of endogenous KLF4. In contrast, hyperplastic lesions induced by GLI1, a control, showed uniform transgene expression. In KLF4-induced dysplasia and SCC the complementarity of KLF4 and PCNA was replaced by concordance of the two proteins. These studies show that KLF4 transcripts are normally suppressed in cycling cells in a promoter-independent fashion, consistent with a post-transcriptional control, and reveal loss of this control in the transition from hyperplasia to dysplasia. Like the mouse tumors, human cutaneous SCCs and adjacent dysplasias frequently showed maturation-independence of KLF4, with co-expression of KLF4 and PCNA. A smaller subset of human SCCs showed complementarity of KLF4 and PCNA, similar to hyperplastic mouse skin. The results identify parallels between a mouse model and human primary tumors, and show that successive increases of KLF4 in the nuclei of basal keratinocytes leads to occult cell turnover followed by hyperplasia, dysplasia, and invasive SCC.

A randomized controlled trial assessing the efficacy of fluconazole in the treatment of pediatric tinea capitis.

BACKGROUND: Griseofulvin is considered first-line therapy for tinea capitis, and the Physician's Desk Reference currently recommends 11 mg/kg per day microsize formulation for use in children. Diverse selective pressures have resulted in waning clinical efficacy of griseofulvin, such that higher doses and longer courses of treatment are required. These events have prompted the search for therapeutic alternatives. Fluconazole is one such treatment option, and a variety of studies using this drug have shown promise in the treatment of pediatric tinea capitis. OBJECTIVE: We sought to assess the efficacy, safety, and optimal dose and duration of fluconazole therapy compared with standard-dose griseofulvin (11 mg/kg per day microsize formulation) in the treatment of pediatric tinea capitis. METHODS: This randomized, multicenter, third-party-blind, 3-arm trial was designed as a superiority study to identify a therapeutically superior agent/regimen from the 3 treatment arms: (1) fluconazole 6 mg/kg per day for 3 weeks followed by 3 weeks of placebo, (2) fluconazole 6 mg/kg per day for 6 weeks, and (3) griseofulvin 11 mg/kg per day for 6 weeks. Efficacy variables included mycological, clinical, and combined outcomes. The primary efficacy variable was the combined outcome of the modified intent-to-treat population at week 6. Patient safety was assessed throughout the study. Statistical analysis of the efficacy variables was conducted by means of the Cochran-Mantel-Haenszel test. RESULTS: At the end of treatment, mycological cures were present in 44.5%, 49.6%, and 52.2% of the fluconazole 3-week, fluconazole 6-week, and griseofulvin groups, respectively. Analysis of the primary efficacy variable failed to identify any superior agent, and differences between the combined outcomes of the fluconazole 6-week and griseofulvin groups at week 6 were not significant (P = .32). Regarding mycological, clinical, and combined outcomes, no significant differences between the fluconazole 6-week and griseofulvin groups were detected at any time point in the study. No new safety concerns were raised by this trial, and the incidence of treatment-related adverse events noted in this study is concordant with previous reports. Patients in the fluconazole arms of the study fared similarly. At the end of the trial, the difference in mycological cures between the fluconazole arms was only 7.5%, and increases in the incidence of certain treatment-related adverse events were observed in the fluconazole 6-week group. LIMITATIONS: Adjunctive topical therapies and the impact of infected contacts were not assessed in this trial. CONCLUSION: Systemic therapy with fluconazole 6 mg/kg per day and standard-dose griseofulvin produces comparable but low mycological and clinical cure rates. The limited efficacy of standard-dose griseofulvin and the lack of consensus regarding dose and duration of griseofulvin therapy in tinea capitis emphasize the need for controlled trials to identify optimal treatment parameters. Although the efficacy of fluconazole is no better than that of standard-dose griseofulvin, it may still be useful in select patients with a contraindication or intolerance to high-dose griseofulvin. The outcomes observed in this trial highlight the need to more clearly define the relative importance of adjunctive topical therapies and the evaluation and treatment of infected contacts as factors affecting cure rates.

Induction of KLF4 in basal keratinocytes blocks the proliferation-differentiation switch and initiates squamous epithelial dysplasia.

KLF4/GKLF normally functions in differentiating epithelial cells, but also acts as a transforming oncogene in vitro. To examine the role of this zinc finger protein in skin, we expressed the wild-type human allele from inducible and constitutive promoters. When induced in basal keratinocytes, KLF4 rapidly abolished the distinctive properties of basal and parabasal epithelial cells. KLF4 caused a transitory apoptotic response and the skin progressed through phases of hyperplasia and dysplasia. By 6 weeks, lesions exhibited nuclear KLF4 and other morphologic and molecular similarities to squamous cell carcinoma in situ. p53 determined the patch size sufficient to establish lesions, as induction in a mosaic pattern produced skin lesions only when p53 was deficient. Compared with p53 wild-type animals, p53 hemizygous animals had early onset of lesions and a pronounced fibrovascular response that included outgrowth of subcutaneous sarcoma. A KLF4-estrogen receptor fusion protein showed tamoxifen-dependent nuclear localization and conditional transformation in vitro. The results suggest that KLF4 can function in the nucleus to induce squamous epithelial dysplasia, and indicate roles for p53 and epithelial-mesenchymal signaling in these early neoplastic lesions.

Safety and immunogenicity of adenovirus-vectored nasal and epicutaneous influenza vaccines in humans.

The increasing number and density of the human population, the emergence of lethal influenza strains, and the potential use of designer influenza virus as a bioweapon, collectively highlight a critical need for more rapid production of influenza vaccines and less invasive means of delivery. We have developed a nonreplicative adenovirus-vectored influenza vaccine that can be produced without the prerequisite of growing influenza virus. This new class of vaccines can be administered as a nasal spray or skin patch by personnel without medical training. We report here that adenovirus-vectored nasal and epicutaneous influenza vaccines were well tolerated by human volunteers. The nasal vaccine was more potent than its epicutaneous counterpart under the adjuvant-free experimental condition. These results provide the foundation for further human testing of needleless vectored vaccines as promising alternatives to current vaccines.

Identification of Bacillus anthracis proteins associated with germination and early outgrowth by proteomic profiling of anthrax spores.

The use of anthrax spores as a bioweapon has spurred efforts aimed at identifying key proteins expressed in Bacillus anthracis. Because spore germination and outgrowth occur prior to and are required for disease manifestations, blocking germination and early outgrowth with novel vaccines or inhibitors targeting critical B. anthracis germination and outgrowth-associated factors is a promising strategy in mitigating bioterror. By screening 587 paired protein spots that were isolated from dormant and germinating anthrax spores, respectively, we identified 10 spore proteins with statistically significant germination-associated increases and decreases. It is likely that proteins whose levels change during germination may play key roles in the germination and outgrowth processes, and they should be listed as priority targets for development of prophylactic and therapeutic agents against anthrax. The 31 new proteins identified in this study also complement an emerging proteomic database of B. anthracis.

Epidemiologic surveillance of cutaneous fungal infection in the United States from 1999 to 2002.

BACKGROUND: Cutaneous fungal infections are common in the United States, and causative organisms include dermatophytes, yeasts, and nondermatophyte molds. These organisms are in constant competition for their particular environmental niche, often resulting in the emergence of one or more predominant pathogens and displacement of other less competitive species. Changes in the incidence of fungal pathogens can be followed from laboratory culture results of infected cutaneous tissues over time. These data can be used to ascertain past and present trends in incidence, predict increases in antifungal resistance and the adequacy of our current pharmacologic repertoire, and provide insight into future developments. OBJECTIVE: This study identifies epidemiologic trends and the predominant organisms causing superficial fungal infections in the United States. METHODS: A total of 15,381 specimens were collected from clinically suspected tinea corporis, tinea cruris, tinea capitis, tinea faciei, tinea pedis, tinea manuum, and finger and toe onychomycosis from 1999 through 2002. Specimens were submitted to the Center for Medical Mycology in Cleveland, Ohio, for fungal culture and identification, and the incidence of each species was calculated. RESULTS: Dermatophytes remain the most commonly isolated fungal organisms except from clinically suspected finger onychomycosis, in which case Candida species comprise >70% of isolates. Trichophyton rubrum remains the most prevalent fungal pathogen, and increased incidence of this species was observed in finger and toe onychomycosis, tinea corporis and tinea cruris, tinea manuum, and tinea pedis. As the causal agent of tinea capitis, T tonsurans continues to increase in incidence, achieving near exclusionary proportions in the United States. CONCLUSION: Consideration of the current epidemiologic trends in the incidence of cutaneous fungal pathogens is of key importance to investigational efforts, diagnosis, and treatment.

Comparative proteomic profiling of murine skin.

Mammalian skin is regularly exposed to different environmental stresses, each of which results in specific compensatory changes in protein expression that can be assessed by proteomic analysis. We have established a reference proteome map of BALB/c murine skin allowing the resolution of greater than 500 protein spots in a single two-dimensional polyacrylamide gel. Forty-four protein spots, corresponding to 28 different cutaneous proteins, were identified using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry and the Mascot online database searching algorithm. Twenty-five proteins were expressed at higher levels in the epidermis, whereas only nine were found predominantly in the subepidermal tissues. A subset of protein spots exhibited strain-specific expression. Proteins of diverse function were identified, including those involved in stress response, apoptosis, growth inhibition, the maintenance of structural integrity, translational control, energy metabolism, calcium binding, cholesterol transport, and the scavenging of free radicals. Prohibitin expression was detected cutaneously, with more abundant protein and mRNA levels in the epidermis. Five molecular chaperones including protein di-sulfide isomerase, 78 kDa glucose-regulated protein precursor, heat shock protein 60 (HSP60), HSP70, and HSP27 were also identified. Of these, HSP27 expression was confined mainly to the epidermis, and expression of protein disulfide isomerase was found primarily in the subepidermal tissues. Proteomic analysis of skin following heat or cold shock resulted in increased levels of HSP27, HSP60, and HSP70 suggesting involvement of these chaperones in the cutaneous response mechanism to temperature stress. These data establish numerous reference markers within the proteome map of murine skin and provide an important framework for future efforts aimed at characterization of the epidermal and subepidermal responses to environmental changes.