Conversion of psoriasis patients from the conventional formulation of cyclosporin A to a new microemulsion formulation: a randomized, open, multicentre assessment of safety and tolerability.

OBJECTIVE: To assess the safety, tolerability and efficacy of a new cyclosporin A (CyA) microemulsion formulation, Sandimmun Neoral (Neoral), in patients with severe psoriasis that was stable on CyA administered as Sandimmun (SIM). METHODS: In this 24-week, open, randomized, prospective, multicentre trial, 28 patients continued on the same dosage of SIM, while 30 converted to Neoral at 2.5 mg/kg/day or a dosage equivalent to their pre-conversion SIM dosage. During the study, dosages could be adjusted to maintain efficacy, because of adverse events or after disease stabilization. The maximum permitted dosage for either formulation was 5.0 mg/kg/day. Primary efficacy criteria were change in Psoriasis Area and Severity Index (PASI) from baseline and time to relapse. RESULTS: The dosage was increased to maintain efficacy in 22 patients (Neoral 13; SIM 9) and 20 dose reductions for safety were required (Neoral 14, SIM 6). In both groups, PASI scores remained stable throughout and relapses were primarily a result of dosage reduction after disease stabilization. No significant difference was found between groups in the proportion of patients remaining relapse-free. Adverse events were recorded in 20 patients receiving Neoral and 14 receiving SIM. Most drug-related events were of mild or moderate severity and reflected the known CyA side-effect profile. Dose titration guidelines ensured that mean blood pressure and serum creatinine concentrations remained stable in both groups. CONCLUSIONS: If the guidelines for CyA use are followed and the Neoral dosage does not exceed 5 mg/kg/day, conversion of stable patients with severe psoriasis from SIM to Neoral should present no clinically relevant safety or tolerability problems and efficacy of treatment is maintained.

Cyclosporine in severe childhood atopic dermatitis: a multicenter study.

BACKGROUND: Severe atopic dermatitis (AD) remains difficult to treat. Cyclosporine is effective in adults but has not previously been investigated in children with AD. OBJECTIVE: The aims were to investigate the efficacy, safety, and tolerability of cyclosporine in severe refractory childhood AD. METHODS: Subjects 2 to 16 years of age were treated for 6 weeks with cyclosporine, 5 mg/kg per day, in an open study. Disease activity was monitored every 2 weeks by means of sign scores, visual analogue scales for symptoms, and quality-of-life questionnaires. Adverse events were monitored. Efficacy and tolerability were assessed with five-point scales. RESULTS: Twenty-seven children were treated. Significant improvements were seen in all measures of disease activity. Twenty-two showed marked improvement or total clearing. Quality of life improved for both the children and their families. Tolerability was considered good or very good in 25 subjects. CONCLUSION: Cyclosporine may offer an effective, safe, and well-tolerated short-term treatment option for children with severe AD.

Absence of Epstein-Barr viral encoded RNA (EBER) in primary cutaneous t-cell lymphoma.

Epstein-Barr virus (EBV) has been associated with various extracutaneous lymphoproliferative diseases and it has been suggested that EBV may have a similar aetiological role in cutaneous T-cell lymphoma. In this study, in situ hybridization was used to investigate the presence of EBV encoded RNAs (EBER-1 and EBER-2) in 37 biopsies from 28 cases of primary cutaneous T-cell lymphoma originating from the U.K. The results showed that EBV had no demonstrable pathogenic role in the lymphomas studied, as EBER was not detected in any case.

Morphologic observations on the dermal nerves in vitiligo: an ultrastructural study.

BACKGROUND: Vitiligo is a common idiopathic skin disorder. The etiology is unknown, although various hypotheses have been advanced. These include the neuronal hypothesis, where neuronal factors are thought to play a role in the pathogenesis of this disease. METHODS: Skin biopsies were taken from marginal and central parts of four vitiligo patients. Biopsies were also taken from nonvitiliginous skin of each patient and from four normal control subjects. Sections were examined under the electron-microscope. Nerve fibers in the superficial dermis were examined. RESULTS: Subtle ultrastructural changes, including regeneration and degeneration, were consistently found in dermal nerves of vitiligo lesions. The most consistent feature, seen in all four vitiligo patients studied (in both lesional and marginal areas), was an increased thickness of the basement membrane of Schwann cells. This change was found in approximately three-quarters of all dermal nerves in vitiligo biopsies, but in only about one-quarter of dermal nerves in normal control skin. About half the abnormal dermal nerves in vitiligo skin showed minor axonal damage, although indicators of regeneration (increased mitochondria and rough endoplasmic reticulum) predominated. The dermal nerves in vitiligo showed no difference in fiber diameter or fiber density in comparison with controls. CONCLUSIONS: In vitiligo both axonal degeneration and nerve regeneration may occur, with the latter possibly being a reactive change to earlier axonal damage. These findings support the hypothesis that there is a neuronal component to this disease.

Fluticasone propionate 0.05% cream in the treatment of atopic eczema: a multicentre study comparing once-daily treatment and once-daily vehicle cream application versus twice-daily treatment.

The aim of this study was to compare the efficacy and safety of once-daily with twice-daily application of a 0.05% cream formulation of fluticasone propionate in the treatment of atopic eczema in adults and children. Two hundred and seventy patients with moderate to severe atopic eczema were enrolled in the study, and randomized to receive either once-daily or twice-daily fluticasone propionate 0.05% cream for 4 weeks. Patients randomized to the once-daily group also received the vehicle cream to ensure that the study remained blinded. The clinical response of a preselected target area of affected skin was assessed by investigators at weekly intervals and compared with the baseline. Analysis of the investigators' overall assessment of the response of the target area for both the 'intent-to-treat' population and the per protocol population showed that 79-85% of patients were judged a clinical success. For both populations, there was no statistically significant difference between the response to once-daily and twice-daily active treatment (intent-to-treat; P = 0.35; 95% confidence interval for difference -14.2 to +5.0 percentage points: per protocol; P = 0.42; 95% confidence interval for difference -14.7 to +6.2 percentage points.) The improvement in the signs and symptoms was judged a success in 95-97% of patients. There was an equal reduction in severity scores for disease activity in both groups, and the speed of symptom relief was similar.(ABSTRACT TRUNCATED AT 250 WORDS)

Neuropeptides and general neuronal marker in psoriasis--an immunohistochemical study.

Nerve fibres immunoreactive to antibodies to vasoactive intestinal polypeptide (VIP) and substance P (SP) were increased in lesional psoriatic skin when assessed semiquantitatively. Biopsies from psoriatic plaques on the arm were studied in 13 patients and compared with biopsies from non-lesional areas (in three of the same psoriatic subjects) and from normal skin in seven non-psoriatic controls. Immunohistochemical methods were used on cryocut skin sections to demonstrate the neuropeptides SP, VIP, calcitonin gene-related peptide and neuropeptide Y, and the general neuronal marker protein gene product (PGP) 9.5. The immunofluorescence was examined by semiquantitative and, for PGP 9.5, by quantitative methods. VIP reactive nerve fibres were increased at areas of eccrine sweat glands throughout the dermis, at the dermo-epidermal junction, and in the epidermis, in psoriasis lesional skin. SP reactive nerve fibres were increased at the dermo-epidermal junction, where the nerves ran parallel with and perpendicularly through the junction. PGP 9.5 reactive nerve fibres showed an increase at the dermo-epidermal junction, in the papillary dermis, and at the eccrine sweat glands in lesional psoriatic skin but not in non-lesional, or in control skin. These findings support the hypothesis that neuropeptides may be involved in the pathogenesis of psoriasis.

Epstein-Barr virus in cutaneous lymphomatoid granulomatosis.

Epstein-Barr virus (EBV) has been associated with various extra-cutaneous lymphoproliferative diseases and it has been suggested that EBV may have a similar aetiological role in the skin. In this study, 10 biopsies from 7 cases of primary cutaneous lymphomatoid granulomatosis have been analyzed, using in situ hybridisation, for the presence of EBV encoded RNAs (EBER-1 and EBER-2). Only one case showed positive staining with the EBER probes and it is concluded that, in the skin, the relationship between EBV and lymphomatoid granulomatosis is variable. The role of EBV as an etiological agent in primary cutaneous lymphomatoid granulomatosis appears less important than in primary respiratory disease.

Proliferating cell nuclear antigen immunostaining in keratoacanthoma and squamous cell carcinoma of the skin.

Proliferating cell nuclear antigen expression was used to seek differences between keratoacanthoma and squamous cell carcinoma of the skin. These lesions of the skin continue to provoke interest due to their different biological behaviour in spite of histologically similar appearances. The primary antibody, PC10 was used in a three stage avidin biotin peroxidase complex technique on section from 27 cases of KA, 15 of well, 16 of moderately- and 15 of poorly differentiated SCC. The distribution of positive cells was determined and then one thousand randomly chosen lesional epithelial nuclei were categorised for PCNA immunoreactivity and the results expressed as percentage of epithelial nuclei stained. Statistical analysis revealed a highly significant trend in increasing %PCNA with histological grade of skin lesion (P < 0.0001). Poorly differentiated, although not other grades of squamous cell carcinoma have a significantly higher proportion of PCNA labelled nuclei than keratoacanthoma. In addition, the distribution of PCNA positive nuclei in keratoacanthoma are usually peripheral contrasting with the more diffuse pattern seen in most cases of SCC. %PCNA alone was a more powerful predictor of histological subtype than distribution alone. PCNA immunohistochemistry not only provides additional information facilitating the differential diagnosis between keratoacanthoma and moderate or poorly differentiated squamous cell carcinoma but also underlines the perplexing similarity between keratoacanthoma and well differentiated squamous cell carcinoma.

Neuropeptide and neuronal marker studies in vitiligo.

Neuropeptide and neuronal marker immunoreactivity was studied in skin biopsies from lesional and marginal areas in 12 patients with vitiligo, and in seven normal controls. The vitiligo was active in seven, static in two, and of unknown activity in three. Antibodies against general neuronal marker PGP 9.5 (PGP 9.5), substance P (SP), calcitonin gene-related peptide (CGRP), vasoactive intestinal polypeptide (VIP), and neuropeptide Y (NPY), were used. The epidermis, dermo-epidermal junction, papillary and reticular dermis, and appendages, were assessed semiquantitatively for reactivity with each antibody. Staining with PGP 9.5 in the upper dermis was assessed quantitatively by image analysis. An increase in reactivity against NPY antibody was seen in five of 10 cases (three with active vitiligo) in the marginal areas, and in three of 12 subjects (all with active vitiligo) in the lesional vitiligo areas. VIP antibody reactivity showed a minimal increase in the marginal and lesional vitiligo areas (in two cases each, both of whom had active vitiligo). SP and CGRP reactivities did not differ from normal. PGP 9.5 staining was minimally increased at the dermo-epidermal junction and lower Malpighian layer in biopsies from marginal areas in three of 10 subjects (all with active vitiligo). Quantitative analysis of PGP 9.5 reactivity in the upper dermis showed no difference between vitiligo and normal biopsies. These findings support the concept of neuronal or neuropeptide involvement in vitiligo, and in particular suggest that NPY may have a role in the pathogenesis of the disease.

'Anti-metastatic' nm23 gene product expression in keratoacanthoma and squamous cell carcinoma.

An inverse correlation has been demonstrated between nm23 gene expression and metastasis. The gene is located on chromosome 17q (q1.1-q2.1), a region distinct from tumour suppressor gene p53. We have previously reported expression of mutant products of p53 gene to be significantly associated with worsening degrees of differentiation in squamous cell carcinoma. nm23 gene product, which shows complete identity to human erythrocyte nucleoside diphosphate kinase, was used to raise an affinity-purified polyclonal antibody Ab-11 which is applicable to formalin-fixed and paraffin-embedded tissues. Keratoacanthomas and squamous cell carcinomas of the epidermis form a fascinating human tumour model in which to test the hypothesis that the nm23 gene confers 'anti-metastatic' properties, since the former never metastasise while the latter have this potential. Two observers rated immunohistochemistry for the nm23 gene product as the proportion of tumour positive from grades 1-4 (corresponding to 25, 50, 75 and 100% of tumour cells stained). Nineteen typical keratoacanthomas, 20 well, 21 moderately and 8 poorly differentiated epidermal squamous cell carcinomas were studied. The Jonckheere-Terpstra test statistic of association between staining grade and lesion type was 762.5, p = 0.189 (2 tails), p = 0.0945 (1 tail). There was no statistically significant trend in tumour staining from keratoacanthoma through decreasing grades of differentiation of squamous cell carcinoma. nm23 product expression does not appear to correlate with differentiation, itself an indicator of metastatic potential, in this system of human squamous cell neoplasms.(ABSTRACT TRUNCATED AT 250 WORDS)

Mutant p53 oncogene expression in keratoacanthoma and squamous cell carcinoma.

The tumour suppressor gene p53, located on the short arm of chromosome 17, encodes for a nuclear protein which regulates cell proliferation by inhibiting cells entering S-phase. p53 mutations are alleged to be the commonest genetic abnormality in human cancer. We studied mutant p53 oncoprotein expression, using PAb1801 monoclonal antibody immunohistochemistry, in 25 'ideal' keratoacanthomas and 26 well-, 19 moderately and 18 poorly differentiated squamous cell carcinomas of the skin. While there was a highly significant trend in the proportion of p53 oncoprotein-positive lesions from keratoacanthomas to poorly differentiated squamous cell carcinomas (chi 2 = 17.13, df = 1, exact P = 0.00003), p53 expression was inadequate for distinguishing keratoacanthoma from well-differentiated squamous cell carcinoma (chi 2 = 2.55, df = 1, exact P = 0.18; corresponding to a sensitivity of 0.84 and a specificity of only 0.36).

Alpha-melanocyte-stimulating hormone stimulates protein kinase C activity in murine B16 melanoma.

The effect of alpha-melanocyte-stimulating hormone (alpha-MSH) on protein kinase C activity and distribution was investigated in murine B16 F1 melanoma cells. alpha-MSH was found to induce an increased association of protein kinase C (PKC) activity with the particulate fraction of the cells, with an associated loss of enzyme activity from the soluble fraction. The peak response to alpha-MSH occurred between 20 and 60 min of incubation time, and enzyme activities redistributed to those seen in the control cells over the following 12 to 24 h. The average response to alpha-MSH (1 nmol/l) was an approximate 2.5-fold increase in the percentage of enzyme activity associated with the membrane within 1 h of exposure to alpha-MSH; the particulate enzyme activity represented 19.2 +/- 4.4% of total activity in the absence of alpha-MSH and 50.7 +/- 4.7% (means +/- S.E.M., n = 9, P less than 0.005) in the presence of alpha-MSH (1 nmol/l). Cells which had a relatively small percentage of their PKC activity on the membrane initially were significantly (P less than 0.01) more responsive to alpha-MSH stimulation than cells which initially had a relatively large percentage of PKC activity on the membrane. The association of PKC activity with the membrane showed some evidence of being dose-related to alpha-MSH. This is the first report, to the best of our knowledge, of alpha-MSH activating PKC.

Evidence for a calcium/calmodulin involvement in density-dependent melanogenesis in murine B16 melanoma cells.

Previous work from our laboratory has shown that both cyclic AMP and calcium/calmodulin appear to be involved in the regulation of melanogenesis in murine B16 melanoma cells. In these cells as in murine Cloudman S91 cells, melanogenic responsiveness to melanocyte-stimulating hormone (MSH) varies with cell density in culture. Our objective in this study was to learn more about the intracellular systems involved in the control of melanogenesis, particularly the role played by calcium. The melanogenic response to alpha MSH was compared to the response to drugs affecting intracellular free calcium and calmodulin over a range of cell densities in B16F1 cells. alpha MSH-stimulated melanin production was extremely density-dependent but alpha MSH-stimulated cyclic AMP production was independent of cell density. The melanogenic response to agents that increased intracellular calcium (A23187) or inhibited intracellular calmodulin varied with cell density. A drug (TMB8) that lowered intracellular free calcium, however, increased melanogenesis independently of cell density. At high cell density it was found that an elevation in calcium decreased melanogenesis, whereas agents that reduced calcium or inhibited calmodulin activity increased melanogenesis. At low cell density, however, the inhibitory response to A23187 was lost and in some experiments even stimulated melanogenesis. These data suggest that the calcium/calmodulin signalling system has an inhibitory influence on melanogenesis, and its expression, which depends upon cell density, may also modulate the response to stimulatory agents such as alpha MSH.