Equine allergic skin diseases: Clinical consensus guidelines of the World Association for Veterinary Dermatology.

BACKGROUND: Allergic skin diseases are common in horses worldwide. The most common causes are insect bites and environmental allergens. OBJECTIVES: To review the current literature and provide consensus on pathogenesis, diagnosis, treatment and prevention. MATERIALS AND METHODS: The authors reviewed the literature up to November 2022. Results were presented at North America Veterinary Dermatology Forum (2021) and European Veterinary Dermatology Congress (2021). The report was available to member organisations of the World Association for Veterinary Dermatology for feedback. CONCLUSIONS AND CLINICAL RELEVANCE: Insect bite hypersensitivity (IBH) is the best characterised allergic skin disease. An immunoglobulin (Ig)E response against Culicoides salivary antigens is widely documented. Genetics and environmental factors play important roles. Tests with high sensitivity and specificity are lacking, and diagnosis of IBH is based on clinical signs, seasonality and response to insect control. Eosinophils, interleukin (IL)-5 and IL-31 are explored as therapeutic targets. Presently, the most effective treatment is insect avoidance. Existing evidence does not support allergen-specific immunotherapy (ASIT) using commercially available extracts of Culicoides. Hypersensitivity to environmental allergens (atopic dermatitis) is the next most common allergy. A role for IgE is supported by serological investigation, skin test studies and positive response to ASIT. Prospective, controlled, randomised studies are limited, and treatment relies largely on glucocorticoids, antihistamines and ASIT based on retrospective studies. Foods are known triggers for urticaria, yet their role in pruritic dermatitis is unknown. Recurrent urticaria is common in horses, yet our understanding is limited and focussed on IgE and T-helper 2 cell response. Prospective, controlled studies on treatments for urticaria are lacking. Glucocorticoids and antihistamines are primary reported treatments.

C1q and mannose binding lectin engagement of cell surface calreticulin and CD91 initiates macropinocytosis and uptake of apoptotic cells.

Removal of apoptotic cells is essential for maintenance of tissue homeostasis, organogenesis, remodeling, development, and maintenance of the immune system, protection against neoplasia, and resolution of inflammation. The mechanisms of this removal involve recognition of the apoptotic cell surface and initiation of phagocytic uptake into a variety of cell types. Here we provide evidence that C1q and mannose binding lectin (MBL), a member of the collectin family of proteins, bind to apoptotic cells and stimulate ingestion of these by ligation on the phagocyte surface of the multifunctional protein, calreticulin (also known as the cC1qR), which in turn is bound to the endocytic receptor protein CD91, also known as the alpha-2-macroglobulin receptor. Use of these proteins provides another example of apoptotic cell clearance mediated by pattern recognition molecules of the innate immune system. Ingestion of the apoptotic cells through calreticulin/CD91 stimulation is further shown to involve the process of macropinocytosis, implicated as a primitive and relatively nonselective uptake mechanism for C1q- and MBL-enhanced engulfment of whole, intact apoptotic cells, as well as cell debris and foreign organisms to which these molecules may bind.

A hierarchical role for classical pathway complement proteins in the clearance of apoptotic cells in vivo.

The strongest susceptibility genes for the development of systemic lupus erythematosus (SLE) in humans are null mutants of classical pathway complement proteins. There is a hierarchy of disease susceptibility and severity according to the position of the missing protein in the activation pathway, with the severest disease associated with C1q deficiency. Here we demonstrate, using novel in vivo models of apoptotic cell clearance during sterile peritonitis, a similar hierarchical role for classical pathway complement proteins in vivo in the clearance of apoptotic cells by macrophages. Our results constitute the first demonstration of an impairment in the phagocytosis of apoptotic cells by macrophages in vivo in a mammalian system. Apoptotic cells are thought to be a major source of the autoantigens of SLE, and impairment of their removal by complement may explain the link between hereditary complement deficiency and the development of SLE.

Phosphatidylserine (PS) induces PS receptor-mediated macropinocytosis and promotes clearance of apoptotic cells.

Efficient phagocytosis of apoptotic cells is important for normal tissue development, homeostasis, and the resolution of inflammation. Although many receptors have been implicated in the clearance of apoptotic cells, the roles of these receptors in the engulfment process have not been well defined. We developed a novel system to distinguish between receptors involved in tethering of apoptotic cells versus those inducing their uptake. Our results suggest that regardless of the receptors engaged on the phagocyte, ingestion does not occur in the absence of phosphatidylserine (PS). Further, recognition of PS was found to be dependent on the presence of the PS receptor (PSR). Both PS and anti-PSR antibodies stimulated membrane ruffling, vesicle formation, and "bystander" uptake of cells bound to the surface of the phagocyte. We propose that the phagocytosis of apoptotic cells requires two events: tethering followed by PS-stimulated, PSR-mediated macropinocytosis.

Apoptosis: getting rid of the bodies.

Cells that die by apoptosis need to be removed before lysis to preserve tissue integrity and function. Recent studies have identified components of the uptake machinery used by phagocytes, but much remains to be learnt, particularly about the recognition mechanisms and their coupling to the uptake machinery.

Apoptotic cell removal.

Ingestion by professional or amateur phagocytes is the fate of most cells that undergo apoptosis. Studies in both Caenorhabditis elegans and mammals are now converging to reveal some of the key mechanisms and consequences of this removal process. At least seven corpse removal genes in nematodes have mammalian equivalents, and represent elements of signaling pathways involved in uptake. In mammals, a wide variety of apoptotic cell recognition receptors has been implicated and appears to be divided into two categories, involved in tethering the apoptotic cell or triggering an uptake mechanism related to macropinocytosis. Apoptotic cell removal is normally efficient and non-inflammatory. By contrast, the process may become subverted by parasites to yield a more favorable growth environment, or in other cases lead to fibrosis. Removal may also clinch the apoptotic process itself in cells not yet completely committed to death.

Macrophages that have ingested apoptotic cells in vitro inhibit proinflammatory cytokine production through autocrine/paracrine mechanisms involving TGF-beta, PGE2, and PAF.

Apoptosis in vivo is followed almost inevitably by rapid uptake into adjacent phagocytic cells, a critical process in tissue remodeling, regulation of the immune response, or resolution of inflammation. Phagocytosis of apoptotic cells by macrophages has been suggested to be a quiet process that does not lead to production of inflammatory mediators. Here we show that phagocytosis of apoptotic neutrophils (in contrast to immunoglobulin G-opsonized apoptotic cells) actively inhibited the production of interleukin (IL)-1beta, IL-8, IL-10, granulocyte macrophage colony-stimulating factor, and tumor necrosis factor-alpha, as well as leukotriene C4 and thromboxane B2, by human monocyte-derived macrophages. In contrast, production of transforming growth factor (TGF)-beta1, prostaglandin E2, and platelet-activating factor (PAF) was increased. The latter appeared to be involved in the inhibition of proinflammatory cytokine production because addition of exogenous TGF-beta1, prostaglandin E2, or PAF resulted in inhibition of lipopolysaccharide-stimulated cytokine production. Furthermore, anti-TGF-beta antibody, indomethacin, or PAF receptor antagonists restored cytokine production in lipopolysaccharide-stimulated macrophages that had phagocytosed apoptotic cells. These results suggest that binding and/or phagocytosis of apoptotic cells induces active antiinflammatory or suppressive properties in human macrophages. Therefore, it is likely that resolution of inflammation depends not only on the removal of apoptotic cells but on active suppression of inflammatory mediator production. Disorders in either could result in chronic inflammatory diseases.

Epithelial cells as phagocytes: apoptotic epithelial cells are engulfed by mammary alveolar epithelial cells and repress inflammatory mediator release.

Clearance of apoptotic cells is critical to tissue homeostasis and resolution of inflammatory lesions. Macrophages are known to remove dying cells and release anti-inflammatory mediators in response; however, many cells traditionally thought of as poor phagocytes can mediate this function as well. In the lactating mammary gland following weaning, alveolar epithelial cell death is massive, yet the gland involutes rapidly, attaining its prepregnancy state in a matter of days. We found histologic evidence of apoptotic cell phagocytosis by viable mammary epithelial cells (MEC) in the involuting mouse mammary gland. Cultured MEC were able to engulf apoptotic cells in vitro, utilizing many of the same receptors used by macrophages, including the phosphatidylserine receptor (PSR), CD36, the vitronectin receptor alpha(v)beta3, and CD91. In addition, MEC, like macrophages, produced TGFbeta in response to stimulation of the PSR by apoptotic cells or the anti-PSR ab 217G8E9, and downregulated endotoxin-stimulated proinflammatory cytokine production. These data support the hypothesis that amateur phagocytes play a significant role in apoptotic cell clearance and its regulation of inflammation.

If phosphatidylserine is the death knell, a new phosphatidylserine-specific receptor is the bellringer.

Recognition of phosphatidylserine (PtdSer) is essential for engulfment of apoptotic cells by mammalian phagocytes. Engagement of a new phosphatidylserine-specific receptor (PtdSerR) appears to be necessary for uptake of apoptotic cells. Many other mammalian receptors have been described to function in the clearance of apoptotic cells. The emerging picture is that many of these receptors may provide the strong adhesion needed to increase the likelihood of contact between the PtdSerR and its phospholipid ligand, which is required for uptake. Furthermore, stimulation of this receptor on different types of phagocytes by apoptotic cells, PtdSer-containing liposomes or an IgM monoclonal anti-PtdSer antibody initiates release of TGFbeta, known to be involved in the anti-inflammatory effects of apoptotic cells. Although highly homologous genes exist in C. elegans and Drosophila melanogaster, their role in engulfment of apoptotic cells remains to be determined.

The role of phosphatidylserine in recognition of apoptotic cells by phagocytes.

Exposure of phosphatidylserine on the outer leaflet of the plasma membrane is a surface change common to many apoptotic cells. Normally restricted to the inner leaflet, phosphatidylserine appears as a result of decreased aminophospholipid translocase activity and activation of a calcium-dependent scramblase. Phosphatidylserine exposure has several potential biological consequences, one of which is recognition and removal of the apoptotic cell by phagocytes. It is still not clear which receptors mediate PS recognition on apoptotic cells; however, several interesting candidates have been proposed. These include the Class B scavenger and thrombospondin receptor CD36, an oxLDL receptor (CD68), CD14, annexins, beta2 glycoprotein I, gas-6 and a novel activity expressed on macrophages stimulated with digestible particles such as beta-glucan. Whether PS is the sole ligand recognized by phagocytes or whether it associated with other molecules to form a complex ligand remains to be determined.

Beryllium-stimulated apoptosis in macrophage cell lines.

In vitro stimulation of bronchoalveolar lavage cells from patients with chronic beryllium disease (CBD) induces the production of TNF-alpha. We tested the hypothesis that beryllium (Be)-stimulated TNF-alpha might induce apoptosis in mouse and human macrophage cell lines. These cell lines were selected because they produce a range of Be-stimulated TNF-alpha. The mouse macrophage cell line H36.12j produces high levels of Be-stimulated TNF-alpha. The mouse macrophage cell line P388D.1 produces low, constitutive, levels of TNF-alpha and does not up-regulate Be-stimulated TNF-alpha production. The DEOHS-1 human CBD macrophage cell line does not produce constitutive or Be-stimulated TNF-alpha. Apoptosis was determined by microscopic observation of propidium iodide stained fragmented nuclei in unstimulated and BeSO(4)-stimulated macrophage cell lines. BeSO(4) induced apoptosis in all macrophage cell lines tested. Beryllium-stimulated apoptosis was dose-responsive and maximal after 24 h of exposure to 100 microM BeSO(4). In contrast, unstimulated and Al(2)(SO(4))(3)-stimulated macrophage cell lines did not undergo apoptosis. The general caspase inhibitor BD-fmk inhibited Be-stimulated macrophage cell line apoptosis at concentrations above 50 microM. Our data show that Be-stimulated macrophage cell line apoptosis was caspase-dependent and not solely dependent on Be-stimulated TNF-alpha levels. We speculate that the release of Be-antigen from apoptotic macrophages may serve to re-introduce Be material back into the lung microenvironment, make it available for uptake by new macrophages, and thereby amplify Be-stimulated cytokine production, promoting ongoing inflammation and granuloma maintenance in CBD.

Molluscum contagiosum in a horse with granulomatous enteritis.

Widespread cutaneous papules in a yearling Standardbred filly were attributed by light and electron microscopic examination to molluscum contagiosum. Concomitant granulomatous enteritis, suspected clinically due to protein-losing enteropathy, was verified histopathologically. An associated altered altered immune response is suggested as the reason for the widespread poxvirus infection.

Equine insect hypersensitivity: skin test and biopsy results correlated with clinical data.

Forty-four seasonally pruritic horses and 21 asymptomatic horses in Florida, USA, were tested for insect, grass and mould hypersensitivity by intradermal injection of allergenic extracts. The affected horses ranged in age from 10 months to over 30 years and included a variety of breeds. Affected horses reacted to varying dilutions of extracts made from Culicoides, mosquitoes, horse flies and black flies. Reactions to Culicoides were more intense than those caused by injection of antigens from other arthropods. Mild pruritus existed from the end of February until the end of June when the condition worsened and remained severe until November when it improved to an asymptomatic state. Histopathological examination of skin biopsies demonstrated changes compatible with arthropod hypersensitivity. Three clinical syndromes associated with insect hypersensitivity were described as follows: 1) horses with lesions on face, ears, mane, withers, rump and tail; 2) horses with lesions on face, ears, intermandibular space, chest, belly and groin, and 3) those with a combination of dorsal and ventral lesions.

Treatment of canine idiopathic seborrhea with isotretinoin.

The efficacy and safety of isotretinoin in the treatment of idiopathic seborrhea in dogs were examined. Isotretinoin was judged effective in only 1 of 8 dogs. Side effects included mild conjunctivitis, transient erythematous rash, and increased serum cholesterol and triglyceride concentrations.

Canine and feline thyroid function assessment with the thyrotropin-releasing hormone response test.

A canine and feline pituitary-thyroid function test based on thyrotropin-releasing hormone (TRH) stimulation of endogenous thyrotropin is described. Serum thyroxine is measured before and after stimulation with TRH. A positive response to TRH indicated a functionally intact pituitary-thyroid axis. At TRH doses of 0.002 to 10.0 mg/kg of body weight, dose response of serum thyroxine to TRH stimulation was determined. Increasing the dose of TRH increased the duration, but not the magnitude, of thyroxine stimulation. At TRH doses greater than 0.1 mg/kg, drug side effects were salivation, defecation, urination, vomition, miosis, tachycardia, and tachypnea. A useful procedure for pituitary-thyroid function testing was serum thyroxine measurement before and 6 hours after TRH (0.1 mg/kg) stimulation.

Responses of atopic dogs to regional allergens: 268 cases (1981-1984).

Responses of atopic dogs to intradermal challenge with 60 allergens were determined and compared for 4 regions of the United States Twenty-seven allergens incited significantly higher responses in atopic dogs residing in northern Florida, when compared with dogs in Illinois; responses to 28 allergens were more significant in dogs residing in southern Florida vs Illinois. Only 1 allergen caused more responses in atopic dogs in northern Florida, compared with dogs in southern Florida. Females had a higher tendency to develop clinical signs of atopy. Dogs of the West Highland White Terrier, Cairn Terrier, English Setter, Irish Setter, Dalmatian, Lhasa Apso, Golden Retriever, and Labrador Retriever breeds were found to be predisposed to develop clinical signs of atopy. Dogs of the Poodle, Pug, German Shepherd Dog, Cocker Spaniel, Bulldog, Schnauzer, Doberman Pinscher breeds, of mixed breeding, and of terrier breeds other than the 2 aforementioned were not found to have a higher prevalence, when compared with the general hospital population. Of the atopic dogs evaluated in Florida, 79% had a significant response to flea antigen, compared with only 9% of atopic dogs evaluated in Illinois.

Hyperprogesteronemia associated with Sertoli cell tumor and alopecia in a dog.

Hyperprogesteronemia was found in a dog with alopecia and Sertoli cell tumor. Alopecia began in the lumber areas; the entire coat was dull and dry, and epilated easily. The only laboratory abnormalities were high serum progesterone concentration and incomplete suppression of cortisol after low-dose dexamethasone administration. The hair regrew after castration, and the progesterone concentration decreased toward normal.

Familial allergic rhinitis in cattle.

A group of Angus X Holstein cattle were determined to have allergic rhinitis. Clinical signs included nasal discharge, tearing, sneezing, and nasal pruritus. The diagnosis was made on the basis of intradermal skin testing of affected and clinically normal cattle. The affected cattle had positive test results to various tree, grass, weed, and mold allergens. The clinical signs and seasonal occurrence were similar to those features for allergic rhinitis in man. Breeding data indicated an inherited mode of transmission, although only females were affected.