Establishment and Utility of SwedAD: A Nationwide Swedish Registry for Patients with Atopic Dermatitis Receiving Systemic Pharmacotherapy.

SwedAD, a Swedish nationwide registry for patients with atopic dermatitis receiving systemic pharmacotherapy, was launched on 1 September 2019. We describe here the establishment of a user-friendly registry to the benefit of patients with atopic dermatitis. By 5 November 2022, 38 clinics had recorded 931 treatment episodes in 850 patients with an approximate national coverage rate of 40%. Characteristics at enrolment included median Eczema Area and Severity Index (EASI) 10.2 (interquartile range 4.0, 19.4), Patient-Oriented Eczema Measure (POEM) 18.0 (10.0, 24.0), Dermatology Life Quality Index (DLQI) 11.0 (5.0, 19.0) and Peak Itch Numerical Rating Scale-11 (NRS-11) 6.0 (3.0, 8.0). At 3 months, median EASI was 3.2 (1.0, 7.3) and POEM, DLQI, and NRS-11 were improved. Regional coverage varied, reflecting the distribution of dermatologists, the ratio of public to private healthcare, and difficulties in recruiting certain clinics. This study highlights the importance of a nationwide registry when managing systemic pharmacotherapy of atopic dermatitis.

Correction: Differences in cutaneous melanoma treatment and patient satisfaction.

[This corrects the article DOI: 10.1371/journal.pone.0205517.].

Epigenetic alterations in skin homing CD4+CLA+ T cells of atopic dermatitis patients.

T cells expressing the cutaneous lymphocyte antigen (CLA) mediate pathogenic inflammation in atopic dermatitis (AD). The molecular alterations contributing to their dysregulation remain unclear. With the aim to elucidate putative altered pathways in AD we profiled DNA methylation levels and miRNA expression in sorted T cell populations (CD4+, CD4+CD45RA+ naïve, CD4+CLA+, and CD8+) from adult AD patients and healthy controls (HC). Skin homing CD4+CLA+ T cells from AD patients showed significant differences in DNA methylation in 40 genes compared to HC (p < 0.05). Reduced DNA methylation levels in the upstream region of the interleukin-13 gene (IL13) in CD4+CLA+ T cells from AD patients correlated with increased IL13 mRNA expression in these cells. Sixteen miRNAs showed differential expression in CD4+CLA+ T cells from AD patients targeting genes in 202 biological processes (p < 0.05). An integrated network analysis of miRNAs and CpG sites identified two communities of strongly interconnected regulatory elements with strong antagonistic behaviours that recapitulated the differences between AD patients and HC. Functional analysis of the genes linked to these communities revealed their association with key cytokine signaling pathways, MAP kinase signaling and protein ubiquitination. Our findings support that epigenetic mechanisms play a role in the pathogenesis of AD by affecting inflammatory signaling molecules in skin homing CD4+CLA+ T cells and uncover putative molecules participating in AD pathways.

Differences in cutaneous melanoma treatment and patient satisfaction.

Although clinical guidelines exist, the management of patients with cutaneous melanoma (CM) is a complex process that may vary between different care providers with potential dysfunctions ultimately mirrored in the overall patient satisfaction. The aim of the present study was to investigate the CM management as related to lead times, surgical quality and diagnosis communication with the hypothesis that the care may differ between providers and disparities may impact patient satisfaction. Medical records of 181 patients were retrospectively analyzed with parallel patient satisfaction evaluation by telephone interviews. Overall mean lead times from initial diagnosis until completion of all surgery and histopathology reports were 80-100 days and delays occurred at every step of the process. General practitioners performed excision biopsies faster however this was mitigated by slower histopathology processing. University level CM care showed less lag time between excision biopsy, wide local excision for thick melanomas and histopathology confirmation. University level care operated with twice the surgical margin as compared to general practitioners and non-university level specialists. Male patients had larger excision biopsy margins and significantly shorter lead times than female patients. Patient satisfaction rates were generally higher in the academic hospitals as compared to general practitioners and non-university dermatology clinics. Surprisingly, there was no correlation between lead times and patient satisfaction. Taken together, CM show substantial variation and caution should be practiced when using patient satisfaction as a quality indicator.

IgE Sensitization Profiles Differ between Adult Patients with Severe and Moderate Atopic Dermatitis.

BACKGROUND: Atopic dermatitis (AD) is a complex chronic inflammatory disease where allergens can act as specific triggering factors. AIM: To characterize the specificities of IgE-reactivity in patients with AD to a broad panel of exogenous allergens including microbial and human antigens. METHODOLOGY: Adult patients with AD were grouped according to the SCORAD index, into severe (n = 53) and moderate AD (n = 126). As controls 43 patients were included with seborrhoeic eczema and 97 individuals without history of allergy or skin diseases. Specific IgE reactivity was assessed in plasma using Phadiatop®, ImmunoCap™, micro-arrayed allergens, dot-blotted recombinant Malassezia sympodialis allergens, and immune-blotted microbial and human proteins. RESULTS: IgE reactivity was detected in 92% of patients with severe and 83% of patients with moderate AD. Sensitization to cat allergens occurred most frequently, followed by sensitization to birch pollen, grass pollen, and to the skin commensal yeast M. sympodialis. Patients with severe AD showed a significantly higher frequency of IgE reactivity to allergens like cat (rFel d 1) and house dust mite (rDer p 4 and 10), to Staphylococcus aureus, M. sympodialis, and to human antigens. In contrast, there were no significant differences in the frequencies of IgE reactivity to the grass pollen allergens rPhl p 1, 2, 5b, and 6 between the two AD groups. Furthermore the IgE reactivity profile of patients with severe AD was more spread towards several different allergen molecules as compared to patients with moderate AD. CONCLUSION: We have revealed a hitherto unknown difference regarding the molecular sensitization profile in patients with severe and moderate AD. Molecular profiling towards allergen components may provide a basis for future investigations aiming to explore the environmental, genetic and epigenetic factors which could be responsible for the different appearance and severity of disease phenotypes in AD.

[Treated patients in survey: High satisfaction with botulinum toxin in palmar hyperhidrosis]. / Behandlade patienter i enkätundersökning:--Hög nöjdhet med botulinumtoxin vid palmar hyperhidros.

When debilitating, hyperhidrosis can be seen as a disease and not just as a symptom. It is most often a primary condition but can be secondary to other diseases. Aluminum chloride products are the initial treatment modality for palmar hyperhidrosis followed by anticholinergics, iontophoresis and botulinum toxin. The Dermatology Department of the Karolinska University Hospital in Stockholm, Sweden treated 151 patients at 289 visits with botulinum toxin for palmar hyperhidrosis during a two year period (2012-2013). It was found that botulinum toxin had good effect, which lasted between two and five months in 72% of cases. Muscle weakness (pincer grip) was reported at 41% of return visits and was present for less than one to four weeks in 62% of cases. At 56% of return visits, no side effects of botulinum toxin were reported. 90% of patients surveyed thought that botulinum toxin worked well or very well for their condition and 99% valued the treatment they received at the clinic as good to excellent.

The expression of BAFF, APRIL and TWEAK is altered in eczema skin but not in the circulation of atopic and seborrheic eczema patients.

The TNF family cytokines BAFF (B-cell activating factor of the TNF family) and APRIL (a proliferation-inducing ligand) are crucial survival factors for B-cell development and activation. B-cell directed treatments have been shown to improve atopic eczema (AE), suggesting the involvement of these cytokines in the pathogenesis of AE. We therefore analyzed the expression of these TNF cytokines in AE, seborrheic eczema (SE) and healthy controls (HC). The serum/plasma concentration of BAFF, APRIL and a close TNF member TWEAK (TNF-like weak inducer of apoptosis) was measured by ELISA. The expression of these cytokines and their receptors in skin was analyzed by quantitative RT-PCR and immunofluorescence. Unlike other inflammatory diseases including autoimmune diseases and asthma, the circulating levels of BAFF, APRIL and TWEAK were not elevated in AE or SE patients compared with HCs and did not correlate with the disease severity or systemic IgE levels in AE patients. Interestingly, we found that the expression of these cytokines and their receptors was altered in positive atopy patch test reactions in AE patients (APT-AE) and in lesional skin of AE and SE patients. The expression of APRIL was decreased and the expression of BAFF was increased in eczema skin of AE and SE, which could contribute to a reduced negative regulatory input on B-cells. This was found to be more pronounced in APT-AE, the initiating acute stage of AE, which may result in dysregulation of over-activated B-cells. Furthermore, the expression levels of TWEAK and its receptor positively correlated to each other in SE lesions, but inversely correlated in AE lesions. These results shed light on potential pathogenic roles of these TNF factors in AE and SE, and pinpoint a potential of tailored treatments towards these factors in AE and SE.

Nanovesicles from Malassezia sympodialis and host exosomes induce cytokine responses--novel mechanisms for host-microbe interactions in atopic eczema.

BACKGROUND: Intercellular communication can occur via the release of membrane vesicles. Exosomes are nanovesicles released from the endosomal compartment of cells. Depending on their cell of origin and their cargo they can exert different immunoregulatory functions. Recently, fungi were found to produce extracellular vesicles that can influence host-microbe interactions. The yeast Malassezia sympodialis which belongs to our normal cutaneous microbial flora elicits specific IgE- and T-cell reactivity in approximately 50% of adult patients with atopic eczema (AE). Whether exosomes or other vesicles contribute to the inflammation has not yet been investigated. OBJECTIVE: To investigate if M. sympodialis can release nanovesicles and whether they or endogenous exosomes can activate PBMC from AE patients sensitized to M. sympodialis. METHODS: Extracellular nanovesicles isolated from M. sympodialis, co-cultures of M. sympodialis and dendritic cells, and from plasma of patients with AE and healthy controls (HC) were characterised using flow cytometry, sucrose gradient centrifugation, Western blot and electron microscopy. Their ability to stimulate IL-4 and TNF-alpha responses in autologous CD14, CD34 depleted PBMC was determined using ELISPOT and ELISA, respectively. RESULTS: We show for the first time that M. sympodialis releases extracellular vesicles carrying allergen. These vesicles can induce IL-4 and TNF-α responses with a significantly higher IL-4 production in patients compared to HC. Exosomes from dendritic cell and M. sympodialis co-cultures induced IL-4 and TNF-α responses in autologous CD14, CD34 depleted PBMC of AE patients and HC while plasma exosomes induced TNF-α but not IL-4 in undepleted PBMC. CONCLUSIONS: Extracellular vesicles from M. sympodialis, dendritic cells and plasma can contribute to cytokine responses in CD14, CD34 depleted and undepleted PBMC of AE patients and HC. These novel observations have implications for understanding host-microbe interactions in the pathogenesis of AE.

IL-18 skews the invariant NKT-cell population via autoreactive activation in atopic eczema.

Atopic eczema (AE) is a chronic relapsing inflammatory skin disease where the commensal yeast Malassezia can act as a microbial trigger factor. Malassezia activates human DC to produce IL-18, an innate cytokine that is elevated in serum of AE patients; however, the precise role of IL-18 in human AE etiology is unknown. Herein, we investigated the effect of IL-18 on the human invariant NKT (iNKT) cell compartment in AE. We found that IL-18 was a potent activator of human iNKT-cells and promoted a pro-inflammatory CD1d-dependent response, even in the absence of exogenous ligands. Chronic activation via IL-18 on the other hand was inhibitory and skewed the iNKT-cell pool by selectively suppressing CD4(+) iNKT-cells. This was mimicked in AE patients where the proportion of CD4(+) iNKT-cells was reduced in peripheral blood and coincided with elevated plasma levels of IL-18. Furthermore, a reduced CD4(+) iNKT-cell pool was associated with elevated IgE levels in plasma, and the plasma levels of IL-18 correlated with both total IgE and disease severity in the AE patients. Based on these findings, we propose that IL-18-mediated activation and subsequent dysregulation of the CD1d-restricted iNKT-cells plays a role in the pathogenesis of human AE.

Elevated peripheral allergen-specific T cell response is crucial for a positive atopy patch test reaction.

BACKGROUND: Atopic eczema is a chronic inflammatory skin disease in which several subgroups of cases can be identified. Atopy patch testing (APT) reveals allergen sensitization also in atopic eczema patients devoid of detectable allergen-specific IgE, suggesting the importance of factors other than IgE in the reaction. Here we investigate the relationship between APT reactions and allergen-specific peripheral IgE and T cell reactivity in atopic eczema patients. METHODS: Adult patients with atopic eczema (n = 64) and healthy controls (n = 24) were analyzed for reactivity to Malassezia sympodialis extract by APT, measurement of specific plasma IgE and in vitro determination of the frequency of allergen-reactive peripheral blood mononuclear cells producing interleukin-4 and interleukin-5 using the ELISpot method. RESULTS: When combining the results of the APT, IgE measurements and the ELISpot analyses, reactivity to M. sympodialis was found in a majority of the atopic eczema patients (69%), whereas the healthy controls were negative throughout. T cell reactivity to M. sympodialis, manifested by production of both interleukins 4 and 5, was highly predictive for a positive APT reaction and displayed a strongly positive correlation with the APT score. In contrast, the allergen-specific IgE levels did not predict the APT outcome, and no correlation could be found between the IgE levels and the APT score. CONCLUSION: Peripheral allergen-specific T helper 2 cell-mediated reactivity appears to be required for a positive APT reaction to M. sympodialis. The diagnostic potential of measuring peripheral allergen-specific T cell responses should be considered in atopic eczema.

Early expression of interleukin-2 mRNA by peripheral blood mononuclear cells isolated from nickel-allergic subjects and subsequently exposed to nickel in vitro.

The aim pf the present study was to characterize the time course of the synthesis of mRNA encoding interleukin-2 (IL-2) by peripheral blood mononuclear cells (PBMCs) isolated from nickel-allergic women and subsequently exposed to nickel sulphate in vitro. The level of this mRNA (determined by employing real-time polymerase chain reaction [PCR]) and of the corresponding protein (quantitated using an enzyme-linked immunosorbent assay [ELISA]) were significantly increased after only 10 and 24 h of incubation, respectively. The increased level of mRNA coding for IL-2 supports the hypothesis that this process is a key part of the response to nickel stimulation of PBMCs of hypersensitive subjects.

Serotonergic mechanisms in human allergic contact dermatitis.

Expression of serotonin (5-hydroxytryptamine; 5-HT), 5-HT receptors 1A (5-HT1AR) and 2A, and serotonin transporter protein (SERT) was studied in positive epicutaneous reactions to nickel sulphate in nickel-allergic patients, at 72 h post-challenge with the antigen. In addition, the effects of 5-HT2AR agonist 2,5-dimethoxy-4-iodoamphetamine (DOI), and the selective serotonin reuptake inhibitors (SSRIs) citalopram and fluoxetine, were tested on nickel-stimulated peripheral blood mononuclear cells from nickel-allergic patients, regarding their proliferation and interleukin (IL)-2 production, as well as the effect of these SSRIs on a murine Langerhans' cell-like line (XS52), regarding its IL-1beta production. Serotonin-positive platelets were increased in the inflamed skin compared with control skin. A decrease (p <0.01) in 5-HT1AR-positive mononuclear cells was evident in the eczematous skin compared with control skin, whereas 5-HT2AR- and SERT-positive cells were increased (p <0.001 for both) in the eczematous skin. Treatment of nickel-stimulated peripheral blood mononuclear cells with 5x10(-5) mol/l of DOI inhibited (p <0.01) the proliferation of nickel-stimulated peripheral blood mononuclear cells, while no effect was found regarding IL-2 production. Citalopram at 10(-6) mol/l tended to inhibit the production of IL-1beta by the XS52 cell line. These results indicate the implication of the serotonergic system in the contact allergic reaction.

MicroRNAs: novel regulators involved in the pathogenesis of psoriasis?

MicroRNAs are a recently discovered class of posttranscriptional regulators of gene expression with critical functions in health and disease. Psoriasis is the most prevalent chronic inflammatory skin disease in adults, with a substantial negative impact on the patients' quality of life. Here we show for the first time that psoriasis-affected skin has a specific microRNA expression profile when compared with healthy human skin or with another chronic inflammatory skin disease, atopic eczema. Among the psoriasis-specific microRNAs, we identified leukocyte-derived microRNAs and one keratinocyte-derived microRNA, miR-203. In a panel of 21 different human organs and tissues, miR-203 showed a highly skin-specific expression profile. Among the cellular constituents of the skin, it was exclusively expressed by keratinocytes. The up-regulation of miR-203 in psoriatic plaques was concurrent with the down-regulation of an evolutionary conserved target of miR-203, suppressor of cytokine signaling 3 (SOCS-3), which is involved in inflammatory responses and keratinocyte functions. Our results suggest that microRNA deregulation is involved in the pathogenesis of psoriasis and contributes to the dysfunction of the cross talk between resident and infiltrating cells. Taken together, a new layer of regulatory mechanisms is involved in the pathogenesis of chronic inflammatory skin diseases.

The expression and functional significance of the serotonin(2C) receptor in murine contact allergy.

Serotonin (5-hydroxytryptamine, 5-HT) was proposed to modulate murine contact allergy by binding to 5-HT(1A/2A) receptors (R). We examined the expression of 5-HT(2C)R in the skin of mice with contact allergy, as well as the effects of an agonist and antagonist of this receptor on the elicitation phase of this type of allergy. Immunohistochemistry revealed the presence of 5-HT(2C)R on epidermal dendritic cells, and in the inflamed skin the cells expressing this antigen were increased in number (P < 0.01) and exhibited longer dendrites than in the control tissue. Furthermore, the majority of these cells also stained positively for I-A, a specific marker for Langerhans cells (LCs). Treatment of the skin of sensitized mice in vivo with RO60-0175 (0.5 and 1.0 mg/kg, once daily for 3 days prior to the challenge with antigen), an agonist for 5-HT(2C)R, enhanced the degree of contact eczema (P < 0.05 and P < 0.01 for the two doses respectively), as indicated by ear thickness. This enhancement could be prevented (P < 0.001) by the 5-HT(2C)R antagonist SB 242084 at 3 mg/kg. Addition of 5 x 10(-5) mol/l RO60-0175 to murine XS52 cells, which resembles LCs, potentiated their secretion of interleukin (IL)-1beta (P < 0.05); whereas 10(-10) mol/l attenuated this secretion (P < 0.05). Under the same conditions, the level of IL-1beta mRNA in these cells (as assessed by RT-PCR) was unaltered suggesting that this agonist may exert its effect on IL-1beta secretion at the post-transcriptional or even at the secretory level. In conclusion, our findings indicate that the 5-HT(2C)R is involved in modulating contact allergy in mice.

Multicentre patch test study of air-oxidized ethoxylated surfactants.

Frequent exposure to water and surfactants is considered to be the main cause of hand eczema from wet work. Ethoxylated surfactants are susceptible to oxidation and some of the oxidation products formed have proved to be contact sensitizers in guinea pigs. The question of human sensitization to oxidized surfactants was addressed in a multicentre study in the Stockholm region. 528 consecutive dermatitis patients were patch tested with widely used ethoxylated surfactants in oxidized and non-oxidized form as well as certain identified oxidation compounds. 61 patients presented with mild, clearly irritant reactions to some of the surfactants tested. 18 patients showed not only erythema but also oedema and/or papules and vesicles, using a morphologic descriptive system for reading the patch test reactions. These reactions occurred mostly to oxidized surfactants and oxidation products. When retesting 9 of these 18 patients only an allergic reaction to acetaldehyde was confirmed. We conclude that oxidized ethoxylated surfactants have increased irritant potential compared to non-oxidized material. Our working hypothesis is that oxidized surfactants of technical quality exert a lower risk of sensitization than do oxidized homologous pure surfactants. Among the potential allergens formed during autoxidation, formaldehyde and acetaldehyde must be considered as a source of unexpected exposure.

Galanin expression in a murine model of allergic contact dermatitis.

Galanin is a neuropeptide widely distributed in the nervous system. The expression of galanin was investigated in murine contact allergy using immunohistochemistry, radioimmunoassay and in situ hybridization. Female BALB/c mice were sensitized with oxazolone and 6 days later challenged on the dorsal surface of ears, while control mice received vehicle. After 24 h, one ear was processed for immunostaining using a biotinylated fluorescence technique, while the other ear was frozen and processed for radioimmunoassay or in situ hybridization. Galanin immunoreactive nerve fibres were more numerous (p < 0.01) in the eczematous compared with control ears. Double-staining with antibody to the nerve fibre marker PGP (protein gene product) 9.5 revealed colocalization of PGP 9.5 and galanin in nerve fibres. Radioimmunoassay demonstrated a decrease (p < 0.04) in galanin concentration in eczematous compared with control ears. Our results suggest a role for galanin in murine contact allergy.

Antibiotic-resistant Propionibacterium acnes on the skin of patients with moderate to severe acne in Stockholm.

The objective was to study the prevalence and antibiotic susceptibility patterns of Propionibacterium acnes strains isolated from patients with moderate to severe acne in Stockholm, Sweden and to determine the diversity of pulsed-field gel electrophoresis types among resistant P. acnes strains. One hundred antibiotic-treated patients and 30 non-antibiotic-treated patients with moderate to severe acne participated in the investigation. Facial, neck and trunk skin samples were taken with the agar gel technique. The susceptibility of P. acnes strains to tetracycline, erythromycin, clindamycin and trimethoprim-sulfamethoxazole was determined by the agar dilution method. The genomic profiles of the resistant strains were determined by pulsed-field gel electrophoresis. In the group of patients treated with antibiotics, resistant P. acnes strains were recovered in 37%, while in the non-antibiotic group of patients the incidence of resistant strains was 13%. Thus antibiotic-resistant P. acnes strains were significantly more often isolated from antibiotic-treated patients with moderate to severe acne than from non-antibiotic-treated patients (odds ratio, 3.8; P=0.01). There was a genetic diversity among the P. acnes strains. Forty-four different patterns of SpeI DNA digests were detected and two predominant clones were found. P. acnes strains exhibited different antibiotic susceptibility patterns and identical genotypes or vice versa. A person can be colonized with different strains with varying degrees of antibiotic resistance. The risk of increased resistance of P. acnes must be considered when treating acne patients with antibiotics, and especially long-term therapy should be avoided.

Perceptual matching for assessment of itch; reliability and responsiveness analyzed by a rank-invariant statistical method.

The aim of this study was to evaluate the reliability and responsiveness of a new device-perceptual matching by Matcher (Cefar Medical AB, Lund, Sweden)-in the assessment of the progress of experimentally induced itch as well as determine the reliability of the method in patients with skin disease and itch. The perceptual matching unit electrically stimulates the skin of the fingers in the left hand. When the amplitude of the sensation corresponded to that of the experienced itch, the subject was instructed to halt the stimulation and a value was automatically saved in the electronic device. A total of 36 healthy subjects and nine patients participated in the study. The healthy subjects were asked to rate the level of itch every 30 s during the first 5 min and thereafter every minute. The reliability was determined in a test-retest procedure of the time points 5, 10, and 15 min after induction of itching. To test the stability of the method, the first sensation of pain in healthy subjects without itch was determined every 10th minute during 60 min. In patients, the test-retest procedure was repeated within 5 min. Perceptual matching was found to be a reliable method of itch assessment, with no evidence for random individual disagreement between the assessments. The augmented rank order coefficient ra was excellent: 1.00 at 5 min; 0.99 at 10 min; and 1.00 at 15 min. There was a clear indication of responsiveness for detecting changes in itch over time, p

Expression of serotonin receptors in allergic contact eczematous human skin.

The expression of the serotonin (5-HT) receptors 5-HT1AR, 5-HT2AR and 5-HT3R was investigated in allergic contact eczematous human skin by an indirect fluorescence method. 5-HT1AR expression was found in basal epidermal NK1-beteb-positive cells, which were more elongated and showed longer dendritic processes in contact eczematous skin than in control skin. Immunoreactivity for 5-HT1AR was also found in the upper part of the epidermis, with no difference between eczematous and control skin. 5-HT1AR expression was also found in 33.3+/-6.5% and 63.7+/-11.3% of papillary dermal mononuclear cells in inflamed skin and control skin, respectively ( P<0.001), as well as in vessel walls. Some of these mononuclear cells were tryptase-positive, and found in both eczematous and control skin. 5-HT2AR-positive cells were found in the upper part of the epidermis in eczematous skin, but were more evenly distributed in the epidermis of control skin. In addition, inflammatory dermal mononuclear cells and vessel walls showed immunoreactivity for this receptor. 5-HT3R expression was found in the basal epidermal layer of eczematous and control skin. These findings indicate a plasticity in the effects of serotonin, especially regarding 5-HT1AR, in allergic contact eczematous skin.