Untreated Psoriatic Patients Research Articles

Non-Canonical WNT/Wnt5a Pathway Activity in Circulating Monocytes of Untreated Psoriatic Patients: An Exploratory Study of Its Association with Inflammatory Cytokines and Cardiovascular Risk Marker-ADAMTS7

The leading cause of death in psoriasis is cardiovascular disease. The determinants that induce the increase in this risk are not known. The systemic inflammatory process is dependent on lymphocytes and monocytes, as has been proposed. However, adaptation modules such as mTOR have recently been mentioned as having a role. Other factors, such as WNT and its non-canonical WNT5a-inducing pathway, are relevant in inflammation, cell migration, and neoangiogenesis. Thus, we studied circulating monocytes from untreated severe psoriatic patients and characterized inflammatory cytokines, chemokines, mTOR activity, and the cardiovascular risk marker ADAMTS7. Peripheral blood from ten severely psoriatic patients (Psoriasis severity index greater than 10) was extracted and age- and sex-matched with healthy subjects. Surface and intracellular flow cytometry were performed for cytokine, chemokine receptors, and mTOR activity. ADAMTS7 was measured using ELISA. Psoriatic patients had a higher frequency of WNT5a+ cells in monocytes, which also had higher levels of IL-1β, IL-6, CXCR3, CCR2, and phosphorylated S6R protein. We found that M1 monocytes are dominant in the WNT5a+ cell group, and intracellular levels of WNT5a were also augmented. Levels of WNT5a were correlated with ADAMTS7, a blood marker related to the pathogenesis of atheromatosis. WNT5a could be relevant to the cardiovascular risk of psoriatic patients considering its association with higher levels of inflammatory cytokines, chemokine receptors and the pro-atherogenic profile of circulating monocytes.

Increased dermal expression of chromatin-associated protein HMGB1 and concomitant T-cell expression of the DNA RAGE in patients with psoriasis vulgaris.

PurposePsoriasis vulgaris (PV) is an autoimmune-related chronic inflammatory disease of the skin, with both vascular and metabolic effects. Aggravating factors have been identified that initiate and maintain inflammation, including expression of Th1-, Th17-, and Th22-cell derived cytokines. Recently, we showed that the evolutionarily ancient and highly conserved damage-associated molecular pattern molecule “high mobility group box 1 (HMGB1)” is significantly increased in the serum of PV patients with disease progression and is decreased under standard therapies.Materials and methodsTo better understand the role of HMGB1 in the pathogenesis of PV, we recruited 22 untreated psoriatic patients with either mild or severe disease, defined by the Psoriasis Area Severity Index. We assessed HMGB1 and receptor for advanced glycation end products (RAGE) expression in the skin by immunohistochemistry and analyzed the immune-phenotype of Treg and Th17 cells by flow cytometry.ResultsWe found increased staining for HMGB1 in the dermis of psoriatic plaques in comparison to uninvolved skin of patients with PV. In addition, the major histocompatibility complex class III-encoded DNA and HMGB1 RAGE, induced by HMGB1, were highly expressed on psoriatic CD8+ T cells and CD4+ Treg. High expression of HMGB1 in the lesional skin was associated with even higher expression of its receptor, RAGE, on the cell surface of keratino-cytes in patients with severe PV.ConclusionThe presence of HMGB1 and RAGE signaling may impact orchestration of chronic inflammation in PV which might have implications for Treg and Th17 cells.

Biological therapy induces expression changes in Notch pathway in psoriasis.

Psoriasis is a chronic inflammatory skin disease, characterized by hyperproliferation of keratinocytes and by skin infiltration of activated T cells. To date, the pathophysiology of psoriasis has not yet been fully elucidated. The Notch pathway plays a determinant role in cell fate determination, proliferation, differentiation, immune cell development and function. Many biological agents, used in the treatment of psoriasis, include TFN-α inhibitors, such as etanercept, adalimumab, and anti IL-12/IL-23 p40 antibody, such as ustekinumab. This study aimed to determine mRNA expression levels by real-time RT-PCR, and protein expression levels, analysed by Western blot and immunohistochemistry, of some components of the Notch pathway, such as NOTCH1, NOTCH2, JAGGED1, and HES1 after biological treatments in psoriatic patients. mRNA and protein levels of NOTCH1, NOTCH2, JAGGED1 and HES1 were upregulated in skin samples from untreated psoriatic patients compared with normal controls. Biological therapy showed to downregulate differently the protein expression levels of the molecules under study. Our study suggests that Notch pathway components might be a potential therapeutic target against psoriasis.

Protein structure is changed in psoriatic skin on the unaffected region — Imaging possibility with ATR-FTIR spectroscopy

Psoriasis is a T lymphocyte-mediated inflammatory disorder that affects the skin. A number of studies have demonstrated the occurrence of lipid alterations in psoriatic skin, resulting in a highly perturbed stratum corneum (SC). Relatively little attention has been paid to the protein conformation of the SC. In this study, the attenuated total reflection Fourier transform infrared (ATR-FTIR) spectrum of the untreated psoriatic patients' unharmed SC was obtained after tape stripping. We focused on the amide-I band components in order to establish whether there are any protein alterations in the intact areas of psoriatic skin. Fourier self-deconvolution (FSD) of the amide-I band was followed by curve-fitting to generate the underlying components. Integration of band areas provided an estimate of the secondary structure. The results indicated decreases in all amide-I band components, the peak at 1660cm−1 revealing the most dramatic change. This peak is characteristic of the turn structure in the protein chain. The decrease is marked in the case of the β-sheet structure at 1630cm−1 too. This ATR-FTIR imaging is a rapid and simple noninvasive method, promotes a better understanding of the disease, and would be helpful in following the treatment.

Upregulation of PI3K/AKT/mTOR, FABP5 and PPARβ/δ in Human Psoriasis and Imiquimod-induced Murine Psoriasiform Dermatitis Model.

Psoriasis is a common, and currently incurable chronic immune-mediated skin disease (1), with incompletely understood etiology partially due to the unavailability of animal models that can emulate major features of the disease. The phospho-inositol-3 kinase (PI3K)/protein kinase B(Akt) and mammalian target of rapamycin (mTOR) signaling which regulate metabolism, cell proliferation, survival, apoptosis, and frequently deregulated in diverse cancers (2, 3), has recently emerged as a clinically relevant target for inflammatory diseases including psoriasis (4, 5). This pathway is tightly regulated through feedback loops in part via 2 mTOR complexes, (C1 and 2), with linkage through Akt. PI3K activation triggers the phosphorylation of a 3-hydroxyl group, which then activates Akt kinase and promotes keratinocyte hyperproliferation and inhibit differentiation, as observed in psoriasis (4). Initial clinical data suggest that secondgeneration inhibitors (targeting both mTOR and PI3-K kinases) provide therapeutic benefit for psoriasis (6). Additionally, psoriasis-associated epidermal-type fatty acid-binding protein (FABP-5) involved in cytosolic fatty acid-transport, as well as the peroxisome proliferatoractivated receptor β/δ (PPAR β/δ), a ligand-activated transcription factor and member of the nuclear hormone receptors superfamily, are upregulated in psoriasis (7–9). The goal of this study was to assess whether mTOR, its upstream (PI3K and Akt) and downstream S6K1 (specifically S6Ser235/236 and S6Ser240/244) targets, as well as FABP5 and PPARβ/δ, are overexpressed in inflamed toll-like receptor-7/8 ligand imiquimod (IMQ)induced Balb/c mouse skin lesions and, whether their expressions simulate those observed in inflamed skin lesions from untreated psoriatic patients compared with matched controls.

C‐reactive protein in psoriasis: a review of the literature

A great deal of research has addressed the elevation of C-reactive protein (CRP) among psoriatic patients and the role of this marker in assessment of disease severity and progression. However, there are some discrepancies in this area. We sought to figure out the relationship between CRP values and disease severity as well as the changes in marker levels after treatment through an extensive literature review. Comparison between CRP levels in psoriatic patients and those in healthy or non-psoriatic individuals was also another focus of this review. A thorough search in Pubmed and Embase was conducted for articles investigating different aspects of CRP measurement in patients with psoriasis. Overall, 32 articles were found to meet our inclusion criteria. Of 28 studies comparing the CRP values in psoriatic patients with those of controls, 24 found a statistically significant difference. In addition, 12 out of 16 papers examining the association between disease severity and CRP values noted significant results. With regard to CRP changes over the course of a treatment, all 15 studies addressing this issue revealed a significant decrease in marker levels. In conclusion, high CRP levels only for moderate and severe forms of disease might be inferred from the literature and there is no sufficient evidence suggesting a similar association for mild disease as well. Moreover, CRP may serve interchangeably with Psoriasis Area and Severity Index (PASI) as a measure of disease severity in the case of untreated psoriatic patients who do not have disease related arthritis. For other patients, however, a careful clinical examination and PASI calculation still remain the mainstay of severity assessment.

Persistent Expression of CD26/DPPIV After Treatment with Infliximab in Psoriasis Despite Clinical Improvement

Sir, Tumour necrosis factor α (TNF-α) is a proven adequate target for treatment of psoriasis. The chimeric TNF-α antibody infliximab binds to the transmembrane receptors and induces a neutralizing effect on soluble TNF by reversed signalling, ultimately causing a reduction in lesional T cells and, indirectly, increased programmed cell death of keratinocytes (1). CD26/dipeptidylpeptidase IV (DPPIV) is a multifunctional glycoprotein known to be present and upregulated on the surface of keratinocytes and T cells in psoriatic skin compared with the skin of healthy volunteers (2). The expression of CD26/DPPIV on peripheral blood T-lymphocytes of untreated psoriatic patients, however, was found to be substantially reduced, in particular on the CD8+CD26bright subset (3). Furthermore, TNF-α has been reported to influence CD26/DPPIV expression (4, 5). In vitro cell cultures have shown that anti-TNF-α can upregulate the expression of CD26/DPPIV on human-activated lymphocytes (6). CD26/DPPIV expression may have a crucial role and might function as a marker correlating with disease activity in the pathogenesis of psoriasis. The objective of this study was therefore to determine whether antiTNF-α therapy with infliximab modulates CD26/DPPIV expression on keratinocytes and T cells.

Long pentraxin 3: A marker of inflammation in untreated psoriatic patients

Psoriasis is a common cutaneous disorder characterized by abnormal epidermal differentiation, proliferation and inflammation mediated by dermal infiltrates, such as T cells, neutrophils, dendritic cells and macrophages. There are renewed interest in the role of components of the innate immune system. Cytokines such as tumor necrosis factor-alpha (TNF-alpha) and interleukin (IL)-6, and -1beta involved in pathogenic phenomena in psoriasis are known as inducers of the acute phase response. Among the large group of acute phase reactants, C-reactive protein (CRP) and fibrinogen are of special interest in psoriasis. The PTX-3, a long pentraxin sharing similarities with the classical short proteins. Thus, considering the numerous biological roles of inflammatory cytokines and their relationship with inflammatory markers, such as CRP and fibrinogen we have investigated the role of PTX3 in psoriasis. To this aim PTX3, TNF-alpha, IL-6 and IL-1beta in plasma and in monocytic cultures by enzyme linked immunosorbent assay (ELISA) in 44 patients including severe and mild psoriasis were measured. An increased production of PTX3, both in supernatant of purified monocytes and in plasma from patients with severe psoriasis, was found. The significant correlation, between cellular production and plasma levels of PTX3 in psoriasis was found as a sign of cellular activation by monocytes/macrophages that first infiltrate the psoriatic lesion. In severe psoriasis, a significant correlation between psoriasis area and severity index (PASI) score and TNF-alpha and IL-6 levels in both supernatant of monocytes and plasma was found. In contrast, no correlation was found for IL-1beta. By immunohistochemistry and immunofluorescence, a strong PTX3 staining in fibroblasts, endothelial cells and monocytes/macrophages in severe psoriatic lesional skin was detected. Finally, a positive correlation between PTX3 and disease activity of psoriasis was observed as PASI score was elevated. These findings suggest that PTX3 could be used as a further marker of disease activity of psoriasis.

Microorganisms in Intertriginous Psoriasis: No Evidence of Candida

Infection can be a trigger and an aggravating factor in psoriasis. Antibacterial and/or antifungal agents are commonly used in the treatment of intertriginous psoriasis, because it is believed that flexures in psoriasis are often colonized by Candida species and Staphylococcus aureus. Bacterial and fungal cultures were studied from 32 psoriatic patients with no topical treatment in the intertriginous areas, from 13 psoriatic patients treated with topical steroids and from 19 patients with no psoriasis or other affections of the skinfolds. Untreated psoriatic patients were colonized by S. aureus significantly more often than the control group but infection seemed to be unlikely. Candida was not found in any of the groups. It is proposed that intertriginous psoriasis be treated with topical steroids alone and that the routine use of antimycotic and antibacterial combinations should be avoided.

Circulating T cells of patients with active psoriasis respond to streptococcal M-peptides sharing sequences with human epidermal keratins.

Psoriasis is a T-cell mediated inflammatory skin disease which has been associated with group A, beta-haemolytic streptococcal infections. Four 20 a.a. long M6-peptides sharing 5-6 a.a. sequences with human epidermal keratins were identified. To investigate the role of potentially cross-reactive T cells in the pathogenesis of psoriasis, interferon-gamma (IFN-gamma) and interleukin-4 (IL-4) responses of circulating T cells to these peptides were analysed by ELISPOT and RT-PCR in 14 psoriatic patients, 12 healthy individuals and six patients with atopic dermatitis (AD). Untreated psoriatic patients' responses were significantly higher to these peptides than healthy and AD controls, while responses to a control M6-peptide, not sharing sequences with keratin, were negligible in all groups. No difference was found in response to streptokinase/streptodornase (SK/SD). M6-protein and peptides exclusively elicited IFN-gamma production, with little IL-4 production, even in AD patients. Interferon-gamma responses to all the M6-peptides were abolished after successful treatment of psoriatic patients, but responses to SK/SD were unaffected. The results indicate that active psoriasis is associated with Th1-like cells responding to streptococcal M6-peptides sharing sequences with human epidermal keratin. This is consistent with the hypothesis that psoriasis may be induced and exacerbated in susceptible individuals by M-protein specific Th1-like cells that cross-react with human epidermal keratin.

Autologous mixed lymphocyte reaction is reduced in patients with psoriasis

The autologous mixed lymphocyte reaction (auto-MLR) was studied to test the interactions between immunocompetent cells in patients with psoriasis. The auto-MLR in 20 patients with psoriasis was significantly lower than in 16 normal controls. Lower values were found in untreated psoriatic patients than in those in remission following treatment. The values in the latter group were significantly lower than in controls and in six patients with atopic dermatitis in remission. The tendency for an increase in the auto-MLR with a decrease in disease activity was further confirmed in five patients studied before and after treatment. In contrast, the allogeneic lymphocyte reaction (allo-MLR) in psoriatics was similar to that in normal controls.

Increased phosphorylation of two 48 kDa nuclear proteins in fibroblasts derived from psoriatic patients.

Psoriasis is a hereditary disease primarily affecting the skin and characterized by an abnormally high proliferation rate of the epidermal cells. Based on some recent reports indicating that the dermal compartment of the skin is involved in the hyperproliferative process, too, we investigated the nuclear protein pattern of human skin fibroblasts in cell cultures obtained from skin biopsy specimens of normal volunteers and from involved and healthy skin of untreated psoriatic patients. To eludicate the extent of phosphorylation of these proteins which occurs as a cell cycle-specific event, we performed in vitro phosphorylation of the 5 M ureasoluble nuclear proteins after serum stimulation of starved fibroblasts. Without exogeneous kinase in the assay the phosphorylation of several acidic proteins was detected. Two of them with a pI of 3.5 and a molecular mass near 48 kDa seem to be enhanced in synthesis and modification in the psoriatic fibroblasts indicating a specific function particularly in these cells.

Epidermal proliferation and accumulation of polymorphonuclear leukocytes in the psoriatic lesion.

Biopsies were removed from the margin of plaques in 11 untreated psoriatic patients, and 8-microns sections prepared using the cryostat. Alternate sections were stained with H and E to assess the accumulation of polymorphonuclear leukocytes. The remaining sections were stained with the monoclonal antibody Ki67 in order to determine the number of cycling epidermal cells. In areas where polymorphonuclear leukocytes occurred in the stratum Malpighi the number of cycling epidermal cells was relatively low. In contrast, a positive correlation was shown between the density of microabscesses of Munro and the number of cycling epidermal cells. The clinically uninvolved skin of psoriatic patients shows a moderate enhancement of epidermal growth in the absence of any infiltrate. In the lesional skin the recruitment of cycling epidermal cells does not coincide with the invasion of polymorphonuclear leukocytes into the epidermis, but rather follows the penetration of these cells.

Reduction of leukotriene B4-induced intraepidermal accumulation of polymorphonuclear leukocytes by methotrexate in psoriasis.

The leukotriene B4 (LTB4)-induced intraepidermal accumulation of polymorphonuclear leukocytes (PMN) was quantified, using an elastase assay, in psoriatic patients receiving methotrexate and in untreated psoriatic patients. Methotrexate in therapeutic dosages inhibited PMN infiltration in six patients who had improved considerably on treatment with the drug, a gradual increase being seen during the days on which no methotrexate was taken. Two patients were in relapse, despite methotrexate treatment, and both failed to show any change in LTB4-induced accumulation of PMN.

Flow cytometric quantification of T6-positive cells in psoriatic epidermis after PUVA and methotrexate therapy.

We describe a flow cytometric technique for measuring the percentage of T6-positive cells in suspensions prepared by trypsinization of human epidermis. The value obtained for healthy controls (1.55 +/- 0.52%) corresponds to about 600 T6-positive cells per mm2 of skin surface, a figure in line with histological estimates. No significant change was found in the percentage of T6-positive cells in either the uninvolved or lesional epidermis of untreated psoriatic patients. PUVA treatment resulted in a significant reduction in T6-positive cells. A cyclic fluctuation in the numbers of T6-positive cells was shown to accompany methotrexate administration on a weekly divided dose schedule.

Increased aggregation and arachidonic acid transformation by psoriatic platelets: evidence that platelet-derived 12-hydroxy-eicosatetraenoic acid increases keratinocyte DNA synthesis in vitro

Certain arachidonic metabolites may play a pathogenic role in psoriasis. Platelets are rich sources of 12-hydroxy-eicosatetraenoic acid (12-HETE) and thromboxane A2, mediators of skin inflammation and platelet aggregation, respectively. We have studied untreated psoriatic patients without a history of diabetes mellitus and smoking. In psoriatics, platelet aggregation elicited by thrombin, ADP, and ristocetin was significantly enhanced as compared with healthy adult volunteers. Enhancement of platelet aggregation was detected in patients with both minimal and widespread disease. The formation of 12-hydroxy-5,8,10-heptadecatrienoic acid (HHT), a cyclooxygenase product, and 12-HETE, a 12-lipoxygenase product, was increased in psoriatics with widespread disease but not in those with minimal disease. Formation of 12-HETE was stimulated to a higher degree (125%) than HHT (98%) in psoriasis (P less than 0.05). Addition of platelet-derived 12-HETE to cultured human epidermal keratinocytes resulted in a stimulation of the DNA synthesis (68% at 10(-7) M). These data suggest that platelet activation occurs in psoriasis, and that release of inflammatory and mitogenic compounds by activated platelets may play a role in the pathophysiology of psoriasis. Whether enhanced platelet aggregation in psoriasis is associated with occlusive vascular disease needs further investigation.

Methotrexate inhibits the leukotriene B4 induced intraepidermal accumulation of polymorphonuclear leukocytes.

The penetration of polymorphonuclear leukocytes (PMNs) into the epidermis following topical application of leukotriene B4 was assessed in the clinically uninvolved skin of psoriatic patients treated with methotrexate and of psoriatic patients without treatment, and in normal controls. Inhibition of PMN infiltration was observed in those patients treated with methotrexate while there was no significant difference between untreated psoriatic patients and normal controls.

Accumulation of Urinary Cancer-related Glycoprotein, EDCl, in Psoriasis

EDCl is a novel glycoprotein, mol wt 27,000, isolated in 1976 from leukemic urine. It inhibits the serine proteases trypsin and chymotrypsin and is antigenically related to interalpha trypsin inhibitor (IATI), mol wt 170,000, a normal plasma antiprotease. Since psoriasis is a non neoplastic hyperproliferative state, we have now measured EDCl by a specific radioimmunoassay (RIA) in plasma and urine of 24 untreated psoriatic patients. EDCl was not detectable in normal urine (less than 1 mg/gm creatinine) or plasma (less than 1 mg/L). 55% of psoriatic urine specimens were positive by RIA, containing 8 to 110 mg/gm creatinine. 75% of plasmas were positive, containing 12 to 32 mg/L. Plasma and urine contents of EDCl were significantly (P less than .05) correlated with severity of clinical disease (% skin involved) but not with age, sex, distribution or type of lesion, family history or arthritis.

Serum uric acid levels in untreated and PUVA-treated patients with psoriasis.

Hyperuricemia occurs frequently in patients with psoriasis. An increased purin breakdown due to the enhanced epidermal turnover was stressed as a reasonable explanation. To prove this theory serum uric acid, cholesterol, triglyceride levels and the average body overweight were determined in 318 untreated psoriatic patients and the parameters were correlated with the extent of psoriatic skin involvement. In more than 100 psoriatic patients treated by oral photochemotherapy (PUVA), uric acid serum levels were examined additionally after the PUVA clearing phase and during PUVA maintenance treatment. The present study demonstrates: (1) There is no relationship between the frequency of hyperuricemia and the extent of psoriatic skin involvement, indicating that the increased epidermal turn over may not play a role in psoriatic hyperuricemia. (2) The most reasonable explanation for elevated uric acid in psoriasis seems to be a combination of genetic predisposition and hyperalimentation. (3) No significant change was found in the incidence of hyperuricemia under the influence of photochemotherapy.

Effects of Methotrexate and Hydroxyurea on Psoriatic Epidermis

Systemic administration of methotrexate produced histologically damaged cells in biopsy specimens of skin taken from areas clinically consistent with psoriasis. These cells were not found in the epidermis of uninvolved, normal appearing skin biopsy specimens taken from the same patient at the same time intervals. In addition, the appearance of the damaged cells was related to the dosage of methotrexate administered. Similarly damaged cells were seen after administration of hydroxyurea. Again, selective cytotoxicity was noted in that damaged appearing cells were present in involved psoriatic epidermis and were absent in uninvolved normal appearing epidermis. No damaged cells were seen in biopsy specimens obtained from untreated psoriatic patients or patients treated with steroids administered topically or systemically.