Recent studies have suggested that T cells play a critical role in the pathogenesis of psoriasis. Guttate psoriasis is a well-defined form of psoriasis frequently associated with streptococcal throat infection. This study tested the hypothesis that T cells in acute guttate psoriasis skin lesions may be activated by streptococcal superantigens. Peripheral blood as well as lesional and perilesional skin biopsies were analyzed for T cell receptor Vfi repertoire using monoclonal antibodies against 10 different V8 families. Skin biopsies from all patients with acute guttate psoriasis, but not skin biopsies from patients with acute atopic dermatitis or inflammatory skin lesions induced in normal subjects with sodium lauryl sulfate, demonstrated selective accumulation of Vfi2+ T cells (P < 0.05). The expansion of V.82+ T cells occurred in both the CD4+ and the CD8+ T cell subsets.Sequence analysis of T cell receptor chain genes of V/32-expressing T cells from skin biopsies of patients with guttate psoriasis showed extensive junctional region diversity that is more compatible with a superantigen rather than a conventional (nominal) antigen-driven T cell response. All streptococcal isolates from patients with guttate psoriasis secreted streptococcal pyrogenic exotoxin C, a superantigen known to stimulate marked Vj32+ T cell expansion. These data support the concept that acute guttate psoriasis is associated with superantigenic stimulation of T cells triggered by streptococcal superantigen(s). (J. Clin. Invest. 1995. 96:2106-2112
Imiquimod is the first of the immune response modifiers to stimulate a localized immune response to treat infectious skin conditions. The reported TLR-7 activation to provoke an immune response suggests that imiquimod might mimic a microbial antigen. The immune response initiated by induced production of IFN-alpha and TFN-alpha is specifically aimed at an infectious antigen and appears mediated (in part) by enhanced migration of Langerhans' cells to regional lymph nodes. The approved indication for imiquimod is for treatment of genital warts. The drug has demonstrated a 50% to 60% clearance rate and a 12% to 20% recurrence rate for this indication (Table 1). This recurrence rate is the lowest reported among the currently recommended treatment modalities. The self-applied treatment avoids costly and painful office-based procedures. Case reports and open-label studies have demonstrated the efficacy of imiquimod in treating some cases of common, plantar, and flat warts, as well as molluscum contagiosum and leishmaniasis. Common and plantar warts respond better to imiquimod in combination with cryosurgery, occlusion, and keratolytics. Reports of successful imiquimod treatment of granuloma annulare, alopecia areata, and vitiligo might suggest an infectious etiology to those conditions, although this hypothesis is highly speculative.
Both EMLA and ice decreased the discomfort associated with needle injection. Although EMLA performed better in pain control, ice has advantages in ease of use, fast action, and is less expensive than EMLA. Both EMLA and ice were good topical anesthetics, each with advantages and disadvantages in clinical use.
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