T cells assume a fundamental function in immunosurveillance and maintenance of the cutaneous immune barrier, yet derangement of their requisite role effects a range of cutaneous autoimmune diseases with significant associated morbidity. While blistering skin diseases, such as pemphigus vulgaris (PV), pemphigus foliaceus (PF) and bullous pemphigoid (BP) are mediated by antibodies directed against autoantigens found in the skin, recent evidence has shown that T cell activation is crucial for the initiation and coordination of this humoral response. Non-blistering skin diseases, such as alopecia areata (AA), vitiligo (VL) and psoriasis (PS) are increasingly believed to be directly mediated by the activities of autoreactive T cells. Here, we examine T lymphocyte control of antibody-mediated and cell-mediated processes involved in the pathoimmunology of the above mentioned skin diseases.
A 44-year-old woman presented with an 18-month history of a pruritic dermatitis in the axillae bilaterally, beginning in the springtime. There was no history of significant hyperhidrosis. The patient did not recall any change in deodorant, soap, detergent, or other topical products. Her family history was unremarkable for anyone with similar symptoms. Physical examination revealed hyperpigmented plaques on an erythematous base in both axillae. The inframammary and intertriginous folds were free of lesions. Histologic examination taken from the left axilla was notable for mild digitate papillomatosis, compact hyperparakeratosis with large nuclei, and retained keratohyaline granules within the stratum corneum (Figure), consistent with axillary granular parakeratosis. A periodic acid-Schiff stain was negative for hyphae. Patch testing utilizing the thin-layer rapid-use epicutaneous test (T.R.U.E. Test, Mekos Laboratories, Hillerod, Denmark) was unremarkable. The patient was initially treated with fluticasone propionate 0.05% cream without notable improvement. She then received Clostridium botulinum type A neurotoxin injections to the axillae (50 U/axilla) with complete resolution of the rash within a few days. At 6-months' follow-up, the patient remained asymptomatic.
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