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

Polyunsaturated fatty acids (PUFA) have been used with some success in the treatment of canine atopic dermatitis (CAD). Correspondent in vitro studies revealed that PUFA play a crucial role in the exocytosis of mast cells. n3 PUFA such as α-linolenic acid (LNA), eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), as well as the n6 PUFA linoleic acid (LA) have been shown to arrest the secretion of inflammatory mediators. Contrary, the n-6 PUFA arachidonic acid (AA) has been proven to promote the production of mast cell inflammatory mediators. However, we are still lacking a complete picture of the mode of action. The goal of this work was to further characterize the modulatory effects of PUFA supplementation on the plasma membrane lipid composition of mast cells. Furthermore the consequences of a membrane modulation of mast cells by PUFA on the localization and activity on of the membrane bound enzyme phospholipases D (PLD) were investigated. Canine mastocytoma cells (C2) were supplemented with one of the following PUFA: LNA, EPA, DHA, LA or AA. To investigate the influence of PUFA on the lipid composition of membrane microdomains, lipid rafts were separated from non-raft plasma membranes of mast cells for the first time using a detergent-free isolation technique. Results show that PUFA are significantly increased in rafts as well as in non-rafts microdomains (Publication 1). The incorporation of PUFA into the membrane goes along with an increase of the unsaturation status and the fluidity of the membrane. This rise in membrane fluidity may result in a reorganization of membrane signaling molecules and enzymes such as the PLD. To define the impact of a PUFA supplementation on PLD trafficking, C2 were transfected with green fluorescent protein (GFP) fusion plasmids encoding PLD1 or PLD2. Since the transfection ability of the suspension cell line C2 is limited, a special transfection protocol was established, suitable for non-adherent cell lines. Transfection succeeded using chicken egg white as coating material for the cell culture plates. The transfection efficiency rose to 50% versus 5% in uncoated plates. In addition to the obvious increase in the transfection efficiency, the new technique is simple and economic and might be suitable for a wide range of suspension cell lines (Publication 2). Using this optimized protocol the influence of PUFA on the trafficking of PLD isoforms was studied. LNA, EPA, DHA and LA but not AA prevented the stimulation-induced translocation of PLD1 to the plasma membrane. Since the translocation of PLD1 is important for mast cell exocytosis, LNA, EPA, DHA and LA do have an inhibiting effect on the stimulation-induced release of pro-inflammatory mediators. All PUFA tested boosted the total PLD activity. In order to rule out, which PLD isoform was affected by the PUFA, the mast cells were supplemented with DHA or AA in the presence of specific PLD isoform inhibitors. DHA completely abolished the inhibitiory effect of the PLD1 inhibitor but had no effect on the inhibitory effect of PLD2 inhibitor. On the other hand, AA suppressed the inhibitory effect of both PLD1 and PLD2 inhibitor (Publication 3). Taking together, the studies provide a mechanistic base for the role of PUFA in the exocytosis processes of mast cells. PUFA of the n3 and the n6 families impact the lipid composition of membrane microdomains, which in turn lead to a modulation of the physiochemical properties of the membrane. LNA, EPA, DHA and LA suppress the release of inflammatory mediators through their inhibitory action on the stimulation-induced translocation of the PLD1. Contrariwise, AA permits the stimulation-induced migration of PLD1 to the plasma membrane and increases the activity of both PLD isoforms. Therefore, LNA, EPA, DHA and LA but not AA inhibit the release of mast cell inflammatory mediators upon stimulation. / Mehrfach ungesättigte Fettsäuren (PUFA) können mit einigem Erfolg zur Behandlung der caninen atopischen Dermatitis (CAD) eingesetzt werden. In vitro-Studien zeigten, dass PUFA eine entscheidende Rolle in der Exozytose von Mastzellen spielen. N-3-PUFA wie α-Linolensäure (LNA), Eicosapentaensäure (EPA), Docosahexaensäure (DHA) sowie die n-6-PUFA Linolsäure (LA) können die Sekretion von Entzündungsmediatoren vermindern. Arachidonsäure (AA) als n-6 mehrfach ungesättigte Fettsäure hingegen fördert die Entzündungsmediatoren-Freisetzung aus den Mastzellen. Eine vollständige Aufklärung der Wirkungsweise fehlt aber weiterhin. Das Ziel dieser Arbeit war eine weitergehende Charakterisierung der modulierenden Effekte einer PUFA-Supplementierung auf die Lipidzusammensetzung der Plasmamembran von Mastzellen. Darüber hinaus wurden die Auswirkungen von PUFA auf die Lokalisation und Aktivität des Membran-gebundenen Enzyms Phospholipase D (PLD) untersucht. Canine Mastozytom-Zellen (C2) wurden mit einer der folgenden PUFA kultiviert: LNA, EPA, DHA, LA oder AA. Um den Einfluss von PUFA auf die Lipidzusammensetzung der Membran-Mikrodomänen zu untersuchen, konnten sowohl Lipid Raft als auch Nicht-Raft Plasmamembran-Anteile von Mastzellen zum ersten Mal mittels einer Detergenzien-freien Isolationsmethode getrennt werden. Hervorzuheben ist, dass PUFA signifikant vermehrt in Raft- sowie in Nicht-Raft Membranmikrodomänen eingelagert werden (Publikation 1). Die Integration von PUFA in die Membran geht mit einer Steigerung der Doppelbindungsanzahl und der Fluidität der Membran einher. Diese Erhöhung der Membranfluidität kann zu einer Reorganisation von membranären Signalmolekülen und Enzymen wie der PLD führen. Um die Auswirkungen einer PUFA-Supplementierung auf den intrazellulären Transport der PLD in C2 zu bestimmen, wurden die Zellen mit PLD1- oder PLD2-codierenden grün fluoreszierenden Protein-(GFP-)Fusionsplasmiden transfiziert. Da die Transfektionsfähigkeit der Suspensions-Zelllinie C2 begrenzt ist, wurde ein für nicht-adhärente Zelllinien geeignetes Transfektionsprotokoll etabliert. Mit Hühnereiweiß als Beschichtungsmaterial für die Zellkultur-Platten stieg die Transfektionseffizienz auf 50% im Vergleich zu 5% bei unbeschichteten Platten. Neben der deutlichen Erhöhung der Transfektionseffizienz ist die neu etablierte Technik einfach durchzuführen sowie wirtschaftlich und kann für eine Vielzahl von Suspension-Zelllinien geeignet sein (Publikation 2). Unter Verwendung dieses optimierten Protokolls wurde der Einfluss von PUFA auf die Translokation der PLD-Isoformen untersucht. LNA, EPA, DHA und LA, nicht aber AA verhindern die stimulationsinduzierte Translokation der PLD1 an die Plasmamembran. Die Translokation der PLD1 ist wichtig für die Mastzell-Exozytose. LNA, EPA, DHA und LA haben hier eine hemmende Wirkung auf die stimulationsinduzierte Freisetzung von proinflammatorischen Mediatoren. Alle getesteten PUFA verstärken die Gesamt-PLD-Aktivität. Um zu unterscheiden, welche PLD-Isoform durch PUFA beeinflusst ist, wurden die Mastzellen mit DHA oder AA in Gegenwart von PLD-Isoform-Inhibitoren supplementiert. DHA hebt die inhibitorische Wirkung des PLD1-Inhibitors vollständig auf, zeigte aber keinen Einfluss auf die hemmende Wirkung des PLD2-Inhibitors. Andererseits unterdrückt AA die hemmende Wirkung des PLD1- als auch des PLD2-Inhibitors (Publikation 3). Zusammenfassend bietet die Studie eine mechanistische Basis für die Rolle von PUFA bei Exozytose-Prozessen von Mastzellen. PUFA der n-3- und n-6-Familie beeinflussen die Lipidzusammensetzung von membranären Mikrodomänen, was wiederum zu einer Modulation der physikalisch-chemischen Eigenschaften der Membran führt. LNA, EPA, DHA und LA verhindern die Freisetzung von Entzündungsmediatoren durch ihre hemmende Wirkung auf die stimulationsinduzierte Translokation der PLD1. Umgekehrt erlaubt AA eine stimulationsinduzierte Migration der PLD1 zur Plasmamembran und steigert die Aktivität der beiden Isoformen der PLD. Somit hemmen LNA, EPA, DHA und LA, aber nicht AA die Freisetzung von Mastzell-Entzündungsmediatoren nach Stimulation.

Die Haut ist das größte Organ des Menschen und bildet die Barriere gegenüber Einwirkungen aus der Umwelt. Die Störung der Hautbarriere durch exogene und endogene Reize führt zu einer Entzündungsreaktion in der Haut. In der Folge können Hauterkrankungen wie die irritative oder Atopische Dermatitis entstehen. Der Tumor Nekrose Faktor-α (TNF-α) ist ein pleiotrop wirksames Zytokin, das eine zentrale Rolle bei entzündlichen Prozessen spielt. Ziel der vorgelegten Promotionsarbeit war zu untersuchen, ob und wie TNF-α zu Entzündungsgeschehen, ausgelöst durch exogene und endogene Faktoren, beiträgt. Die Bedeutung von TNF-α wurde in TNF-ko Mäusen in verschiedenen Hautmodellen untersucht. Für das Irritationsmodell wurden chemische und physikalische Reize verwendet. TSLP (Thymic stromal lymphopoietin) wurde durch die verschiedenen Stimuli signifikant induziert. Diese Induktion war unabhängig von der endogenen TNF-α Produktion, gezeigt durch den Einsatz von TNF- ko Mäusen . Da endogenes TNF-α für die Hautirritation keine notwendige Bedingung darstellte, wurde die Bedeutung von TNF-α bei der atopischen Dermatitis (AD) untersucht. TNF-α defiziente Mäuse zeigen verstärkt Ekzeme im Vergleich zu Wildtyp Mäusen. Die Behandlung von TNF-ko Mäusen mit einem TSLP Antikörper führte zu einer Verminderung des Ekzems. Mastzellen wurden vermehrt in läsionaler Haut gefunden und korrelierten mit dem Schweregrad des atopischen Ekzems sowie der TSLP-Expression. / The skin is the largest organ of an individuum and builds the barrier for a host against the environment. Skin barrier disruption by exogenous or endogenous stimuli can lead to skin inflammation. As a consequence, irritant or atopic eczema, frequent skin diseases, may evolve. Tumor necrosis factor-α (TNF-α) is a pleiotropic cytokine which plays a central role in inflammatory processes. The main aim of this thesis was to clarify whether and how endogenous TNF-α is contributing to skin inflammation driven by exogenous and endogenous triggers. The role of endogenous TNF-α was studied using TNF knockout (-/-) mice. In an irritation model, chemical and physical stimuli were applied on to mouse skin. Thymic stromal lymphopoietin (TSLP) was significantly induced by the used irritants. This TSLP induction was independent from endogenous TNF-α proven by using TNF-/- mice. Next the role of TNF-α in atopic dermatitis (AD) promoting an allergic skin inflammation was investigated. TNF-/- mice developed more severe AD compared to the wildtype mice and TSLP was significantly increased and correlated with the severity of the eczema. To prove the pathophysiological role of TSLP for AD progression, TNF-/- mice were pretreated with an TSLP antibody. Indeed, these mice developed less AD symptoms compared to the control mice. Mast cells (MCs) were also significantly increased in lesional skin in the AD model and moreover, correlated with AD severity, but also with TSLP expression.

Ziel der hier vorgelegten Untersuchung war es, die Bedeutung von S. aureus-Exotoxinen/Superantigenen als Pathogenitätsfaktor bei der AD zu analysieren, da kausalpathogenetisch ausgerichtete Experimentalansätze sowie systematische klinische Untersuchungen zu dieser Thematik bei Patienten mit AD ausstanden. In einer Querschnittsstudie war eine Assoziation zwischen dem Grad der S. aureus-Besiedlung und dem Schweregrad der AD nachzuweisen. Von 74 Kindern mit AD waren 60 (81%) mit S. aureus kolonisiert. S. aureus Exotoxin-sezernie-rende Stämme wurden bei 40 Patienten (53%) von der Haut isoliert. Am häufigsten wurden SEA- und SEC-sezernierende Stämme nachgewiesen, gefolgt von SEB, TSST-1 und SED. Der ausgeprägteste Schweregrad der AD wurde in der mit Exotoxin-sezernierenden S. aureus-kolonisierten Gruppe beobachtet. Für die Schwere der Erkrankung, gemessen am SCORAD-Score wurde eine Varianzaufklärung von 30% für die Exotoxine und 50% für die S. aureus-Infektion errechnet. In einer Subgruppe von Patienten wurde der Einfluß von S. aureus-Exotoxinen auf intradermale T-Zell-Rezeptor-Vß-Repertoir-Veränderungen untersucht. Bei den Patienten mit chronischer AD, die mit SEB-sezernierendem S. aureus besiedelt waren, war mittels immunhistologischer Untersuchung in der Haut nachzuweisen, dass zwischen 25% und 65% der intradermalen T-Zellen das zugehörige Superantigen-reaktive Vß-T-Zell-Repertoire gegenüber 5% bis 17% der T-Zellen im Blut exprimieren. Weder in der Haut noch im Blut war eine Akkumulation nicht-superantigenreaktiver T-Zell-Subpopulationen nachzuweisen. Auch fand sich keine selektive Akkumulation von Vß-T-Zell-Subpopulationen bei Kindern mit S. aureus-Kolonisierung ohne Exotoxinnachweis. Die Ergebnisse belegen, dass bei Kindern mit AD und positivem S. aureus-Exotoxinnachweis auf ekzematöser Haut ein Grossteil der dermal akkumulierten T-Zellen auf diese S. aureus-Exotoxine/Superantigene reagieren können und wesentlich an der Pathogenese der AD beteiligt sind. In einer Teilpopulation bei 58 Kindern mit AD wurden Prävalenz und Rolle von Serum-IgE-Antikörpern gegen die S. aureus-Exotoxine SEA und SEB untersucht. Bei 34% der Kinder mit AD (20/58) konnten wir spezifische IgE-Antikörper gegen SEA und/oder SEB nachweisen (45% zu SEB, 10% zu SEA und 45% zu SEA und SEB). Alle gegen SEA und SEB sensibilisierten Kindern waren mit S. aureus kolonisiert gegenüber 71% (27/38) der nicht-sensibilisierten Kinder. Der Grad der S. aureus-Besiedlung, die Prävalenz von SEB-sezernierendem S. aureus auf der Haut, sowie die Prävalenz von S. aureus-Hautinfektionen war in der sensibilisierten Gruppe höher. Die höchste Varianzaufklärung von 37% wurde zwischen dem Vorliegen von S. aureus-Hautinfektionen und dem Nachweis spezifischer SEA/SEB-IgE-Antikörper ermittelt; diese stellen somit einen Risikofaktor für eine Sensibilisierung gegen S. aureus-Exotoxine dar. Die SEA/SEB-sensibilisierte Gruppe zeigte einen höheren Schweregrad der AD, höhere Serum-Gesamt-Spiegel und eine polyvalente Sensibilisierung gegen Inhalations- und Nahrungsmittelallergene. Insgesamt belegen unsere klinischen, immunologischen und statistischen Ergebnisse, dass die S. aureus-Exotoxine einen wesentlichen Einfluss auf die Immunpathogenese der AD haben. Eine orale Therapie mit CyA kann bei S. aureus-kolonisierten Kindern die S. aureus-Besiedlungsdichte reduzieren. In der S. aureus-infizierten Gruppe war die Prävalenz von Exotoxin-produzierendem S. aureus und die Krankheitsaktivität höher, wobei eine Verminderung der Besiedlung nicht beobachtet wurde. Die Ergebnisse dieser Arbeit erlauben den Schluss, dass S. aureus-Exotoxine als Triggerfaktor die Exazerbation der AD im Kindesalter wesentlich unterstützen. Deswegen sollte in ein therapeutisches Konzept eine konsequente Prävention bzw. eine Behandlung von S. aureus-Infektionen einbezogen werden. Kinder mit bereits schwerer AD profitieren von einer immunmodulatorischen Therapie. / Background: The skin of patients suffering from atopic dermatitis (AD) exhibits a striking susceptibility to colonization with S. aureus. Some strains of S. aureus secrete exotoxins with T cell superantigen activity (toxigenic strains) and abnormal T cell functions are known to play a critical role in AD. Objective: The aim of this study was to determine the impact of exotoxin production by skin-colonizing S. aureus on disease severity and the presence of T-cell subsets in lesional skin. Furthermore, we investigated the effect of oral cyclosporin A in severe pediatric atopic dermatitis on disease severity and S. aureus colonization density. Methods: In a cross sectional study of 74 children with atopic dermatitis, the presence and density of toxigenic and non-toxigenic strains of S. aureus was correlated with disease severity. In a subgroup of patients the T cell receptor (TCR) Vß repertoire of peripheral blood and lesional T cells was investigated and correlated with individual superantigen activity of skin colonizing S. aureus. Furthermore, in a subgroup of patients, the presence of IgE antibodies to SEA and SEB was correlated with severity of the disease and the total and other unrelated allergen-specific IgE titers and density of colonization with S. aureus strains on atopic skin and episodes of superficial S. aureus skin infections. Eleven children with severe AD (SCORAD score > 50) were treated for eight weeks with 2.5 to 5 mg/kg CyA. In five children the skin was only colonized with S. aureus whereas the remaining six patients had clinically relevant skin infections with requirement for systemic antibiotic therapy. The isolates from the latter patients were sensitive for the selected antibiotics. Clinical and microbiological investigations were performed before and after CyA therapy. Results: 53% of children with AD were colonized with toxigenic strains of S. aureus producing SEC, SEA, TSST-1, SEB and SED in decreasing frequency. Children colonized with toxigenic S. aureus strains presented with higher disease severity as compared to the non-toxigenic and S. aureus negative groups. The influence of exotoxin production on the SCORAD score was determined as R2 = 0.3 (ie, 30% of the SCORAD score is explained by exotoxin production), whereas infection with S. aureus revealed R2 = 0.5. Patients colonized with toxigenic S. aureus exhibited shifts in the intradermal TCR Vß repertoire which correspond to the respective superantigen-responsive T cell subsets. In a subgroup of patients, twenty of 58 children (34%) were sensitized to superantigens (45% to SEB, 10% to SEA, 45% to SEA and SEB). In this group, severity of AD and levels of specific IgE to food and air allergens were higher. The degree of disease severity correlated to a higher extent with the presence of SEA/SEB-specific antibodies than with total serum IgE levels. Density of colonization with superantigen-secreting S. aureus strains was higher in the superantigen IgE-positive group. Sixty-three of these children experienced repeated episodes of superficial S aureus skin infections. The influence of S. aureus skin infection on the presence of SEA/SEB-specific antibodies was determined as R2 = 0.37 (ie, 37% of the the presence of SEA/SEB-specific antibodies is explained by S. aureus superficial skin infection). In the group of patients, who were treated with CyA, clinical signs and symptoms of AD improved in all patients (mean SCORAD score reduction from 74 to 29). However, disease severity was more supressed by CyA in the "colonized" patients compared with the patients with clinical S. aureus infections. Furthermore, there was a significant decrease in S. aureus density on atopic skin after CyA treatment in "colonized" patients but not in "infected" patients. The prevalence of exotoxin producing strains was higher in the "infected" group. Conclusion: The data demonstrate that S. aureus released exotoxins can modulate disease severity and dermal T cell infiltration. Patients, suffering from AD may take profit from both consequent prevention or treatment of S. aureus skin infection as well as immunmodulating approaches.

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.

Ching, Ka Wai. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2009. / Includes bibliographical references (leaves [69-80]). / Abstract also in Chinese. / Abstract (in English) --- p.ii / Abstract (in Chinese) --- p.v / Acknowledgement --- p.viii / Table of Contents --- p.ix / List of Tables --- p.xii / List of Figures --- p.xiii / Glossary of Terms and Abbreviations --- p.xv / Chapter Chapter 1: --- Introduction --- p.1 / Chapter 1.1 --- Introduction of Atopic Eczema (AE) --- p.1 / Chapter 1.1.1 --- Definition and classification of AE --- p.1 / Chapter 1.1.2 --- Epidemiology --- p.3 / Chapter 1.1.2.1 --- The hygiene hypothesis --- p.5 / Chapter 1.2 --- Pathogenesis and Etiology --- p.6 / Chapter 1.2.1 --- Biphasic type-1/type-2 T-helper lymphocyte (Thl/Th2) immunological responses --- p.6 / Chapter 1.2.2 --- Nature and involvements of immunoglobin E (IgE) --- p.8 / Chapter 1.2.3 --- Microbial colonization --- p.9 / Chapter 1.2.4 --- Cytokines involvement --- p.10 / Chapter 1.2.5 --- Pruritus inducing neurotrophic factors --- p.11 / Chapter 1.2.6 --- "Food allergens, aeroallergens" --- p.12 / Chapter 1.2.7 --- Dysregulation of innate immune system --- p.13 / Chapter 1.2.7.1 --- Dysregulation of antimicrobial peptides --- p.14 / Chapter 1.2.7.2 --- Skin barrier impairment --- p.14 / Chapter 1.2.8 --- Genetic predisposition --- p.15 / Chapter 1.3 --- Assessments of Atopic Eczema (AE) --- p.17 / Chapter 1.3.1 --- AE severity assessment --- p.17 / Chapter 1.3.1.1 --- Scoring of atopic dermatitis (SCORAD) system --- p.17 / Chapter 1.3.1.2 --- Nottingham eczema severity score (NESS) --- p.20 / Chapter 1.3.2 --- Dermatological parameter - skin hydration (SH) and transepidermal water loss (TEWL) --- p.22 / Chapter 1.4 --- Chitinase (CHIA) --- p.22 / Chapter 1.4.1 --- Chitin and CHIA --- p.22 / Chapter 1.4.2 --- Association of acid mammalian chitinase (AMCase) with asthma --- p.23 / Chapter 1.4.3 --- Hygiene hypothesis implies: AMCase and allergy relationship --- p.24 / Chapter Chapter 2: --- Hypothesis and Objectives --- p.25 / Chapter 2.1 --- Hypothesis - based on CHIA involvements in canine AE --- p.25 / Chapter 2.2 --- Hypothesis --- p.25 / Chapter 2.3 --- Objective 226}0ؤ based on AMCase single nucleotide polymorphism (SNPs) in asthma susceptibility --- p.25 / Chapter 2.4 --- Objectives --- p.27 / Chapter Chapter 3: --- Methodology --- p.28 / Chapter 3.1 --- Recruitment of cases and controls --- p.28 / Chapter 3.2 --- Assessment of clinical parameters --- p.29 / Chapter 3.2.1 --- Scoring of atopic dermatitis (SCORAD) system --- p.29 / Chapter 3.2.2 --- Nottingham eczema severity score (NESS) --- p.29 / Chapter 3.2.3 --- Dermatologic parameters --- p.29 / Chapter 3.2.3.1 --- Cutaneous bacterial colonization --- p.29 / Chapter 3.2.3.2 --- Skin hydration (SH) and transepidermal water loss (TEWL) --- p.30 / Chapter 3.3 --- Peripheral blood collection and genomic deoxyribonucleic acid (DNA) extraction --- p.30 / Chapter 3.4 --- Acid mammalian chitinase (AMCase) polymorphism genotyping --- p.31 / Chapter 3.4.1 --- Polymerase chain reactions (PCR) amplification of AMCase gene --- p.31 / Chapter 3.4.1.1 --- List of PCR reagents --- p.32 / Chapter 3.4.1.2 --- Electrophoresis reagents --- p.33 / Chapter 3.4.2 --- Restriction fragment length polymorphism (RFLP) analysis of AMCase and confirmation with direct sequencing --- p.33 / Chapter 3.5 --- Statistical analysis --- p.34 / Chapter Chapter 4: --- Results and Data Analysis --- p.36 / Chapter 4.1 --- Results --- p.36 / Chapter 4.1.1 --- Demographic data of cases and controls --- p.36 / Chapter 4.1.2 --- PCR amplification and RFLP analysis of AMCase gene --- p.37 / Chapter 4.1.3 --- PCR cycle sequencing of the PCR fragments --- p.40 / Chapter 4.2 --- Data analysis --- p.41 / Chapter 4.2.1 --- Data overview --- p.41 / Chapter 4.2.2 --- Genotypes distribution of AMCase polymorphisms --- p.43 / Chapter 4.2.2.1 --- Allele frequency comparison of AMCase single nucleotide polymorphism (SNPs) by chi-square --- p.43 / Chapter 4.2.2.2 --- Allele frequency comparison of AMCase SNPs by logistic regression analysis --- p.44 / Chapter 4.2.3 --- Haplotype frequency estimation via maximum likelihood algorithm --- p.45 / Chapter 4.2.4 --- Association of AMCase polymorphism with Atopic Eczema (AE) clinical parameters --- p.47 / Chapter 4.2.4.1 --- Peripheral blood eosinophil counts --- p.48 / Chapter 4.2.4.2 --- Serum immunoglobin E (IgE) level --- p.49 / Chapter 4.2.4.3 --- Dermatologic factors --- p.49 / Chapter 4.2.4.3.1 --- Cutaneous Staphylococcus aureus colonization --- p.49 / Chapter 4.2.4.3.2 --- Skin hydration (SH) and transepidermal water loss (TEWL) --- p.50 / Chapter Chapter 5: --- Discussion --- p.52 / Chapter 5.1 --- Data overview --- p.52 / Chapter 5.2 --- AMCase rs3806448 polymorphism was significantly different among AE cases and controls --- p.53 / Chapter 5.2.1 --- Allele frequency comparison of AMCase SNPs polymorphisms by chi-square --- p.53 / Chapter 5.2.2 --- Allele frequency comparison of AMCase SNPs polymorphisms by logistic regression analysis --- p.54 / Chapter 5.2.3 --- The possible genetic modification by rs3806448 homozygous recessive genotype --- p.55 / Chapter 5.3 --- "Significant difference of haplotype frequency, 2212 among case-control comparison" --- p.56 / Chapter 5.4 --- Strong associations between AMCase SNPs polymorphisms and clinical parameters of AE --- p.57 / Chapter 5.4.1 --- Peripheral blood eosinophil counts --- p.57 / Chapter 5.4.2 --- Dermatologic factors --- p.58 / Chapter 5.4.2.1 --- Cutaneous Staphylococcus aureus colonization --- p.58 / Chapter 5.4.2.2 --- Skin hydration (SH) and transepidermal water loss (TEWL) --- p.59 / Chapter 5.5 --- Limitation of the present study --- p.59 / Chapter Chapter 6: --- Conclusion and Future Prospect --- p.62 / Chapter 6.1 --- Conclusion --- p.62 / Chapter 6.2 --- Future prospect --- p.62 / Chapter Chapter 7: --- Appendices --- p.64 / Chapter Chapter 8: --- References --- p.69

Background: Evidence-based treatment algorithms, successfully established for asthma, are missing for atopic eczema (AE). Objectives: To investigate whether treatment according to an evidence-based algorithm is an effective and applicable concept for the management of AE. Methods: Based on a systematic literature review, we developed an evidence-based severity-score-oriented treatment algorithm for AE and compared its effectiveness to that of an individualised symptom-oriented treatment (individual therapy) in a randomised controlled trial. Sixty-three participants were randomised to algorithm (n = 32) or individual therapy (n = 31) and treated accordingly for 12 months. Study end points included difference between baseline SCORAD and mean SCORAD under treatment (primary end point), quality of life and treatment utilisation. Analysis was by intention to treat (registration: ClinicalTrials.gov:NCT00148746). Results: No statistically significant differences in clinical or subjective response were observed between groups. Treatment following the algorithm and individual treatment both effectively controlled AE. Mean SCORAD reductions were 47% (95% confidence interval, CI = 38–55; algorithm) and 42% (95% CI = 29–54; individual). Clinical response was paralleled by improved quality of life in both groups. Physicians adhered to the algorithm option in 93% of their treatment decisions. Conclusion: Treatment following an evidence-based algorithm is an effective and applicable concept for the management of AE but does not show clear advantages compared to individualised treatment in a dermatological setting. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Background: Financial constraints challenge evidence of the effectiveness of dermatological inpatient management. Objective: To evaluate the effectiveness of hospitalization in atopic dermatitis and psoriasis regarding initial and sustained benefits. Methods: Prospective study on adults with psoriasis vulgaris (n = 22) and atopic dermatitis (n = 14). At admission, discharge, and 3 months after discharge, validated outcomes of objective and subjective disease severity were assessed by trained investigators. Results: Hospitalization resulted in substantial benefit in quality of life and clinical disease severity. Looking at mean scores, the observed benefit appeared stable until 3-month follow-up. The analysis of individual patient data revealed significant changes in disease severity between discharge and 3-month follow-up with some patients relapsing, others further improving. Reasons for hospitalization and treatment performed were not related to sustained benefit. Conclusions: In psoriasis vulgaris and atopic dermatitis, hospitalization effectively improved quality of life and clinical disease severity. Further research should focus on prognostic factors for sustained improvement. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Background: Pimecrolimus cream (Elidel®, SDZ ASM 981), a non-steroid inhibitor of inflammatory cytokines, is effective in the treatment of atopic dermatitis (AD). We assessed whether early treatment of AD signs/symptoms reduces the need for topical corticosteroids. Objective: To investigate the efficacy and safety of pimecrolimus cream 1% in the long-term management of adult AD. Methods: 192 adults with moderate to severe AD were randomised (1:1) for twice daily (b.i.d.) treatment of early signs or symptoms of AD with either pimecrolimus cream 1% or vehicle cream (control group) to prevent progression to flares. Treatment was given as needed for 24 weeks. In the event of flares, a moderately potent corticosteroid (prednicarbate 0.25% cream) was permitted as rescue medication in both groups. The percentage of days on which a topical corticosteroid was used to treat disease flares was the main outcome measure. Results: Corticosteroid medication was used on 14.2% (95% confidence interval, CI: 8.3–21.1) of the days of the 24-week treatment period in the pimecrolimus group and on 37.2% (95% CI: 30.4–44.0) of the days in the control group (p < 0.001). In total, 44.8% (43/96) of patients in the pimecrolimus group did not experience a flare compared with 18.8% (18/96) of patients in the control group. The median time to first flare was 144 days in the pimecrolimus group and 26 days in the control group (p < 0.001). Pimecrolimus treatment was also associated with improvement in signs and symptoms of AD, pruritus, patients’ self-assessment and quality of life. Conclusions: Pimecrolimus cream 1% b.i.d. is an effective, well-tolerated, long-term treatment for AD in adults, substantially reducing the number of flares compared to a conventional therapy and consequently reducing or eliminating the need for corticosteroid treatment. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Les eczémas [eczéma allergique de contact (EAC) et l'eczéma atopique (EA)] sont des dermatoses inflammatoires fréquentes des pays industrialisés. Elles sont induites suite au recrutement et à l'activation dans la peau de lymphocytes T spécifiques d'allergènes, qui sont présents dans notre environnement, et qui sont habituellement très bien tolérés par la majoritédes individus exposés. Ce travail de thèse porte sur un aspect novateur de la physiopathologie des eczémas, à savoir : la contribution des lymphocytes T mémoires résidants (LTrm) dans la peau à la chronicité et à la sévérité de ces maladies.Capitalisant sur des modèles précliniques pertinents ainsi que sur des échantillons cliniques prélevés chez les patients, ce travail a permis d'acquérir de nouvelles connaissances : (i) de nombreux LTrm CD8+ spécifiques colonisent les lésions d'eczéma (ii) ils s'accumulent avecla persistance de l'allergène dans la peau, (iii) ils jouent un rôle majeur dans les récidives de la maladie, mais (iv) ils expriment à leur surface divers récepteurs inhibiteurs, tels que PD-1 ou TIM-3, qui empêchent la survenue de réponses allergiques excessives.Ces travaux apportent donc des informations majeures sur la nature unique des LTrm CD8+ spécifiques d'allergènes et des mécanismes qui contrôlent leur réactivation, afin de préserver l'intégrité de la peau et la survenue de réactions chroniques sévères. Le développement des nouvelles stratégies thérapeutiques ciblant la réactivation des LTrm via leurs récepteursinhibiteurs pourrait permettre de restaurer la tolérance chez les individus allergiques / Allergic contact dermatitis (ACD) and atopic dermatitis (AD), also referred to contact or atopic eczema, are frequent skin inflammatory diseases with increasing prevalence and high socioeconomic impact in Western countries. Eczemas are the prototype of skin delayed-type hypersensitivity reactions. Skin lesions are induced by the recruitment and activation in the skin of effector/memory T cells specific for environmental antigens that are innocuous to healthy non-allergic individuals.The aim of this work was to better understand the pathophysiology of eczemas by a comprehensive analysis of the contribution of skin resident memory T cells (Trm) to the chronicity and severity of these diseases.Capitalizing on relevant preclinical eczema models and on clinical samples collected from allergic patients, this work showed that: (i) numerous allergen-specific CD8+Trm colonize the eczema lesion, (ii) they accumulate in the epidermis in response to the long-term persistence of the allergen in the skin, (iii) they are instrumental for the recurrence of eczema, but (iv) theyexpress several inhibitory check point receptors (ICRs, such as PD-1, TIM-3) at their surface, which keep them in check to prevent the development of severe immunopathology.Thus, our work provides important information for considering the unique nature of hapteninduced CD8+ Trm and the mechanisms that prevent their unwanted reactivation and subsequent development of chronic or severe skin allergy. The development of therapeutic strategies targeting the reactivation of skin Trm in situ via their ICRs should open new avenues to restore tolerance in allergic individuals