BRIEF COMMUNICATION

Local effects of TL01 phototherapy in psoriasis

Bernadette DeSilva1, Roddie C. McKenzie1, John A. A. Hunter1 & Mary Norval2
1

Department of Dermatology and 2Department of Biomedical Sciences, University of Edinburgh, Edinburgh, UK

Summary
Key words:
Langerhans cells; p53; psoriasis; sunburn cells; TL01

Correspondence:
Prof. Mary Norval, Department of Biomedical Sciences, University of Edinburgh Medical School, Teviot Place, Edinburgh EH8 9AG, Scotland, UK. Tel: 144 131 650 3167 e-mail: m.norval@ed.ac.uk

Accepted for publication:

19 March 2008

The mechanisms whereby narrowband ultraviolet B (UVB) (311313 nm, TL01) phototherapy are effective in psoriasis may differ from those occurring in broadband UVB phototherapy. In the present study, changes in epidermal cells as a result of TL01 therapy were assessed in the skin of patients with psoriasis. The non-lesional skin of ve subjects with plaque psoriasis was biopsied before and after a series of 12 whole-body TL01 treatments. Following appropriate staining of skin sections, the numbers of p53-positive keratinocytes, sunburn cells and Langerhans cells in the epidermis were counted. TL01 therapy induced a threefold increase in the number of p53-positive epidermal cells, a 12-fold increase in sunburn cells and a twofold decrease in Langerhans cells. The increase in epidermal p53 expression and apoptosis of keratinocytes together with the depletion of Langerhans cells in the non-lesional skin of psoriasis patients are likely to contribute to the effectiveness of TL01 phototherapy.

Conicts of interest:
None declared.

he mechanisms by which narrowband ultraviolet B (UVB) (311313 nm, TL01) phototherapy achieves therapeutic clearing of psoriasis are thought to be different, at least in degree, from those that occur in broadband UVB phototherapy (1, 2). Previous studies in human subjects have shown that exposure to TL01 thrice weekly for 5 weeks induced a 69% decrease in the number of epidermal Langerhans cells in normal skin (3), and TL01 therapy resulted in an increase in p53expressing keratinocytes in psoriasis plaques (4). We wished to extend these observations by assessing the effect of TL01 treatment on numbers of p53-positive epidermal cells, sunburn cells and Langerhans cells in the non-lesional skin of patients with plaque psoriasis.

Patients and methods

Five subjects (three males and two females; mean age standard error of the mean 49.2 7.0, range 2766) were randomly selected from patients with plaque psoriasis attending the phototherapy clinic at the Royal Inrmary of Edinburgh. They were all white Caucasians of phototype II or II who had mild to moderate psoriasis and were not using topical tars or dithranol, nor had any evidence of immunosuppressive disease. None were taking topical or systemic immunosuppressive drugs or potent steroids, although some were using emollients or topical vitamin D analogues. Informed consent was obtained from all the subjects, and the study was approved by the Ethical Committee of the Lothian Trust Health Board. Their PASI scores ranged from

4.8 to 8.2 (mean 6.2 0.6). Punch biopsies (4 mm) were taken from non-lesional buttock skin before the start of the phototherapy and 24 h after the last of 12 whole-body treatments (three times weekly) in Waldmann cabinets tted with TL01 lamps. The mean dose received after the 12 exposures was 13.39 3.17 J/m2 (range 3.3020.40 J/m2). The biopsies were parafn-embedded, sectioned and immunostained, using standard ABC procedures (5), with a monoclonal antibody specic for p53 (DO7, diluted 1 : 1000, Dako Ltd, Ely, Cambridgeshire, UK) that recognizes both wild-type and mutated p53, and a monoclonal antibody specic for CD1a (diluted 1 : 400, Dako Ltd), which detects Langerhans cells. Sunburn cells were counted after haematoxylineosin staining and the average counts in 6 high-power elds (HPF, 400) were calculated.

Results and discussion

As shown in Fig. 1, TL01 treatment induced a threefold increase in the number of p53-positive epidermal cells. Although the difference between the pre- and postirradiation values was not statistically signicant, this was probably due to the small number of patients in the study. The change in p53 expression is similar to that observed by Jasim et al. (4) in lesional skin from patients with plaque-type psoriasis during TL01 phototherapy. There was also a 12-fold increase in the number of sunburn cells (Fig. 2), thought to represent apoptotic keratinocytes. The apoptotic death of sunburn cells is triggered by up-regulation of

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Local effects of TL01 phototherapy in psoriasis

550 500

NS

CELLS/mm BASEMENT MEMBRANE

450 400 350 300 250 200 150 100 50 0 p53 p53+TL01 CD1a CD1a+TL01

TREATMENT
Fig. 1. Mean number of p53-positive cells and Langerhans cells (CD1a1) ( standard error of the mean) in non-involved buttock skin of psoriatic patients following TL01 therapy. The number of p53-positive cells, overwhelmingly keratinocytes, was counted per millimeter basement membrane in biopsy sections before (p53) and 24 h after the nal of 12 TL01 exposures (p531TL01). Langerhans cells were counted in the same biopsies following staining with CD1a antibody. Signicantly different from CD1a, P o 0.01, paired t-test (n = 5), NS, non-signicant difference.

Langerhans cells was decreased by 50% following the TL01 therapy (Fig. 1). Such a reduction concurs with that observed in normal volunteers exposed to TL01 (3) and is considerably less than occurs after broadband (TL12) therapy (2). In summary, this study indicates that TL01 therapy causes an increase in epidermal p53 expression and apoptosis of keratinocytes, together with a depletion in Langerhans cells in the non-lesional skin of psoriasis patients. These changes may contribute to the effectiveness of the treatment. Skin samples from non-lesional sites were collected due to ethical difculties in obtaining equivalent samples from psoriatic lesions. It is not known if the changes, noted here, induced by TL01 irradiation will also occur in the psoriatic plaque, but this is thought possible as non-lesional skin contains at least some of the features seen in lesional skin such as up-regulation in various molecular markers, for example K16 and vascular adhesion protein-1, keratinocyte hyperproliferation, lack of rete ridges and dermal papillae in dermalepidermal junctions in some areas. A randomized comparison of equivalent erythemal regimes of narrowband and broadband phototherapy in subjects of the same phototype or MED would explore further the diversity in cutaneous outcomes following irradiation with UV lamps emitting different spectra.

7 SUNBURN CELLS/HPF 6 5 4 3 2 1 0 ()TL01 TREATMENT

Acknowledgements
This study was funded by the British Skin Foundation and the Agnes Hunter Memorial Trust.

References
1. Walters IB, Ozawa M, Cardinale I, et al. Narrowband (312-nm) UV-B suppresses interferon gamma and interleukin (IL) 12 and increases IL-4 transcripts: differential regulation of cytokines at the single-cell level. Arch Dermatol 2003; 139: 155161. 2. El-Ghorr AA, Norval M. Biological effects of narrow-band (311 nm TL01) UVB irradiation: a review. J Photochem Photobiol B: Biol 1997; 38: 99106. 3. Viac J, Goujon C, Misery L, et al. Effect of UVB 311 nm irradiation on normal human skin. Photodermatol Photoimmunol Photomed 1997; 13: 103108. 4. Jasim ZF, Lioe TF, McKenna KE, Rodson T, Ouhtit A. The effect of ultraviolet B (TL01) phototherapy on epidermal expression of p53 protein in psoriatic plaques. Photodermatol Photoimmunol Photomed 2006; 22: 1217. 5. Szepietowski JC, Walker C, McKenna DB, Hunter JAA, McKenzie RC. Leukaemia inhibitory factor and interleukin-8 expression in nonmelanoma skin cancers. Clin Exp Dermatol 2001; 26: 7278. 6. Sheehan JM, Young AR. The sunburn cell revisited: an update on mechanistic aspects. Photochem Photobiol Sci 2002; 1: 365377. 7. Tjioe M, Smits T, van de Kerkhof PC, Gerritsen MJ. The differential effects of broad band vs. narrow band UVB with respect to photodamage and cutaneous inammation. Exp Dermatol 2003; 12: 729733. 8. Ibuki Y, Allanson M, Dixon KM, Reeve VE. Radiation sources providing increased UVA/UVB ratios attenuate the apoptotic effects of the UVB waveband UVA-dose-dependently in hairless mouse skin. J Invest Dermatol 2007; 127: 22362244.

(+)TL01

Fig. 2. Mean number of sunburn cells (SBC) ( standard error of the mean) in non-involved skin of psoriatic patients following TL01 therapy. The number of SBC per high-power eld (HPF) in biopsy sections stained with haematoxylin and eosin before [( )TL01] and 24 h after the nal of 12 TL01 exposures [(1)TL01]. Signicantly different from ( )TL01, P = o 0.0001, paired t-test (n = 5).

p53, as well as by p53-independent mechanisms (reviewed in (6)). Tjioe et al. (7) have shown that a single exposure of healthy volunteers to three minimal erythemal doses (MED) of broadband UVB led to approximately a 10-fold increase in the number of sunburn cells; an equivalent dose of TL01 in terms of MED (about eight times higher than the broadband UVB dose) led to a similar increase. Recently it has been revealed, using hairless mice that there is a UVA/UVB waveband interaction regarding sunburn cell induction such that, as the proportion of UVA increases with a constant UVB dose, the number of sunburn cells decreases (8). In addition to these changes, the number of

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