Influence of ultraviolet B exposure on immune responses following hepatitis B vaccination in human volunteers.

Exposure to ultraviolet radiation can modulate immune responses in animal and humans. Remarkably, the ultraviolet-induced immunosuppression is not restricted to the exposed skin but is also found at other body sites, i.e., systemic immunosuppression. Effects of ultraviolet radiation on infections cannot be determined by experimentation on humans, but the effects of ultraviolet on vaccination may serve as a model. Moreover, it is important in its own right to assess whether ultraviolet radiation affects vaccination responses. In this study the effect of ultraviolet B exposure on the development of immune responses after hepatitis B vaccination in human volunteers was investigated. To this end, 191 human volunteers were vaccinated against hepatitis B with the Engerix-B vaccine. Ninety-seven of them were prior to the first vaccination exposed to ultraviolet B on 5 consecutive days with one personal minimal erythema dose per day. At several time-points before and after the ultraviolet B exposure regimen and the vaccination, blood samples were taken. Parameters for specific as well as nonspecific cellular and humoral immunity were analyzed. It was demonstrated that ultraviolet B exposure prior to hepatitis B vaccination did not alter the cellular (lymphocyte stimulation test) nor the humoral (antibody titers) immune response against hepatitis B surface antigen significantly. In contrast, contact hypersensitivity to diphenylcyclopropenone was significantly suppressed after ultraviolet B exposure, as was natural killer cell activity. These latter results confirm earlier findings and demonstrate immunosuppressive effectiveness of the ultraviolet regimen. In summary, although natural killer cell activity and contact hypersensitivity responses were suppressed, the ultraviolet B radiation protocol did not alter the humoral nor the cellular immune responses against hepatitis B surface antigen after vaccination.

Psychosocial impact of acne vulgaris. evaluation of the relation between a change in clinical acne severity and psychosocial state.

BACKGROUND: Although knowledge concerning the impact of acne vulgaris on quality of life has increased in recent years, relatively few studies have assessed the effect of a change in clinical severity on psychosocial state. OBJECTIVE: Assessment of the effect of a change in clinical acne severity on psychosocial state. METHODS: This was investigated by means of questionnaires and clinical assessments by acne patients and dermatologists. Fifty females with mild to moderate facial acne were seen before and after a 9-month treatment with oral contraceptives. RESULTS: The results showed a great variability in psychosocial impairment between individuals. After 9 months, a significant reduction in clinical severity was seen overall which did not relate to the significant improvements in self-esteem, stability of self-esteem and acceptance of appearance. CONCLUSION: Perceived psychosocial impairment is individually based, is greater in women who subjectively overrate their acne and does not relate to clinical improvement.

The incidence of erythroderma: a survey among all dermatologists in The Netherlands.

BACKGROUND: Erythroderma is a rare skin disorder, and studies on its incidence and causes are lacking. The annual incidence has been estimated to be 1 to 2 patients per 100,000 inhabitants. OBJECTIVE: We investigated the incidence and cause of erythroderma in an unselected population and evaluated the referral pattern of erythrodermic patients by nonacademic dermatologists. METHODS: A survey was performed among all nonacademic dermatologists in The Netherlands, using a mailed questionnaire. Questions dealt with the number of patients diagnosed with erythroderma in the year 1997, the cause of the erythroderma, and whether these patients were referred to a university hospital. A questionnaire was also sent to all university hospitals. RESULTS: Seventy-eight percent of the nonacademic dermatologists answered the questionnaire, and all 8 university hospitals responded. In the year 1997, 141 patients were diagnosed with erythroderma in The Netherlands. The annual incidence of erythroderma based on these figures is 0.9 patients per 100,000 inhabitants. Compared with the university hospitals, erythroderma was more often diagnosed as an exacerbation of preexisting dermatoses (61% vs 51%; P =.37) and less often as idiopathic (14% vs 31%; P =.04) among the nonacademic dermatologists. Cutaneous T-cell lymphoma was rarely the cause, occurring in only 1% of patients diagnosed by the nonacademic dermatologists but in 6% of patients at the university hospitals. Overall, only 37% of nonacademic dermatologists referred patients with erythroderma to a university hospital. CONCLUSIONS: The incidence of erythroderma in The Netherlands is slightly lower than the earlier estimate in the literature. Moreover, the cause of erythroderma is different among patients diagnosed in an academic and a nonacademic setting. The majority of dermatologists in The Netherlands treat patients with erythroderma themselves and do not refer these patients to university hospitals.

Prognostic factors in primary cutaneous large B-cell lymphomas: a European multicenter study.

PURPOSE: Most primary cutaneous B-cell lymphomas have an excellent prognosis. However, primary cutaneous large B-cell lymphomas (PCLBCLs) of the leg have been recognized as a distinct entity with a poorer prognosis in the European Organization for Research and Treatment of Cancer (EORTC) classification. This distinction on the basis of site has been debated. Our aim was to identify independent prognostic factors in a large European multicenter series of PCLBCL. PATIENTS AND METHODS: The clinical and histologic data of 145 patients with PCLBCL were evaluated. According to the EORTC classification, 48 patients had a PCLBCL of the leg and 97 had a primary cutaneous follicle center-cell lymphoma (PCFCCL). Data from both groups were compared. Univariate and multivariate analyses of specific survival were performed using a Cox proportional hazards model. RESULTS: Compared with PCFCCL, PCLBCL-leg were characterized by an older age of onset, a more recent history of skin lesions, a more frequent predominance of tumor cells with round nuclei and positive bcl-2 staining, and a poorer 5-year disease-specific survival rate (52% v 94%; P <.0001). Univariate survival analysis in the entire study group showed that older age, a more recent onset of skin lesions, the location on the leg, multiple skin lesions, and the round-cell morphology were significantly related to death. In multivariate analysis, the round-cell morphology (P <.0001), the location on the leg (P =.002), and multiple skin lesions (P =.01) remained independent prognostic factors. The round-cell morphology was an adverse prognostic factor both in PCLBCL-leg and in PCFCCL, whereas multiple skin lesions were associated with a poor prognosis only in patients with PCLBCL-leg. CONCLUSION: With site, morphology, and number of tumors taken into account, guidelines for the management of PCLBCL are presented.

Lymphomatoid papulosis in children: a study of 10 children registered by the Dutch Cutaneous Lymphoma Working Group.

Lymphomatoid papulosis (LyP) is a chronic recurrent self-healing condition, with histological features suggestive of a malignant lymphoma. Only a few cases have been described in children. We report 10 children with this skin disease and compare them with the adult type of LyP and childhood cases described in the literature. Although LyP has the same clinical picture and histology in both age groups, in contrast with the adult type no transformation into malignancy has been described in childhood.

Photodynamic therapy with violet light and topical 6-aminolaevulinic acid in the treatment of actinic keratosis, Bowen's disease and basal cell carcinoma.

BACKGROUND: Most clinical studies using photodynamic therapy (PDT) with topical application of delta-aminolaevulinic acid (delta-ALA) use red light because it allows greater depth of penetration. However, given the porphyrin-like spectrum of delta-ALA-induced photosensitivity, violet light provides a maximal overlap with the excitation spectrum of protoporphyrin IX, meaning that PDT with violet light uses less light energy to induce the phototoxic reaction. AIM: To study the efficacy of violet light in combination with topical delta-ALA PDT in the treatment of pre-malignant and malignant skin lesions. METHODS: Eight hours after 20% delta-ALA was applied topically, photoirradiation was performed with an incoherent light source (Philips HPM-10, 400 W) emitting predominantly violet light (400-450 nm). Lesions received 10-20 J/cm2 during an exposure time of 30 min. The 38 subjects treated included three with basal cell naevus syndrome with multiple (> 30) superficial and nodular basal cell carcinomas (BCCs), one subject had multiple lesions of Bowen's disease, involving 50% of the scalp, and the remaining 34 subjects presented a total of 35 superficial BCCs, 10 nodular BCCs, four large solar keratoses and five solitary lesions of Bowen's disease. RESULTS: Complete remission both clinically and histologically was seen after a single treatment in 82% of the superficial BCCs (100% after a second treatment), 50% of the nodular BCCs, one of the four solar keratosis lesions (partial remission in the other three) and 90-100% of the solitary lesions of Bowen's disease. CONCLUSIONS: delta-ALA PDT using violet light appears to be a well tolerated and effective alternative treatment for premalignant and malignant skin lesions, especially when there are multiple lesions or large patches comprising a large area of skin.

Interleukin 4 and interferon-gamma expression of the dermal infiltrate in patients with erythroderma and mycosis fungoides. An immuno-histochemical study.

BACKGROUND: Erythroderma, or generalized erythema of the skin, may result from different causes. At present it is unclear whether the underlying patho-mechanisms that lead to erythroderma are identical or different depending on the original disease. The aim of this study was to investigate the dermal cytokine profile in different types of erythroderma and mycosis fungoides. METHODS: Snap-frozen skin biopsy specimens from 33 patients with erythroderma were studied. Thirteen had idiopathic erythroderma, 7 erythrodermic atopic dermatitis, 5 Sézary syndrome and 8 had erythroderma from miscellaneous causes. We also studied 6 patients with mycosis fungoides (5 plaques and 1 tumor) and 5 healthy non-atopic volunteers. The biopsies were immunohistochemically stained for interleukin 4 (IL-4) and interferon gamma (IFN-gamma). All positive cells for IL-4 and IFN-gamma in the dermis were counted and the number of positive cells was calculated per mm2. IL-4/IFN-gamma ratio was calculated for each biopsy. RESULTS: The patients with idiopathic erythroderma, atopic dermatitis and miscellaneous erythroderma, all showed more IFN-gamma-positive cells than IL-4-positive cells in the dermis. The median IL-4/ IFN-gamma ratio for these three groups was 0.6, 0.9 and 0.45, respectively. These differences were not statistically significant. All patients with Sézary syndrome however, showed more IL-4-positive cells than IFN-gamma-positive cells. The median IL-4/IFN-gamma ratio was 1.8, which is significantly higher than in the other groups p<0.05). In mycosis fungoides roughly the same number of cells expressed IL-4 and IFN-gamma. The median IL-4/IFN-gamma ratio was 1.0, which is significantly lower than in Sézary syndrome (p<0.05). CONCLUSIONS: The dermal infiltrate in patients with Sezary syndrome mainly shows a T-helper 2 (Th2) cytokine profile, this in contrast to T-helper 1 (Th1) cytokine profile in benign reactive erythroderma. This indicates that although a relative uniform clinical picture of erythroderma is obvious, a different patho-mechanisms may be underlying.

Expression of VCAM-1, ICAM-1, E-selectin, and P-selectin on endothelium in situ in patients with erythroderma, mycosis fungoides and atopic dermatitis.

BACKGROUND: Erythroderma may result from different causes. At present it is unclear whether the patho-mechanisms that lead to these different types of erythroderma are identical or different. Adhesion molecules and their ligands play a major role in endothelial-leukocyte interactions, which affect the binding, transmigration and infiltration of lymphocytes and mononuclear cells during inflammation, injury, or immunological stimulation. The aim of this study was to investigate the adhesion molecule expression on endothelial cells in erythroderma in situ. METHODS: Snap-frozen skin biopsy specimens from 23 patients with erythroderma were studied. Eight had idiopathic erythroderma, 5 erythrodermic atopic dermatitis, 4 Sézary syndrome and 6 had erythroderma from miscellaneous causes. As a control we studied skin specimens from 10 patients with mycosis fungoides, 5 patients with atopic dermatitis and 5 healthy non-atopic volunteers. To determine adhesion molecule expression on endothelial cells in situ, sections were immuno-histochemically double stained with biotinylated Ulex Europaeus agglutinin 1 as a pan-endothelial cell marker, and for the adhesion molecules VCAM-1, ICAM-1, E-, and P-selectin. All double- and single-stained blood vessels in the dermis were counted. RESULTS: Mean endothelial expression in erythroderma was as follows: VCAM-1 51.4%, ICAM-1 70.1%, E-selectin 43.5%, and P-selectin 52.6%. There was no statistical difference between different groups of erythroderma. Mean expression of all adhesion molecules tested, was in Sézary syndrome higher than in mycosis fungoides albeit not significant. In erythrodermic atopic dermatitis only VCAM-1 expression was significantly higher than in lesional skin of atopic dermatitis. No differences were observed in expression of the other three adhesion molecules. CONCLUSIONS: There is no difference regarding adhesion molecule expression on endothelial cells between different types of erythroderma.

Linkage and LOH studies in 19 cylindromatosis families show no evidence of genetic heterogeneity and refine the CYLD locus on chromosome 16q12-q13.

Familial cylindromatosis is an autosomal dominant predisposition to multiple neoplasms of the skin appendages. The susceptibility gene has previously been mapped to chromosome 16q12-q13 and has features of a recessive oncogene/tumour suppressor gene. We have now evaluated 19 families with this disease by a combination of genetic linkage analysis and loss of heterozygosity in cylindromas from affected individuals. All 15 informative families show linkage to this locus, providing no evidence for genetic heterogeneity. Recombinant mapping has placed the gene in an interval of approximately 1 Mb. There is no evidence, between families, of haplotype sharing that might be indicative of common founder mutations.

Impact of global genome repair versus transcription-coupled repair on ultraviolet carcinogenesis in hairless mice.

The nucleotide excision repair (NER) system is comprised of two subpathways, i.e., transcription-coupled repair (TCR) and global genome repair (GGR). To establish the relative importance of TCR and GGR for UV effects on the skin, we have used hairless knockout mouse strain lacking either TCR (CSB -/-) or GGR (XPC -/-). In single exposure experiments, we found that CSB -/- mice have a 7-16 times higher susceptibility to sunburn than XPC -/- mice and than heterozygous (+/-) and wild-type (+/+) controls. Exposure to 80 J/m2 UV radiation (i.e., suberythemogenic in CSB -/-) on 10 consecutive days gives rise to epidermal hyperplasia in CSB -/- and XPC -/-, whereas repair-proficient controls do not show epidermal hyperplasia from these exposures. In addition, CSB -/- mice develop marked parakeratosis, whereas XPC -/- mice and controls do not. Under continued exposure to this daily dose, squamous cell carcinomas appear in CSB -/-, XPC -/-, and in the control groups, whereas only in the CSB -/- animals is a fairly high number of benign papillomas also found. The median latency time of squamous cell carcinomas (diameters > or = 1 mm) is 84 days for the XPC -/- mice, 115 days for the CSB -/- mice, and 234-238 days for the heterozygous and wild-type control groups. These results indicate that GGR is more important than TCR in protection against UV-induced carcinomas of the skin but not against other UV effects such as sunburn, epidermal thickening, scaling of the stratum corneum, and development of papillomas. These results also indicate that GGR capacity may serve as a better predictor for skin cancer susceptibility than sensitivity to sunburn. The relative cancer susceptibilities of GGR- and TCR-deficient skin could well depend on the balance between an increased mutation rate and the presence (in CSB -/-) or lack (in XPC -/-) of a compensatory apoptotic response.

Primary and secondary cutaneous CD30(+) lymphoproliferative disorders: a report from the Dutch Cutaneous Lymphoma Group on the long-term follow-up data of 219 patients and guidelines for diagnosis and treatment.

To evaluate our diagnostic and therapeutic guidelines, clinical and long-term follow-up data of 219 patients with primary or secondary cutaneous CD30(+) lymphoproliferative disorders were evaluated. The study group included 118 patients with lymphomatoid papulosis (LyP; group 1), 79 patients with primary cutaneous CD30(+) large T-cell lymphoma (LTCL; group 2), 11 patients with CD30(+) LTCL and skin and regional lymph node involvement (group 3), and 11 patients with secondary cutaneous CD30(+) LTCL (group 4). Patients with LyP often did not receive any specific treatment, whereas most patients with primary cutaneous CD30(+) LTCL were treated with radiotherapy or excision. All patients with skin-limited disease from groups 1 and 2 who were treated with multiagent chemotherapy had 1 or more skin relapses. The calculated risk for systemic disease within 10 years of diagnosis was 4% for group 1, 16% for group 2, and 20% for group 3 (after initial therapy). Disease-related 5-year-survival rates were 100% (group 1), 96% (group 2), 91% (group 3), and 24% (group 4), respectively. The results confirm the favorable prognoses of these primary cutaneous CD30(+) lymphoproliferative disorders and underscore that LyP and primary cutaneous CD30(+) lymphomas are closely related conditions. They also indicate that CD30(+) LTCL on the skin and in 1 draining lymph node station has a good prognosis similar to that for primary cutaneous CD30(+) LTCL without concurrent lymph node involvement. Multiagent chemotherapy is only indicated for patients with full-blown or developing extracutaneous disease; it is never or rarely indicated for patients with skin-limited CD30(+) lymphomas. (Blood. 2000;95:3653-3661)

Mycosis fungoides: disease evolution and prognosis of 309 Dutch patients.

OBJECTIVES: To determine the disease course of Dutch patients with mycosis fungoides and to define factors related to disease progression and survival. DESIGN: A multicenter, 13-year, retrospective cohort analysis. SETTING: Eight dermatology departments collaborating in the Dutch Cutaneous Lymphoma Group. PATIENTS: Three hundred nine patients with mycosis fungoides registered between October 1985 and May 1997, including 89 patients with limited patches or plaques (stage Ia), 135 with generalized patches or plaques (stage Ib), 46 with skin tumors (stage Ic), 18 with enlarged but uninvolved lymph nodes (stage II), 18 with lymph node involvement (stage III), and 3 with visceral involvement (stage IV). MAIN OUTCOME MEASURES: Response to initial treatment, sustained complete remission, actuarial disease progression, and overall and disease-specific survival per clinical stage. RESULTS: The median follow-up was 62 months (range, 1-113 months). For the entire group, the actuarial overall and disease-specific survival was 80% and 89% at 5 years, and 57% and 75% at 10 years, respectively. The actuarial 5-year disease-specific survival of patients with stage Ia, Ib, and Ic disease was 100%, 96%, and 80%, respectively, and only 40% for patients with stage III disease. Using multivariate analysis, the presence of extracutaneous disease, the type and extent of skin involvement, the response to initial treatment, and the presence of follicular mucinosis were independently associated with higher disease progression and mortality rates. The calculated risks of disease progression at 5 and 10 years gradually increased from 4% to 10% for those with stage Ia disease, from 21% to 39% for those with stage Ib disease, and from 32% to 60% for those with stage Ic disease; for those with stage III disease, the risk remained at 70% at 5 and 10 years. The overall risk of disease progression at 5 and 10 years was 24% and 38%, respectively, for the total study group. CONCLUSION: At least within the first 10 years after diagnosis, disease progression and mycosis fungoides-related mortality occur in only a subset of patients generally presenting with advanced disease.

Polymorphous light eruption: A clinical, photobiologic, and follow-up study of 110 patients.

BACKGROUND: Polymorphous light eruption is a common chronic idiopathic photodermatosis. The action spectrum and therapy are under debate. OBJECTIVE: The aim of the study was to analyze the clinical aspects of this dermatosis, the photodiagnostic tests, and the results of therapy in an academic center. METHODS: To obtain a reasonable follow-up period, we examined all available data of the patients who underwent diagnostic phototests in the period 1985 through 1991. Our procedure of phototesting included determination of minimal erythema doses, photoprovocation tests, and photopatch tests. The evaluation of the effect of the therapy was based on the patients' experiences, time spent outdoors, and amount of sun exposure. RESULTS: Our collection included data on 35 men and 75 women. The age at onset differed significantly between men and women (averages 46 and 28 years, respectively; P <.01). The minimal erythema doses for UVB were lowered in 43% of the men and in 4% of the women (P <.01); the minimal erythema doses for UVA were lowered in 37% of the men and in 11% of the women (P <.01). The photoprovocation tests showed a pathologic reaction to both UVB and UVA in 88% of the men and in 52% of the women (P <.01). In the remaining patients we found pathologic reactions to UVB alone (for men 9%, for women 24%; P >.05) or UVA alone (for men 3%, for women 24%; P <.01). The abnormal reactions to visible light were almost exclusively observed in those patients who reacted pathologically to both UVB and UVA (43% of the male patients, 11% of the female patients; P <.01). The photopatch tests showed a large number of positive test results, mainly to skin care products or sunscreens (75% of all patients). The 70 most sensitive patients (64%) were treated with prophylactic UVB therapy 2 or 3 times a week at home or initially in the outpatient department. This treatment was normally done from February to June, but in severe cases throughout the whole year. CONCLUSION: Phototests revealed abnormal reactions to UVB as well as UVA and to some extent also to visible light. Prophylactic UVB therapy is a successful treatment for polymorphous light eruption.

Treatment of multifocal primary cutaneous B-cell lymphoma: a clinical follow-up study of 29 patients.

PURPOSE: Although patients with primary cutaneous B-cell lymphoma (CBCL) and localized skin lesions are generally treated with radiotherapy and have an excellent prognosis, the clinical behavior and optimal treatment of CBCL presenting with multifocal skin lesions are less well defined. In this study, we evaluated the clinical behavior of and results of treatment for multifocal CBCL in 29 patients, and we formulated therapeutic guidelines. PATIENTS AND METHODS: The study group included 16 patients with primary cutaneous follicular center-cell lymphoma (PCFCCL), eight with primary cutaneous immunocytoma (PCI), and five with primary cutaneous large B-cell lymphoma presenting on the legs (PCLBCL of the leg). RESULTS: Only one of the 24 patients with multifocal PCFCCL or PCI developed extracutaneous disease, and no patient died from lymphoma (median follow-up, 54 months). In patients with PCFCCL, treatment with either multiagent chemotherapy (nine patients) or radiotherapy directed toward all skin lesions (five patients) proved equally effective in terms of complete remission, relapse, and survival. In contrast, all five patients with PCLBCL of the leg developed extracutaneous disease, and four of the five died from systemic lymphoma, 8 to 36 months (median, 21 months) after diagnosis. CONCLUSION: The results of these preliminary studies suggest that patients with PCFCCL or PCI presenting with multifocal skin lesions have the same excellent prognosis that patients with localized PCFCCL or PCI have and that radiotherapy directed toward all skin lesions is as effective as multiagent chemotherapy. Patients with PCLBCL of the leg have a more unfavorable prognosis, particularly patients presenting with multifocal skin lesions. This last group should always be treated with multiagent chemotherapy.

Multidrug resistance related proteins in primary cutaneous lymphomas.

BACKGROUND: In patients with primary cutaneous B-cell lymphomas (CBCL) and primary cutaneous T-cell lymphomas (CTCL), extracutaneous sites may become involved and then polychemotherapy is indicated. Multi-agent chemotherapy may induce long lasting complete remissions in CBCL's. Most CTCL's, especially mycosis fungoides (MF), and CD30 negative primary cutaneous large T-cell lymphoma (PCLTCL) respond poorly or partially to Multi-agent Chemotherapy. PURPOSE: We have studied whether cutaneous lymphomas express the following multidrug resistance (MDR) related proteins: multidrug resistance protein (MRP), lung resistance protein (LRP) and P-glycoprotein (Pgp). METHODS: From the files of the Dutch Cutaneous Lymphoma Working Group we selected pretreatment punch biopsy specimens of the skin from 14 patients with MF, 10 patients with a PCLTCL and 8 patients with a CBCL. In several patients with a clinical relapse of their disease after multi-agent chemotherapy, punch biopsy specimens of cutaneous lesions were available (6 MF, 3 PCLTCL, 1 CBCL). Benign dermatoses with a dense lymphoid infiltrate were included as a control. Immunohistochemistry was done on formalin fixed, paraffin-embedded punch biopsy specimens with monoclonal antibodies MRPrl (anti-MRP); LRP-56 (anti-LRP); C219 (anti-Pgp). Staining was performed by the biotin-streptavidin immunoperoxidase method. RESULTS: MRPrl staining was found in the cytoplasm of > or = 5%-50% of lymphoid cells in 13 out of 14 cases of MF and in 6 out of 10 patients with a PCLTCL. In 2 out of 8 cases of CBCL > or = 5%-50% positive tumorcells were found. Strong staining (> or = 50% of the cells positive) was found in 10 out of the total of 24 CTCL cases. LRP56 staining of lymphoid cells was found in 1 out of 14 cases of MF and in 1 out of 10 cases of PCLTCL and in 1 out of 8 cases of CBCL. C219 expression was found in 4 out of 10 cases of PCLTCL and in 2 out of 8 cases of CBCL. After chemotherapy both a higher staining intensity and a higher number of positive cells were found with MRPrl especially in patients with MF. CONCLUSION: The present study shows that lymphoid cells in both primary cutaneous lymphomas and benign skin disorders may express MDR related proteins and that the expression profile of these proteins is roughly related to the tumor cell phenotype. However, the functional role of these proteins in clinical drug resistance in primary cutaneous lymphomas has to be proven.