Treatment decision-making for patients with the Herlitz subtype of junctional epidermolysis bullosa.

The Herlitz subtype of junctional epidermolysis bullosa (JEB-H) is a lethal genetic disorder characterized by recurrent and persistent erosions of the epithelial surfaces that heal with exuberant granulation tissue. In addition, respiratory distress, refractory anemia and failure to thrive are often seen. Mortality in the first year of life approaches 90%. JEB-H is caused by mutations in the genes that encode the protein laminin 5, a structural molecule involved in the adhesion of epidermis to dermis. There is currently no cure for JEB-H. Medical interventions treat complications but do not ultimately limit mortality. Ethical principles contend that offering comfort and company to the patient and family, not aggressive therapies, should comprise the mainstay of care for affected infants.

Induction of the skin endogenous protective mitochondrial MnSOD by Vitreoscilla filiformis extract.

Vitreoscilla filiformis (Vf), a filamentous bacteria living in fresh water is thought to contribute to the observed beneficial effects of Spa water on skin. An active fraction obtained from a Vf biomass was evaluated for its ability to modulate mRNA expression in cultured skin cells. cDNA array analysis was conducted first using a customized membrane including 1176 selected and fully identified genes involved in skin physiology and homeostasis then the newly developed full genome U133 plus 2.0 GeneChip from Affymetrix. The mitochondrial protective manganese superoxide dismutase (MnSOD/SOD-2) was identified as a preferentially induced mRNA target in both normal human dermal fibroblasts and keratinocytes. Induction at the transcriptional level in both cell types was confirmed using quantitative real time/polymerase chain reaction and a kinetic analysis revealed a maximal increase in mRNA expression 20 h after stimulation with Vf extract (Vfe). Using immunofluorescent (fluorescent cell sorter) analysis, an induction of MnSOD protein in both normal human dermal skin fibroblasts (x1.6; P < 0.01) and epidermal keratinocytes (x1.4; P < 0.01) was confirmed. As MnSOD is a major inducible free-radical scavenger in skin, these results suggest that the Vfe could induce skin cells to produce their own endogenous protective defences in vivo against both exogenous environmental stressors such as UV irradiation or microflora as well as to combat endogenous sources of deleterious free radicals involved in skin ageing. Finally, in order to confirm the in vivo potential of this original extract in human, we evaluated its protective activity vs. placebo on the generation of sunburn cells in epidermis under UVB stress. As expected from in vitro profiling, Vfe was indeed found to significantly inhibit the appearance of sunburn cells in UVB-exposed areas, a signature of skin alteration which has been suggested to be linked to a defect in MnSOD protective activity. Altogether, those data suggest that the combination of a suitable protective UV filter together with this bioactive Vfe might improve skin protection through complementary pathways.

Identification of bullous pemphigoid, pemphigus, laminin, and anchoring fibril antigens in human fetal skin.

Human fetal skin was evaluated for sequential and regional development of several epidermal antigens. Indirect immunofluorescent methods were used to detect laminin, bullous pemphigoid antigen, pemphigus antigen, and anchoring fibril antigens identified by monoclonal antibodies AF1 and AF2. Eighty-three human fetal skin biopsies from 32 human fetuses were examined. The fetuses examined ranged from estimated gestational age (EGA) of 7-38 weeks. Laminin was present in the basement membrane zone of all the fetal tissues examined. Bullous pemphigoid antigen developed first in the palm and sole, 9 weeks EGA, and was present in all other sites by 17 weeks EGA. Pemphigus antigen was present by 11 weeks EGA. AF1 and AF2 staining was not present until 26 weeks EGA, AF1 and AF2 stained epidermal basal cells in addition to the basement membrane zone area. Comparison of human fetal skin development with basal cell carcinoma identified similarities between basal cell carcinoma and early fetal development.

Intraepidermal formation of Merkel cells in xenografts of human fetal skin.

An experimental transplantation model using human fetal skin was applied to approach the question of the embryologic origin of human Merkel cells. Palmar and plantar skin from five fetuses, between 8 and 11 weeks of estimated gestational age (EGA), was xenografted to subcutaneous beds of nude mice. After 4 or 8 weeks of growth, biopsies were taken from these xenografts and examined for the presence of Merkel cells, using immunocytochemistry with antibodies specific for simple epithelial-type cytokeratins and neuron-specific enolase (NSE) as well as using electron microscopy. Skin from the same fetuses at the time of transplantation was screened in the same way. In all fetuses, no (or very scarce) epidermal Merkel cells were detected at the transplantation time, but in all cases abundant epidermal Merkel cells of apparent human origin were found after 4 or 8 weeks in xenograft culture. Dermal nerve fibers, as recognized by neurofilament antibodies, were scarce or essentially absent in the xenografts. These results indicate that Merkel cells regularly develop in epidermis dissected and xenografted in an early fetal stage, although the dissection implies the interruption of the dermal nerves. The results strongly support the notion of the origin of Merkel cells from epidermal precursor cells. The apparent absence of dermal Merkel cells and dermal nerve fibers in the xenografts suggests that the presence of dermal sensory nerve fibers may be required for the dropping off of epidermal Merkel cells into the upper dermis, which occurs in normal fetal development.

Development of human fetal skin transplanted to the nude mouse.

Thirty-five human fetal skin (HFS) grafts were transplanted to nude mice for 7 to 70 d and evaluated histologically with 64 biopsies. The estimated gestational ages (EGA) of the grafts at the time of the transplantation ranged from 8 to 19 weeks. The maturation of the engrafted fetal skin was evaluated by assessing epidermal, dermal, and appendage development. Within the nude mouse, the HFS demonstrated progression in stratification and maturation of the epidermis. The dermis increased in depth, adding fibrovascular stroma and adipose tissue. The appendages demonstrated invagination, differentiation, and progression of organogenesis. Subcutaneously placed grafts showed the same rate of HFS development as HFS in utero. The grafts transplanted to the surface of the nude mice and exposed to air demonstrated an acceleration of development. We conclude that HFS transplanted to the nude mouse is an effective in vivo model for maintaining and altering HFS maturation.

Detection of gluten in human sera by an enzyme immunoassay: comparison of dermatitis herpetiformis and celiac disease patients with normal controls.

We have developed a triple sandwich enzyme immunoassay to detect circulating gluten in human sera. With human sera containing known amounts of added gluten as controls, the assay was sensitive in the range of 0.75 to 75 micrograms of gluten per ml of serum. Forty-one control subjects were compared to 21 patients with dermatitis herpetiformis and 11 patients with celiac disease. The dermatitis herpetiformis and celiac disease patients had significant elevation of serum gluten values over the control subjects. Circulating gluten antigenemia is a previously unrecognized feature which may be important in understanding the pathogenesis of dermatitis herpetiformis and celiac disease.

Monoclonal antibody to a 35 kD epidermal protein induces cell detachment.

A murine monoclonal antibody (ECS-1) was prepared from BALB/c mice immunized with trypsinized cultured human foreskin keratinocytes. The antibody showed a pattern suggestive of intercellular staining on the nucleated layers of normal human epidermis, adult palm, mouse lip epidermis, and cultured human keratinocytes. ECS-1 stained human fetal skin by 9 weeks estimated gestational age. ECS-1 reacted with a 35 kD protein extracted from neonatal foreskin epidermis and cultured human keratinocytes. The protein required Nonidet P-40 or sodium dodecyl sulfate and mercaptoethanol for solubilization. ECS-1 induced epidermal cell detachment which was enhanced by complement. ECS-1 shares characteristics with human pemphigus antibodies.

Monoclonal antibodies to two different epitopes in a 30-kD CNBr peptide of the K1 and K2 keratins.

Two anti-keratin monoclonal antibodies, Kab-2 and Kab-3, with specificities for different epitopes of type II (basic) human epidermal keratins, were produced. These antibodies had different immunofluorescent staining patterns on human fetal epidermis. Western blots and solid phase RIA showed both antibodies bound to 65-67-kD basic keratins (K1 and K2) extracted from foreskin epidermis. Competitive binding studies with the two Kab antibodies and other anti-keratin monoclonal antibodies showed that Kab-2 and Kab-3 recognized related epitopes, distinct from the epitopes recognized by other anti-keratin antibodies AE-1, 2, and 3. Kab-2 and Kab-3 epitopes were distinguished by differences in their reactivity with peptides generated by Staphylococcus aureus V8 protease digestion of the K1 keratin; the antibodies recognized both common and unique peptides. Western blots of cyanogen bromide digests of the K1 keratin showed that both Kab antibodies reacted with a 30-kD fragment of the molecule presumed to be the N-terminal CNBr peptide. We interpret these data to indicate that in tissues, portions of the N-terminal region of the K1 keratin are differentially available for reaction with these monoclonal antibodies and that morphologic differences in staining with monoclonal antibodies to the same molecule can reflect epitope specificity or epitope availability related to supramolecular organization.

Class-specific antibodies to gluten in dermatitis herpetiformis.

An immune reaction to wheat protein has been previously proposed to explain the pathogenesis of dermatitis herpetiformis. In order to detect and characterize antibodies to gluten in human sera, we developed an enzyme immunoassay for class-specific antibodies. Results of this assay in 49 patients with dermatitis herpetiformis were compared with those of 38 normal control subjects, 11 patients with celiac disease, and 6 small-bowel bypass patients. IgA antibodies to gluten were significantly more frequent in dermatitis herpetiformis sera (28/49) than in normal control sera (4/38). IgG antibodies to gluten were significantly more frequent in both celiac disease (10/11) and dermatitis herpetiformis (16/49) sera than in control (5/38) sera. Dermatitis herpetiformis sera also had an increased prevalence of IgM antibodies to gluten (19/49). Small-bowel bypass patients demonstrated no antibody to gluten. Antibodies to gluten in dermatitis herpetiformis objectively mark a state of immune reactivity to wheat protein and may be involved in the genesis of the cutaneous IgA immune deposits and the skin disease.

Organ-specific, phylogenetic, and ontogenetic distribution of the epidermolysis bullosa acquisita antigen.

The organ-specific, phylogenetic, and ontogenetic distribution of the epidermolysis bullosa acquisita (EBA) antigen, a newly recognized basement membrane component, was determined using polyclonal sera from patients with EBA and a mouse monoclonal antibody, H3a. Both antibodies are distributed at the basement membrane zone of skin, oral, anal, and vaginal mucosae, and esophagus, but not in kidney, urinary bladder, lymph nodes, placenta, or blood vessels. Both polyclonal and monoclonal EBA antibodies react with a basement membrane antigen in primate and other mammalian skin, but not in avian, amphibian, or reptilian skin. The antigen is present initially in the 8-week-old human fetus, and increases in density until the adult linear pattern is reached at 15 weeks' gestational age.

Effects of aging and xerosis on the amino acid composition of human skin.

Amino acid compositions of skin samples from young and old subjects and from age-matched donors with dry skin syndrome (xerosis) were examined. The amino acid contents of the free amino acid (FAA) fraction, soluble hydrolysate (SH) fraction, and whole cell hydrolysate (WCH) were determined. The greatest differences were observed between the FAA compositions of the young and old normal subjects. Xerosis did not appear to affect the amino acid compositions of samples from young subjects as much as old subjects. Overall, the effect of aging on the amino acid contents was more pronounced than the effect of xerosis. The amino acid composition of the FAA showed a high degree of similarity to filaggrin, whereas the WCH showed a similarity to keratin.

Neonatal lupus erythematosus. A clinical, serological and immunogenetic study with review of the literature.

Neonatal lupus erythematosus (NLE) is an inflammatory disorder of neonates characterized by transient cutaneous lesions and/or congenital heart block. The cutaneous lesions usually heal with minimal scarring, but healing may be delayed for many months in occasional cases. Photosensitivity is recognized as a component of this syndrome. A large proportion of this maternal population is asymptomatic, although the mothers' potential risk for developing CTD in the future remains to be determined. Moreover, this maternal group may exhibit a tendency to fetal wastage. La(SSB) and/or Ro(SSA) antibody is almost universally present in the sera of the neonatal lupus mothers and their infants. Since these antibodies may have a pathogenetic role in NLE, screening of infants with isolated CHB and/or cutaneous lesions suggestive of LE, and their mothers, for the presence of Ro(SSA) and La(SSB) antibodies is strongly recommended. HLA studies reveal that infants of Ro-positive mothers bearing the HLA, A1, B8, DR3, MB2 and MT2 phenotypes are at increased risk of developing neonatal lupus, in sharp contrast to infants of Ro-positive mothers bearing the DR2 and/or MB1/MT1 phenotypes. Recognition of the protean manifestations of this complex disorder by obstetricians, pediatricians, cardiologists, and dermatologists will undoubtedly lead to increased detection of NLE and afford further opportunity to elucidate more fully the etiology of this syndrome.

Effects of repeated application of emollient cream to premature neonates' skin.

OBJECTIVE: Emollient cream moisturizers are often used on premature newborns in neonatal intensive care units without accurate knowledge of the risks or benefits to the neonate. DESIGN: We prospectively compared premature neonates treated with a water-in-oil emollient cream for up to 16 days to untreated premature neonates. SETTING: The study was completed in a neonatal intensive care unit on neonates admitted for respiratory distress and/or possible sepsis. PATIENTS: Thirty-four neonates, between 29 and 36 weeks estimated gestational age, entered the study. INTERVENTIONS: One-half of the neonates were treated twice a day with an water-in-oil emollient cream, and the other half served as controls. OUTCOME MEASURES: The skin condition of the neonates' hands, feet, and abdomen was evaluated on entering the study and twice a week. Fungal cultures and quantitative bacterial cultures were obtained from the axilla and abdomen on entering the study and twice a week. RESULTS: The mean gestational age of the treated neonates was 32.3 weeks, whereas the mean gestational age of the control neonates was 32.5 weeks. The neonates treated with emollient cream demonstrated statistically less dermatitis of their hands (day 2 through day 11), their feet (day 2 through day 16), and their abdomen (day 7 through day 11). Fungal cultures and quantitative bacterial cultures of the abdomen and axilla were equivalent in both groups. CONCLUSIONS: These studies document that emollient cream moisturizer therapy of premature neonates decreases dermatitis without changing the microbiological flora.

Diaper dermatitis: current concepts.

Diaper dermatitis may result from prolonged skin contact with wetness and bacteria. Ammonia plays no apparent role in the generation of diaper dermatitis. Candida albicans frequently contaminates a diaper dermatitis and should be considered present in any diaper dermatitis and should be considered present in any diaper dermatitis known to be present for longer than three days. Topical fluorinated glucocorteroids, boric acid, and mercury-containing preparations should be avoided in the diaper area because of their toxicity.

Twin transfusion syndrome causing cutaneous erythropoiesis.

Two cases of twin transfusion syndrome are described in which the donor twin exhibited blueberry muffin-like macules and papules associated with cutaneous erythropoiesis. No evidence was found in either case for intrauterine viral infection, the most common cause of cutaneous erythropoiesis. Cutaneous erythropoiesis is these two cases is considered to be due to persistence or reactivation of fetal dermal erythropoiesis secondary to prolonged, severe intrauterine anemia.

Semipermeable dressing and transepidermal water loss in premature infants.

Within the first days of life, 10 infants, of 32 weeks' gestational age or less, began 2 weeks of treatment with a semipermeable wound dressing over a small area of skin. The effects of the dressing on transepidermal water loss and cutaneous microflora were evaluated. Transepidermal water loss from the semipermeable dressing-treated skin was significantly less than that from the untreated skin immediately after placement of the dressing (8.1 +/- 1.8 g/m2.h-1 vs 17.7 +/- 3.5 g/m2.h-1, P less than .0001). The normal accelerated skin maturation process that occurs in these infants continued beneath the semipermeable dressing. The number of gram-negative bacilli or other bacteria did not increase beneath the semipermeable dressing beyond that seen on the untreated site. Malassezia furfur was found only on the control site, never beneath the semipermeable dressing. According to results of this preliminary study, a semipermeable dressing can be safely used in premature infants and the use of a semipermeable dressing may decrease the excessive transepidermal water loss associated with prematurity.

Herpes simplex virus in childhood erythema multiforme.

Although an association between herpes simplex virus (HSV) infection and erythema multiforme (EM) minor has been documented in adults, this has not been reported in the pediatric population. This study assessed the potential role of HSV infection in the pathogenesis of EM minor in children. Erythema multiforme skin lesions from 20 children, aged 1 to 16 years, were examined for the presence of HSV by using the polymerase chain reaction. The children included all fit strict clinical criteria for EM minor. Ten had a clinical history of an antecedent herpes infection ("herpes-associated EM"), and 10 did not ("idiopathic EM"). Herpes simplex virus DNA was detected in skin lesions of 8 of 10 children with herpes-associated EM and in 8 of 10 with idiopathic EM. Control skin biopsies from children with other bullous inflammatory diseases were negative. In addition, no HSV could be detected in a biopsy of normal uninvolved skin of a child in whom HSV was present in lesional skin. In situ hybridization on selected biopsies by means of an HSV-specific riboprobe confirmed the presence of HSV and localized it to the epidermis. It is concluded that HSV is a significant precipitating factor for EM minor in children, as it is in adults, and that clinicians should maintain a high index of suspicion of HSV even in the absence of a known history of herpes infection.

The involvement of 6p in melanoma.

Karyotype analysis of first passage cells from a melanoma, occurring in a patient with a giant congenital nevus, revealed monosomy of chromosomes #6 and #11, and trisomy of chromosomes #8 and #22. Five marker chromosomes were present, including two ring chromosomes. The origin of three of the marker chromosomes was determined, and all were found to contain the region 6p21.1-6p23. The ring chromosomes were also thought to contain this region, to which the major histocompatibility locus has been mapped. The significance of these findings is discussed in the light of recent reports of chromosome studies of melanoma cells.