Effect of amelogenin extracellular matrix protein and compression on hard-to-heal venous leg ulcers: follow-up data.

OBJECTIVE: To undertake a follow-up of patients with hard-to-heal venous leg ulcers (VLUs) who had participated in a randomised controlled trial in which they had been treated with either compression therapy in combination with amelogenin extracellular matrix protein or compression therapy alone for 12 weeks or until their ulcers had healed, whichever occurred first. METHOD: Patients were randomised to receive either high compression therapy plus amelogenin (n=42) or high compression therapy alone (n=41) for a period up to and including 12 weeks. The method and initial findings are detailed in an earlier paper. Twelve weeks after the final visit, the patients were followed up and the wounds were re-evaluated. RESULTS: The initial results demonstrated clinically and statistically significant benefits for the patients in the amelogenin group. The results of the follow-up showed that the successful healing response had been maintained. Significantly more patients continued to show a reduction in ulcer size from baseline in the amelogenin-treated group versus the control group (p=0.02), and there was a statistically significant (p=0.01) larger reduction in the amelogenin-treated group. This group also had a significantly (p=0.02) higher percentage of patients with decreases in wound size. The overall number of patients with healed wounds was greater (n=9) in the amelogenin-treated group than in the control group (n=3). Pain continued to be significantly reduced in the amelogenin-treated group compared with the control group (p=0.001). CONCLUSION: Amelogenin therapy in conjunction with high compression therapy was beneficial in the treatment of hard-to-heal VLUs when compared with treatment with high compression alone. These beneficial effects were maintained post-treatment and were identified at follow-up.

Eosinophilic pustular folliculitis.

Eosinophilic pustular folliculitis is a rase dermatosis and the treatment is difficult because the underlying pathogenic mechanism is unknown. The authors report a case of eosinophilic pustular folliculitis (Ofuji's disease) in a 50-year-old man who died 9 years after onset of the disease.

Positive skin and oral challenge responses to potato and occurrence of immunoglobulin E antibodies to patatin (Sol t 1) in infants with atopic dermatitis.

The clinical significance and molecular specificity of hypersensitivity reactions to raw and cooked potatoes remain ambiguous. We therefore investigated the clinical hypersensitivity to raw and cooked potato in infants suspected to have potato allergy and compared the findings with the occurrence of immunoglobulin E (IgE) antibodies to patatin (Sol t 1), characterized as the primary allergen of potato. Twelve infants (10 to 24 months of age) suffering from atopic dermatitis (AD) and suspected to have adverse reactions to potato, were examined. As a skin exposure test we used rubbing with both raw and cooked potato, and used open oral challenge with cooked potato for 7 days. A special eczema scoring system (SCORAD) was used to assess the severity of symptoms and signs of AD. Skin-prick tests (SPTs) were performed with raw potato and natural Sol t 1, and serological studies included measurement of total serum IgE and IgE antibodies to Sol t 1, and potato radioallergosorbent testing (RAST). The skin-rubbing test with raw potato was positive in seven (58%) and the oral challenge positive in eight (67%) infants. One infant presented with an immediate reaction and seven with a delayed reaction, i.e. exacerbation of AD, after oral challenge responses to cooked potato. Nine (75%) infants had IgE antibodies to Sol t 1 in enzyme-linked immunosorbent assay (ELISA), and SPT to natural Sol t 1 was positive in six (50%) potato-allergic infants. In conclusion, we observed positive challenge responses to both raw and cooked potato in food-allergic atopic infants. The presence of IgE antibodies and concomitant positive SPTs to the heat-stable potato allergen, Sol t 1, suggest that cooked potato can be an allergenic food for infants suffering from AD.

Identification of four novel potato (Solanum tuberosum) allergens belonging to the family of soybean trypsin inhibitors.

BACKGROUND: We have previously identified patatin (Sol t 1) of potato tubers as a major food allergen among atopic children. In addition to Sol t 1, concomitant IgE binding to other, then unidentified, potato proteins was observed. METHODS: Purification and identification of the putative allergens were done by both standard and advanced methods of protein chemistry. The patient series comprised 39 children with positive skin prick test (SPT) to raw potato. Immunoblotting and ELISA were used to examine IgE-binding ability and skin prick testing to assess in vivo reactivity of the purified potato proteins. RESULTS: Four IgE-binding potato proteins with molecular masses ranging from 16 to 20 kDa were purified and identified as cathepsin D-, cysteine-, and aspartic protease inhibitors belonging to the family of soybean trypsin inhibitors (Kunitz type). The proteins were designated Sol t 2, Sol t 3.0101, Sol t 3.0102, and Sol t 4. In ELISA, 51% of the sera of the 39 atopic children showed specific IgE to Sol t 2, 43% to Sol t 3.0101, 58% to Sol t 3.0102, and 67% to Sol t 4, respectively. All these four allergens were able to produce positive wheal-and-flare responses in SPT. CONCLUSION: In addition to Sol t 1, potato tubers contain several proteins belonging to the family of soybean trypsin inhibitors against which atopic children with positive SPT responses to raw potato have in vitro and in vivo reactive IgE antibodies.

Increased concentration of fecal alpha1-antitrypsin is associated with cow's milk allergy in infants with atopic eczema.

BACKGROUND: The use of fecal alpha1-antitrypsin in the monitoring of intestinal inflammation in infants with atopic eczema and food allergy was evaluated. METHODS: The study material comprised 26 atopic infants with confirmed food allergy. Fecal samples were collected before an elimination diet and 3 months later for the determination of alpha1-antitrypsin. RESULTS: Nine (35%) of the 26 patients demonstrated an increased fecal concentration of alpha1-antitrypsin (median 3 mg/g; range 2.8-6.4 mg/g). In all nine patients (100%) the oral cow's milk challenge was positive as opposed to only six (35%) in those with normal alpha1-antitrypsin concentration (P = 0.0024). No further connections between alpha1-antitrypsin and other food allergies were detected. As a result of an adequate elimination diet, the fecal concentration of alpha1-antitrypsin was normalized in seven patients, with a favourable clinical response in atopic eczema in six and no improvement in one patient. CONCLUSIONS: Our results indicate that serial determinations of fecal alpha1-antitrypsin provide a useful non-invasive tool for the detection and follow-up of intestinal inflammation in a certain group of atopic infants with cow's milk allergy and severe inflammation of the gut.

Eosinophil protein X and eosinophil cationic protein as indicators of intestinal inflammation in infants with atopic eczema and food allergy.

BACKGROUND: The aim of this study was to evaluate the presence of allergic intestinal inflammation in infants with food allergy and atopic eczema before and after elimination diet, and to evaluate the use of eosinophil protein X (EPX) and eosinophil cationic protein (ECP) in the monitoring of inflammatory activity. METHODS: The study material comprised 25 infants with atopic dermatitis and food allergy. Thirteen healthy infants served as controls. Faecal and serum samples were collected before an elimination diet (on the first visit to the hospital) and approximately 3 months later for the determination of EPX and ECP. RESULTS: Before the elimination diet, infants with atopic dermatitis demonstrated markedly higher faecal concentrations of EPX and ECP than healthy controls (P = 0. 0003, P < 0.0001, respectively). The faecal concentrations of EPX and ECP showed a distinct decrease as a result of an adequate elimination diet in patients with favourable clinical response (P = 0.0027, P = 0.004, respectively). CONCLUSIONS: The results indicate the presence of marked intestinal inflammation in patients with atopic dermatitis and food allergy. The determination of faecal ECP and especially of faecal EPX provides a promising noninvasive tool in monitoring intestinal inflammation and disease activity in infants with atopic eczema and food allergy.

Wheat allergy: diagnostic accuracy of skin prick and patch tests and specific IgE.

BACKGROUND: Food allergy makes an important contribution to the pathogenesis of atopic eczema in infants. However, clinical data on cereal allergy are scanty. The objective was to study the relevance of patch testing, skin prick tests, and the concentration of wheat-specific IgE antibodies (CAP RAST) in correlation with oral wheat challenge in infants with suspected wheat allergy. In particular, we aimed to determine whether the patch test could increase the diagnostic accuracy in detecting wheat allergy. METHODS: The study material comprised 39 infants under the age of 2 years. Of these patients, 36 were suffering from atopic eczema and three had only gastrointestinal symptoms. The patients were subjected to a double-blind, placebo-controlled or open wheat challenge. Wheat-specific IgE was measured by CAP RAST, and skin prick and patch tests were performed. RESULTS: Of the total 39 wheat challenges, 22 (56%) were positive. Of the positive reactions, five involved immediate-type skin reactions over a period of 2 h from the commencement of the challenge. In 17 patients, delayed-onset reactions of eczematous or gastrointestinal type appeared. Of the infants with challenge-proven wheat allergy, 20% showed elevated IgE concentrations to wheat, 23% had a positive skin prick test, and 86% had a positive patch test for wheat. The specificities of CAP RAST, skin prick tests, and patch tests were 0.93, 1.00, and 0.35, respectively. CONCLUSIONS: Our study demonstrated that patch testing with cereals will significantly increase the probability of early detection of cereal allergy in infants with atopic eczema and is helpful in the planning of successful elimination diets before challenge. The specificity of the patch test was lower than that of other tests. Therefore, confirmation of the diagnosis with the elimination-challenge test is essential in patients with positive patch test results.

Cow's milk allergy: diagnostic accuracy of skin prick and patch tests and specific IgE.

BACKGROUND: The objective of the present study was to evaluate the relevance of skin tests and the concentration of cow's milk-specific IgE antibodies in correlation with oral cow's milk challenge in infants with suspected cow's milk allergy. METHODS: The study material comprised 143 infants under the age of 2 years who had undergone a diagnostic elimination challenge because of suspected cow's milk allergy in 1996. Cow's milk-specific IgE was measured, and skin prick and patch tests were performed. RESULTS: Of the 143 oral cow's milk challenges performed, 72 (50%) were positive. Of the positive reactions, 22 involved immediate-type reactions. In 50 patients, delayed-onset reactions of eczematous or gastrointestinal type appeared. Of the infants with challenge-proven cow's milk allergy, 26% showed elevated IgE concentrations to cow's milk, 14% had a positive skin prick test, and 44% had a positive patch test for cow's milk. Interestingly, in most patch test-positive patients, the prick test for cow's milk was negative. CONCLUSIONS: Our study demonstrated that many patients with a negative prick test result had a positive patch test to cow's milk. The patch test was a more sensitive method than the prick test or RAST to detect cow's milk allergy in this study population. Our results indicate that patch testing will significantly increase the probability of early detection of cow's milk allergy. Confirmation of the diagnosis is essential in patients with negative test results but a clinical suspicion of food allergy, and in patch test-positive patients. For this purpose, the most reliable method is the elimination-challenge procedure.

Altered expression of IgG and complement receptors indicates a significant role of phagocytes in atopic dermatitis.

BACKGROUND: Strict dietary precautions against allergic sensitization may benefit a group of predisposed children. OBJECTIVE: To develop new strategies for identifying these children, a better understanding of the processes that initiate sensitization and regulate and perpetuate the inflammatory response is needed. METHODS: We measured the expression of the receptors for the constant (Fc) region of IgG (Fc gamma RI, Fc gamma RII, and Fc gamma RIII) and that for the complement fragments C3b and C3bi (CR1 and CR3) in neutrophils and monocytes from 39 children with atopic dermatitis, 17 disease control patients with acute infections, and 17 healthy control subjects. The capacity of phagocytes to produce reactive oxygen species was also determined. To find the best way of discriminating the patients with atopic dermatitis from control subjects, a stepwise logistic binary regression model was made. RESULTS: The stepwise logistic regression analysis was based on differences in individual receptor expression between the study groups. Because acute infections strongly affected receptor expression in both neutrophils and monocytes, to avoid diagnostic bias, children with acute infections were excluded from the analysis. The combination of the receptors CR1 in neutrophils and Fc gamma RI and Fc gamma RII in monocytes was the best indicator of atopic dermatitis. A significant correlation between the expression of CR1 in neutrophils and in monocytes, as well as reactive oxygen species production of phagocytes, and the severity of the eczema was detected. CONCLUSIONS: These results suggest that a distinct receptor profile of phagocytic cells can be characterized in patients with atopic dermatitis, providing a new direction to the search for early identification of children predisposed to allergic sensitization.

Probiotics: a novel approach in the management of food allergy.

BACKGROUND: The gastrointestinal microflora is an important constituent of the gut mucosal defense barrier. We have previously shown that a human intestinal floral strain, Lactobacillus GG (ATCC 53103), promotes local antigen-specific immune responses (particularly in the IgA class), prevents permeability defects, and confers controlled antigen absorption. OBJECTIVE: The aim of this study was to evaluate the clinical and immunologic effects of cow's milk elimination without (n = 14) and with (n = 13) the addition of Lactobacillus GG (5 x 10(8) colony-forming units/gm formula) in an extensively hydrolyzed whey formula in infants with atopic eczema and cow's milk allergy. The second part of the study involved 10 breast-fed infants who had atopic eczema and cow's milk allergy. In this group Lactobacillus GG was given to nursing mothers. METHODS: The severity of atopic eczema was assessed by clinical scoring. The concentrations of fecal alpha 1- antitrypsin, tumor necrosis factor-alpha, and eosinophil cationic protein were determined as markers of intestinal inflammation before and after dietary intervention. RESULTS: The clinical score of atopic dermatitis improved significantly during the 1-month study period in infants treated with the extensively hydrolyzed whey formula fortified with Lactobacillus GG. The concentration of alpha 1-antitrypsin decreased significantly in this group (p = 0.03) but not in the group receiving the whey formula without Lactobacillus GG (p = 0.68). In parallel, the median (lower quartile to upper quartile) concentration of fecal tumor necrosis factor-alpha decreased significantly in this group, from 709 pg/gm (91 to 1131 pg/gm) to 34 pg/gm (19 to 103 pg/gm) (p = 0.003), but not in those receiving the extensively hydrolyzed whey formula only (p = 0.38). The concentration of fecal eosinophil cationic protein remained unaltered during therapy. CONCLUSION: These results suggest that probiotic bacteria may promote endogenous barrier mechanisms in patients with atopic dermatitis and food allergy, and by alleviating intestinal inflammation, may act as a useful tool in the treatment of food allergy.

Evaluation of the gut mucosal barrier: evidence for increased antigen transfer in children with atopic eczema.

BACKGROUND: Intestinal antigen handling determines subsequent immune response to the antigen. Antigens are absorbed across epithelium along two functional pathways. The main pathway is degradative, which reduces the immunogenicity of the antigen. A minor pathway allows the transport of intact proteins, which is crucial for antigen-specific immune responses. The Ussing chamber method allows the quantitative measurement of protein transfer across the intestinal mucosa. OBJECTIVE: This study was designed to explore the theory that altered antigen transfer across the intestinal mucosa is a factor in the pathogenesis of atopic eczema, characterized by hyperactivity to environmental antigens. METHODS: The absorption and degradation of horseradish peroxidase (molecular weight, 40,000 d) were studied in vitro in Ussing chambers. Eighteen biopsy specimens of upper small intestinal mucosa from 14 patients (aged 0.5 to 8 years) with atopic eczema and 18 specimens from 15 age-matched control subjects were examined. RESULTS: The mean (95% confidence interval) absorption of intact horseradish peroxidase was significantly higher in children with atopic eczema than in control subjects: 242 (81-404) pmol . hr(-1) . cm(-2) versus 23 (12-33) pmol . hr(-1) . cm(-2); t = 2.86, p = 0.007. The absorption of degraded horseradish peroxidase was 972 (732-1213) pmol . hr(-1) . cm(-2) in patients with atopic eczema and 672 (532-811) pmol . hr(-1) . cm(-2) in control subjects; t = 2.29, p = 0.03. CONCLUSIONS: Our results may reflect a primarily altered antigen transfer in patients who have atopic eczema, which may initiate and perpetuate prompt immune responses to common environmental antigens, including foods.

Intestinal inflammation in children with atopic eczema: faecal eosinophil cationic protein and tumour necrosis factor-alpha as non-invasive indicators of food allergy.

BACKGROUND: Food allergy is contemplated in atopic eczema. Early recognition of food allergies is difficult and the diagnosis is often missed because of the non-specificity of symptoms. New non-invasive tests are clearly needed. OBJECTIVE AND METHODS: We measured the concentrations of tumour necrosis factor-alpha, eosinophil cationic protein and alpha-1 antitrypsin in faeces as indicators of intestinal inflammation induced by double-blind placebo-controlled oral cow's milk challenge in infants and young children with atopic eczema. RESULTS: An increased alpha-1 antitrypsin concentration (> 2 mg/g) after cow's milk challenge was detected in 43% of the infants positive as compared with 11% of the infants negative to challenge, P = 0.02. The concentration of eosinophil cationic protein in faeces increased after cow's milk challenge in patients positive to challenge (P = 0.02) but not in those negative to challenge (P = 0.79). The concentration of eosinophil cationic protein was enhanced particularly in patients manifesting immediate-type reactions to the cow's milk challenge. The concentration of tumour necrosis factor-alpha increased after cow's milk challenge in patients positive to challenge (P = 0.005) but not in those negative to challenge (P = 0.25). The concentration of tumour necrosis factor-alpha in faeces was enhanced particularly in patients manifesting delayed-type reactions to the cow's milk challenge. CONCLUSION: We conclude that in children with atopic eczema food allergy is associated with intestinal inflammation indicating that more general immunologic disturbances than previously thought take place in these patients. We further suggest that faecal eosinophil cationic protein, tumour necrosis factor-alpha and alpha-1 antitrypsin distinctly indicate various reaction types of food allergy. Parallel testing with eosinophil cationic protein and tumour necrosis factor-alpha may significantly enhance the accuracy in diagnosis of food allergy in patients with atopic eczema.