CORRESPONDENCE
after the event does not allow a firm
conclusion on either the adequacy of
the cross-infection measures or the
infectivity of the different strains.
Finally, I agree that it is important to
define the extent of the potential
problem and use the experience to keep
the risk of this happening again to a
minium.
Duncan Geddes
Department of Respiratory Medicine, Royal
Brompton Hospital, London SW3 6NP, UK
In-vivo dedifferentiation of
keratinocytes to epidermal
stem cells
Sir—In the past few years, some
spectacular works have raised doubts
about many long-standing dogmas in
the stem-cell world. In this context,
Xiaobing Fu and colleagues (Sept 29,
p 1067)1 report a study of a putative
epidermal keratinocyte dedifferen-
tiation.
By immunohistochemistry, they
found some nests of keratin 19 (+) ␤1
integrin (+) cells in suprabasal layers of
regenerating epidermis from leg ulcers
treated with recombinant human
epidermal growth factor (EGF). They
maintain that their findings provide
evidence for cell dedifferentiation to
stem cells. However, their analysis is
unconvincing and seems to be
excessively speculative.
First, the method used and results
stated do not support the conclusions
implied. The stem cells share label-
retaining and clone forming ability.2
The cells are generally slowly cycling,
but they proliferate during wound
healing. Fu and colleagues speculate
that keratin 19 and ␤1 integrin are
specific markers of epidermal stem cells
by immunohistochemistry, but we
know that this is wrong. No keratin 19
staining is seen in label-retaining cells—
the putative stem cells—in the
epidermis, and keratin 19 does not
exclusively stain the bulge label-
retaining cells of the hair follicle; in
contrast, keratin 19 is seen in the basal
cells of the fetal epidermis.3 In addition,
all basal cells express ␤1 integrin, which
suggests that it is inaccurate to suggest
that ␤1 integrin may be a stem cell
marker in immunohistochemical
studies.
Second, wound healing involves a
complex series of interactions involving
several cell types and the release of
cytokines and growth factors. EGF
increases the rate of keratinocyte
migration and induces an increased
expression of some keratins.4 EGF
may play an initial role in wound
528
For personal use. Only reproduce with permission from The Lancet Publishing Group.
healing by stimulating keratinocyte
proliferation and migration. In conven-
tional immunohistochemical sections,
␤1 integrin (+) keratin 19 (+) keratino-
cytes can be seen in the upper layers as a
consequence of upward migration from
the basal layer—a feature common to all
keratinocytes.
Third, the suprabasal keratin 19 (+)
␤1 integrin (+) cells may be transit
amplifying cells, rather than stem cells.
It would be useful to look for the
expression of epidermal-type fatty acid
binding protein in these cells to
differentiate transit amplifying cells
from stem cells.5
Finally, we think that this immuno-
histochemical study cannot clearly show
keratinocyte reversion. Further study
will be needed to prove keratinocyte
dedifferentiation conclusively.
*Michel Brouard, Yann Barrandon
*Department of Dermatology, Geneva University
Hospital, 1211 Geneva 14, Switzerland; and
Department of Biology, École Normale
Supérieure, Paris, France
(e-mail: mcvpb@hotmail.com)
1 Fu X, Sun X, Li X, Sheng Z.
Dedifferentiation of epidermal cells to stem
cells in vivo. Lancet 2001; 358: 1067–68.
2 Oshima H, Rochat A, Kedzia C, Kobayashi
K, Barrandon Y. Morphogenesis and renewal
of hair follicles from adult multipotent stem
cells. Cell 2001; 104: 233–45.
3 Michel M, Torok N, Godbout MJ. Keratin
19 as a biochemical marker of skin stem cells
in vivo and in vitro: keratin 19 expressing
cells are differentially localized in function of
anatomic sites, and their number varies with
donor age and culture stage. J Cell Sci 1996;
109: 1017–28.
4 Barrandon Y, Green H. Cell migration is
essential for sustained growth of keratinocyte
colonies: the roles of transforming growth
factor-alpha and epidermal growth factor.
Cell 1987; 50: 1131–37.
5 Watt F. Stem cell fate and patterning in
mammalian epidermis. Curr Opin Genet Dev
2001; 11: 410–17.
1
Sir—Xiaobing Fu and colleagues
report the occurrence of epidermal
stem-cell islands in the regenerating
epidermis of recombinant human
epidermal growth factor (rhEGF)
treated human skin ulcers.
Immunohistochemistry was done to
identify epidermal stem cells expressing
keratin 19 and ␤1 integrin.2,3 In normal
epidermis, cutaneous epidermal stem
cells form a single layer on the
basement membrane but no groups of
cells positive for ␤1 integrin and keratin
19—ie, epidermal stem-cell islands—
can be seen in the spinous and granular
layers between the basal layer and the
stratum corneum.4
Fu and colleagues show skin biopsy
samples to underlay their hypothesis.
An error seems to have occurred in the
selection of the figures since the panels
showing staining for ␤1 integrin (B)
and keratin 19 (C) are evidently taken
THE LANCET • Vol 359 • February 9, 2002 • www.thelancet.com
from the same histological section from
a slightly different but highly over-
lapping area.
Furthermore, two of the figure
panels, A and D, show strictly vertical
sections, whereas the other two show
oblique cuts of the samples. As a busy
dermatopathologist, I recognised this
artefact first by the much thicker
epidermis in the latter two panels than
in the former (despite similar magnifi-
cation identifiable by comparable size of
nuclei) and more importantly, by the
loss of normal epidermal stratification:
vertical sections conventionally show
vertically oriented oval to elongated
nuclei in the basal layer that become
more and more horizontally oriented in
the spinous and granular layers.
Consequently, cells of stratum granulo-
sum are flat and the granular layers
thin. This description is in contrast to
figure panels B and C, which show no
elongated nuclei of the basal layer, no
great change of orientation in the
spinous layers, and a thickened granular
layer.
Since the epidermis has a three-
dimensional papillary organisation this
leads to a more straightforward expla-
nation of stem-cell islands: these cells
are simply the tangentially dissected
epidermal ends of dermal papillae. This
also explains why control samples had
one layer of cells expressing keratin 19
and ␤1 integrin, whereas treatment
samples had two or more. Fu and
colleagues may not have thought of this
fact leading to their misinterpretation of
stem-cell island occurrence.
*Klaus Eisendle, Bernhard Zelger
Department of Dermatology, University of
Innsbruck, 6020 Innsbruck, Austria
(e-mail: Klaus.eisendle@unibk.ac.at)
1 Fu X, Suna X, Lib X, Sheng Z.
Dedifferentiation of epidermal cells to stem
cells in vivo. Lancet 2001; 358: 1067–68.
2 Cotsarelis G, Kaur P, Dhouailly D,
Hengge U, Bickenbach J. Epithelial stem
cells in the skin: definition, markers,
localization and functions. Exp Dermatol
1999; 8: 80–88.
3 Jones PH, Watt FM. Separation of human
epidermal stem cells from transit amplifying
cells on the basis of differences in integrin
function and expression. Cell 1993; 73:
713–24.
4 Turksen K, Troy T. Epidermal cell lineage.
Biochem Cell Biol 1998; 76: 889–98.
Sir—We think that Xiaobing Fu and
colleagues’ results1 should be carefully
reassessed, because the stem-cell
islands they report may be only stem-
cells around dermal ridges.
In contrast to the control samples or
normal skin, the epidermis of the
patients treated with rhEGF had a
thicker layer probably because of the
rhEGF. We wonder whether the
rhEGF-treated skin was vertically