京都大学 / 0048 / 新制・課程博士 / 博士(薬学) / 甲第17862号 / 薬博第793号 / 新制||薬||236(附属図書館) / 30682 / 京都大学大学院薬学研究科医療薬科学専攻 / (主査)教授 髙倉 喜信, 教授 橋田 充, 教授 佐治 英郎 / 学位規則第4条第1項該当 / Doctor of Pharmaceutical Sciences / Kyoto University / DFAM

Atopische Dermatitis (Atopisches Ekzem) ist die häufigste Erkrankung der Haut, und sie ist mit der Entwicklung anderer schwerwiegenden atopischen Erkrankungen wie Lebensmittelallergien, allergischer Rhinitis, Heuschnupfen und Asthma vergesellschaftet. Inaktivierende Mutationen im Filaggrin (FLG) Gen zeigten die stärkste Assoziation mit dem Krankheitsbild der atopischen Dermatitis. FLG wird fast ausschließlich in der Epidermis der Haut ausgeprägt und trägt maßgeblich zur normalen Differenzierung von Keratinozyten und zur Integrität der Hautbarriere bei. Bi-allelische inaktivierende Mutationen in dem Gen verursachen die Hauterkrankung Ichthyosis vulgaris, bei es zu Ausbildung einer übermäßig trockenen und schuppigen Hautoberfläche kommt. Etwa die Hälfte aller Ichthyosis vulgaris Patienten entwickeln ebenfalls atopische Dermatitis im Laufe Ihres Lebens. Zusätzlich treten in Ichthyosis vulgaris Patienten häufiger atopische Krankheitsbilder auf als in Gesunden. Als Modell zur Erforschung molekularer Grundlagen der Pahtologie des atopischen Ekzemes und von Pathomechanismen der Atopie eignet sich die „flaky tail“ Mauslinie. Diese Mäuse entwickeln typische Merkmale einer systemischen Atopie wie z.B. einen Barriere Defekt der Haut, ein Hautekzem, eine Entzündung der Lunge, sowie erhöhte Mengen an Immunglobulin E im Serum. In diesem Modell wird die Krankheitsentwicklung durch zwei natürlich entstandene Mutationen in den Genen Flg und Tmem79 verursacht. Die das Gen Flg betreffende Mutation bewirkt eine reduzierte Expression, welche einen Ichthyosis vulgairs ähnlichen Phänotyp auslöst, der durch Schuppenartige („flaky“) Haut am Schwanz („tail“) gekennzeichnet ist (Flgft). Die Mutation im Tmem79 Gen bewirkt eine matte Fellfarbe und wird daher als „matted“ Mutation (Tmem79ma) bezeichnet. Obwohl die Mutationen in benachbarten Regionen des Maus Chromosoms 3 zu finden sind, konnten diese genetisch getrennt werden. Dadurch gelang es zu zeigen, dass allein die Tmem79ma Mutation ausreicht, um Ekzeme und systemische Atopie in Mäusen auszulösen. Nach Rückkreuzung der Flgft Mutation auf den pro-allergischen BALB/c genetischen Hintergrund entwickelten die Flgft/ft BALB/c Mäuse eine - Erkrankung ähnlich der atopischen Dermatitis, die ebenfalls von spontanem Asthma und hohen IgE Konzentrationen im Serum gekennzeichnet war. Beides sind Hauptmerkmale des sogenannten atopischen Marsches. Diese Versuche implizierten, dass Filaggrin eine wichtige Funktion im Schutz vor der Entwicklung von Atopie in Mäusen ausübt. Im Gegensatz zu diesen Ergebnissen wurden nach dem Rückkreuzen von Flg knockout (Flg-/-) Mäusen auf den BALB/c Hintergrund nur ein transienter neonataler Ichthyose Phänotyp, aber keine Hautentzündung oder Atopie beobachtet. Um diese Diskrepanz besser zu verstehen, generierten wir Flg knockout Mäuse direkt im BALB/c Hintergrund. Diese genetisch reinen Flg-/-/BALB/c Mäuse rekapitulierten den neonatalen Ichthyose Phänotyp, und sie zeigten einen Barriere Defekt, der die perkutane Sensibilisierung förderte. Spontane Entzündungen der Haut oder systemische Atopie wurden allerdings nicht beobachtet. Um die genetische Ursache der Atopie in Flgft/ft BALB/c Mäusen zu verstehen, sequenzierten wir das Genom mittels PacBio long read sequencing und verglichen es mit dem BALB/c Referenzgenom. Überraschenderweise zeigte die Analyse, dass die kongenen Flgft/ft BALB/c Mäuse ebenfalls die Atopie-verursachende Tmem79ma Mutation im homozygoten Zustand trugen. Zuvor wurde berichtet, dass die Flgft und Tmem79ma Mutationen vor dem Rückkreuzen des Flgft Allels auf den BALB/c Hintergrund voneinander getrennt werden konnten. Unsere Beobachtungen erklären nun die phänotypische Diskrepanz zwischen den Flgft/ft BALB/c und den Flg-/-/BALB/c Mäusen. Die Daten implizieren, dass der alleinige Funktionsverlust von FLG keine Atopie auslöst und werden durch Beobachtungen in einem Teil der FLG-defizienten Ichthyosis vulgaris Patienten gestützt, die ebenfalls keine Atopie zeigen. Es ist trotzdem wahrscheinlich, dass der Verlust von Filaggrin im Zusammenspiel mit weiteren genetischen Barriere Defekten, wie z.B. Mutationen im Tmem79 Gen das Krankheitsbild der Atopie qualitativ beeinflusst.:Abbreviations 6 Summary 9 Zusammenfassung 11 Introduction 13 Skin 13 Epidermis 13 The immune system 15 Adaptive immune response effector mechanisms 17 Allergic diseases 19 Atopic march 19 Atopic dermatitis 19 Metabolics of AD skin 23 Filaggrin and AD 25 Current mouse models of barrier defect and AD 29 Induced AD mouse models 29 Transgenic and knock out (KO) AD mouse models 30 Inbred mouse strains spontaneously developing AD-like disease 31 Mouse models of FLG-deficiency 32 AD and microbiome 34 Aim 37 Material and methods 38 Generation of Flg-/- mice 38 Crispr targeting strategy 38 α-FLG Western Blot 39 Protein extract preparation 39 SDS Electrophoresis 39 α-FLG Immunofluorescence staining 40 PCR Typing 40 Isolation of genomic DNA from mouse tail tips 40 PCR typing strategy 41 H&E staining of neonatal mouse ear skin 42 Ear thickness measurement 44 Quantification of transepidermal water loss (TEWL) 44 Quantification of total and antigen-specific IgE 44 Whole back skin RNA Sequencing (RNA-Seq) 44 Sorting of basal ear skin keratinocytes for RNA extraction, by fluorescence-activated cell sorting (FACS) 45 Quantitative real time PCR (qRT-PCR) 47 Flow cytometric analysis of ear skin 48 Analysis of DO11.10+/4get transgenic T cell response to epicutaneous OVA immunization 49 Skin microbiome analysis 50 S.aureus colonization of Flg mutant mice 51 Long-term epicutaneous OVA treatment 52 Mapping of reads, assembly, annotation and variant calling 53 Statistical analysis 55 Results 56 Generation and validation of Flg-/-/ BALB/c mice 56 Large sequence deletions detected in Flg-mutant mice by PCR 56 Complete loss of FLG protein expression in Flg-/- mice 57 Flg-/-/BALB/c mice show a barrier-defective skin 59 FLG-deficient skin is devoid of inflammation 61 FLG-deficient skin shows age-related inside-out barrier defect 62 Mild T cell expansion and no other changes in the epidermal compartment of the Flg-/-/BALB/c mice 62 γδ T cell expansion in the whole ear skin suspensions of FLG-deficient mice 64 Lack of systemic atopy in FLG-deficient mice, as indicated by IgE quantification 67 S. aureus colonization does not trigger eczema or atopy in FLG-deficient mice 68 Sensitization with a protein Ag does not trigger inflammation in FLG-deficient mice 69 FLG-deficient skin shows age-related outside-in barrier defect 69 Mild inflammatory signature detected in Flg-/-/BALB/c back skin by RNA sequencing 71 Type 2 immune response signalling detected in Flg-/-/BALB/c ear skin keratinocytes by RNA sequencing 72 FLG-deficient ear skin shows elevated IL-1b expression 74 Reduced cutaneous commensal microbial diversity in FLG-deficient mice 75 Presence of atopy-causing Tmem79ma mutation in Flgft/ft BALB/c mouse genome account for phenotypic differences with our Flg-/-/BALB/c mice 76 Discussion 81 FLG-deficiency in mice does not trigger spontaneous atopic disease 81 FLG-deficiency in mice causes mild immunological perturbation 82 Atopic march, observed in Flgft/ft BALB/c congenic strain, can be explained by the presence of the matted mutation 88 Relevance of filaggrin deficiency for the pathogenesis of atopy in mouse and man 89 References 92 Acknowledgments 136 Erklärung zur Eröffnung des Promotionsverfahrens 137 Erklärung über die Einhaltung der gesetzlichen Vorgaben 138

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京都大学 / 新制・課程博士 / 博士(農学) / 甲第23579号 / 農博第2478号 / 新制||農||1088(附属図書館) / 学位論文||R3||N5363(農学部図書室) / 京都大学大学院農学研究科応用生命科学専攻 / (主査)教授 栗原 達夫, 教授 小川 順, 教授 木岡 紀幸 / 学位規則第4条第1項該当 / Doctor of Agricultural Science / Kyoto University / DGAM

Atopiskt eksem kännetecknas av en torr hud med hudsprickor som ger en svår klåda. Behandlingen går ut på att identifiera, minimera och eliminera faktorer som är utlösande och försämrande. Mjukgörande medel används dagligen för att före-bygga uppkomsten av nytt eksem. Att leva med atopiskt eksem kan vara ett stort handikapp med personliga, sociala och ekonomiska inskränkningar som leder till en sämre livskvalitet. Syftet med litteraturstudien är att klargöra om patienter med atopiskt eksem kan förbättra sin livskvalitet genom att få utbildning om sin sjuk-dom. Metoden som har använts är en litteraturstudie där artiklar har sökts i data-basen PubMed och bedömts efter ett modifierat granskningsprotokoll för kvali-tetsvärdering av artiklarna. Sammanställningen bygger på 10 artiklar där resultatet inte ger ett starkt stöd för att patientutbildning ger en förbättrad livskvalitet. Ytter-liggare forskning behövs med större och mer omfattande studier för att kunna på-visa huruvida patientutbildning ger förbättringar i livskvaliteten hos patienter med atopiskt eksem. / Atopic eczema is characterized by a dry skin with dermal tearing giving a severe itching. The treatment is to identify, minimize and eliminate factors that trigger and adverse. Softening agents are used daily to prevent the formation of new eczema. Living with atopic eczema can be a major handicap with personal, social and economic restrictions that might lead to a reduced quality of life. The purpose of this literature study is to clarify whether patients with atopic eczema may improve their quality of life by receiving education of their illness. The method used is a literature review which items have been sought in the database PubMed and assessed by a modified examination protocol for quality assessment of articles. The compilation is based on 10 articles in which the results do not provide strong support for patient education provides an improved quality of life. Further research is needed with larger and more extensive studies to demonstrate if improvements can be shown in quality of life in patients with atopic eczema.

Chronic itch has a significant impact on quality of life for millions of patients worldwide, on a level comparable to that of chronic pain. Yet, although there are a host of effective drugs available for pain, there are no therapies that specifically target chronic itch. Current experimental approaches to investigate the pathogenesis of chronic pruritus and to test novel therapeutic agents are largely limited to rodent models. However, rodent models display significant dermatological, neurophysiological, and immunological differences from humans with chronic itch. The disadvantages of the current rodent paradigms call for the design of a valid primate model of chronic itch. For four years, we have monitored scratching behavior in a primate colony (n=35) of Cynomolgus macaques (Macaca fascicularis) suffering from idiopathic chronic itch. By comparing molecular and genetic analyses of the primates’ skin to their quantified scratching behavior, we attempted to characterize the underlying mechanisms of chronic itch in this model. Furthermore, the expression of itch-related proteins was examined in both the primate model and in humans with pruritic diseases. The first aim of the study was to characterize the underlying molecular and genetic basis of chronic itch in the primate model. We were able to distinguish specific peripheral targets related to pruritus by correlating the genetic and protein expression results to the primates’ scratching severity. In Aim 1a, RNA-sequencing was performed on skin biopsies from the primates to identify differentially expressed genes in pruritic, lichenified versus non-pruritic, non-lichenified skin. These results were then correlated to the quantified primate scratching behavior. This led to the identification of over 400 genes that were differentially expressed in the skin based on scratching intensity. Many of these differentially expressed transcripts were associated with sensory nerve fibers, keratinocytes, mast cells, or lymphocytes. Selected genes that were overexpressed and correlated to itch intensity were then targeted for immunohistochemical and proteomic analysis in Aim 1b. Immunohistochemical examination of the primate skin biopsies revealed that histamine levels were not elevated in primates that exhibited increased scratching behavior. However, mast cells containing tryptase were significantly increased in the skin of primates with severe scratching as compared to primates with mild scratching. The increased levels of gastrin-releasing peptide and substance P in lichenified skin were also found to be correlated to the primates’ scratching behavior. Of note, transient receptor potential channels V1, V3, and A1 were increased in the epidermis of primate skin, but the numbers of TRPV1+ and TRPA1+ nerve fibers were not significantly different between lichenified and non-lichenified skin. Transcriptome analysis of the opioid receptors and their ligands showed that primates with severe scratching behavior had a significant imbalance between the µ- and κ-opioid receptors and ligands. The µ-opioids had upregulated gene expression, while the κ-opioids were downregulated. In Aim 2, to further characterize this primate model of chronic itch, we compared immunohistochemical results from the primate studies to human findings. Lesional and non-lesional skin biopsies from patients with atopic dermatitis, psoriasis, and cutaneous T-cell lymphoma underwent immunohistochemical analysis in order to reveal the similarities and differences between the primate model and different types of chronic itch in humans. As in the primate model, substance P was found to be increased in the skin of lesional atopic and psoriasis skin. Additionally, similar to primate skin, human atopic and psoriatic skin had high levels of tryptase and its receptor in the epidermis. While IL-31 was only slightly elevated in primates, patients with cutaneous T-cell lymphoma or atopic dermatitis showed a significant correlation between itch severity and IL-31 levels. In conclusion, our primate model displayed expression patterns of many endogenous pruritogens and receptors that were similar to those of humans with atopic dermatitis or psoriasis. While the primate model did not completely mimic these specific pruritic diseases, the overlap of pruritic components suggests a commonality of signaling pathways across several different chronic itch states. The similarity of this primate model to human disease offers the combined advantages of experimental modeling and long-term behavioral follow-up. / Biomedical Sciences

Introduction: Atopic dermatitis (AD) is characterized by chronic pruritic relapsing eczematous lesions of the skin. Eosinophilic inflammation in AD is driven by activation of type 2 inflammatory cells including CD4+ T cells and type 2 innate lymphoid cells (ILC2s). We have shown that type 2 cytokines, namely interleukin (IL)-5 and IL-13, stimulate migration and terminal differentiation of eosinophil progenitor cells (EoPs). We propose that these cytokines are important drivers of tissue eosinophilia in AD lesional skin. This study aimed to quantify, by flow cytometry, cells that produce type 2 cytokines in lesional skin compared to peripheral blood from moderate-severe AD patients. Methods: In a cross-sectional study of patients with moderate-to-severe AD (n=16), type 2 inflammatory cells were enumerated in blood and cells extracted from excised skin biopsies. By flow cytometry, live, singlet CD45+cells were identified as ILC2 (lin-CD127+CD294+), EoP (CD34+125+), and CD4+ T cells (Lin+CD3+CD4+). Intracellular expression of type 2 cytokines (IL-5 and IL-13) were evaluated in each cell population. In addition, we developed a protocol to enumerate ILC2s by fluorescence immune-histochemistry in lesional versus non-lesional skin samples and skin biopsies taken 24h post-intradermal challenge with allergen versus diluent. Data are expressed as median (interquartile range [IQR]) unless otherwise stated. Cross compartmental comparisons were made using the Wilcoxon rank-sum test and where applicable, correlational analyses were performed using a Spearman’s rank-correlational test. Results: There was a significantly higher number of total ILC2s in lesional skin compared to blood from AD subjects (556 [99 – 5501] vs 235 [67 – 569] cells/mL, p=0.03). Similarly, IL-5+, IL-13+ ILC2s, were significantly greater in skin compared to blood (6 [1 – 666] vs 1 [1 – 19] cells/mL, p=0.03; 28 [1 – 1357] vs 1 [1 – 7] cells/mL, p=0.01, respectively). We found higher numbers of total and type 2 cytokine positive EoP in lesional skin biopsies from AD patients compared to blood (Total EoP: 815 [285 – 2794] vs 112 [46 – 247] cells/mL, p<0.01; IL-5+EoP: 36 [1 – 129] vs 1 [1 – 23] cells/mL, p=0.07; IL-13+EoP: 92 [10 – 182] vs 1 [1 – 8] cells/mL, p<0.01 and IL-5+IL-13+ILC2: 70 [1 – 158] vs 1 [1 – 12] cells/mL, p=0.02, respectively). In contrast, significantly higher numbers of total and type 2 cytokine positive CD4+ cells were found in blood compared to lesional skin biopsies from AD patients (Total CD4+: 1092 [650 – 1742] vs 58.3 [35.3– 152.4] x 103 cells/mL, p<0.01 and IL-5+IL-13+CD4+ cells: 13.5 x 103 [2.1 x 103 – 42.9 x 103] vs 3.8 x 103 [1.6 x 103 – 4.9 x 103] cells/mL, p=0.02, respectively). For IF staining, there was a significant higher number of ILC2s in lesional compared to non-lesional skin biopsies and biopsies taken 24h post allergen- compared to diluent challenge (1 [0 – 2] vs 0 [0 - 0] cells/mm2, p=0.008, and 2 [1 – 2] vs 0 [0 – 0] cells/mm2, p=0.0002, respectively). Interestingly, in sex analyses we found significantly greater levels of blood ILC2 in females compared to males, but this not was found in the skin. Importantly, we found a significant correlation between lesional skin levels of ILC2 measured by flow cytometry and clinical measures of disease severity/symptoms as reported/calculated from the Patient-Oriented Eczema Measure questionnaire (POEM) score (total ILC2: r=0.55, p=0.04; IL-13+ ILC2s, r=0.61, p=0.02 and IL-5+ IL-13+ ILC2s: r=0.75, p=0.002). Conclusions: Preferential increases in skin-resident ILC2 that produce a type 2 rich environment were found in AD subjects. These levels correlated with patient-oriented measure of disease severity. We propose that this increase may encourage recruitment of mature eosinophils and EoP and possibly drive localized differentiation of EoP into mature eosinophils that may drive the pathology of AD lesions. Furthermore, immunofluorescence staining may be a suitable alternative to flow cytometry for identification of ILC2 in the event of a low cell count. These techniques can be used in future studies that target ILC2 biology to fully understand the role of these cells in driving AD. / Thesis / Master of Science (MSc)

Atopic dermatitis (AD) is a common skin disease that is characterized by chronic, relapsing skin inflammation and eczematous, itchy lesions. In AD, systemic and local eosinophilia and basophilia is thought to contribute to disease progression in both acute and chronic lesions. It has been previously shown that in chronic allergic inflammatory diseases, tissue eosinophilia and basophilia may in part result from eosinophil/basophil (Eo/B) progenitors trafficking from the bone marrow and maturing in tissue in response to type 2 cytokines including IL-5 and IL-3. We therefore proposed that a similar mechanism could be contributing to the pathogenesis of AD. First, we compared lesional and non-lesional AD tissue, and found approximately 10-fold higher levels of Eo/B progenitors in the lesional tissue (p<0.05). As previous research has shown an increase in Eo/B progenitors in the airways of allergic asthmatics post inhaled allergen challenge, we next examined whether Eo/B progenitors increased locally in the acute phase of AD using the intradermal allergen challenge model. Compared to intradermal diluent challenge there was an increase in Eo/B progenitors (5.5-fold), eosinophils (18-fold) and basophils (2.5-fold) 24 hours post intradermal allergen challenge (all p<0.05). These increases were consistent with findings in allergic airways. Lastly, we examined the relationship between disease severity and Eo/B progenitors in inflamed lesional (chronic) and allergen-challenged (acute) tissue. We found that Eo/B progenitors in lesional tissue positively correlated with disease severity (EASI R=0.71, p<0.05 and SCORAD R=0.65, p<0.05), while in allergen-challenged tissue a trend was seen for a positive correlation between Eo/B progenitors and disease severity (EASI R=0.48, p=0.07 and SCORAD R=0.46, p=0.09). These results highlight the potential involvement of Eo/B progenitors in the disease pathogenesis of AD. / Thesis / Master of Science (MSc) / Atopic dermatitis is a common skin disease that is characterized by chronic, relapsing skin inflammation and eczematous, itchy lesions. In other allergic diseases, a cell called the “eosinophil/basophil progenitor” contributes to the accumulation of inflammatory cells in the diseased organ. We proposed that eosinophil/basophil progenitors found in the skin may be contributing to the development of local allergic inflammation. In patients with moderate-to-severe atopic dermatitis we compared acute responses to intradermal allergen and chronic skin lesions to diluent-challenged and un-affected skin, respectively. Allergen-challenged skin had more eosinophil/basophil progenitors, mature eosinophils and basophils 24 hours’ post-challenge compared to unchallenged skin (p<0.05). Chronic skin lesions had more eosinophil/basophil progenitors than un-affected skin (p<0.05). The number of eosinophil/basophil progenitors positively correlated to disease severity as determined by EASI and SCORAD. Our results suggest that accumulation of eosinophil/basophil progenitors in skin of atopic dermatitis patients could support allergic inflammation and contribute to disease severity.

No / This review focuses on treatment targets for the most common inflammatory skin diseases, eczema and psoriasis with an emphasis on cytokines expressed in the uppermost layer of the skin which is easily accessible for diagnostic and therapeutic approaches. Recently, a significant body of research has highlighted the influence of the skin barrier and the patients’ microbiome on skin inflammatory responses and we will comment on their impact on mediator regulation. Itch is a prominent dermatology symptom which is influenced by cytokines and can via itch–scratch cycle impact on the skin barrier and mediator expression associated with damage. Taking the contribution of pruritus and superficial skin damage into account, we address cytokines as targets for stratified treatment approaches in subgroups of eczema and psoriasis.

No / Interleukin-33 has recently gained much attention due to its role in allergic responses. It has been shown to amplify Th2 responses and to act as a damage-associated molecular pattern. IL-33 acts on a broad range of cells and has been proposed to link innate and adaptive features of allergic responses. It was the aim of this study to investigate this property of IL-33 in the inflammatory response characterising atopic dermatitis (AD). We have analysed the response of skin-resident cells derived from patients with AD and healthy donors with regard to the expression of IL-33 and its receptor ST2. The functional impact of IL-33 on CD4+ T cells was investigated. Keratinocytes and dermal fibroblasts clearly differ in their regulation of IL-33. In fibroblasts, the concerted action of TNF-α and IL-1β was the strongest inducer, whereas IFN-γ is clearly the key molecule that upregulates IL-33 in keratinocytes with a more pronounced response of cells derived from patients with AD. Keratinocytes from patients with AD showed a markedly higher constitutive expression level of surface ST2. CD4+ T cells respond to IL-33. Unexpectedly, IL-33 failed to induce a significant secretion of IL-5 or IL-13. By contrast, high amounts of IFN-γ were detectable if IL-33 was added to the T-cell receptor-stimulated cells or in combination with IL-12. These results suggest that IL-33 and IFN-γ are closely interlinked in epidermal AD inflammation. IFN-γ induces IL-33 in keratinocytes and IL-33 acts on activated T cells to further increase the release of IFN-γ, therefore contributing to drive skin inflammation towards chronic responses.