|Year : 2015 | Volume
| Issue : 2 | Page : 514-520
Tenascin-C expression in lichen planus
Alaa H Maraee1, Azza G Farag1, Mohamed A El Tahmody2, Hany Y Metawea MSc 3
1 Department of Dermatology, Venereology and Andrology, Menoufia University, Shebein Elkom, Egypt
2 Department of Pathology, Faculty of Medicine, Menoufia University, Shebein Elkom, Egypt
3 Mehalla General Hospital, Mehalla, Gharbia, Egypt
|Date of Submission||12-Jun-2014|
|Date of Acceptance||08-Sep-2014|
|Date of Web Publication||31-Aug-2015|
Hany Y Metawea
Mehalla General Hospital, 16 Gamal Abd El Naser st, Manshiet Al Bakry, Mehalla, Gharbia
Source of Support: None, Conflict of Interest: None
The aims of this study were to evaluate the immunohistochemical expression of tenascin-C (TN-C) in lichen planus (LP) and to highlight its hypothesized role in the etiopathogenesis of this disease entity.
LP is an inflammatory disease of the skin and the mucous membrane, the exact etiology of which is not known; however, multiple theories have been proposed. TN-C is an extracellular matrix glycoprotein that plays different roles, mediating both inflammatory and fibrotic processes. However, little information about its role in LP exists.
Patients and methods
Thirty patients with LP and 10 age-matched and sex-matched volunteers as controls were included. They were subjected to complete history taking, and general and dermatological examination. Skin biopsies were taken from the lesional skin of LP patients and the normal skin of controls. Biopsies were subjected to routine hematoxylin and eosin staining and immunostaining for TN-C.
Forty-three percent of LP cases showed epidermal expression, whereas most of the cases (77%) showed a positive dermal expression. Dermal expression of TN-C is significantly elevated in cases than in controls (P = 0.01). Positive correlations between the dermal expression of TN-C and the intensity of lymphocytic infiltrate and the severity of pruritus were demonstrated. Dermal TN-C expression is significantly elevated in hypertrophic LP cases and in cases with leg lesions. Epidermal expression of TN-C showed no significant correlation with any of the clinical or pathological features.
Prominent TN-C expression in LP lesions magnifies its role in the pathogenesis of this disease.
Keywords: extracellular matrix, lichen planus, tenascin-C
|How to cite this article:|
Maraee AH, Farag AG, El Tahmody MA, Metawea HY. Tenascin-C expression in lichen planus. Menoufia Med J 2015;28:514-20
| Introduction|| |
Lichen planus (LP) is a papulosquamous eruption that is described using the six P's [planar (flat-topped), purple, polygonal, pruritic, papules, plaques]. The lesions are often covered by lacy, reticular, white lines known as the Wickham striae  . Although the exact etiology of LP is unknown, a mechanism involving activated T cells, particularly CD8 + cells, directed against basal keratinocytes has been proposed  . The upregulation of intercellular adhesion molecule-1 (ICAM-1) and cytokines associated with a T-helper 1 immune response, such as interferon g, tumor necrosis factor α (TNFα), and interleukin (IL)-1a, IL-6, and IL-8, may also play a role in the pathogenesis of LP  . Tenascin-C (TN-C) is an extracellular matrix glycoprotein that is specifically and transiently expressed upon tissue injury, and it is reported to be associated with both proinflammatory and anti-inflammatory signaling cascades , . Strong dermal expression of TN-C was observed in patients with acne  and blistering diseases  . TN-C is highly expressed in both the dermis and the epidermis of vitiligo patients  . Besides, an altered expression of TN-C was reported in oral LP lesions , . However the expression of TN-C in cutaneous lesions of LP has been reported in only one study  . Therefore, the aim of this work was to investigate the expression of TN-C in cutaneous lesions of LP.
| Patients and methods|| |
- Patients with cutaneous LP.
- Patients with other known autoimmune diseases.
- Patients receiving topical or systemic treatment in the last 2 weeks.
This study was carried out on 30 patients who presented with LP. The diagnosis was made on clinical and histopathologic bases. For comparison purposes, 10 age-matched and sex-matched apparently normal volunteers are included in the study representing controls. Both patients and control participants were selected randomly from the Outpatient Dermatology Clinics, Menoufia University Hospital. The study was approved by the Committee on Human Rights in Research of Menoufia University. An informed consent was signed by all patients and controls. Skin biopsies were taken under local anesthesia. Each of the selected patients was subjected to complete history taking, including the assessment of pruritus using the Pruritus Grading System developed by Al-Qarqaz et al.  . The Pruritus Grading System score was based on the distribution, the frequency, the severity of itch, and the quality of sleep as shown in [Table 1]. Each patient's itch grade was calculated as the sum of the individual scores as follows: mild grade, if the total score was between 0 and 5; moderate grade, if the total score was between 6 and 11; severe grade, if the total score was between 12 and 19.
Biopsies were formalin-fixed, and paraffin-embedded blocks were prepared from each skin biopsy. Two paraffin sections, each 4-μm-thick, were obtained from each block. One of them was stained by hematoxylin and eosin to evaluate pathologic alternations in all cases. The other sections were cut on poly-l-lysine-coated slides for immunostaining.
Hematoxylin and eosin-stained sections were examined microscopically to evaluate and verify epidermal pathologic alternations (according to the criteria of LP described by Nagao et al.  such as the following:
Immunohistochemical staining for tenascin-C
- Epidermal hyperplasia (acanthosis), saw teething, necrotic keratinocytes, basal-cell degeneration, hypergranulosis, and hyperkeratosis.
- Dermal inflammatory infiltrate (type-density).
Slides were subjected to subsequent steps of deparaffinization, rehydration, blocking of endogenous peroxidase activity, and antigen retrieval by boiling in 10 mmol/l citrate buffer, pH 6.0, for 10 min. The tissues were then incubated overnight at room temperature with the primary antibody (at a dilution of 1: 100) [mouse monoclonal antibody directed against TN-C (Neo Markers; Lab Vision, California, USA)]. The detection kit was the ultravision detection system anti-polyvalent horseradish peroxidase/diaminobenzidine (ready to use, catalog #TP-015-HD; Lab Vision). A chromogenic reaction was carried out with the diaminobenzidine substrate, and the sections were counterstained with Mayer hematoxylin.
The immunostained sections were assessed as follows:
Expression of TN-C was scored as low (+), medium (++), and high (+++) positivity for its staining intensity and distribution in the skin biopsy samples .
Results were collected, tabulated, and statistically analyzed by an IBM personal computer and the statistical package for the social sciences (SPSS, version 11; SPSS Inc., Chicago, Illinois, USA). Qualitative data were expressed as the number and percentage, whereas quantitative data were expressed as the mean (X) and SD or the median and range when appropriate. For comparing qualitative variables, Fisher's exact test or the χ2 -test was used when appropriate. For comparison between non-normally distributed quantitative variables, the Mann-Whitney U-test or the Kruskal-Wallis test was used when appropriate. A P value of less than 0.05 was considered to be statistically significant.
| Results|| |
Clinical data of the selected cases
Patients included 14 male and 16 female participants, their ages ranging from 17 to 64 years, with 39.57 ± 13.01 years as a mean value. Controls were age and sex matched (five male and five female; their ages ranged from 21 to 51 years, with 37.20 ± 10.11 years as a mean value). Most of the patients presented with classic-type LP, moderate itching, no family history, no oral lesions, or associated diseases, and the leg was the most common site of affection.
Histopathological data of the lesional lichen planus skin
Histologic examination of the lesional LP skin showed several pathologic changes with marked hyperkeratosis, mild hypergranulosis, mild acanthosis, mild basal-cell degeneration, and moderate lymphocytic infiltration being common features in our cases. This is shown in [Table 2] and [Figure 1], [Figure 2], [Figure 3].
|Figure 1: A case of lichen planus showing hyperkeratosis, hypergranulosis, acanthosis, and band-like lymphocytic infi ltration (hematoxylin and eosin, ×100)|
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|Figure 2: Acanthosis and focal basal-cell degeneration in a case of lichen planus (hematoxylin and eosin, ×400)|
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|Figure 3: Marked lymphocytic infi ltration in the upper dermis in a case of lichen planus (hematoxylin and eosin, ×200)|
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|Table 2 Descriptive statistics of the pathological parameters among cases|
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Tenascin-C immunohistochemical results
The immunoreactivity for TN-C was cytoplasmic in sections with epidermal expression, but mainly extracellular in the papillary dermis and the dermoepidermal junction in sections with dermal expression.
Tenascin-C expression in control skin
The control group showed low epidermal expression in 50% of the participants, low dermal expression in 20%, whereas 30% of controls were negative.
Tenascin-C expression in lichen planus cases
Forty-three percent of the cases showed epidermal expression, whereas most of the cases (76.6%) showed a positive dermal expression. There was a statistically significant increase in the dermal expression of TN-C in cases than in controls [Table 3] and [Figure 4], [Figure 5], [Figure 6], [Figure 7].
Dermal TN-C expression in LP cases: Correlation between the dermal expression of TN-C with histopathological parameters showed a statistically significant difference with respect to the density of the lymphocytic infiltrate [Table 4]. Correlation between the dermal expression of TN-C with clinical parameters showed a statistically significant difference with respect to itching and the site of lesions, moreover highest expression with hypertrophic LP cases [Table 5].
Epidermal TN-C expression in LP cases: We did not find any significant relationship between TN-C expression in keratinocytes cytoplasm and the other studied clinical or pathological parameters.
|Figure 4: A case of lichen planus exhibiting low extracellular matrix and faint epidermal cytoplasmic expression of tenascin-C in both the dermis and the epidermis (diaminobenzidine, ×400)|
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|Figure 5: Medium dermal expression of tenascin-C (diaminobenzidine , ×400)|
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|Figure 6: Medium extracellular matrix and cytoplasmic inflammatory dermal expression of tenascin-C (diaminobenzidine , ×400)|
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|Figure 7: A case of lichen planus showing high dermal tenascin-C expression (diaminobenzidin e, ×400)|
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|Table 3 Comparison between cases and controls regarding tenascin-C expression|
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|Table 4 Relationship between dermal tenascin-C expression and pathological data|
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|Table 5 Relationship between dermal tenascin-C expression and clinical data|
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| Discussion|| |
LP is a chronic, inflammatory disease with an uncertain etiology  . However, several studies have indicated that LP represents a delayed-type hypersensitivity reaction to an undetermined antigen. An immune reaction against basal keratinocytes seems to be the major event in the development of LP  . TN-C is reported to be associated with both proinflammatory and anti-inflammatory signaling cascades  . It has been identified that TN-C induces the synthesis of proinflammatory cytokines through the activation of Toll-like receptor 4 (TLR4) in inflammatory diseases, leading to an increased expression of TNFα, IL-1, and IL-6  . All of these aforementioned mediators are suspected to play role in the pathogenesis of LP through the induction of an inflammatory reaction  and upregulation of vascular endothelial growth factor expression leading to the initiation of angiogenesis: a recognized pathological feature of LP , . In our study, 20% of the controls showed low-intensity dermal staining, 50% showed low-intensity basal epidermal staining, whereas 30% of the biopsies were negative for TN-C. These findings are supported by the study of Abdou et al.  , who found that normal skin biopsies expressed mild basal staining of the epidermis for TN-C. Meanwhile, Lentini et al.  observed slight and discontinued expression of TN-C at the basal lamina level, which was more evident around the hair follicle; however, Bourdon et al.  failed to detect TN-C in adult mammalian skin, and they explained the failure of human skin to immunoadsorb the monoclonal antibody by the low TN-C content in the skin.
In the current work, there was significant dermal upregulation of TN-C in the skin of LP cases compared with that of controls; however, there was no statistically significant difference regarding epidermal expression. In accordance with this, Tiitta et al.  and Hδkkinen et al.  demonstrated a clearly enhanced TN-C immunoreaction in the subepithelial layer of the lamina propria of oral LP. In contrast, Sule et al.  found that 66% of LP cases were positive for TN-C expression in keratinocytes, with no cases showing dermal expression. Furthermore, TN-C was upregulated in other lichenoid disorders such as lichen nitidus and pityriasis lichenoides. Moreover, TN-C was evident in close apposition to inflammatory cells in alopecia areata, a disease, like LP, with supposed autoimmune etiology  .
Hypertrophic LP showed marked upregulation of TN-C expression followed by classic and guttate types. This may be due to the effect of epidermal hyperplasia in hypertrophic LP. It has been reported that the proliferating epithelium induces the expression of TN-C with its expression being strongly upregulated in the papillary dermis, and epidermal keratinocytes appear to be the primary source  . Regarding the site, the highest TN-C expression was found in biopsies harvested from the leg. This observation was made probably because the leg was the most common site of affection in our study (36.7% of cases) and also because the clinical type of LP lesion, like hypertrophic lichen, is mainly situated in the legs.
Itching was an extremely common complaint, presenting in 86.7% of our patients; this is consistent with Abdallat and Maaita  . In the current study, there was a significant association between TN-C expression and itching. The pathogenesis of pruritus in LP is a field of active research and speculations and is still nearly unknown. Keratinocytes, leukocytes, mast cells, fibroblasts, endothelial cells, and cutaneous nerves may produce several endogenous pruritogens, including histamine, kinins, proteases, neurotrophins, some opioids, and cytokines  . Many of these mediators and modulators can directly activate the itch-sensitive C-fibers or they can act indirectly by inducing the release of pruritogenic mediators. Moreover, interactions among them can exacerbate and strengthen the itch sensation to promote chronic pruritic diseases  . Recently, some studies suggested that increased expression of TNFα stimulates IL-31, which with its receptor could be a key cytokine pathway involved in itching  . As mentioned before, TN-C stimulates TNFα secretion. From these data, it may be speculated that TN-C might play a role in the escalation of the itch sensation in LP through the TNFα-IL-31 pathway.
The current study showed a significant increase in dermal TN-C expression along with an increase in the lymphocytic infiltration density. This is in accordance with Tiitta et al.  , who reported a distinct correlation between the extent of TN-C expression and the density of the inflammatory reaction in oral LP, with the sites of increased immunoreactivity coinciding with the sites of the most intense inflammatory reaction. In contrast, Hδkkinen et al.  found that in areas of the subepithelial connective tissue with only mild inflammatory reaction, TN-C expression was increased as compared with the corresponding normal tissue, whereas in lesions that showed heavy inflammation in the connective tissue, the expression of TN-C was decreased. They attributed the reduced expression of TN-C in the heavily inflamed areas in their study to the degradation of TN-C by proteolytic enzymes present abundantly in the inflammatory infiltrate  . It is of interest that some data suggest that TN-C can antagonize certain functions of fibronectin, including T-cell activation  . This suggests the idea of complexity and reciprocity in such interactions with expected feedback mechanisms. Thus, it is possible that TN-C regulates the extent of inflammatory reaction in LP.
| Conclusion|| |
TN-C may play a role in the etiopathogenesis of LP through its immune modulatory effect. Future research may target TN-C for new therapeutical intervention.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]