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Stimulation of T-cellular immunity by cutaneous application of dinitrochlorobenzene
Volume 14 Number 6 June, 1986
topathology, and immunopathology. 12 Some animals were treated previously with other immunosuppressive therapy with partial to no response. All animals, with the exception of the dog with cutaneous lupus erythematosus, had been treated previously with immunosuppressive dosages of corticosteroids. Most animals were treated with prednisone at 2.2 mg/kg/day. Responses were variable in the pemphigus cases, with only mild initial responses seen. The cat with pemphigus erythematosus had previously responded well to an injection of methylprednisolone acetate. In addition to the corticosteroids, one of the pemphigus dogs was also treated with injectable gold salts for 16 weeks with no clinical improvement. In the present study cyelosporine dosages have ranged from 15 to 27 mglkg/day, depending upon clinical response and side effects. Animals were started at the lower dosage, and if no clinical improvement was seen within 2 to 3 weeks the dosage was raised. Although these dosages are much higher than those used in humans, it is not uncommon to have higher drug dosages in dogs and cats on a per weight basis. This most likely reflects increased drug metabolism. All cases are evaluated weekly the first month, every 2 weeks the second and third months, and monthly until completion of the study, which is tentatively set for 1 year. At each examination complete blood count, chemistry, serum for cyclosporine levels for radioimmunoassay, and urinalysis panels are taken. In addition, examination of cutaneous lesions and monthly photographs are taken to assess clinical improvement. Treatment lengths presently range from 5 to 16 weeks. Side effects have included diarrhea in two dogs, mild ongoing blood creatinine elevation in one of the cats, and, in one dog on high-dose therapy (27 mg/kg/day), a lymphoplasmacytoid nodule with malignant features. This dog was on cyclosporine only, and reducing the dose resulted in resolution of the lesion. All animals have shown response to the cyclosporine treatment, but it has been variable. Improvement is evaluated by reduction in the extent and severity of lesions and is graded as mild, moderate, or marked. One of the dogs with pemphigus had moderate resolution of lesions initially but had an exacerbation that has been refractory to dosages of cyclosporine as high as 27 mg/kg/day. The other dog with pemphigus has had marked improvement of lesions and the dog with cutaneous lupus erythematosus has had moderate reduction of oral lesions. Both of the cats have also been responding, the patient with pemphigus erythematosus is markedly improved after 6 weeks of therapy, and the cat with pemphigus foliaceus is showing mild improvement. Longer treatment and the addition of more patients
Correspondence
1089
are necessary to draw further conclusions regarding cyclosporine's efficacy and safety in immune-mediated skin disease. It certainly appears to have value in the treatment of autoimmune disease. It must be emphasized that the use of cyclosporine is experimental and is not approved in animals or in humans for similar disorders at this time. Until more controlled prospective studies are performed its use should be limited and patients should be closely monitored.
Wayne S. Rosenkrantz, D. V.M.,* Craig E. Griffin, D.V.M.,* Ronald J. Barr, M.D.,** and Catherine A. Biren, M.D.** Animal Dermatology Clinic, Garden Grove, CA,* and the Department of Dermatology, University of California, Irvine**
REFERENCES 1. Mueller W, Herman B: Cyclosporin A for psoriasis. N Engl J Med 301:555, 1979. 2. Van Hooff JP, Levinssen KL, Staak WVD: Cyclosporine and psoriasis. Lancet 1:355, 1985. 3. Thivolet J, Barthelemy M, Rigot-Muller G, et aJ: Effects of cyclosporine on bullous pemphigoid and pemphigas. Lancet 1:334-335, 1985. 4. Weetman AP, McGraw AM, Ludgate M, et al: Cyclosporine improves Grave's ophthalmopathy. Lancet 2: 486-489, 1983. 5. Nussenblatt RB, Palshne AG, Rook AH, et al: Treatment of inflammatory diseases with cyclosporine A. Lancet 2:235-238, 1983. 6. Isenberg DA, Swaith ML, Morrow WJW, et al: Cyclosporin A for the treatment of systemic lupus erythematosus. Int J Immunopharmacol 3:163-169, 1981. 7. Velthuis PJ, Jesserun RFM: Improvement of iehthyosis by cyclosporin. Lancet 1:335, 1985. 8. Puttick L, Pollack A, Fairbum E: Treatment of Sezary syndrome with cyclosporin A. J R Soc Med 76:10631065, 1983. 9. Moreland AA, Robertson DB, Heffner LT: Treatment of cutaneous T cell lymphoma with cyclosporin A. J AM AcAD DERMArOI~12:886, 1985. (Letter to Editor.) 10. Rullan P, Barr RJ, Cole GW: Cyclosporine and murine allergic contact dermatitis. Arch Dermatol 120:11791183, 1984. 11. Bken C, Ganderup G, Lemus L, et al: Topical cyclesporine: Effect on contact-dermatitis in guinea pigs. Clin Res 32:136A, 1984. (Abst.) 12. Muller GH, Kirk RW, Scott DW' Small animal dermatology, ed. 3. Philadelphia, 1983, W. B. Saunders Co., pp. 448-480.
Stimulation of T-cellular immunity by cutaneous application of dinitrochlorobenzene To the Editor: I have collected a series of twenty-six cases from my practice. These cases suggest that topical administration of 1-chloro-2,4-dinitrochlorobenzene (DNCB) to per-
1090
Journal of the American Academy of Dermatology
Correspondence
T a b l e I. Alterations o f lymphocytic parameters by topical application of dinitrochlorobenzene
Normal patients (n = 8)
Before After Change (%)
7,984 7,850 - 2
2,528 2,823 12
237 329 39
1,885 2,002 6
960 1,087 13
841 877 4
1.32 1.42 8
"Moderately" suppressed (n = 12)
Before After Change (%)
5,862 5,190 - ll
1,788 1,849 3
356 259 -27
1,152 1,402 22
390 518 33
799 838 5
0.60 0.76 27
AIDS patients (n = 6)
Before After Change (%)
4,308 3,928 - 9
1,426 1,210 - 15
185 185 0
1,055 886 - 16
175 230 31
871 605 - 31
0.21 0.47 124
*All cell counts are given as cells/mm3.
sons of varying immunologic status induces changes in numbers of circulating T and B lymphocytes and Tlymphocyte subsets, as well as improved transformability of these lymphocytes in vitro by exogenous mitogens. The evidence gained correlates with clinical evidence of enhanced T-cellular function. Normalization of other laboratory abnormalities associated with the acquired immunodeficiency syndrome (AIDS), ineluding anemia, thrombocytopenia, and hypergammaglobulinemia, was noted during the course of the DNCB applications and suggests that topically administered DNCB also promotes reconstitution of T-cell immunoregulatory functions in immunosuppressed patients. Laboratory studies were obtained at intervals both before and after weekly application of 2% DNCB in acetone to the ventral surface of the upper extremities until erythema, edema, and pruritus could be induced by a 1% DNCB solution within 24 to 72 hours after its application to the quarter-sized site. Immediately following administration of the DNCB solution, the site was covert~d with gauze and paper tape; the patient was instructed to remove the dressing and cleanse the site the following morning. The number of applications administered prior to the appearance of delayed hypersensitivity was roughly proportional to the severity of the immune deficiency, if present. Alterations of lymphocyte parameters, as well as other AIDS-associated laboratory abnormalities, were frequently found even prior to the development of cutaneous hypersensitivity in immunosuppressed patients, although eventually all patients were successfully sensitized as judged by clinical examination of the application sites. Normal patients (i.e., with initial OKT4/ OKT8 values >1.0) and "moderately" suppressed patients (i.e., with initial OKT4/OKT8 values <1.0 but
without diagnoses of Kaposi's sarcoma or opportunistic infections) had increases in total T-cell counts, as well as both OKT4 and OKT8 subsets, resulting in an increased OKT4/OKT8 ratio. The AIDS patient group (i.e., with diagnoses of Kaposi's sarcoma and/or Pneumocystis carinii pneumonia who were not receiving any other treatment concurrently) had decreased total T-cell and OKT8 counts but increased OKT4 counts, resulting in approximate doubling of the initial OKT4/OKT8 ration (Table I). Patients with anemia and/or thrombocytopenia underwent increases in red blood cell numbers, hemoglobin, hematocrit, and platelet counts while erythrocyte sedimentation rates and IgG and IgA levels decreased. The immunosuppressed group also demonstrated improved transformability of lymphocytes in vitro to phytohemagglutinin, pokeweed, and concanavalin A mitogens while the Staphylococcus aureus mitogen test usually remained below normal values. Patients with Kaposi's sarcoma underwent changes in their mucocutaneous lesions, consisting of reductions in lesional size, number, and thickness, as well as decreased discoloration when DNCB was applied to foci of involved skin. These changes included DNCB-treated as well as untreated lesions and were generally preceded by perilesional erythema, edema, and pruritus. Diminution of the violaceous discoloration began on interfollicular skin, leaving persistent perifollicular violaceous erythema. This anecdotal collection of cases suggests that cutaneous administration of DNCB may prove to be of therapeutic benefit in the amelioration of the immunologic defect in AIDS, primarily or adjunctively.
L. Bruce Mills, M.D. 450 Sutter St., No. 2304, San Francisco, CA 94108
topathology, and immunopathology. 12 Some animals were treated previously with other immunosuppressive therapy with partial to no response. All animals, with the exception of the dog with cutaneous lupus erythematosus, had been treated previously with immunosuppressive dosages of corticosteroids. Most animals were treated with prednisone at 2.2 mg/kg/day. Responses were variable in the pemphigus cases, with only mild initial responses seen. The cat with pemphigus erythematosus had previously responded well to an injection of methylprednisolone acetate. In addition to the corticosteroids, one of the pemphigus dogs was also treated with injectable gold salts for 16 weeks with no clinical improvement. In the present study cyelosporine dosages have ranged from 15 to 27 mglkg/day, depending upon clinical response and side effects. Animals were started at the lower dosage, and if no clinical improvement was seen within 2 to 3 weeks the dosage was raised. Although these dosages are much higher than those used in humans, it is not uncommon to have higher drug dosages in dogs and cats on a per weight basis. This most likely reflects increased drug metabolism. All cases are evaluated weekly the first month, every 2 weeks the second and third months, and monthly until completion of the study, which is tentatively set for 1 year. At each examination complete blood count, chemistry, serum for cyclosporine levels for radioimmunoassay, and urinalysis panels are taken. In addition, examination of cutaneous lesions and monthly photographs are taken to assess clinical improvement. Treatment lengths presently range from 5 to 16 weeks. Side effects have included diarrhea in two dogs, mild ongoing blood creatinine elevation in one of the cats, and, in one dog on high-dose therapy (27 mg/kg/day), a lymphoplasmacytoid nodule with malignant features. This dog was on cyclosporine only, and reducing the dose resulted in resolution of the lesion. All animals have shown response to the cyclosporine treatment, but it has been variable. Improvement is evaluated by reduction in the extent and severity of lesions and is graded as mild, moderate, or marked. One of the dogs with pemphigus had moderate resolution of lesions initially but had an exacerbation that has been refractory to dosages of cyclosporine as high as 27 mg/kg/day. The other dog with pemphigus has had marked improvement of lesions and the dog with cutaneous lupus erythematosus has had moderate reduction of oral lesions. Both of the cats have also been responding, the patient with pemphigus erythematosus is markedly improved after 6 weeks of therapy, and the cat with pemphigus foliaceus is showing mild improvement. Longer treatment and the addition of more patients
Correspondence
1089
are necessary to draw further conclusions regarding cyclosporine's efficacy and safety in immune-mediated skin disease. It certainly appears to have value in the treatment of autoimmune disease. It must be emphasized that the use of cyclosporine is experimental and is not approved in animals or in humans for similar disorders at this time. Until more controlled prospective studies are performed its use should be limited and patients should be closely monitored.
Wayne S. Rosenkrantz, D. V.M.,* Craig E. Griffin, D.V.M.,* Ronald J. Barr, M.D.,** and Catherine A. Biren, M.D.** Animal Dermatology Clinic, Garden Grove, CA,* and the Department of Dermatology, University of California, Irvine**
REFERENCES 1. Mueller W, Herman B: Cyclosporin A for psoriasis. N Engl J Med 301:555, 1979. 2. Van Hooff JP, Levinssen KL, Staak WVD: Cyclosporine and psoriasis. Lancet 1:355, 1985. 3. Thivolet J, Barthelemy M, Rigot-Muller G, et aJ: Effects of cyclosporine on bullous pemphigoid and pemphigas. Lancet 1:334-335, 1985. 4. Weetman AP, McGraw AM, Ludgate M, et al: Cyclosporine improves Grave's ophthalmopathy. Lancet 2: 486-489, 1983. 5. Nussenblatt RB, Palshne AG, Rook AH, et al: Treatment of inflammatory diseases with cyclosporine A. Lancet 2:235-238, 1983. 6. Isenberg DA, Swaith ML, Morrow WJW, et al: Cyclosporin A for the treatment of systemic lupus erythematosus. Int J Immunopharmacol 3:163-169, 1981. 7. Velthuis PJ, Jesserun RFM: Improvement of iehthyosis by cyclosporin. Lancet 1:335, 1985. 8. Puttick L, Pollack A, Fairbum E: Treatment of Sezary syndrome with cyclosporin A. J R Soc Med 76:10631065, 1983. 9. Moreland AA, Robertson DB, Heffner LT: Treatment of cutaneous T cell lymphoma with cyclosporin A. J AM AcAD DERMArOI~12:886, 1985. (Letter to Editor.) 10. Rullan P, Barr RJ, Cole GW: Cyclosporine and murine allergic contact dermatitis. Arch Dermatol 120:11791183, 1984. 11. Bken C, Ganderup G, Lemus L, et al: Topical cyclesporine: Effect on contact-dermatitis in guinea pigs. Clin Res 32:136A, 1984. (Abst.) 12. Muller GH, Kirk RW, Scott DW' Small animal dermatology, ed. 3. Philadelphia, 1983, W. B. Saunders Co., pp. 448-480.
Stimulation of T-cellular immunity by cutaneous application of dinitrochlorobenzene To the Editor: I have collected a series of twenty-six cases from my practice. These cases suggest that topical administration of 1-chloro-2,4-dinitrochlorobenzene (DNCB) to per-
1090
Journal of the American Academy of Dermatology
Correspondence
T a b l e I. Alterations o f lymphocytic parameters by topical application of dinitrochlorobenzene
Normal patients (n = 8)
Before After Change (%)
7,984 7,850 - 2
2,528 2,823 12
237 329 39
1,885 2,002 6
960 1,087 13
841 877 4
1.32 1.42 8
"Moderately" suppressed (n = 12)
Before After Change (%)
5,862 5,190 - ll
1,788 1,849 3
356 259 -27
1,152 1,402 22
390 518 33
799 838 5
0.60 0.76 27
AIDS patients (n = 6)
Before After Change (%)
4,308 3,928 - 9
1,426 1,210 - 15
185 185 0
1,055 886 - 16
175 230 31
871 605 - 31
0.21 0.47 124
*All cell counts are given as cells/mm3.
sons of varying immunologic status induces changes in numbers of circulating T and B lymphocytes and Tlymphocyte subsets, as well as improved transformability of these lymphocytes in vitro by exogenous mitogens. The evidence gained correlates with clinical evidence of enhanced T-cellular function. Normalization of other laboratory abnormalities associated with the acquired immunodeficiency syndrome (AIDS), ineluding anemia, thrombocytopenia, and hypergammaglobulinemia, was noted during the course of the DNCB applications and suggests that topically administered DNCB also promotes reconstitution of T-cell immunoregulatory functions in immunosuppressed patients. Laboratory studies were obtained at intervals both before and after weekly application of 2% DNCB in acetone to the ventral surface of the upper extremities until erythema, edema, and pruritus could be induced by a 1% DNCB solution within 24 to 72 hours after its application to the quarter-sized site. Immediately following administration of the DNCB solution, the site was covert~d with gauze and paper tape; the patient was instructed to remove the dressing and cleanse the site the following morning. The number of applications administered prior to the appearance of delayed hypersensitivity was roughly proportional to the severity of the immune deficiency, if present. Alterations of lymphocyte parameters, as well as other AIDS-associated laboratory abnormalities, were frequently found even prior to the development of cutaneous hypersensitivity in immunosuppressed patients, although eventually all patients were successfully sensitized as judged by clinical examination of the application sites. Normal patients (i.e., with initial OKT4/ OKT8 values >1.0) and "moderately" suppressed patients (i.e., with initial OKT4/OKT8 values <1.0 but
without diagnoses of Kaposi's sarcoma or opportunistic infections) had increases in total T-cell counts, as well as both OKT4 and OKT8 subsets, resulting in an increased OKT4/OKT8 ratio. The AIDS patient group (i.e., with diagnoses of Kaposi's sarcoma and/or Pneumocystis carinii pneumonia who were not receiving any other treatment concurrently) had decreased total T-cell and OKT8 counts but increased OKT4 counts, resulting in approximate doubling of the initial OKT4/OKT8 ration (Table I). Patients with anemia and/or thrombocytopenia underwent increases in red blood cell numbers, hemoglobin, hematocrit, and platelet counts while erythrocyte sedimentation rates and IgG and IgA levels decreased. The immunosuppressed group also demonstrated improved transformability of lymphocytes in vitro to phytohemagglutinin, pokeweed, and concanavalin A mitogens while the Staphylococcus aureus mitogen test usually remained below normal values. Patients with Kaposi's sarcoma underwent changes in their mucocutaneous lesions, consisting of reductions in lesional size, number, and thickness, as well as decreased discoloration when DNCB was applied to foci of involved skin. These changes included DNCB-treated as well as untreated lesions and were generally preceded by perilesional erythema, edema, and pruritus. Diminution of the violaceous discoloration began on interfollicular skin, leaving persistent perifollicular violaceous erythema. This anecdotal collection of cases suggests that cutaneous administration of DNCB may prove to be of therapeutic benefit in the amelioration of the immunologic defect in AIDS, primarily or adjunctively.
L. Bruce Mills, M.D. 450 Sutter St., No. 2304, San Francisco, CA 94108