[Extracorporeal shock wave therapy as a treatment of a non-healing chronic leg ulcer]. / Extrakorporale Stoßwellentherapie eines komplizierten chronischen Ulcus cruris venosum.

Extracorporeal shock waves are defined as a sequence of sonic pulses characterized by high peak pressure over 100 MPa, fast pressure rise, and short lifecycle. In the 1980s extracorporeal shock wave lithotripsy (ESWL) was first used for the treatment of urolithiasis. Orthopedic surgeons use extracorporeal shock wave therapy (ESWT) to treat non-union fractures, tendinopathies and osteonecrosis. The first application of ESWT in dermatology was for recalcitrant skin ulcers. Several studies in the last 10 years have shown that ESWT promotes angiogenesis, increases perfusion in ischemic tissues, decreases inflammation, enhances cell differentiation and accelerates wound healing. We successfully treated a non-healing chronic venous leg ulcer with ESWT. Furthermore we observed an improvement of the lymphatic drainage after application of ESWT. We are confident that ESWT is a non-invasive, practical, safe and efficient physical treatment modality for recalcitrant leg ulcers.

[Healing times and the need for hospitalization for leg ulcers of different etiologies]. / Unterschiedliche Abheilungsdauer und Häufigkeit der Hospitalisation bei Ulcus cruris verschiedener Ursachen.

BACKGROUND: Leg ulcers are a symptom of a heterogeneous group of diseases. Their treatment causes substantial costs due to the long healing times and extensive wound care measures. There is a paucity of information about healing times and the necessity of hospital treatment for leg ulcers of different etiologies. MATERIALS AND METHODS: In this retrospective study, healing times and the frequency of in-hospital treatment of 355 patients with leg ulcers attending a wound care clinic of a university hospital were examined. RESULTS: The proportion of healed ulcers was 32.0% after 3 months and 54.3% after 6 months with an average treatment duration of 6.1 months for all ulcers. This proportion of healed ulcers was higher for venous ulcers with 45.5% after 3 months and 63.0% after 6 months, whereas only 30.0% of mixed arterial-venous ulcers and 35.0% of hypertensive ischemic leg ulcers (HYTILU) were healed after 6 months. Of the latter group, 71% of patients were hospitalized at least once during the observation period as compared to 47% of patients with a venous ulcer. The duration of the hospital stay was longer for mixed ulcers and HYTILU with an average of 30 days vs. 23 days for venous ulcers. CONCLUSIONS: These data indicate that the healing times of ulcers of different etiologies differ substantially and that especially ulcers with arteriosclerosis as a causative factor have longer healing times. The fact that they require in-hospital treatment more frequently and for longer periods has significant socio-economic consequences.

Post-surgical scalp wounds with exposed bone treated with a plant-derived wound therapeutic.

OBJECTIVE: To evaluate the efficacy of a plant-derived wound dressing, a mixture of hypericum oil (Hypericum perforatum) and neem oil (Azadirachta indica), in scalp wounds with exposed bone. METHOD: A retrospective review was conducted of all patients presenting with scalp wounds with exposed bone following the excision of skin tumours and treated with a plant-derived wound dressings (1 Primary Wound Dressing; Phytoceuticals AG), from January to July 2011. Time to healing, wound size, area of exposed bone, ease of handling, pain and complications were evaluated. RESULTS: Nine consecutive patients were analysed retrospectively. The patients' mean age was 81.2 ± 8.5 years (63-90 years), with a mean wound size of 13.2 ± 6.8cm(2) (0.4-22.6cm(2)) and 6.8 ± 6.5cm(2) (0.3-20.7cm(2)) of exposed bone. The time to complete healing by secondary intention was 4-20 weeks. A rapid induction of granulation tissue was observed, which covered the entire exposed bone surface in six out of nine cases (67%) after 4 weeks, and showed a reduction in the mean area of exposed bone of 95%. Dressing change was easy and without pain and there were no complications. CONCLUSION: This retrospective, non-controlled analysis suggests that ONE is a very simple to use, safe and potentially effective therapy for the treatment of scalp wounds with exposed bone. DECLARATION OF INTEREST: There were no external sources of funding for this study. The authors have no conflict of interest to declare.

Irradiation with water-filtered infrared A plus visible light improves cutaneous scleroderma lesions in a series of cases.

BACKGROUND: Cutaneous scleroderma is a chronic inflammatory disease of the dermal and subcutaneous connective tissue leading to sclerosis. Sclerosis of the skin can lead to dysmorphism, contractures and restrictions of movement. OBJECTIVE: The purpose of the study was to evaluate sclerosis in cutaneous scleroderma patients and to determine the efficacy of water-filtered infrared A plus visible light treatment, wIRA(+VIS), in 10 patients. METHODS: Hardness of the normal and diseased skin was measured by durometry in 10 controls and 8 patients. Moreover, circumscribed scleroderma (CS) was treated with wIRA(+VIS) irradiations in 10 patients who had not responded to conventional therapies. RESULTS: wIRA(+VIS) therapy led to a marked improvement, persistent even during long-term follow-up, in 7 out of 10 patients with CS. Of the other patients, 1 showed decreased sclerosis and disease activity and developed a worsening after cessation of therapy. In 2 further patients, where previous UVA1 treatment had failed to reduce disease activity, wIRA(+VIS) produced a slight decrease in sclerosis, but disease activity was still present. CONCLUSION: wIRA(+VIS) appears to be effective in the treatment of CS. Durometry proved to be helpful in assessing the degree of sclerosis and in documenting the response to therapy in these patients.

Monocyte selectivity and tissue localization suggests a role for breast and kidney-expressed chemokine (BRAK) in macrophage development.

Although numerous chemokines act on monocytes, none of them is specific for these cells. Here, we show that breast and kidney-expressed chemokine (BRAK) is a highly selective monocyte chemoattractant. Migration efficacy and Bordetella pertussis toxin-sensitive Ca(2+) mobilization responses to BRAK were strongly enhanced after treatment of monocytes with the cyclic AMP-elevating agents prostaglandin E(2) and forskolin. BRAK is the first monocyte-selective chemokine, as other types of blood leukocytes or monocyte-derived dendritic cells and macrophages did not respond. Expression in normal skin keratinocytes and dermal fibroblasts as well as lamina propria cells in normal intestinal tissues suggests a homeostatic rather than an inflammatory function for this chemokine. In addition, macrophages were frequently found to colocalize with BRAK-producing fibroblasts. We propose that BRAK is involved in the generation of tissue macrophages by recruiting extravasated precursors to fibroblasts, which are known to secrete essential cytokines for macrophage development.

[Acrodermatitis enteropathica-like skin lesions due to Crohn's disease-associated zinc deficiency]. / Acrodermatitis-enteropathica-ähnliche Hautveränderungen bei Morbus-Crohn-bedingtem Zinkmangel.

We report a case of acrodermatitis enteropathica-like skin eruptions presenting with alopecia, perlèche, glossitis, and genital erosions as well as multifocal eczematoid, psoriasiform, and bullous skin lesions due to zinc deficiency in Crohn's disease.

Incidence of bullous pemphigoid and pemphigus in Switzerland: a 2-year prospective study.

BACKGROUND: Bullous pemphigoid (BP), pemphigus vulgaris (PV) and pemphigus foliaceus (PF) are autoimmune bullous diseases characterized by the presence of tissue-bound and circulating autoantibodies directed against disease-specific target antigens of the skin. Although rare, these diseases run a chronic course and are associated with significant morbidity and mortality. There are few prospective data on gender- and age-specific incidence of these disorders. OBJECTIVES: Our aims were: (i) to evaluate the incidence of BP and PV/PF in Swiss patients, as the primary endpoint; and (ii) to assess the profile of the patients, particularly for comorbidities and medications, as the secondary endpoint. METHODS: The protocol of the study was distributed to all dermatology clinics, immunopathology laboratories and practising dermatologists in Switzerland. All newly diagnosed cases of BP and pemphigus occurring between 1 January 2001 and 31 December 2002 were collected. In total, 168 patients (73 men and 95 women) with these autoimmune bullous diseases, with a diagnosis based on clinical, histological and immunopathological criteria, were finally included. RESULTS: BP showed a mean incidence of 12.1 new cases per million people per year. Its incidence increased significantly after the age of 70 years, with a maximal value after the age of 90 years. The female/male ratio was 1.3. The age-standardized incidence of BP using the European population as reference was, however, lower, with 6.8 new cases per million people per year, reflecting the ageing of the Swiss population. In contrast, both PV and PF were less frequent. Their combined mean incidence was 0.6 new cases per million people per year. CONCLUSIONS; This is the first comprehensive prospective study analysing the incidence of autoimmune bullous diseases in an entire country. Our patient cohort is large enough to establish BP as the most frequent autoimmune bullous disease. Its incidence rate appears higher compared with other previous studies, most likely because of the demographic characteristics of the Swiss population. Nevertheless, based on its potentially misleading presentations, it is possible that the real incidence rate of BP is still underestimated. Based on its significant incidence in the elderly population, BP should deserve more public health concern.

Inhibition of toxic epidermal necrolysis by blockade of CD95 with human intravenous immunoglobulin.

Toxic epidermal necrolysis (TEN, Lyell's syndrome) is a severe adverse drug reaction in which keratinocytes die and large sections of epidermis separate from the dermis. Keratinocytes normally express the death receptor Fas (CD95); those from TEN patients were found to express lytically active Fas ligand (FasL). Antibodies present in pooled human intravenous immunoglobulins (IVIG) blocked Fas-mediated keratinocyte death in vitro. In a pilot study, 10 consecutive individuals with clinically and histologically confirmed TEN were treated with IVIG; disease progression was rapidly reversed and the outcome was favorable in all cases. Thus, Fas-FasL interactions are directly involved in the epidermal necrolysis of TEN, and IVIG may be an effective treatment.

Effects of culture and incubation conditions on membrane fluidity in monolayers of cultured cells measured as fluorescence anisotropy using trimethylammoniumdiphenylhexatriene (TMA-DPH).

Membrane fluidity of coverslip attached living cells was measured as fluorescence anisotropy using 5 microM trimethylammoniumdiphenylhexatriene (TMA-DPH) as fluorescent probe. Fluorescence anisotropy is inversely related to membrane fluidity. Cells were grown on glass coverslips that were inserted and directly incubated in quarz cuvettes. The coverslips were fixed with special holders at an angle of 30 degrees in respect to the incident light. Effects of incubation temperature, of cell growth and densities and of the ionic and nonionic composition of the incubation medium on membrane fluorescence anisotropy were measured. Membranes of growing cells were more fluid than those of stationary cells, while cell densities had no effect except at very low cell numbers. Calcium concentrations increasing from 0 to 8 mmol/l in the incubation medium proportionally decreased membrane fluidity. Hypotonicity of the incubation media increased membrane fluidity while hypertonicity compared to normotonicity had no effect. Differentiated human fibroblasts from different origins exhibited similar membrane fluidities. They were, however, different from those of rat cells. Membrane fluidity of rat brain tumor cells increased with age in culture while membrane fluidity of primary differentiating rat brain cells decreased in with age in culture. Measurement of fluorescence anisotropy in living cells attached to glass coverslips is a convenient tool to study effects of culture--as well as of environmental--conditions on membrane fluidity.

Pmg-1 and pmg-2 constitute a novel family of KAP genes differentially expressed during skin and mammary gland development.

The epidermis, by invagination of the undifferentiated ectodermal cells, gives rise to several distinct structures including hair, sebaceous, eccrine sweat and mammary glands. We have recently isolated a novel gene, pmg-1, expressed in the pubertal mouse mammary gland. While investigating its genomic structure, we identified a related gene in close proximity, which we have termed pmg-2. pmg-1 and pmg-2 are intron-less, are transcribed in opposite directions and are separated by a potential promoter region of 2.8 kb containing putative binding motifs for the developmental transcription factors Lef-1, Sox5 and D-STAT. pmg-1 and pmg-2 encode small proteins rich in G, S, F, Y and Q and contain characteristic repeats reminiscent of the keratin-associated proteins (KAPs). Both genes are expressed in growing hair follicles in skin as well as in sebaceous and eccrine sweat glands. Interestingly, expression is also detected in the mammary epithelium where it is limited to the onset of the pubertal growth phase and is independent of ovarian hormones. Their broad, developmentally controlled expression pattern, together with their unique amino acid composition, demonstrate that pmg-1 and pmg-2 constitute a novel KAP gene family participating in the differentiation of all epithelial cells forming the epidermal appendages.

Endogeneously regulated site-specific differentiation of human palmar skin keratinocytes in organotypic cocultures and in nude mouse transplants.

Palmar and plantar epidermis is characterized by specific features such as the development of a striking lucidum, a very thick stratum corneum, prominent rete ridges and the unique expression of keratin K9. Using organotypic cocultures of keratinocytes and fibroblasts, we investigated to which extent the specific phenotype of palmar keratinocytes is maintained in vitro and under systemic host influences after transplantation onto nude mice. In vitro, palmar keratinocytes developed a thick epithelium with a prominent, although parakeratotic stratum corneum showing no significant differences in proliferation and differentiation in coculture with either palmar or nonpalmoplantar fibroblasts. All differentiation markers including keratohyaline and membrane coating granules as well as keratin K9 were also found, but at reduced levels and with slightly altered localization. In transplants, substantial normalization towards the palmar phenotype occurred. In 3-week-old grafts, a homeostatic state was reached, as illustrated by a constant thickness of the stratum Malpighii, presence of keratin K10 throughout the entire suprabasal compartment, increased numbers of K9- and filaggrin-positive cells, and reduction of keratins K16 and K17. At the ultrastructural level, numerous membrane coating granules and an enlargement of keratohyaline granules were seen accordingly, and immunofluorescence showed intense continuous lining of the dermo-epidermal junction by laminin, type IV collagen and integrin alpha 6. The high percentage of bromodesoxyuridine-positive cells, mainly in the basal compartment, underlined the hyproproliferative state, comparable to palmoplantar epidermis. In conclusion, (i) palmar keratinocytes can preserve the potential to express their specific phenotype upon transfer to culture conditions, and (ii) this intrinsic property is not significantly modulated by the type of cocultured fibroblasts. This suggests that fibroblasts act primarily by sustaining keratinocyte proliferation which is permissive for the fully differentiated phenotype.

Successful treatment of chronic leg ulcers with epidermal equivalents generated from cultured autologous outer root sheath cells.

The outer root sheath cells of hair follicles can substitute for interfollicular epidermal keratinocytes, as during healing of skin wounds when these cells migrate onto the denuded area and contribute to epidermal regeneration. Using improved culture techniques, we generated epidermal equivalents from cultured outer root sheath cells of patients suffering from recalcitrant chronic leg ulcers, primarily of vascular origin. In such epidermal equivalents, tissue organization as well as immunolocalization of epidermal differentiation products (keratin 10, involucrin, filaggrin) and integrins were indistinguishable from normal epidermis. As determined by the number of bromodeoxyuridine-incorporating cells, the basal layer contained a large compartment of proliferative cells irrespective of donor age. FACS analysis of the outer root sheath cells, used to prepare the epidermal equivalents, disclosed a fraction of small cells with enhanced expression of beta1-integrin, a potential stem cell marker. in contrast to acute wounds, a major definitive take of grafted cultured autologous keratinocytes has not been convincingly demonstrated in chronic wounds. In a pilot study, grafting of epidermal equivalents generated in vitro from autologous outer root sheath cells on 11 ulcers in five patients resulted in a definitive take rate of about 80%, with subsequent complete healing within 2 to 3 wk of five out of seven ulcers grafted with densely arranged cultures. This improvement in the treatment of chronic leg ulcers with cultured autologous keratinocytes probably depends on the large compartment of proliferative cells as well as on a well-developed horny layer which prevents disintegration of the grafts. Practical advantages of the new technique are its noninvasiveness, the lack of need for surgical facilities or anesthesia, and a short immobilization period after grafting.

Studies on human skin lymph containing Langerhans cells from sodium lauryl sulphate contact dermatitis.

Immunologic processes in diseased human skin have been extensively investigated, but little is known about the effect of skin diseases on human afferent skin lymph. Starting in the papillary dermis, the skin lymphatics drain the adjacent tissue in a one-way flow toward the regional lymph nodes. The composition of the afferent lymph, therefore, reflects the immunologic inflammatory processes in the drained tissue. To obtain afferent lymph to investigate its content, we inserted a cannula, by means of microsurgery, into a superficial peripheral lymph vessel draining a defined skin area. By manipulating the drained skin area and subsequent examination of the lymph we established an in vivo system for investigating the kinetics of lymph changes during the course of skin reactions. In lymph derived from a mild sodium lauryl sulphate (SLS)--induced contact dermatitis we could demonstrate an increase of both flow and cells. In particular, the number of Langerhans cells (LC) increased enormously during the course of the skin reaction. It, therefore, seems that a large increase in the migration of LC from the skin to the regional lymph nodes is a major feature of SLS-induced contact dermatitis, suggesting that LC may play a major role in the irritant contact dermatitis reaction.

Post-mitotic human dermal fibroblasts efficiently support the growth of human follicular keratinocytes.

For growth at low seeding densities, keratinocytes isolated from human tissues like epidermis or hair follicles are dependent on mesenchyme-derived feeder cells such as the 3T3-cell employed so far. As an alternative method, the present study describes the use of post-mitotic human dermal fibroblasts sublethally irradiated or mitomycin C-treated. Special emphasis was put on efficient growth of primary keratinocyte cultures plated at very low seeding densities. Thus, outer root sheath cells isolated from two anagen human hair follicles and plated in a 35-mm culture dish (3 - 6 X 10(2) attached cells) grew to confluence within 3 weeks (6 - 8 X 10(5) cells). Similar results were obtained for interfollicular keratinocytes. A crucial point for the function of these fibroblast feeder cells is plating at appropriate densities, considering their tremendous increase in cell size at the post-mitotic state. Plating densities of 4 - 5 X 10(3/cm2 allow full spreading of the feeder cells and do not impede the settling and expansion of the keratinocytes. Major advantages of this system include easier handling and better reproducibility than using 3T3-cells. Moreover, homologous fibroblast feeders mimic more closely the physiologic situation and therefore might provide a valuable tool for studying interactions between human mesenchymal and epithelial cells. Finally, potential hazards of using transformed feeder cells from a different species in keratinocyte cultures raised for wound covering in humans could be thus avoided.

In vitro pemphigus vulgaris model using organotypic cultures of human epidermal keratinocytes.

Using the Combi-ring-dish (CRD), a new culture device, organotypic cultures of human epidermal keratinocytes were grown on bovine eye lens capsules. In these highly differentiated cultures, typical suprabasal acantholysis was induced by pemphigus vulgaris antibodies. This in vitro pemphigus vulgaris model may be used to analyse keratinocyte-derived factors causing acantholysis in experimental pemphigus.

Co-culture of human keratinocytes on post-mitotic human dermal fibroblast feeder cells: production of large amounts of interleukin 6.

A large synthesis of human IL-6 was demonstrated in co-cultures of human keratinocytes on post-mitotic human dermal fibroblast (HDF) feeder layers. Immunoreactive IL-1 beta could be detected in the co-cultures and the addition of rabbit anti-IL-1 beta antibodies to the co-cultures considerably reduced the IL-6 synthesis, suggesting that it was induced by endogenous IL-1 beta. Addition of saturating concentrations of IL-1 beta to HDF feeder layers as well as to subcultures of keratinocytes induced in both similar but moderate IL-6 production. Conditioned medium from keratinocyte cultures induced IL-6 secretion in HDF feeder cells, whereas the conditioned medium from HDF feeder layers led to only minimal increase of keratinocyte IL-6 production. The co-cultures of keratinocytes on HDF feeder layers produced much larger amounts of IL-6 than the sum of the IL-6 produced by the feeder cell and keratinocyte cultures after the addition of IL-1 beta. The co-cultures of keratinocytes with HDF feeder layers separated by a permeable membrane in a two-chamber system produced significantly lower amounts of IL-6 than the unseparated co-cultures. These findings indicate that a direct cell contact between keratinocytes and feeder cells is involved in the overproportioned increase of IL-6 production and secretion into the medium.

IgG autoantibodies from bullous pemphigoid patients recognize multiple antigenic reactive sites located predominantly within the B and C subdomains of the COOH-terminus of BP230.

Bullous pemphigoid is a subepidermal bullous disorder characterized by an autoantibody response against the bullous pemphigoid antigen 230 (BP230) and the bullous pemphigoid antigen 180 (BP180), a cytoplasmic component and a transmembrane component, respectively, of hemidesmosomes. Although immunodominant sequences within the extracellular domain of BP180 have been identified, characterization of the antigenic sites on BP230 is still incomplete. To identify autoantibody-reactive sites on BP230 and to examine whether the targeted regions are contained within functionally important domains, recombinant fragments encompassing almost the entire BP230 were used to assess the reactivity of 25 bullous pemphigoid sera by immunoblotting. Our results demonstrate that (i) the region bearing the B and C subdomains of the COOH-terminus of BP230 contains immunodominant sequences recognized by the majority of bullous pemphigoid sera; (ii) additional autoantibody- reactive sites are present over extended regions of the NH2-terminal half of BP230 without evidence for antigenic cross-reactivity between the NH2- and COOH-termini of BP230; and, finally, (iii) autoantibodies reacting with the BP230 tail predominantly belong to the IgG4 and IgG1 subclasses, suggesting that both autoreactive TH2 and autoreactive TH1 cells regulate the autoantibody response to immunodominant sequences of BP230. As the COOH- terminus of BP230 mediates the attachment of keratin intermediate filaments to the hemidesmosomal plaque, whereas its NH2-terminus contains sequences important for its interaction with other constituents of hemidesmosomes, autoantibodies to BP230 might precipitate subepidermal blister formation and perpetuate the disease not only by eliciting an inflammatory reaction but also by interfering with the function of BP230 and thus the stability of hemidesmosomes.

Formation of a regular neo-epidermis by cultured human outer root sheath cells grafted on nude mice.

The outer root sheath of hair follicles mainly consists of basal-like keratinocytes which can substitute for interfollicular epidermal keratinocytes, as during healing of skin wounds when outer root sheath cells migrate onto the denuded area, thus contributing to epidermal regeneration. Human outer root sheath cells represent a repeatedly available source of keratinocytes which can be easily and extensively expanded in culture. Close comparison of organotypic cultures of either outer root sheath cells or epidermal keratinocytes grafted onto nude mice demonstrated that outer root sheath cells formed a stratified epithelium resembling normal epidermis that is virtually indistinguishable from that developed by epidermal keratinocytes. Typical epidermal differentiation markers, such as the suprabasal keratins 1 and 10, involucrin, filaggrin, the basement membrane components collagen type IV and laminin, and the integrin chains alpha 2, alpha 3, alpha 6, and beta 1, were readily expressed in a mostly regular localization. These data suggest that outer root sheath cells, bearing essential advantages as compared with interfollicular keratinocytes, are suitable for skin replacement.