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E-IJD® - ORIGINAL ARTICLE
Year : 2022  |  Volume : 67  |  Issue : 3  |  Page : 312
Assessment of mucosa-associated epithelial chemokine, thymus-expressed chemokine, periostin and zonulin levels in infants with atopic dermatitis


1 Department of Paediatric Allergy, Baskent University Faculty of Medicine, Ankara, Turkey
2 Biostatistics, Hacettepe University, Ankara, Turkey

Date of Web Publication22-Sep-2022

Correspondence Address:
Burcu Tahire Koksal
Department of Paediatric Allergy, Baskent University Faculty of Medicine, Temel Kuguluoglu Sokak, No: 24, Bahcelievler, Ankara - 06490
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.ijd_834_21

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   Abstract 


Background: Atopic dermatitis (AD) is a chronic inflammatory skin disease. Skin and gut are the organs that first encounter antigens and environmental triggers. The mechanisms behind the relation between skin and gut immune responses in AD have not been identified yet. Aims and Objectives: To investigate mucosa-associated epithelial chemokine (MEC/CCL28), thymus-expressed chemokine (TECK/CCL25), periostin and zonulin levels in infants with AD. Materials and Methods: Children under one year old participated in the study. We used a propensity matching score. We included 39 infants who had active AD lesions at the time of evaluation. Serum MEC/CCL28, TECK/CCL25, periostin and zonulin levels were measured. Results: We examined age and sex matched 39 infants with AD and 39 healthy infants. Median value of zonulin was lower in infants with AD [49.2 (27.1–71.8) ng/mL] compared to healthy controls [58.5 (27.3–80.8) ng/mL] (P < 0.001). Infants with zonulin levels ≤55.15 ng/mL had 11.64 times more risk of developing AD than the infants with zonulin levels >55.15 ng/mL. Infants whose MEC/CCL28 levels were ≥8.3 ng/mL had 5.83 times more risk of developing AD than the infants with MEC levels <8.3 ng/mL. Duration of AD and SCORAD index score did not show correlation with MEC/CCL28, TECK/CCL25, periostin and zonulin levels. Conclusion: Low zonulin levels and high MEC/CCL28 levels in infants may show an increased association with AD.


Keywords: Chemokines, cytokines, eczema, immunity, tight junction


How to cite this article:
Koksal BT, Zengin HY, Ozbek OY. Assessment of mucosa-associated epithelial chemokine, thymus-expressed chemokine, periostin and zonulin levels in infants with atopic dermatitis. Indian J Dermatol 2022;67:312

How to cite this URL:
Koksal BT, Zengin HY, Ozbek OY. Assessment of mucosa-associated epithelial chemokine, thymus-expressed chemokine, periostin and zonulin levels in infants with atopic dermatitis. Indian J Dermatol [serial online] 2022 [cited 2022 Oct 6];67:312. Available from: https://www.e-ijd.org/text.asp?2022/67/3/312/356764





   Introduction Top


Atopic dermatitis (AD) is the most common inflammatory skin disease among children.[1] AD is characterized by dysfunction of the skin barrier, infiltration of T cells in skin lesions and alteration of immune responses.[2],[3] Chronic inflammation in the skin exacerbates skin barrier impairment and leads to the development and symptoms of AD. Tight junctions (TJs) play a role in the pathophysiology of AD.[4] TJs are intercellular junctions, located below the stratum corneum and regulate the selective permeability of the paracellular pathway. Dysfunction of TJs contributes to the skin barrier disruption in AD. Infants with AD who have skin barrier disruption permit enhanced allergen penetration and are particularly at risk of developing a food allergy (FA).

Skin and gut are the organs that first encounter antigens. Alterations in local immune responses of the gut may influence systemic as well as skin immune responses and consequently, may facilitate the development of AD.[5],[6],[7] There is a cross-talk between skin and gut immunity. However, the mechanisms behind the relation between skin and gut immune responses have not been identified yet.

Group of chemo-attractant cytokines, which are termed as chemokines, play crucial roles in AD and recruit immune cells to the skin.[8],[9] Mucosa-associated epithelial chemokine (MEC/CCL28) is expressed in epidermal keratinocytes and has been assumed to play an important role in T cell migration to the skin of patients with AD.[10],[11] Periostin, which is an extracellular matrix protein, contributes to the allergic skin inflammation and barrier dysfunction in AD.[12],[13],[14] On the other hand, thymus-expressed chemokine (TECK/CCL25) is important in mucosal immunity, recruits CCR9 expressing T cells and its expression is largely restricted to the gastrointestinal tract.[15],[16] Intestinal permeability is a critical feature of the gastrointestinal epithelium. Gut restricts the entry of antigens and regulates immune responses. Zonulin, which is a useful marker of gut barrier function, controls intestinal permeability by modulation of intercellular TJs.[17],[18] Loss of barrier function secondary to upregulation of zonulin leads to an increase in the passage of allergens and maintains the inflammatory response.[19]

Chemokines and inflammatory markers are involved in the pathogenesis of allergic diseases.[20],[21] However, there is little knowledge about chemokines, periostin and zonulin in infants with AD. Studies that analyse chemokines and intestinal permeability markers might lead to identify the relation between skin and gut immune responses and help to find novel molecular targets for AD treatment. Therefore, in this study, our aim was to investigate MEC/CCL28, TECK/CCL25, periostin and zonulin levels in infants with AD.


   Material and Methods Top


We enrolled infants with AD from Paediatric Allergy unit and healthy infants from outpatient clinics of Paediatrics Department, Baskent University Ankara Hospital, from September 2017 until August 2018. This study was approved by Baskent University Ethical Committee (KA17/234) and supported by Baskent University research fund. Written informed consents were obtained from all parents prior to the study.

Children who were under the age of one year, fulfilled the Hanifin and Rajka criteria and had an active AD at the time of evaluation, were included in the study. We evaluated the severity of AD according to SCORing AD (SCORAD) index.[22] Infants with chronic diseases besides AD, infants with previous and recent immune-suppressive treatment and healthy infants with a family history of allergy were excluded.

For FA diagnosis, food-specific IgE and epidermal skin prick tests, and in suspected cases food challenges were performed. A definitive diagnosis was depended on the disappearance of symptoms after an elimination diet and recurrence of symptoms after administration of the offending food.

Tests for specific IgE to cow's milk and hen's egg and epidermal skin prick tests for cow's milk, hen's egg, wheat, soy, peanut and hazelnut were performed. Blood was drawn from children with AD at the time of diagnosis and from non-allergic controls at the time of their routine visits. The results of allergy tests, complete blood counts, eosinophil counts and eosinophil percentages were recorded. Serum samples for MEC/CCL28, TECK/CCL25, periostin and zonulin were stored at −80°C.

MEC/CCL28 (Cloud-Clone Corp), TECK/CCL25 (Cloud-Clone Corp), periostin (Cloud-Clone Corp) and zonulin (Sunredbio) were measured by ELISA according to the manufacturer's instructions.

Statistics

Propensity score matching was used to adjust for differences in age and gender between infants with AD and the control group while 1:1 matching was performed and the match tolerance was set at 0. Afterwards, the normality of numerical variables was assessed by the Shapiro-Wilk normality test. Homogeneity of group variances was evaluated by using the Levene test. Descriptive statistics were reported, including mean ± standard deviation for normally distributed numerical variables and median (minimum-maximum) for non-normally distributed numerical variables. The student's t-test was used for comparisons between two groups when the parametric test assumptions were met. Otherwise, the Mann-Whitney U test was used. In addition, the Kruskal-Wallis test was used for comparisons between more than two groups due to the violation of parametric test assumptions. Furthermore, Spearman's rho correlation coefficient was used to assess the strength and direction of the association between the numerical variables. Frequency and percentage (n, %) were used to describe categorical variables. Pearson Chi-square test was used to test independence when test requirements were satisfied. Otherwise, Fisher's Exact test was used for comparison. Receiver operating characteristic (ROC) curves were analysed to assess the diagnostic performances for predicting AD and area under the curve was obtained with 95% Confidence Interval. Besides, we calculated the optimal cut-off points of MEC, and zonulin levels using Youden's J Index. In addition, predictive performances of the MEC and zonulin levels at the optimal cut-off point were evaluated using sensitivity, specificity, positive predictive value and negative predictive value with 95% confidence interval using Wilson score method. The significance level was set at 0.05 for all analyses. Statistical analysis was performed by using the IBM SPSS Statistics for Windows, Version 23.0 (Armonk, NY: IBM Corp.).


   Results Top


Thirty-nine infants with AD and age and sex matched 39 healthy infants were included in the study. Clinical characteristics of participants are shown in [Table 1].
Table 1: Clinical characteristics of infants with atopic dermatitis and healthy controls

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Infants with AD [9.9 (5–14.8) ng/mL] had a higher median value of MEC/CCL28 than healthy infants [8.7 (4.8–16.4) ng/mL] (P = 0.013) [Figure 1]. Median value of zonulin was lower in infants with AD [49.2 (27.1–71.8) ng/mL] compared to healthy controls [58.5 (27.3–80.8) ng/mL] (P < 0.001) [Table 2] and [Figure 2].
Figure 1: Comparison of MEC levels between atopic dermatitis and control group

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Figure 2: Comparison of zonulin levels between atopic dermatitis and control group

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Table 2: Laboratory characteristics of infants with atopic dermatitis and healthy controls

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Thirty-four (87.2%) infants with AD had a FA. Sixteen (51.6%) infants had an egg allergy and nine (27.3%) infants had a cow milk's allergy. We also compared healthy infants with the infants who had an AD with FA (n = 34) and without FA (n = 5). We found that at least two groups were significantly different from each other in terms of median MEC/CCL28 (P = 0.035) and zonulin levels (P < 0.001) [Table 3]. Children with FA and AD [9.9 (5–14.8) ng/mL] had higher levels of MEC/CCL28 than healthy children [8.7 (4.8–16.4) ng/mL] (P = 0.029). In addition, children with FA and AD [50.5 (27.1–71.8) ng/mL] had lower levels of zonulin compared to those in control group [58.5 (27.3–80.8) ng/mL] (P < 0.001).
Table 3: Characteristics of infants with food allergy and atopic dermatitis, infants with atopic dermatitis without food allergy and healthy controls

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Chemokines, periostin and zonulin levels did not show any significant difference between children with single (n = 10) and multiple FAs (n = 24). SCORAD index score did not show a significant correlation with MEC/CCL28, TECK/CCL25, periostin and zonulin levels.

ROC curves for MEC and zonulin are given in [Figure 3]. Area under the curve was 0.663 (95% CI: 0.54–0.785) for MEC/CCL28 level (P = 0.013) and 0.781 (95% CI: 0.674–0.888) for zonulin level (P < 0.001). Optimal cut-off points of MEC/CCL28 and zonulin levels were 8.3 ng/mL and 55.15 ng/mL, respectively. We also found that infants whose MEC/CCL28 levels were ≥8.3 ng/mL had 5.83 (95% CI: 1.882–18.049) times more risk of developing AD than the infants with MEC levels <8.3 ng/mL. In addition, infants with zonulin levels ≤55.15 ng/mL had 11.64 (95% CI: 3.972–34.088) times more risk of developing AD than the infants with zonulin levels >55.15 ng/mL. Additional performance measures of MEC/CCL28 and zonulin levels are given in [Table 4].
Figure 3: ROC curves of MEC (ng/mL) (a) and zonulin (ng/mL) (b) levels for diagnosing the atopic dermatitis in children (AUC = 0.663, P = 0.013 vs AUC = 0.781, P < 0.0001, respectively)

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Table 4: Performance of MEC/CCL28 and zonulin levels on predicting atopic dermatitis

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   Discussion Top


Skin and intestinal immune responses are supposed to be linked and there is little knowledge about these events. Therefore, in this study, we examined MEC/CCL25, TECK/CCL28, zonulin and periostin levels in infants with AD. We demonstrated that infants with AD had a higher median value of MEC/CCL28 and a lower median value of zonulin compared to healthy infants. We found that high MEC/CCL28 and low zonulin levels may show an increased association with AD.

More than 70% of immune cells are located in gut-associated lymphoid tissue (GALT). Alterations in local immune responses of gut may influence the development of AD.[5],[6],[7] TECK/CCL25 is expressed gastrointestinally, but we could not find any difference in TECK/CCL25 levels between study groups. Ahrens et al.[23] demonstrated that food sensitized infants had elevated TECK/CCL25 levels. However, in our study, infants with AD who had FA also had similar levels of TECK/CCL25 compared to non-allergic controls. On the other hand, Ahrens et al.[23] mentioned that TECK/CCL25 levels had changed according to the type of food allergen. Children sensitized against hen's egg, wheat and peanut had higher TECK/CCL25 levels, but significant differences were not detected for cow's milk, fish or soy. We think that TECK/CCL25 levels might be affected according to the number and type of allergen as well as duration of AD. In our study, the duration of AD was short and most of the patients had an allergy to egg.

Kagami et al.[11] investigated the relation between MEC/CCL28 and skin diseases and showed upregulation of MEC/CCL28 in AD. Ezzat et al.[10] also found higher MEC/CCL28 levels in children with AD whose ages ranged between 8 months to 120 months compared to controls. Our study was conducted in infants (<12 months) and we also found higher MEC/CCL28 levels in infants with AD compared to controls. On the other hand, infants with FA and AD had higher MEC/CCL28 levels than healthy infants. We think that the presence of FA accompanied by AD may lead to higher MEC/CCL28 results.

Periostin plays an important role in the onset of allergic skin inflammation and barrier dysfunction. Mitamura et al.[13] showed that the IL-13/periostin pathway induces IL-24 production in keratinocytes and plays a role in barrier dysfunction in AD. However, we did not find any difference in periostin levels between infants with AD and controls. Additionally, children with a FA and children without a FA had similar periostin levels. Because our patients were less than one year old and had a shorter duration of disease, we may have found similar results between groups. The studies that found higher periostin levels compared to healthy individuals were conducted in either adults or children with older ages.[12],[13],[14]

Loss of barrier function secondary to upregulation of zonulin leads to an uncontrolled influx of antigens.[18],[24],[25] Serum zonulin has been found to be associated with AD in children aged 5–15 years.[4] In contrast to that study, we found lower zonulin levels in infants with AD compared to healthy infants.[4] We were expecting high zonulin levels in infants with AD. However, we found lower levels compared to controls. We think that as the disease progresses or with the increasing age, zonulin levels might increase. On the other hand, zonulin is a precursor of haptoglobin, which forms a complex with haemoglobin to prevent oxidative damage and has also immunomodulatory properties. Because our patients had active disease, we think that in order to prevent oxidative damage zonulin might be converted to haptoglobin. As a consequence, we may have found lower zonulin levels compared to controls. Longitudinally designed studies that include children with different age groups and evaluate haptoglobin as well as zonulin/haptoglobin ratio are needed to shed light on this subject. Longitudinally designed new studies are also needed in order to increase information to link the skin-gut connection to pathogenesis of AD and define the relationship between chemokines, TJs and intestinal permeability markers in AD.

In conclusion, our results did not suggest any relation between MEC/CCL28, TECK/CCL25, periostin and zonulin levels in AD. However, lower zonulin and higher MEC/CCL28 levels in infants may show an increased association with AD. Because we have found lower zonulin levels, we think that zonulin might be converted to haptoglobin to protect against the harmful effects of inflammation. In order to prove this hypothesis, haptoglobin, zonulin and zonulin/haptoglobin ratio should be evaluated. Additionally, we believe that zonulin is a candidate to be investigated in infants with AD and longitudinally designed studies are needed to determine the risk for AD.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the parents have given their consent for their images and other clinical information to be reported in the journal. The parents understand that their children's names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Baskent University.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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