Tuesday, 20 March 2012

Descending to the Cellular Level of Atopic Dermatitis (AD)



Journal Article

Mathay, C., Pierre, M., Pittelkow, M., Depiereux, E., Nikkels, A., Colige, A., et al. (2010). Transcriptional profiling after lipid raft disruption in keratinocytes identifies critical mediators of atopic dermatitis pathways. [Journal Article]. The Journal Of Investigative Dermatology, 131(1), pp. 46-58.


This primary research article goes down to the cellular level in studying atopic eczema. Here’s a quick introduction of the basic structure of the skin before we delve into the research.

The skin is made up of three layers: the epidermis, dermis and subcutaneous tissue.



The area we are interested in today is the topmost layer called the epidermis. Keratinocytes are the predominant skin cells here. They undergo differentiation to form different kinds of cells in the epidermal layer. New skin cells are forming at the bottom layer and move toward the top while the older cells on top die and rise to the skin’s surface. They then flake off.

Epidermis


In this study conducted by scientists from various Belgium universities and USA laboratories, further research into the function of membrane lipid rafts was conducted, with interesting findings related to atopic dermatitis.

Methods

Quoting verbatim from the article: “whole-genome transcriptional profiling in MBCD-treated keratinocytes was performed”. In English, this means that the scientists messed up the fat in the membranes of this skin cells, than examined them closely.

They measured transcript levels in the cells immediately after cholesterol depletion, 1 hour later and 8 hours later.

What does transcript levels refer to? Transcription is the process of creating a complementary RNA copy of a sequence of DNA. Keratinocytes respond to cholesterol depletion by inducing the transcription of genes that help in making cholesterol.

Cholesterol biosynthesis is a major occurrence after fat is taken out and scientists use this method of studying keratinocytes because combined with bioinformatics data analyses, they can identify and characterize lipid raft-dependent transcriptional targets and cell signaling pathways. Armed with such information, they proceed to do an association of functions and diseases with lipid raft-disrupted keratinocytes.

Results

The study documented various cell responses at different points in time, going into detail with the different types of genes. The results are pretty complex as over 3, 000 genes were differentially regulated, with some like metalloproteinases being highly upregulated and other genes downregulated.



Diagram showing Differential regulations at Time periods


What was most significant for our interest in eczema is that AD associates the most significantly with the transcriptional profile observed at R0h, and AD is second at R1h after lipid raft disruption by MBCD. This means eczema sufferers are found to have this kind of fat-disrupted cell membrane skin cells occurring at time=0h and 1h. This shows that in skin cells of people with eczema, there may be a problem in lipid raft organization and signaling.

Illustration of potential networks showing relevant genes and their possible interactions, either immediately after cholesterol depletion (at 0 hours (R0h (a))


In the second part of the study they compared AD skin with normal skin by collecting skin biopsy specimens of acute lesions and surrounding normal-appearing skin of AD patients (average age: 39 years), as well as biopsy specimens of healthy volunteers (average age: 43 years) after informed consent. The transcript levels of several major targets of cholesterol depletion were analyzed.

Skin Biopsy.  http://www.beliefnet.com/healthandhealing/getcontent.aspx?cid=14861




Regarding the results of this part of the study, the article says that: “In summary, when comparing AD skin with normal skin, increased expression levels of IVL, TGM1, HB-EGF, IL-8, and PLAUR are detected simultaneously with a decreased expression of FLG and LOR.”

How clever! We will take their word for it. These results agree with their results in the first part of the transcriptional analysis of gene expression in lipid raft-disrupted keratinocytes, strongly suggesting that membrane organization and signaling might be disturbed in AD keratinocytes.

Normal skin VS Eczematous Skin
 http://www.yalescientific.org/2011/05/the-mechanisms-and-perception-of-itch/


Understanding more about genes connected to atopic dermatitis may not have a direct impact on the day-to-day skin care program of eczema sufferers, but it portends future developments in possibly gene therapy and personalized medicine. Perhaps in the future scientists may invent a medicine that can enhance residual enzyme activity in the membrane of keratinocytes that lead to AD.

The current treatment of eczema is concerned with managing the symptoms and this research offers the tantalizing prospect of targeting the root of the problem. But we are like people in Plato’s cave who cannot ‘see’ and our evaluation of the importance of this study can at best be speculative. Its worth would eventually be revealed with the passing of time and progress of medicine. 


Wednesday, 7 March 2012

Are steroids safe to use?


The controversy I have chosen to discuss centres around the use of corticosteroids to treat atopic eczema.




Mild cortisone (or steroid) cream or ointment are often prescribed to control the symptoms of atopic eczema by reducing the inflammation and promoting healing.

In 1952, Sulzberger and Witten70 published a report which promoted the use of a new topical drug in dermatology,5 17 hydroxycortisonee 21 acetate. Improvement was judged after 1 week based on clinical criteria, namely decreased pruritus, diminished erythema, and reduced scaling. Since its first use in dermatology, TCS therapy has been developed so success-fully that dermatology cannot be envisaged without TCS. (1) 

Therefore, steriods have proven to be effective in most cases and most doctors would recommend a mild steroid together with moisturizers as a standard treatment for eczema sufferers.

However, concern over the side effects has caused some people reject the use of cortisone for eczema entirely. Side effects associated with corticocosterioid use include skin atrophy, meaning that the skin is thinned out and more vulnerable. When large amounts are applied and absorbed into the body, it may cause hypothalamic-pituitary-adrenal axis suppression, where the functioning of the endocrine system is affected. Steroids may also cause glaucoma if they enter the eye.



I personally feel that these fears are exaggerated and with proper use, steroids can aid in the treatment of eczema without those nasty side effects.

This is the recommended treatment found in an academic journal about management of eczema:

• topical steroids -- helpful in inflammatory atopic eczema. Potent steroid preparations should be used only to get the eczema under control, and should not be used on the face. They can safely be followed by a mild steroid. Steroids under wet tube gauze (wet wrap) will sometimes be effective, and prevent scratching. (2)

This video here from the National Eczema Association talks about the use of topical medications from 6:10. It says that "When used correctly, these medications are safe and effective."




Topical steroids can be used but patients should take heed of those warnings and use it in a thin layer over affected areas only. The first line of defense would still be to moisturize.



References

1. G, T., D, W., & A, T. (2007). Topical therapy of atopic dermatitis: controversies from Hippocrates to topical immunomodulators. Journal Of The American Academy Of Dermatology, 56(2), pp. 295-301.

2. Watkins, J. (2009). Eczema: types, presentation, causes and management. Practice Nurse, 38(4), p11-18.