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.

No / Background  Interleukin (IL)-33 is a member of the IL-1 family and has been implicated in Th2-driven allergic diseases such as atopic dermatitis (AD) and asthma. The principal Th2 cytokine IL-4, found highly expressed in acute allergic eczema, is known to downregulate human β-defensin 2 (hBD2) expression in human keratinocytes and this is associated with superinfection in patients with AD. Objectives  To investigate the effect of IL-33 on the expression of hBD2 in human keratinocytes. Methods  hBD2 production by stimulated keratinocytes was measured by enzyme-linked immunosorbent assay. Results  Our results showed that serum is a very potent inducer of hBD2 and 2·5% human serum was much more potent in inducing hBD2 than 20 ng mL−1 of tumour necrosis factor-α. Interestingly, serum from patients with AD showed an impaired ability to induce hBD2 in normal keratinocytes. IL-33 significantly downregulated serum-induced hBD2. The downregulatory capacity of IL-33 was found to be 1·5- to 2-fold weaker compared with IL-4. Conclusions  Our data suggest that IL-33 can significantly contribute to the decreased expression of hBD2 in acute eczematous reaction clinically characterized by spongiosis and oozing – thus indicative for contact of the epidermis with serum components.

京都大学 / 新制・論文博士 / 博士(社会健康医学) / 乙第13613号 / 論社医博第19号 / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 森田 智視, 教授 椛島 健治, 教授 村井 俊哉 / 学位規則第4条第2項該当 / Doctor of Public Health / Kyoto University / DFAM

Introdução: Dermatite atópica (DA) é uma doença cutânea crônica, predominante na infância, cujo sintoma principal é o prurido de intensidade variável, e os sinais são classicamente as lesões de padrão eczematoso. Há anormalidades na formação e função da barreira cutânea, que estão presentes não somente nas lesões cutâneas como na pele clinicamente não afetada. Objetivo: Analisar a correlação entre as medidas biofísicas da função de barreira cutânea e os critérios clínicos e intensidade da dermatite, de acordo com os critérios de Rajka e Langeland. Métodos: 231 doentes do Departamento de Dermatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, com diagnóstico clínico de dermatite atópica segundo os critérios diagnósticos de Rajka e Langeland foram avaliados por exame físico, anamese, medidas biofísicas de grau de hidratação de camada córnea pelo método de capacitância (corneometria) e pelo método de perda de água transepidérmica (TEWL); a medida sérica de IgE também foi solicitada no ato do exame. Resultados: Houve uma relação significativa entre as medidas de corneometria, TEWL e gravidade clínica da dermatite atópica. Os dados demonstraram uma correlação inversamente proporcional entre a corneometria e o TEWL, e houve uma diferença estatisticamente significativa (p<0,001) entre as médias de corneometria e TEWL e grau de DA (leve, moderada ou intensa). Com relação aos níveis séricos de IgE, as medidas de corneometria apresentaram uma correlação negativa significativa; para TEWL, a correlação positiva foi estatisticamente significativa (p<0,001). Conclusão: As medidas biofísicas de barreira cutânea na DA, mesmo em pele aparentemente não lesada, podem funcionar como fator de avaliação do grau clínico da DA e da intensidade do prurido. / Background: Atopic dermatitis (AD) is a chronic dermatosis, predominant in childhood, characterized by pruritus and eczematous type lesions with xerosis as the proeminent clinical sign. Objectives: To analyze the correlation between biophysical measurements of skin barrier function and other assessment criteria of clinical severity according to Rajka and Langelands criteria. Methods: Biophysical measurements (Transepidermal water loss and corneometry) were obtained from 231 patients from the department of dermatology, Hospital das Clinicas FMUSP with the diagnsosis of atopical dermatitis. Serum levels of IgE were also evaluated. Results: A significant correlation between corneometry, TEWL and clinical severity of atopic dermatitis were found. Data showed an inverse correlation between corneometry, TEWL, and AD severity, and a significant difference (p<0,001) between means of corneometry and TEWL and AD severity (mild, moderate and severe). As for IgE levels, corneometry had significant negative correlation, in contrast with TEWL, wich showed a significant positive correlation (p<0,001). Conclusion: Biophysical measurements of skin barrier in non lesional skin of atopic dermatitis may work as an evaluation factor for AD severity and pruritus.

Introdução: Dermatite atópica (DA) é uma doença cutânea crônica, predominante na infância, cujo sintoma principal é o prurido de intensidade variável, e os sinais são classicamente as lesões de padrão eczematoso. Há anormalidades na formação e função da barreira cutânea, que estão presentes não somente nas lesões cutâneas como na pele clinicamente não afetada. Objetivo: Analisar a correlação entre as medidas biofísicas da função de barreira cutânea e os critérios clínicos e intensidade da dermatite, de acordo com os critérios de Rajka e Langeland. Métodos: 231 doentes do Departamento de Dermatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, com diagnóstico clínico de dermatite atópica segundo os critérios diagnósticos de Rajka e Langeland foram avaliados por exame físico, anamese, medidas biofísicas de grau de hidratação de camada córnea pelo método de capacitância (corneometria) e pelo método de perda de água transepidérmica (TEWL); a medida sérica de IgE também foi solicitada no ato do exame. Resultados: Houve uma relação significativa entre as medidas de corneometria, TEWL e gravidade clínica da dermatite atópica. Os dados demonstraram uma correlação inversamente proporcional entre a corneometria e o TEWL, e houve uma diferença estatisticamente significativa (p<0,001) entre as médias de corneometria e TEWL e grau de DA (leve, moderada ou intensa). Com relação aos níveis séricos de IgE, as medidas de corneometria apresentaram uma correlação negativa significativa; para TEWL, a correlação positiva foi estatisticamente significativa (p<0,001). Conclusão: As medidas biofísicas de barreira cutânea na DA, mesmo em pele aparentemente não lesada, podem funcionar como fator de avaliação do grau clínico da DA e da intensidade do prurido. / Background: Atopic dermatitis (AD) is a chronic dermatosis, predominant in childhood, characterized by pruritus and eczematous type lesions with xerosis as the proeminent clinical sign. Objectives: To analyze the correlation between biophysical measurements of skin barrier function and other assessment criteria of clinical severity according to Rajka and Langelands criteria. Methods: Biophysical measurements (Transepidermal water loss and corneometry) were obtained from 231 patients from the department of dermatology, Hospital das Clinicas FMUSP with the diagnsosis of atopical dermatitis. Serum levels of IgE were also evaluated. Results: A significant correlation between corneometry, TEWL and clinical severity of atopic dermatitis were found. Data showed an inverse correlation between corneometry, TEWL, and AD severity, and a significant difference (p<0,001) between means of corneometry and TEWL and AD severity (mild, moderate and severe). As for IgE levels, corneometry had significant negative correlation, in contrast with TEWL, wich showed a significant positive correlation (p<0,001). Conclusion: Biophysical measurements of skin barrier in non lesional skin of atopic dermatitis may work as an evaluation factor for AD severity and pruritus.