Chapter 13 :: Basic Principles of Immunologic Diseases in Skin

(Pathophysiology of Immunologic/Inflammatory Skin Diseases)

AT A GLANCE

 Immunologic/inflammatory skin diseases result from inappropriate and

frequently exaggerated responses to endogenous skin constituents or
external stimuli and are orchestrated by leukocytes and nonleukocytes.
 Disease pathogenesis is often incompletely understood, but select
experimental models and skin diseases have provided insight into the
pathogenesis of human immunologic/ inflammatory skin diseases.
 This chapter provides examples where disease pathogenesis is reasonably
well understood and describes contemporary approaches that have resulted
in improved understanding and, in some instances, improved therapy.

INTRODUCTION

The skin is a physical barrier that is vital for the main- tenance of organismal
homeostasis. It experiences, and reacts to, a constant barrage of external insults
includ- ing environmental changes (heat extremes, changes in humidity, sunlight
exposure, etc), allergens, toxic chemicals, and pathogenic microbes. In addition to
keratinocytes, Merkel cells, melanocytes, fibroblasts, adipocytes, and vascular
cells, recent studies docu- ment that skin harbors a community of resident leu-
kocytes whose composition and activation status is tuned by commensal microbes.
In aggregate, these leukocytes and nonleukocytes constitute a critically important
immunologic interface between organism and other.

Immune responses involving skin are highly orches- trated. Appropriate

immune responses are directed exclusively (or primarily) against external agents,
they are sufficiently (but not excessively) vigorous and they are time-limited.
Correspondingly, there are mul- tiple mechanisms that promote and suppress
immune and inflammatory reactions in skin. Inappropriate or dysregulated local or
systemic responses against self- antigens, foreign antigens, or microbes that are
associ- ated with, or enter via, skin may result in skin diseases. Examples include
allergic and inflammatory skin diseases, autoimmune diseases, and drug reactions.

Selected examples of each of these disease categories will be discussed.

Ultimately, detailed understanding of mechanisms that cause
immunologic/inflammatory skin diseases will facilitate development of less toxic,
more effective therapies.

ALLERGIC CONTACT

DERMATITIS

Allergic contact dermatitis (ACD) is a common inflam- matory skin

condition caused by repeated exposures to haptens, typically low-
molecular-weight chemicals and metals, which interact with endogenous
proteins to form immunogenic (complete) antigens after enter- ing skin.
ACD can be acute or chronic, depending on the nature, dose, and frequency
of allergen exposure. For example, after sensitization to urushiol (a lipid
component of poison ivy sap), individuals predict- ably develop acute ACD
after reexposure. In contrast, occupational ACD commonly results from
long-term exposure to low doses of metal ions such as nickel or chromium.
Topical or systemic corticosteroids are com- monly prescribed for ACD, but
avoiding reexposure to the relevant allergen is crucial for effective
treatment. However, it is not uncommon for the offending aller- gen to be
difficult to identify, particularly in patients with occupational ACD.

Individual susceptibility and/or familial predis- position to ACD has been

observed in studies where haptens were used to sensitize human volunteers
in controlled experiments. However, evidence suggest- ing that genetic
susceptibility to ACD is important is not strong. HLA haplotype
associations have been reported, but results of different studies are conflict-
ing. Polymorphisms in genes including ACE, TNFA, and IL16 have been
described,1-3 but the cohorts stud- ied were small and the significance of
these findings remains to be determined. A recent genomewide asso- ciation
studies (GWAS) performed in a Korean popu- lation with patch test–proven
nickel allergy reported associations of SNPs in Netrin-4 and Pellino-1 with
ACD.4 Although the functional significance of these SNPs remains to be
validated, the suggested involve- ment of Pellino-1 in ACD is interesting
because Pellino-1 participates in toll-like receptor 4 (TLR4)– mediated
signaling, a pathway known to be involved in nickel allergy. Possible
explanations for conflicting results in different GWASs may relate to the
diver- sity of chemicals that cause ACD and the varying genetic
compositions of the populations selected for investigation.

Rodent models of ACD (hapten-induced con- tact hypersensitivity [CHS]

responses) have been extensively studied. These studies have provided
mechanistic insights into initial responses to allergen introduction and those
that occur after subsequent challenge. In the laboratory, CHS is initiated by
apply- ing haptens to shaved mouse abdominal skin. Haptens are typically
dissolved in mixtures of organic sol- vents that penetrate stratum corneum
and are mildly irritating after topical application. Although initial exposures
to haptens do not cause dermatitis, the innate immune system is engaged,
leading to activa- tion of antigen-presenting cells (APCs) that acquire or
express complete antigens and subsequently stimulate allergen-specific
memory T cells, completing the sen- sitization (afferent) phase (Fig. 13-
1A). When haptens are subsequently applied to mouse ear skin, T cell–
mediated dermatitis results (Fig. 13-1B). The intensi- ties of the immune
responses that ensue during this elicitation phase is quantitated by
measuring ear thick- ness (ear swelling).
Initial exposures to haptens that commonly elicit ACD in patients signal via
inflammasomes and/or toll- like receptors (TLRs); 2 major pathways involved in
innate immunity. In the case of urushiol, skin cells are stimulated to release ATP
and other danger-associated molecular patterns (DAMPs), as well as reactive
oxygen species (ROS), which generates low-molecular-weight hyaluronic acid.
These events lead to inflammasome activation, resulting in release of
proinflammatory chemokines and cytokines including IL-1β, IL-18, and TNF-α.5
The human contact allergen Ni2+ directly binds to human, but not mouse, TLR4.6
Ni2+ is not an effective sensitizer in control mice, but TLR4-deficient mice that
have been genetically engineered to express human TLR4 exhibit Ni2+-induced
CHS. After bind- ing to TLR4, Ni2+ stimulates production of interferons, IL-1β
and IL-18. Cr2+, another metal ion and common contact allergen, stimulates the
innate immune cells by engaging both TLRs and inflammasomes.7 TLR- signaling
mediates an initial priming event to induce pro-IL-1β synthesis, and activation of
the inflamma- some component NLRP3 via ROS leads to processing of pro-IL-1β
into bioactive cytokine.

The frequently used experimental haptens TNCB, DNFB, oxazolone, and

fluorescein isothiocyanate (FITC) also activate multiple immunologically rel- evant
signaling pathways. Activation of inflamma- somes is critical because mice that are
individually deficient in inflammasome components (Asc, Card9 and Nalp3 or
caspase-1) each exhibit impaired CHS responses.8-10 Deficiency of MyD88, an
adaptor mol- ecule that is required for signaling by most TLRs, and simultaneous
deficiency of TLR2 and TLR4 also lead to impaired CHS responses in mice,
indicating that TLRs play important roles.11 Thus, epicutaneous application of
contact sensitizers activates multiple pathways that result in an inflammatory milieu
that activates APCs in skin and leads to expansion of antigen-specific T cells. These
innate proinflammatory processes may originate in leukocytes and nonleukocytes,
and are important upstream events that are required for con- tact sensitization.
Although Langerhans cells (LCs) have long been considered to be critically
important APCs in CHS, evi- dence supporting this concept is not entirely convinc-
ing. Because haptens easily penetrate epidermis and reach the dermis, both LCs and
dermal dendritic cells (DDCs) encounter contact allergens. Analysis of CHS
responses in a mouse model in which LCs were consti- tutively depleted revealed
enhanced CHS responses,12 whereas 2 mouse models involving transient LC
deple- tion exhibited unchanged or slightly reduced CHS responses.13,14 Although
different haptens were used in these latter studies and the timing of LC depletion
also differed, none of these reports concluded that LCs were absolutely essential
for CHS responses. DDCs have been demonstrated to contribute to CHS responses
and may compensate for the loss of LCs in the experiments just described. Indeed,
CD8α+ DCs and DDCs, but not LCs, contribute to CD8+ T-cell responses during
antivi- ral responses.15 It is possible that antigen-specific CHS responses are
primarily dependent on DCs other than LCs. Another possibility is that immune
responses to chemically distinct contact allergens involve different signaling
pathways and/or even different leukocyte subpopulations. Recent studies propose
that urushiol binds to CD1a, an MHC-related cell surface molecule that is expressed
by LCs, and that CD1a-bound uru- shiol stimulates antigen-reactive T cells to
release cytokines.16 This may be an example in which LCs play a critical role in
ACD because LCs preferentially form the complete antigen.

After activation, allergen-bearing DC migrate to skin-draining lymph nodes to

initiate T-cell expan- sion and development of hapten-specific memory T cells (Fig.
13-1A). CD8+ T cells appear to be the pri- mary mediators of skin inflammation in
ACD, but CD4+ T-cell activation may be required for optimal CD8+ T-cell
responses (Fig. 13-1B). CD8+ T cells accu- mulate not only in lesional and
postlesional skin, but they also distribute to distant skin sites where they can persist
locally as resident memory T cells (TRMs)17 (Fig. 13-1C). After contact allergen
exposure, antigen- activated naï ve T cells undergo clonal expansion and
differentiate into both TRM and central memory T cells.18 TRMs mediate rapid
CHS responses, whereas central memory T cells cause delayed responses. The
existence of these distinct T-cell subpopulations explains why ACD can be induced
in sensitized indi- viduals after prolonged periods of time and why ACD frequently
involves multiple skin sites. As is true in most T cell–mediated diseases, regulatory
T cells are thought to play major roles in attenuation or termina- tion of
inflammation in CHS.

DRUG REACTIONS

Severe cutaneous adverse reactions (SCARs) are potentially life-threating

conditions that are thought to be caused by aberrant immune responses that are

elicited by drugs, and represent another example of immunologic/inflammatory

skin diseases caused by external agents. SCARs include Stevens–Johnson syn-
drome (SJS), toxic epidermal necrolysis (TEN), and drug-induced hypersensitivity
syndrome (DiHS) (or drug reaction eosinophilia with systemic symptoms
[DRESS]).19 Acute generalized exanthematous pustu- losis is commonly included
as SCAR, but is, in general, less severe than SJS/TEN and DiHS/DRESS.19

Prompt identification and discontinuation of offend- ing drugs is critical for

treatment of SCARs. SCARs have not been effectively modeled in experimental
animals.

Evidence of genetic predisposition to SCARs and other drug eruptions has emerged
in recent years. In cohorts of Han-Chinese patients, SJS/TEN that is caused by
allopurinol and carbamazepine is strongly associated with the HLA haplotypes
B∗58:0120 and B∗15:02,21 respectively. These studies indicate that HLA
haplotypes predispose to SCARs and also demonstrate that the relationship between
genotype and SJS/TEN susceptibility is drug-specific. Importantly, HLA hap-
lotypes B∗58:01 and B∗15:02 are not associated with SJS/TEN in European or
Japanese cohorts, indicating that genetic predispositions are dependent on ethnicity.
Along these lines, dapsone hypersensitivity syndrome, a form of DiHS/DRESS, has
been associated with the HLA-B∗13:01 haplotype in Asians but not in Europe- ans

and Africans.22 The striking association of specific MHC Class I haplotypes with
SCARs is consistent with the concept that T-cell receptor engagement on drug-
specific CD8+ T cells is causal. Although genetic pre- disposition to SCARs in non-
Asians is also likely, this has yet to be demonstrated.

Cytotoxic T cells can be readily detected in SJS/ TEN lesions, suggesting that these
cells are patho- genic. In early SJS, CD8+ T cells accumulate along the dermal–
epidermal junction, causing interface derma- titis with keratinocyte apoptosis (Fig.
13-2) as is also observed in erythema multiforme. The involvement of CD8+ T cells
in SJS/TEN is consistent with the GWAS data alluded to above, because CD8+ T
cells recognize antigen epitopes that are associated with MHC Class I antigens.
Fixed drug eruptions (FDEs) also feature CD8+ T cell–mediated interface
dermatitis. In FDE, discrete erythema multiforme-like lesions predictably recur in
previously involved locations after systemic drug administration. This phenomenon
probably reflects the existence of clones of drug-reactive CD8+ resident memory T
(TRM) cells that remain at sites of previous skin lesions where they are poised to
respond if offending drugs are readministered. Indeed, persis- tence of CD8+ T cells
can be detected in skin long after FRD lesions have resolved.23

Cytotoxic T cells responses are less prominent in DiHS/DRESS. Here patients

present with maculo- papular or morbilliform lesions that may coalesce and become
confluent. Peripheral eosinophilia is a hall- mark feature of DiHS/DRESS, but the
role of eosino- phils in disease pathogenesis is uncertain. The presence of
lymphadenopathy and appearance of atypical (acti- vated) lymphocytes in
peripheral blood suggests a T cell–mediated pathophysiology. Expansion of regu-
latory T cells may result in immunocompromise in the initial stage of
DiHS/DRESS,24 allowing reactivation of herpes virus infections, including human
herpes viruses 6 and 7, Epstein–Barr (EB) virus, and cytomeg- alovirus. EB virus–
specific CD8+ T cells are reported to be increased in the circulation and cause tissue
dam- age in EB virus–infected tissues, including liver, that is typical of
DiHS/DRESS.25 B cells, which serve as a reservoir for EB virus, also may be
targeted because patients frequently exhibit hypogammagloblinemia.

DiHS/DRESS patients exhibit immunologic abnor- malities long after resolution of

the acute phase and may develop autoimmune diseases such as Hashimoto
thyroiditis, systemic lupus erythematosus, and Type I diabetes.26 Accentuated
immune responses against herpes viruses and the occurrence of autoimmune dis-
eases suggest that breakdown of peripheral tolerance is a major contributor to
DiHS/DRESS.

Drugs that cause SCARs are small molecules that are unlikely to be directly
recognized by T cells. The nature of epitopes that are recognized and mechanisms
that are responsible for their generation have not been delineated with certainty.
Several models have been proposed27 (Fig. 13-2). As is the case in CHS, drugs that
cause SCARs may act like haptens, forming complete antigens by combining with
endogenous proteins. Penicillins, for example, may bind to carrier proteins to form
immunogenic neoantigens that may become targets of adaptive immunity. In
abacavir hypersensi- tivity, the altered peptide model proposes that abacavir binds
directly to the peptide-binding groove of HLA- B∗57:01, thereby modifying the
self-peptides that are presented, creating functionally abacavir-dependent
neoantigens that can be recognized by CD8+ T cells. The pharmacologic interaction
with immune recep- tors (p-i) concept posits that drugs bypass classic antigen-
processing mechanisms and trigger immune responses through direct, noncovalent
interactions with human leucocyte antigen (HLA) alleles and/or T-cell receptors
(TCRs) that are expressed on cell sur- faces. Activation of preexisting T cells via
such mecha- nisms could explain why drug reactions occur within hours to few
days in patients after initial exposure to causative drugs.

Finally, the altered TCR repertoire model proposes that drugs bind directly to TCRs
and promote inappro- priate T-cell reactivity to self-antigens. Using a T-cell clone
isolated from a patient with a maculopapular drug eruption, it was shown that
sulfamethoxazole binds to TCR containing Vβ20-1 variable domains. TCR–drug
binding could induce a conformational change in the TCR that could alter TCR
specificity. TCR VB-11-ISGSY was the predominant clonotype in carbamazepine-
reactive T cells (those that prolifer- ate and produce the cytotoxic molecule
granulysin) from SJS/TEN in Taiwanese patients harboring HLA B∗15:02. In these
studies, activation of T cells by car- bamazepine was inhibited by a blocking
antibody against TCR VB-11, reinforcing the importance of TCR engagement in
drug hypersensitivity.

Recent human studies have improved our under- standing of the pathophysiology
of drug reactions (Fig. 13-2), but much remains to be learned. Develop- ment of
humanized mouse models in which mecha- nisms can be dissected in vivo may
advance the field considerably.

ATOPIC DERMATITIS

Atopic dermatitis (AD) is a common inflammatory skin disease that is characterized

by dry skin and eczematous dermatitis with severe itching. Classic AD arises in
children and may be accompanied by the later onset of asthma, allergic rhinitis,
and/or food allergies (“the atopic march”) (Fig. 13-3). Serum levels of IgE and
CCL17 (TARC), both of which are characteristic of Type 2 immune responses, are
increased in AD. Other immune cells, including T helper Type 1 (Th1), Th17, and
Th22 cells, likely mediate the dermatitis, however (Fig. 13-3). AD commonly
remits in late childhood, but can recur later in life and persist for years thereafter.
AD is routinely treated with combinations of topical steroids, immunosuppressives,
and emollient creams but current therapies are inadequate. Anti-histamines are
commonly prescribed, but unrelieved pruritis is a major clinical problem.

Combinations of endogenous and exogenous factors have long been suspected to

be involved in AD patho- genesis but, until recently, causal factors had not been
identified. The discovery that AD patients harbor loss- of-function mutations in the
gene encoding the struc- tural protein filaggrin provided compelling evidence that
impairment of an epidermal structural protein contributes to AD pathogenesis.28
GWAS have demon- strated that single-nucleotide polymorphisms (SNPs) in a
number of other genes are also associated with AD.29,30 Many of these genes are
expressed in immune cells and/or pathways (eg, IL2, IL6R, IL7RA, and IL18R1),
strongly suggesting that AD etiology is mul- tifactorial. Importantly, GWASs
involving genetically distinct patient cohorts have identified both overlap- ping and
nonoverlapping gene associations, consistent with the clinical observations that AD
symptoms and signs may differ depending on the patients’ ethnici- ties, and
supporting the concept that different genes may influence AD susceptibility in
different patient populations.

Although GWASs identify candidate loci that may be involved in AD pathogenesis,

SNPs may not result in functional alterations in gene function. Addition- ally, SNPs
may be genetically linked to, but distinct from, genes that are actually involved in
AD (linkage disequilibrium). Studies of rare genetic diseases that are caused by
mutations in known genes may provide mechanistic insights if clinical features of
these dis- eases overlap with those of AD. For example, Nether- ton syndrome, a
disease with eczematous dermatitis as a prominent feature, is caused by mutations
in the cell surface protease inhibitor SPINK5.31 Loss of SPINK5 leads to increased
activity of cell surface serine prote- ases that compromises the barrier function of
the stra- tum corneum. Interestingly, SPINK5 polymporphisms have been
associated not with AD, but with elevated IgE levels in patients with AD.32 Job
syndrome (hyper IgE syndrome) is characterized by dermatitis and impaired Th17
responses leading to increased suscep- tibility to Staphylococcus aureus
colonization or infec- tion, and is caused by loss of function mutations in STAT3.33
A STAT3 SNP has been identified in classic AD,30 suggesting that pathway
dysregulation that occurs in Job syndrome might also contribute to AD. Mouse
models that feature mutations of genes that are involved in genetic forms of human
AD or that cor- respond to SNPs that are characteristic of AD could provide
important mechanistic information that is rel- evant to patients.

Whereas asthma, allergic rhinitis, and food allergies are clearly IgE-mediated
allergic diseases, the mecha- nisms that drive skin inflammation in AD are not well
understood. Patch testing identifies allergens that cause contact dermatitis, but the
utility of patch testing in AD patients is controversial, suggesting that skin
inflammation that occurs in AD may not result from repetitive exposure to contact
allergens. S. aureus com- monly colonizes AD skin, but the role that this microbe
plays in AD pathogenesis also has been controversial. Microbe detection and
identification based on DNA sequencing has led to major advances in our under-
standing of the diversity of microbial communities that reside in human skin
(collectively termed the “skin microbiome”).34 Using next-generation DNA
sequenc- ing, it has been determined that although only 20% to 30% of non-AD
patients carry S. aureus as a commensal microbe, both the abundance and relative
frequency of S. aureus representation in the skin microbiome is increased in AD
patients, even when their disease is quiescent. When patients experience acute
exacerba- tions of AD, staphylococci (primarily S. aureus) become predominant in
the skin microbiome, indicating an intimate relationship between AD disease
activity and staphylococcal dysbiosis.35

A mouse model that recapitulates aspects of AD and the relationship between

disease activity and changes is skin microbiome composition has been established
recently.36 In this model, mice exhibited spontaneous microbial dysbiosis
characterized by S. aureus predom- inance accompanied by severe eczematous
derma- titis. Furthermore, cutaneous application of S. aureus caused eczema,
whereas a commensal Corynebacte- rium species did not. Interestingly,
Corynebacterium enhanced Th2 responses that promote IgE production and that
may be relevant to the atopic march in AD patients. This suggests that AD might
be effectively treated by manipulating the cutaneous microbiome. Bleach baths
modify the cutaneous microbiome and thus represent a practical and cost-effective
means of therapy, but mechanisms by which bleach baths con- trol AD have yet to
be characterized in detail. Because topical steroids can reverse microbial dysbiosis
even in the absence of antibacterial therapy, both inflammation and microbial
dysbiosis are likely to be important con- tributors in a vicious cycle that drives skin
inflamma- tion in AD.

The recent development of biologic agents or “biologics” allows selective targeting

of mediators or cells, and the efficacy of these interventions can provide insight into
the involvement of the targeted pathways in inflammatory skin diseases including
AD. Omali- zumab, a humanized monoclonal anti-IgE antibody, effectively treats
asthma, food allergies and urticaria, but it has not been effective in AD.37 Although
this lack of efficacy may be attributed to the high serum levels of IgE in AD
patients, an alternative conclusion is that skin inflammation in AD is not mediated
by an IgE- dependent mechanism. Signaling pathways involving IL-4 and/or IL-13
also may be relevant in AD. Phase 3 trials document that dupilumab, which blocks
IL-4 and IL-13 signaling by binding to IL-4Rα, is effective in AD.38 The
leukocytes that produce IL-4 and IL-13 in AD remain to be determined. Human and
mouse Th2 cells are known to be major sources of IL-4, and murine innate
lymphoid cells (lymphoid cells that lack conventional T-cell antigen receptors)
have been identified as major sources of IL-13. The contribution of innate lymphoid
cells to human AD will be assessed in future studies.

Small molecules that occupy the ATP-binding sites of Janus kinases (JAKs) are
effective inhibitors of cytokine receptor signaling. JAK1 and JAK3 play critical
roles in signaling mediated by the Th2 cytokines IL-3 and IL-13, as well as IL-7
and IL-15. These cytokines collectively support the maintenance of T lymphocytes,
NK cells, and innate lymphoid cells. Tofacitinib and ruxolitinib inhibit both JAK1
and JAK3 and have activity in inflam- matory diseases including rheumatoid
arthritis, psoriasis and alopecia areata. In light of the efficacy of IL-4/IL-13
blockade and the association of IL-7 and IL-15 receptor polymorphisms in AD,
JAK inhibitors may be useful in this patient population. Indeed, topical tofacitinib
has been reported to improve Eczema Area and Severity Index (EASI) scores in a
Phase IIa randomized trial in AD. Studies of newly developed targeted therapeutic
agents are likely to provide additional insights into mechanisms that play important
roles in AD pathogenesis.

PSORIASIS

Psoriasis is a common, recalcitrant inflammatory skin disease characterized by

discrete plaques with adher- ent micaceous scales occurring at sites of predilection,
including locations of minor skin trauma. Nail involve- ment is frequent, and
characteristic arthritis (“psoriatic arthritis”) can co-occur or occur in the absence of
skin lesions. Psoriasis has not been effectively modeled in mice until recently,
requiring that advances in under- standing disease pathogenesis and developing
effec- tive therapies be driven by clinical research involving patients. Very recent
work indicates that psoriasis is a systemic disease in which skin inflammation is
dra- matically evident, rather than a disease whose impact is restricted to skin.

The histology of psoriatic lesions is typified by a thickened, hyperproliferative

epidermis featuring markedly reduced basal keratinocyte transit times, abnormal
keratinocyte differentiation, neutrophilic and lymphocytic inflammation, and
prominent cap- illary loops that extend into the very superficial der- mis. At various
times, competing schools of thought espoused that psoriasis was caused by
abnormalities in keratinocytes, immunocytes, and endothelial cells. The ability of
antimetabolites (eg, methotrexate) and ultraviolet radiation (UVB or psoralen +
UVA) to ame- liorate aspects of the disease was consistent with the concept that
keratinocyte growth was abnormal in psoriasis and that this might reflect intrinsic
keratino- cyte defects, but these interventions also have immu- nomodulatory
properties.

The critical involvement of lymphocytes in psoriasis pathogenesis was

convincingly demonstrated when increasingly selective therapies became
available.40 The calcineurin inhibitor cyclosporine is a remarkably effective
antipsoriatic agent. The ability of high con- centrations of cyclosporine to modulate
keratinocyte growth and gene expression in vitro did not exclude keratinocytes as
relevant targets in psoriatic patients with certainty, but follow-up clinical studies
with the specific lymphocyte-depleting agents denileukin difti- tox (an IL-2
receptor–directed cytotoxin) and alefacept (a CD2-binding LFA-3/Fc fusion
protein) settled this question. Both of these agents were too toxic to be rou- tinely
administered to psoriatic patients because they have broad-spectrum
antilymphocyte effects, but stud- ies with increasingly selective immunomodulators
have informed our understanding of psoriasis patho- genesis and identified effective
therapeutics.

Improved treatment of psoriasis and more detailed understanding of psoriasis

pathogenesis has devel- oped in concert with the revolution in “biologic therapy.”
Although the anti-TNFα neutralizing anti- body infliximab (one of the first widely
used biologics) was first tested in patients with inflammatory bowel diseases,41
improvement in skin lesions in patients with concurrent psoriatic led to formal
testing of infliximab and demonstration of efficacy in patients with severe psoriasis
vulgaris. TNFα is a primary proinflamma- tory cytokine with many sources, targets,
and actions in skin and elsewhere, so initially it was not obvious why infliximab
and other TNFα-targeting agents were particularly effective in patients with
psoriasis.

The effectiveness of lymphocyte-depleting and lym- phocyte-modulating agents in

patients with psoriasis indicated that T cells and perturbations in cellular immunity
were critical. Prior to the advent of biolog- ics, atopic dermatitis was conceptualized
as a Th2- predominant disease whereas psoriasis was thought to be Th1 mediated,
with IFNγ as an important effec- tor cytokine. Discovery of entirely new T cell
subsets, especially Th17 cells that produce IL-17, opened an entirely new avenue
for psoriasis research. TNFα is coproduced by dermal dendritic cells that also
produce IL-23, a cytokine that is required for Th17-cell devel- opment. IL-23 is a
heterodimeric protein composed of IL-23–specific p19 as well as p40, a polypeptide
that is shared with the Th1-promoting cytokine IL-12. IL-17 promotes neutrophil-
predominant inflammation and plays important roles in responses to microbial
patho- gens, in part because IL-17 modulates gene expression in keratinocytes
leading to increased production of antimicrobial peptides, defensins, and other
inflam- matory mediators. TNFα augments the effects of IL-17 on keratinocytes.

TNFα, IL-23, and IL-17 production is elevated in lesional skin from patients with
psoriasis, and effective treatment reduces the levels of these cytokines. The
existence of an IL-17–dependent, TNFα-augmented feed-forward loop that
amplifies inflammation in pso- riatic lesions provides a construct for understanding
why agents that antagonize TNFα signaling are effica- cious in this disease. The
relevance of the IL-23/IL-17 axis in psoriasis has been even more convincingly
demonstrated in subsequent studies with increasingly selective therapeutics.
Ustekinumab (anti-human p40) had dramatic effects in patients with psoriasis in
pilot studies, and its efficacy has been borne out in sub- sequent, now long-term,
Phase III studies. Because p40 is a polypeptide subunit that is shared by Th17-
modulating IL-23 and Th1-modulating IL-12, effects of ustekinumab could not be
definitively attributed to modulation of Th17 cells and Il-17.

The anti-IL-17A monoclonal antibodies secukiumab and ixekinumab are now FDA
approved for use in patients with psoriasis because they are remarkably effective
with rapid onset of action and frequently complete or almost complete responses,
convincingly solidifying IL-17’s critical role in psoriasis pathogen- esis. Anti-IL-
23 p19 monoclonal antibodies (includ- ing guselkumab) are also reported to be
efficacious in psoriatic patients and may be commercially available soon. The
utility of agents that target signaling of the Th17-cell product IL-22 that may cause
acanthosis by acting directly on keratinocytes has yet to be demon- strated, but this
approach may also have merit.

One unanswered question relates to the cellular source of IL-17 in psoriatic skin.
Conventional T cells bearing antigen-specific receptors composed of α and β chains
were presumed to be responsible, but the pos- sible involvement of recently
discovered innate lym- phocytes must now be considered. Subsets of innate
lymphocytes (termed ILC1, ILC2, and ILC3) have the capacity to produce T-cell
cytokines (IFNγ, IL-5/IL-13, and IL-17, respectively) but do not recognize and are
not activated by peptide antigens. These cells also do not need to proliferate to
express effector function. The extent to which ILCs participate in psoriasis will
require further study.

Another unanswered question relates to the aggres- siveness with which psoriasis
patients should be treated with biologic agents. As of this writing, stud- ies have
involved only patients with moderate to severe psoriasis. Several effective biologics
have been remarkably well tolerated, but the cost of therapy is significant and cures
or long-term remissions do not typically result. The discovery that patients with
pso- riasis have significant comorbidities, including cardio- vascular disease,42 and
decreased life spans suggests that widespread use of systemic treatments might be
appropriate. It is possible that biologics may have general health-promoting
activities, even in patients with mild psoriasis. Additional clinical research will be
required.

From a disease pathogenesis perspective, the major unanswered question in

psoriasis relates to the nature of the initial triggering event(s) and the process(es)
by which the IL-23/IL-17 axis becomes engaged. Related to this, identification of
the source(s) of the lynchpin cytokine IL-17 is critical (see before). Increasingly
large and sophisticated GWASs have been conducted with psoriasis patients over
the past several decades in an effort to obtain mechanistic insights.43 Despite that
fact that currently identified susceptibility loci explain only a minor component of
the genetic predisposition in psoriasis, some conclusions can be drawn. Genetic
susceptibility loci in atopic dermatitis and psoriasis are largely nonoverlapping,44
consistent with the concept that disease-causing mechanisms are distinct in these 2
disorders. GWASs of patients with differing ethnici- ties yield differing results,
reaffirming that psoriasis is a complex multifactorial/multigenic disorder. GWASs
of psoriasis variants (including pustular psoriasis and psoriatic arthritis) also
highlight different genetic loci, as might be expected in studies of patients with such
distinct clinical features.45

Most single nucleotide polymorphisms (SNPs) that have been linked to psoriasis
occur in regions of the genome that do not encode proteins. Some genetic vari- ants
may occur in important gene regulatory regions or may influence gene expression
indirectly via transcrip- tion of gene regulatory noncoding RNAs. However, it is
likely that at least some (and perhaps most) SNPs are actually in linkage
disequilibrium with the genetic alterations that are causative. Higher-resolution
stud- ies that involve more extensive genetic characteriza- tion (whole exome or
whole genome sequencing, for example) and/or even larger numbers of patients
may be additionally informative.

SNPs in the MHC Class I locus confer the largest amount of genetic risk in both
European and Chinese psoriasis populations.46 Other well-established genetic risk
loci include the gene encoding endoplasmic retic- ulum aminopeptidase 1, genes
encoding components of signaling pathways that are operative in innate immunity,
and genes that influence the activity of the IL-23/IL-17 axis. There are rare
examples of patients with causative mutations in individual genes of inter- est.
These genes include IL23R, CARD14 (a scaffold- ing protein that participates in
NFkB signaling), and IL36RN. It is not difficult to incorporate linkage of pso- riasis
to genetic alterations in genes regulating innate immunity and/or the IL-23/IL-17
axis. Strong linkage of psoriasis to genetic alterations in the MHC Class I locus
suggests that adaptive immunity and conven- tional T cells are also very important.

Modern concepts of psoriasis pathogenesis can eas- ily incorporate conventional T

cells, but the accepted importance of Th17 cells would predict that variants of
interest would occur in the MHC Class II locus, rather than the MHC Class I locus.
Despite this, it has been possible to identify MHC Class I–restricted IL-17–
producing CD8+ T cells that react with melanocyte- derived ADAMTS-like protein
5 in some psoriatic patients.47 In other studies, CD4+ and CD8+ T cells reac- tive
with keratinocyte-derived antimicrobial peptide LL37 have been identified.48 T
cells producing IL-17 as well as IFNγ, IL-22, and IL-21 in response to LL37 are
more prevalent in psoriatic patients than controls, and frequencies of antigen LL37-
reactive T cells in peripheral blood correlate with disease severity. LL37 is an
interesting protein antigen because it is more pro- miscuous with respect to MHC
restriction than typi- cal protein antigens. LL37/self DNA complexes are also potent
inducers of IFNα/β production by acces- sory cells, so it is possible that the adjuvant
properties of LL37 are also relevant to psoriasis. Undoubtedly, future studies will
provide additional insights into early aspects of psoriasis pathogenesis.

ALOPECIA AREATA

Alopecia areata (AA) is an often chronic and disabling disease that is characterized
by intermittent and/or long-lasting hair loss of varying severity that can occur in
association with other autoimmune diseases includ- ing thyroiditis. The 3 major
phenotypic variants are termed patchy, universalis (involving the entire scalp), and
totalis (involving entire integument). Scalp biop- sies obtained from the peripheries
of expanding lesions feature lymphocyte-predominant inflammation and patients
may respond to locally administered or sys- temic corticosteroids, both consistent
with an immune- mediated etiology. Preferential association of lesional
lymphocytes with anagen hair bulbs (Fig. 13-4), rather than the stem cell–
containing bulge regions, is consis- tent with the characterization of AA as a
nonscarring alopecia and the ability of skin that appears devoid of terminal hairs to
“re-grow” apparently normal com- plements of hair in some instances.

AA is an example of a fascinating skin disease that has been studied for many years
and that has only recently begun to reveal its secrets. Progress can be attributed to
multidisciplinary studies of thousands of AA patients buttressed by work involving
animal models. Interestingly, studies with patients and rodents have proceeded in
parallel and results obtained have often been highly complementary.
Several animal models have been particularly informative.49 One particular mouse,
the C3H/HeJ mouse, develops inflammatory lesions that resemble AA with some
regularity as it ages. This occurrence in mice and AA patients is thought to result
from loss of “immune privilege” that is a property of normal hair follicles (HFs).
The HF antigens that are targeted by lymphocytes and the mechanisms that protect
HFs from immune-mediated damage under normal cir- cumstances have not been
completely characterized. Immune privilege may depend on low-level expres- sion
of MHC Class I and Class II antigens by HF kera- tinocytes and local production
of immunosuppressive cytokines and perhaps neuropeptides. The frequency of
disease development in C3H/HeJ mice can be greatly enhanced by transferring
lymphocytes from affected mice into disease-free mice, documenting the
importance of lymphocytes in disease pathogenesis and providing an experimental
platform with which to characterize the properties of pathogenic cells, poten- tially
dissecting mechanisms that cause HF damage and test novel therapeutic
interventions.

Studies in the C3H/HeJ mouse demonstrate that CD8+ (cytotoxic) T cells and IFNγ
are important effec- tors in this model,50 inducing HF dystrophy and pre- mature
entry into catagen via mechanisms that are incompletely characterized (Fig. 13-4).
The cytokine IL-15 is known to be important for CD8+ T-cell induc- tion and/or
persistence, so it is not surprising that neutralization of IL-15 also attenuates AA
activity. Coadministration of CD4+ CD25– (helper) T cells with CD8+ T cells
promotes disease progression whereas coadministration of CD4+ CD25+
(regulatory) T cells with CD8+ T cells prevents disease induction.

The use of xenograft models that involve placement of AA patient scalp skin or
normal volunteer glabrous skin onto immunocompromised SCID or SCID beige
mice followed by introduction of syngeneic or alloge- neic human leukocytes
locally or systemically serves
as a bridge between studies of the C3H/HeJ mouse model and studies of AA
patients. Adoptive transfer of leukocytes results in hair loss within the xenografts,
resulting in an experimental system that may facilitate delineation of pathogenic
mechanisms and trials of new therapies in a relevant preclinical model. Initial
studies of mice engrafted with AA scalp documented the pathogenicity of
intracutaneous CD8+ T cells, but logistics limited the general utility of this
approach. Attempts to substitute skin and leukocytes from nor- mal volunteers for
those from AA patients demon- strated that activated lymphocytes, including NK
cells, from even normal individuals could induce AA-like hair loss from syngeneic
or allogeneic skin after local injection. Although this “AA” model does not allow
assessment of patient-specific factors, it has been used to characterize mechanisms
that can lead to hair dys- trophy and to screen for agents, including phosphodi-
esterase inhibitors and ion channel blockers, that may have utility in AA.

There are important physiologic differences between cutaneous immune systems

and hair follicles in mice and humans and, as alluded to above, xenograft stud- ies
have significant limitations. Fortunately, using con- temporary approaches, in
recent years it has become possible to move from observational, correlative studies
of limited scope to large-scale studies of AA patients who were initially hypothesis-
generating and later hypothesis-testing. One important consequence is the
identification of targeted therapies that can be expected to have a major impact on
AA in the immedi- ate future.

Initial GWASs involving >1000 AA patients and >3000 case controls identified a
number of single- nucleotide polymorphisms (SNPs) that were disease-
associated.51 The location of these SNPs suggested the possible involvement of
genes related to T cell– mediated immune responses (CTLA4, ICOS, IL21/IL2,
IL2RA), NK cells (NKG2D ligand genes), as well as anti- gen presentation (HLA-
DR/DQ genes). Subsequent GWASs and related studies have highlighted addi-
tional candidate genes that reinforce the importance of T-cell regulators and the role
of HLA-DR (encoding MHC Class II antigens) as the dominant susceptibil- ity
locus.52 In follow-up studies of the C3H/HeJ AA mouse model, the importance of
CD8+ NKG2D+ T cells and the T-cell cytokines IFNγ, IL-2, and IL-15 was con-
vincingly demonstrated.50 Involvement of CD8+ T cells, IFNγ and IL-15, in
conjunction with studies of gene expression in lesional skin, suggested a critical
role for JAKs and STAT (signal transducers and stimulators of transcription)
transcription factors and the JAK/STAT pathway as a possible target for
intervention. Subse- quent studies indicated that selective JAK1 inhibitors have
considerable activity in this model, whereas JAK3 inhibitors did not.

The best source of critical information regarding disease effector mechanisms and
disease activity is involved tissue obtained from patients. Global tran- scriptional
profiling of lesional skin is an unbiased and comprehensive way to gain insights
into cells and proteins that are likely to be present at sites of disease activity.
Patient- and animal model-derived samples can be subjected to analogous analyses,
so results in these 2 settings can be easily compared. Recent stud- ies of patients
with patchy AA (AAP), AA universalis (AAU), and AA totalis (AAT) reinforce
preexisting con- cepts and provide new insights as well.53 Comparison of AA and
normal cutaneous transcriptomes resulted in an AA gene expression signature with
∼1000 ele- vated and ∼1000 reduced transcripts in AA lesional skin as compared
with controls. Principal components analysis indicated that the gene expression
signatures of controls and AAP patients could be distinguished from those of AAU
and AAT patients, while the gene expression profiles of AAU and AAT patients
did not segregate. Highly represented transcripts in AA biop- sies were attributable
to the presence of CD8+ T cells, chemokines involved in leukocyte trafficking, and
IFNγ signaling (Th1-predominant inflammation). Gen- eration of numerical scores
that reflected the aggre- gate deviation of the gene expression signatures in AA
biopsies from those of normal individuals confirmed that AAP patients could be
differentiated from con- trols and AAU/AAT patients, and that profiles from
AAU/AAT patients were more abnormal than AAP profiles. Because
transcriptional profiling is a measure
of ongoing physiologic activity, the latter result sug- gests that disease is active in
AAU/AAT skin and per- haps even more active than in AAP skin. This result is not
compatible with the concept that the AAU/AAT is end stage, that HFs are in
irreversible catagen, and that antiinflammatory therapies cannot be of benefit in
these recalcitrant AA variants.

Although the final solution of the AA puzzle is not yet available, complementary
laboratory and clinical research has led to great progress. It is not yet possible to
prospectively identify individuals who are at risk or to prevent disease
development, but rational and effec- tive targeted therapies are likely to be in
widespread use soon. Indeed, recent Phase II studies document significant
responses to JAK inhibitors in subpopu- lations of AA patients.54,55 One can make
the case that AA could be a “poster child” for immunologic/ inflammatory skin
diseases of uncertain etiology, and analogous laboratory and clinical research
approaches could someday result in similar advances.

AUTOIMMUNE BLISTERING

DISEASES

Autoimmune blistering diseases are chronic, debili- tating diseases that manifest as
blisters or erosions involving skin and/or mucous membranes. Some auto- immune
blistering diseases are fatal if left untreated. Classification of these diseases is based
on clinical fea- tures, including lesion distribution and gross and his- tologic
morphology. Pemphigus and pemphigoid are the most common autoimmune
blistering disorders. Pemphigus can additionally be subcategorized into pemphigus
vulgaris (PV) and pemphigus foliaceous (PF). PV manifests with flaccid bullae or
erosions involving mucous membranes and skin, whereas PF affects only the skin
and presents with fragile blisters or superficial erosions. Bullous pemphigoid may
man- ifest with urticarial lesions with subsequent develop- ment of tense bullae on
skin and, much less commonly, erosions on mucous membranes. This stands in
contra- distinction to mucous membrane pemphigoid and epi- dermolysis bullosa
acquisita, which feature primarily mucosal lesions and mucosal and cutaneous
lesions, respectively.

Results from routine histology and direct or indirect immunofluorescence

microscopy can provide impor- tant diagnostic information. The identification and
characterization of autoantigens in blistering diseases, coupled with the
demonstration that autoantibodies are pathogenic, have enabled development of
novel diagnostic enzyme-linked immunosorbent assays (ELISAs) that detect
circulating autoantibodies that react to corresponding autoantigens.

Pemphigus and bullous pemphigoid (BP) are the 2 most intensively studied
autoimmune blistering diseases. Studies of patients’ sera identified autoan- tibodies
that react with the epidermis in the case of pemphigus patients and with the
basement mem- brane zone in patients with bullous pemphigoid.

The demosomal protein desmoglein 3 (Dsg3) is the major autoantigen targeted

initially by antibodies in pemphigus vulgaris, and desmoglein 1 (Dsg1) is the
primary autoantigen in pemphigus foliaceus.56 PV patients typically develop anti-
Dsg1 autoantibodies at some point after anti-Dsg3 autoantibodies appear. Dsg3 is
a major component of desmosomes that medi- ate cell adhesion between
keratinocytes in the lower layers of the epidermis, whereas Dsg1 is a major des-
mosomal protein expressed by superficial epidermal keratinocytes. The distribution
of Dsg3 and Dsg1 in epidermis determines the locations of blister formation in PV
and PF, and the sequence of appearance of oral and cutaneous lesions in PV.
Because Dsg3, but not Dsg1, is expressed in oral and esophageal mucosae, mucosal
involvement is observed in PV but not in PF. Other rare forms of pemphigus include
IgA pemphi- gus, in which IgA autoantibodies against desmocollin 1 (another
component of desmosomes), Dsg1, or Dsg3 cause disease, and paraneoplastic
pemphigus, which is associated with autoantibodies against multiple des- mosomal
proteins as well as T cells that may contrib- ute to epidermal–dermal interface
destruction.57
 BP is caused by IgG autoantibodies that react with components of
hemidesmosomes, adhesive struc- tures that mediate adhesion of basal
keratinocytes to the basement membrane. Two major antigens are targeted in BP;
collagen XVII (COL17, also known as BP180 or BPAG1) and the plakin family
protein BP230 (BPAG2).58 COL17 is expressed on cell surfaces and it is
considered to be the major BP autoantigen. Although anti-BP230 antibodies also
can be frequently detected in patients, the pathophysiologic role of anti-BP230
antibodies is uncertain because BP230 is an intracellu- lar protein. Related diseases
include pemphigoid ges- tationis and pemphgoid herpetiformis. Pemphigoid
gestationis exhibits clinical features and autoantibody profiles that are identical to
BP and develops only in pregnant women. Mucous membrane pemphigoid has been
reported in patients with circulating antibod- ies reactive with COL17, BP230,
laminin 5, laminin 6, Type VII collagen (COL7), laminin 5, laminin 6, and β4
integrins,59 whereas epidermolysis bullosa acquisita is caused by anti-COL7
antibodies.60

Injection of human PV-derived IgG causes blister development in mice.61 Studies

involving recombi- nant Dsg3 and Dsg1, as well as engineered molecules in which
the extracellular domains were exchanged, demonstrated that the anti-Dsg3
autoantibodies that cause skin blistering target N-terminal domains of Dsg3
(extracellular domains 1 and 2).62,63 Generation of Dsg3 knockout (KO) mice
allowed development of an active disease model for PV.64 Dsg3-reactive T and B
cells are generated when Dsg3 KO mice are immu- nized with recombinant Dsg3.
When splenocytes from Dsg3-immune Dsg3 KO mice were transferred into Dsg3-
sufficient mice, recipient mice developed skin and mucosal lesions and
autoantibodies reactive with Dsg3. Formation of anti-Dsg3 autoantibodies by B
cells in these mice is dependent on the presence of CD4+ T cells. Patients with PV
and PF also harbor autoanti- bodies that react with antigens other than Dsg3 and
Dsg1.56,65 It is possible that these autoantibodies also contribute to pemphigus
pathogenesis. Lesion forma- tion is not thought to be complement-dependent, and
anti-DSG antibodies may cause acantholysis by trig- gering intracellular signaling
in keratinocytes.

In BP patients, the majority of anti-COL17 IgG auto- antibodies target the NC16a
domain.66 In contrast to PV, passive transfer of IgG from BP patients does not
cause disease in mice.67 This may reflect varying amino acid sequences in the
NC16A domains of COL17 in mice and humans. Supporting this, transgenic mice
that express human COL17 do develop blisters after injection with IgG from BP
patients.68 Mechanisms that cause lesion formation in BP appear to be different
from those that cause blisters in pemphigus patients. Complement (C3) deposition
in the basement membrane zone is universal in BP. Passive transfer of rabbit anti-
COL17 into mice causes blisters in normal mice, but not in complement- deficient
mice, indicating a critical role for complement in BP lesion formation.69 Consistent
with this, passive trans- fer of recombinant Fab fragments of human anti-NC16a
domain autoantibodies does not cause disease in human COL17-expressing
transgenic mice.66 Local complement activation in BP lesions attracts neutrophils
in mice, and these cells are also thought to participate in blister forma- tion, perhaps
by producing metalloproteinases. Promi- nent tissue and peripheral blood
eosinophilia also occurs in BP, and IgE autoantibodies can be detected in the sera
and skin of a subset of BP patients, consistent with the concept that the immune
mechanisms operative in BP are distinct from those in pemphigus.66

Autoimmune diseases develop when the immune system inappropriately attacks

self-antigens. Central and peripheral tolerance, immune regulatory mecha- nisms
acting in the thymus and peripheral organs, respectively, prevent the immune
system from react- ing against self in normal individuals. Mechanisms responsible
for loss of tolerance in patients with auto- immune diseases have not been
elucidated. However, the increased incidence of pemphigus (especially PF) in
patients with thymoma suggests that impairment of central tolerance relates to the
onset of pemphi- gus. Some patients with pemphigoid gestationis also develop
autoimmune thyroiditis, suggesting that loss of tolerance may occur in these
patients as well, and that both autoimmune diseases arise due to dysregu- lated
immunity that occurs during pregnancy.

Autoimmune blistering diseases are commonly treated with systemic

glucocorticoids with or without other immunosuppressive agents, including
azathio- prine, mycophenolate mofetil, and cyclophosphamide. The development
of the monoclonal antibody ritux- imab has allowed targeted therapies for
autoimmune bullous diseases, in particular pemphigus, that has redefined standard
care of these diseases.70,71 Rituximab binds the cell surface protein CD20 that is
expressed by B cells. This leads to the depletion of both normal and autoreactive B
cells in patients, and the possibility of prolonged remissions. Rituximab therapy is
well toler- ated, and its efficacy and safety as first line of therapy in combination
with short-term corticosteroid has been recently demonstrated.71

A recent study reports development of an alterna- tive approach involving chimeric

autoantigen recep- tor (CAAR) T cells.72 T cells are genetically modified to
express Dsg3 that was engineered to activate T cells after surface crosslinking.
When Dsg3-expressing CAAR T cells bind to B cells that express surface anti-
Dsg3 IgG, the CAAR T cells are activated and they subsequently destroy Dsg3-
reactive B cells. This strat- egy, or related strategies, may ultimately lead to novel
antigen-specific therapies in pemphigus (and other autoantibody-mediated
disorders) that are safer and more efficacious than those in use currently.

CONCLUSIONS AND FUTURE DIRECTIONS

This chapter summarizes our current understand- ing of the pathophysiology of

several immunologic/ inflammatory skin diseases. We have selected exam- ples of
diseases where our understanding is detailed. This list is short, whereas the list of
immunologic/ inflammatory skin diseases in which our understand- ing of disease
pathogenesis is inadequate is long. Although studies of experimental animal
models, in many cases, provide fundamental knowledge that is prerequisite for
studies of humans, the efficiency with which studies of patients yield information
that affects patient care is increasing. In the case of immunologic/ inflammatory
skin diseases, the advent of “low cost” GWAS and other genetic studies and the
availability of biologic agents with exquisite specificity have been both timely and
important. It seems likely that the types of approaches that have been successful in
pso- riasis and alopecia areata will have utility in studies of patients with other
immunologic/inflammatory skin diseases if implemented with similar enthusiasm,
and that improved therapies will result.