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284 Epidermal activation of p38 MAPK is essential for the induction of IL-17-producing cells and psoriasis-like dermatitis
ABSTRACTS | Clinical Research: Pathophysiology and Therapeutics 279
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Phase I study of the nivolumab combined with IFN-B in patients with advanced melanoma T Fujimura1, Y Kambayashi1, S Furudate1, T Hidaka1 and S Aiba2 1 Tohoku University Graduate School of Medicine, Sendai, Japan and 2 Department of Dermatology Tohoku University Graduate School of Medicine, Sendai, Japan Since the efficacy rate of nivolumab is higher than other anti-melanoma drugs, combined therapy that enhances the anti-tumor immune response in patients with metastatic melanoma is of great interest among dermato-oncologists. As we previously reported, IFN-B increases the number of cytotoxic T cells in the tumor sites, leading to enhance the anti-tumor immune response of anti-PD-1 Abs against B16F10 melanoma in vivo. To apply this combination therapy for metastatic melanoma patients, we performed open label, non-randomized, phase 1 trial, using standard 3+3 test. Patients were eligible if they had unresectable stage III or stage IV melanoma. The administration of nivolumab is fixed at 2 mg/kg every 3 weeks. IFN-B is administered at a dose of 1 million units, 2 million units and 3 million units in each group at day 0. The dose-limiting toxicities (DLTs) were defined as any grade 3 or 4 adverse events (AE) at least possibly related to nivolumab and IFN-B occurring between day 0 and day 42. The tumor response was clinically evaluated by investigators by measuring the longest diameter of the target lesions over time. A data and safety monitoring committee was established to provide oversight of safety and efficacy considerations. Of the 9 patients who received this combined therapy, none experienced DLT and all completed the treatment phase of this study. The patients were followed up on every 6 months. 5 out of 9 patients developed progression disease and changed treatment during follow up. No patient in the study or follow up phase developed a grade 3w5 AE. There were two irCR (22%), one irPR (11%), two SD (22%) and four PD (45%). Hence the objective response rate was 55%. Our present study revealed that safe dose of IFN-B is 3 million units.
Presence of inducible skin-associated lymphoid tissue (iSALT)-like structures with CXCL13+ fibroblast-like cells in secondary syphilis T Nomura1, T Kogame2 and K Kabashima3 1 Department of Dermatology, Kyoto University, Kyoto, Japan, 2 Kyoto Medical Center, Kyoto, Japan and 3 Department of Dermatology, Kyoto Univ., Kyoto, Japan Chronic inflammation induces ectopic accumulation of lymphoid cells in non-lymphoid organs. An example of such structures is mucosa-associated lymphoid tissue (MALT). Similarly, the concept of skin-associated lymphoid tissue (SALT) was proposed in 1978. Recently, we identified inducible lymphoid structures composed of macrophages, dermal dendritic cells, and effector T cells in mice, which we termed inducible SALT (iSALT). However, it remains unknown if the concept of iSALT can be applicable to the human skin. To address this issue, we have studied various lesions of chronic inflammatory skin diseases by immunohistochemistry. Here, we present our analysis of the skin lesions of patients with secondary syphilis. We found that CD4+ T cells, CD8+ T cells, and B cells were densely infiltrated in the perivascular area in the upper dermis. Some blood vascular endothelial cells expressed PNAd, indicating differentiation toward high endothelial vessels (HEVs), a feature of lymphoid organs. We further found numerous CXCL13+ fibroblast-like cells in the upper dermis. CXCL13 is known to be important in lymphoid tissue development as it recruits lymphoid-tissue inducer cells during embryonic lymph node development. It is also involved in B cell follicle development by attracting B cells. In syphilitic lesions, CXCL13 may work as a lymphoid tissue-organizing factor, because we found few B cells co-localized with CXCL13+ fibroblast-like cells. In conclusion, the clusters of immune cells with HEVs in syphilis lesions may represent a human counterpart of iSALT.
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A possible role of SCF for the formation of stem cell niche in extramedullary hematopoiesis in the skin T Kogame, T Nomura and K Kabashima Department of Dermatology, Kyoto University, Kyoto, Japan Extramedullary hematopoiesis (EMH) represents a manifestation of myeloproliferative disorders, which is often seen in the context of primary myelofibrosis. A recent murine model suggested that splenic EMH driven by bone marrow depletion is governed by SCF and SDF-1 (CXCL12), which were produced by splenic stromal cells. SCF is reported to play essential roles for maintenance of hematopoietic stem cell, and disruption of SCF function causes perinatal death owing to severe macrocytic anemia. SDF-1 induces potent chemotactic response to CD34+ hematopoietic progenitor cells via CXCR4. Yet our knowledge of cutaneous EMH has been fragmentary, for it occurs very rarely. Here, we investigated the expression pattern of SCF and SDF-1 in the lesion of a cutaneous EMH. Asymptomatic purpuric papules had appeared on the torso of 64-year-old woman, who had been suffered from primary myelofibrosis. The biopsied skin lesion indicated the infiltrations of multiple lineages of cells such as lobulated granulocytes, erythrocytes, erythroblasts, and large undifferentiated blasts around the vessels. Immunohistochemistry proved clusters of cells expressing CD33, CD235a, and CD61 indicating differentiation for myelomonocytic, erythrocyte, and platelet lineage, respectively. We also found that perivascular fibroblastoid cells in the upper dermis expressed both SCF and SDF-1, suggesting that these cytokines play a role in creating a niche in the skin for hematopoietic stem cells. Taken together, the above findings raise the possibility that human skin may share the same mechanism with that of splenic EMH analyzed in murine system. Our findings may be important to understand why the skin can be a platform for EMH.
Risk of skin infections with dupilumab for atopic dermatitis: Systematic review and meta-analysis of randomized controlled trials A Drucker1 and P Fleming2 1 Brown Unversity, Providence, RI and 2 University of Toronto, Toronto, Canada Atopic dermatitis (AD) is characterized by skin barrier defects, immune activation in the Th2 pathway, and increased risk for cutaneous infections. In clinical trials dupilumab, a monoclonal antibody targeting the IL-4 and IL-13 pathway, appeared to decrease rates of skin infections in AD. Our primary objective was to determine the impact of dupilumab on rates of skin infection in patients with moderate-to-severe AD using a systematic review and metaanalysis of randomized controlled trials (RCTs). We searched for RCTs of dupilumab for AD using Pubmed. As an assessment of publication bias, we searched clinicaltrials.gov and the WHO ICTRP databases. Risk ratios (RR) and 95% confidence intervals (CI) of skin infections for dupilumab compared with placebo were calculated using binary random-effects metaanalysis. In total, 7 independent trials in 3 publications with 1,965 participants met our inclusion criteria. The search of trial registries returned 3 completed and as yet unpublished studies and 2 ongoing studies. The study population in each trial consisted of adult patients with moderate-to-severe AD, with specific inclusion and exclusion criteria being slightly different in different trials. Multiple dupilumab dosing schemes were used and follow-up time ranged between 4 and 16-weeks. Meta-analysis including all dosing schedules and follow-up times showed a RR of skin infection of 0.50 (95% CI 0.36-0.70) for dupilumab compared with placebo. In analyses for the two most common dupilumab schedules and limited to 16-week follow-up, RRs were 0.62 (95% CI 0.40-0.96) and 0.65 (95% CI 0.42-1.00) for dupilumab 300 mg every other week and once weekly, respectively, compared with placebo. All trials were considered low risk of bias using the Cochrane tool for assessing risk of bias. In this meta-analysis of RCTs, dupilumab appeared to significantly decrease the risk of skin infections in adults with moderate-to-severe AD up to 16-weeks of follow-up.
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Toxic epidermal necrolysis in the setting of acute graft-versus-host disease successfully treated with tumor necrosis factor alpha inhibitors L Seminario-Vidal1 and N Vera2 1 USF, Department of Dermatology, Tampa, FL and 2 USF, Morsani College of Medicine, Tampa, FL Toxic epidermal necrolysis (TEN) in the context of acute graft-versus-host disease (aGVHD) is an extremely rare condition with almost 100 % mortality. Differentiation of both conditions is challenging, since the histopathological findings are indistinguishable. Current therapeutic recommendations differ between these two conditions. High doses of systemic corticosteroids are safe and effective for the treatment of aGVHD, however, they have been associated with higher mortality rates in patients with TEN, thereby posing a treatment dilemma. We present 2 patients that within 45 days of hematopoietic stem cell transplantation (HSCT) developed a pruritic, morbilliform eruption, consistent with grade 2 aGVHD by histopathological analysis, unresponsive to high dose steroids. Subsequently, the eruption progressed to painful epidermal detachment. Both patients received trimethoprim-sulfamethoxazole (TMP/SMX) 1 to 3 weeks prior to developing the eruption. Neither patient had diarrhea, vomiting or elevated bilirubin at presentation of disease. Skin biopsies demonstrated full thickness epidermal necrosis. One patient was a 100% donor chimera, suggesting aGVHD. However, the same patient and its donor had HLA-C*06:02, indicating a high risk for TMP/ SMX induced TEN. Both patients were managed in a burn unit, where steroids were tapered down, and tumor necrosis factor (TNF)-alpha inhibitor therapy was initiated. Infliximab was used in one patient based on its rapid onset of action. The second patient received etanercept followed by intravenous immunoglobulin. Etanercept was selected based on its potential to block not only TNF-alpha but also lymphotoxin-alpha, which has been implicated in the pathogenesis of GVHD. Skin lesions resolved in both patients and both remain alive. While these cases illustrate the need for better diagnostic techniques that will allow differentiation between of TEN and aGVHD, they support the use of TNF-alpha inhibitors as an effective therapeutic option for these patients.
S48 Journal of Investigative Dermatology (2017), Volume 137
Epidermal activation of p38 MAPK is essential for the induction of IL-17producing cells and psoriasis-like dermatitis K Sakurai1, T Dainichi1, R Matsumoto1, Y Nakano2 and K Kabashima1 1 Department of Dermatology, Kyoto University, Kyoto, Japan and 2 Department of Dermatology, Kyoto University, Osaka, Japan It has been well known that external stresses to the epidermis can induce psoriasis in predisposed individuals; however, a molecular cue, which is attributed to the epidermal stresses and inherited tendencies, remains to be clarified. We previously reported that keratinocytespecific double knockout (DKO) of NF-kB p65 and c-Rel leads to develop psoriatic dermatitis (J Immunol 2015) while the activation of p38 in keratinocytes of psoriasis was reported. We therefore hypothesized that accidental activation of p38 in the epidermis by extrinsic stresses and genetic tendencies might be a primary cue for the development of psoriasis. Firstly, we discovered that p38 is activated in the p65/c-Rel DKO epidermis. Consistently, the treatment with a p38 activator anisomycin rapidly induced the expression of IL-1, IL-6, and CXCL1 in cultured keratinocytes from both mice and humans. In addition, daily topical treatment with anisomycin to mouse ears induced a dose-dependent increase in the ear thickness, scaly erythema with acanthosis, expression of the IL-23-IL-17 axis genes, and infiltration of neutrophils and IL-17+ T cells, all of which are key signatures in human psoriasis. Intriguingly, the above anisomycin-induced responses were reduced in IL-17-deficient mice, and the treatment with a p38a-specific inhibitor BIRB796 attenuated all these responses in cultured keratinocytes and in mice treated with anisomycin. Moreover, the expression of inflammatory mediators in the lesional specimens taken from psoriasis patients was reduced by BIRB796 in an organ culture assay. Taken together, our findings suggest that the epidermal activation of p38 is a key molecular event to induce the IL-23-IL-17 axis in psoriasis, and we propose the new theory for the topical treatment.
280
Phase I study of the nivolumab combined with IFN-B in patients with advanced melanoma T Fujimura1, Y Kambayashi1, S Furudate1, T Hidaka1 and S Aiba2 1 Tohoku University Graduate School of Medicine, Sendai, Japan and 2 Department of Dermatology Tohoku University Graduate School of Medicine, Sendai, Japan Since the efficacy rate of nivolumab is higher than other anti-melanoma drugs, combined therapy that enhances the anti-tumor immune response in patients with metastatic melanoma is of great interest among dermato-oncologists. As we previously reported, IFN-B increases the number of cytotoxic T cells in the tumor sites, leading to enhance the anti-tumor immune response of anti-PD-1 Abs against B16F10 melanoma in vivo. To apply this combination therapy for metastatic melanoma patients, we performed open label, non-randomized, phase 1 trial, using standard 3+3 test. Patients were eligible if they had unresectable stage III or stage IV melanoma. The administration of nivolumab is fixed at 2 mg/kg every 3 weeks. IFN-B is administered at a dose of 1 million units, 2 million units and 3 million units in each group at day 0. The dose-limiting toxicities (DLTs) were defined as any grade 3 or 4 adverse events (AE) at least possibly related to nivolumab and IFN-B occurring between day 0 and day 42. The tumor response was clinically evaluated by investigators by measuring the longest diameter of the target lesions over time. A data and safety monitoring committee was established to provide oversight of safety and efficacy considerations. Of the 9 patients who received this combined therapy, none experienced DLT and all completed the treatment phase of this study. The patients were followed up on every 6 months. 5 out of 9 patients developed progression disease and changed treatment during follow up. No patient in the study or follow up phase developed a grade 3w5 AE. There were two irCR (22%), one irPR (11%), two SD (22%) and four PD (45%). Hence the objective response rate was 55%. Our present study revealed that safe dose of IFN-B is 3 million units.
Presence of inducible skin-associated lymphoid tissue (iSALT)-like structures with CXCL13+ fibroblast-like cells in secondary syphilis T Nomura1, T Kogame2 and K Kabashima3 1 Department of Dermatology, Kyoto University, Kyoto, Japan, 2 Kyoto Medical Center, Kyoto, Japan and 3 Department of Dermatology, Kyoto Univ., Kyoto, Japan Chronic inflammation induces ectopic accumulation of lymphoid cells in non-lymphoid organs. An example of such structures is mucosa-associated lymphoid tissue (MALT). Similarly, the concept of skin-associated lymphoid tissue (SALT) was proposed in 1978. Recently, we identified inducible lymphoid structures composed of macrophages, dermal dendritic cells, and effector T cells in mice, which we termed inducible SALT (iSALT). However, it remains unknown if the concept of iSALT can be applicable to the human skin. To address this issue, we have studied various lesions of chronic inflammatory skin diseases by immunohistochemistry. Here, we present our analysis of the skin lesions of patients with secondary syphilis. We found that CD4+ T cells, CD8+ T cells, and B cells were densely infiltrated in the perivascular area in the upper dermis. Some blood vascular endothelial cells expressed PNAd, indicating differentiation toward high endothelial vessels (HEVs), a feature of lymphoid organs. We further found numerous CXCL13+ fibroblast-like cells in the upper dermis. CXCL13 is known to be important in lymphoid tissue development as it recruits lymphoid-tissue inducer cells during embryonic lymph node development. It is also involved in B cell follicle development by attracting B cells. In syphilitic lesions, CXCL13 may work as a lymphoid tissue-organizing factor, because we found few B cells co-localized with CXCL13+ fibroblast-like cells. In conclusion, the clusters of immune cells with HEVs in syphilis lesions may represent a human counterpart of iSALT.
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282
A possible role of SCF for the formation of stem cell niche in extramedullary hematopoiesis in the skin T Kogame, T Nomura and K Kabashima Department of Dermatology, Kyoto University, Kyoto, Japan Extramedullary hematopoiesis (EMH) represents a manifestation of myeloproliferative disorders, which is often seen in the context of primary myelofibrosis. A recent murine model suggested that splenic EMH driven by bone marrow depletion is governed by SCF and SDF-1 (CXCL12), which were produced by splenic stromal cells. SCF is reported to play essential roles for maintenance of hematopoietic stem cell, and disruption of SCF function causes perinatal death owing to severe macrocytic anemia. SDF-1 induces potent chemotactic response to CD34+ hematopoietic progenitor cells via CXCR4. Yet our knowledge of cutaneous EMH has been fragmentary, for it occurs very rarely. Here, we investigated the expression pattern of SCF and SDF-1 in the lesion of a cutaneous EMH. Asymptomatic purpuric papules had appeared on the torso of 64-year-old woman, who had been suffered from primary myelofibrosis. The biopsied skin lesion indicated the infiltrations of multiple lineages of cells such as lobulated granulocytes, erythrocytes, erythroblasts, and large undifferentiated blasts around the vessels. Immunohistochemistry proved clusters of cells expressing CD33, CD235a, and CD61 indicating differentiation for myelomonocytic, erythrocyte, and platelet lineage, respectively. We also found that perivascular fibroblastoid cells in the upper dermis expressed both SCF and SDF-1, suggesting that these cytokines play a role in creating a niche in the skin for hematopoietic stem cells. Taken together, the above findings raise the possibility that human skin may share the same mechanism with that of splenic EMH analyzed in murine system. Our findings may be important to understand why the skin can be a platform for EMH.
Risk of skin infections with dupilumab for atopic dermatitis: Systematic review and meta-analysis of randomized controlled trials A Drucker1 and P Fleming2 1 Brown Unversity, Providence, RI and 2 University of Toronto, Toronto, Canada Atopic dermatitis (AD) is characterized by skin barrier defects, immune activation in the Th2 pathway, and increased risk for cutaneous infections. In clinical trials dupilumab, a monoclonal antibody targeting the IL-4 and IL-13 pathway, appeared to decrease rates of skin infections in AD. Our primary objective was to determine the impact of dupilumab on rates of skin infection in patients with moderate-to-severe AD using a systematic review and metaanalysis of randomized controlled trials (RCTs). We searched for RCTs of dupilumab for AD using Pubmed. As an assessment of publication bias, we searched clinicaltrials.gov and the WHO ICTRP databases. Risk ratios (RR) and 95% confidence intervals (CI) of skin infections for dupilumab compared with placebo were calculated using binary random-effects metaanalysis. In total, 7 independent trials in 3 publications with 1,965 participants met our inclusion criteria. The search of trial registries returned 3 completed and as yet unpublished studies and 2 ongoing studies. The study population in each trial consisted of adult patients with moderate-to-severe AD, with specific inclusion and exclusion criteria being slightly different in different trials. Multiple dupilumab dosing schemes were used and follow-up time ranged between 4 and 16-weeks. Meta-analysis including all dosing schedules and follow-up times showed a RR of skin infection of 0.50 (95% CI 0.36-0.70) for dupilumab compared with placebo. In analyses for the two most common dupilumab schedules and limited to 16-week follow-up, RRs were 0.62 (95% CI 0.40-0.96) and 0.65 (95% CI 0.42-1.00) for dupilumab 300 mg every other week and once weekly, respectively, compared with placebo. All trials were considered low risk of bias using the Cochrane tool for assessing risk of bias. In this meta-analysis of RCTs, dupilumab appeared to significantly decrease the risk of skin infections in adults with moderate-to-severe AD up to 16-weeks of follow-up.
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Toxic epidermal necrolysis in the setting of acute graft-versus-host disease successfully treated with tumor necrosis factor alpha inhibitors L Seminario-Vidal1 and N Vera2 1 USF, Department of Dermatology, Tampa, FL and 2 USF, Morsani College of Medicine, Tampa, FL Toxic epidermal necrolysis (TEN) in the context of acute graft-versus-host disease (aGVHD) is an extremely rare condition with almost 100 % mortality. Differentiation of both conditions is challenging, since the histopathological findings are indistinguishable. Current therapeutic recommendations differ between these two conditions. High doses of systemic corticosteroids are safe and effective for the treatment of aGVHD, however, they have been associated with higher mortality rates in patients with TEN, thereby posing a treatment dilemma. We present 2 patients that within 45 days of hematopoietic stem cell transplantation (HSCT) developed a pruritic, morbilliform eruption, consistent with grade 2 aGVHD by histopathological analysis, unresponsive to high dose steroids. Subsequently, the eruption progressed to painful epidermal detachment. Both patients received trimethoprim-sulfamethoxazole (TMP/SMX) 1 to 3 weeks prior to developing the eruption. Neither patient had diarrhea, vomiting or elevated bilirubin at presentation of disease. Skin biopsies demonstrated full thickness epidermal necrosis. One patient was a 100% donor chimera, suggesting aGVHD. However, the same patient and its donor had HLA-C*06:02, indicating a high risk for TMP/ SMX induced TEN. Both patients were managed in a burn unit, where steroids were tapered down, and tumor necrosis factor (TNF)-alpha inhibitor therapy was initiated. Infliximab was used in one patient based on its rapid onset of action. The second patient received etanercept followed by intravenous immunoglobulin. Etanercept was selected based on its potential to block not only TNF-alpha but also lymphotoxin-alpha, which has been implicated in the pathogenesis of GVHD. Skin lesions resolved in both patients and both remain alive. While these cases illustrate the need for better diagnostic techniques that will allow differentiation between of TEN and aGVHD, they support the use of TNF-alpha inhibitors as an effective therapeutic option for these patients.
S48 Journal of Investigative Dermatology (2017), Volume 137
Epidermal activation of p38 MAPK is essential for the induction of IL-17producing cells and psoriasis-like dermatitis K Sakurai1, T Dainichi1, R Matsumoto1, Y Nakano2 and K Kabashima1 1 Department of Dermatology, Kyoto University, Kyoto, Japan and 2 Department of Dermatology, Kyoto University, Osaka, Japan It has been well known that external stresses to the epidermis can induce psoriasis in predisposed individuals; however, a molecular cue, which is attributed to the epidermal stresses and inherited tendencies, remains to be clarified. We previously reported that keratinocytespecific double knockout (DKO) of NF-kB p65 and c-Rel leads to develop psoriatic dermatitis (J Immunol 2015) while the activation of p38 in keratinocytes of psoriasis was reported. We therefore hypothesized that accidental activation of p38 in the epidermis by extrinsic stresses and genetic tendencies might be a primary cue for the development of psoriasis. Firstly, we discovered that p38 is activated in the p65/c-Rel DKO epidermis. Consistently, the treatment with a p38 activator anisomycin rapidly induced the expression of IL-1, IL-6, and CXCL1 in cultured keratinocytes from both mice and humans. In addition, daily topical treatment with anisomycin to mouse ears induced a dose-dependent increase in the ear thickness, scaly erythema with acanthosis, expression of the IL-23-IL-17 axis genes, and infiltration of neutrophils and IL-17+ T cells, all of which are key signatures in human psoriasis. Intriguingly, the above anisomycin-induced responses were reduced in IL-17-deficient mice, and the treatment with a p38a-specific inhibitor BIRB796 attenuated all these responses in cultured keratinocytes and in mice treated with anisomycin. Moreover, the expression of inflammatory mediators in the lesional specimens taken from psoriasis patients was reduced by BIRB796 in an organ culture assay. Taken together, our findings suggest that the epidermal activation of p38 is a key molecular event to induce the IL-23-IL-17 axis in psoriasis, and we propose the new theory for the topical treatment.