Atopic dermatitis (AD) is a chronic inflammatory skin disease that is often associated with the development of food allergy and asthma. New insights into AD reveals an important role for structural abnormalities in the epidermis resulting in a leaky epithelial barrier as well as chronic immune activation that contribute to the pathophysiology of this common skin disease. Patients with AD have a predisposition to colonization or infection by microbial organisms, most notably Staphylococcus aureus and herpes simplex virus (HSV). Measures directed at healing and protecting the skin barrier and controlling the immune activation are needed for effective management of AD. Early intervention may improve outcomes for AD as well as reduce the systemic allergen sensitization that may lead to associated allergic diseases in other organs.

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A technique to visualize living cell activation in a real time manner without any labeling is required in the fields of life sciences and medicine. We have reported that surface plasmon resonance (SPR) sensors detect large changes of refractive index (RI) with living cells, such as mast cells, human basophils and lymphocytes. However conventional SPR sensors detect only an average change of RI with thousands of cells at detectable area on a sensor chip. Therefore, we developed an SPR imaging (SPRI) sensor with a CMOS camera and an objective lens in order to visualize RI of individual living cells and their changes upon stimuli. The SPRI sensor we developed could detect reactions of individual rat basophilic leukemia (RBL-2H3) cells and mouse keratinocyte cells in response to specific or nonspecific stimuli. Moreover, the sensor could detect the reactions of individual human basophils isolated from patients in response to antigens (allergens). Thus the technique can visualize the effect of various stimuli, inhibitors and/or conditions on cell reactions as change of intracellular RI distribution at single cell levels. Establishment of the technique to rapidly isolate cells from patient blood should enable us to utilize SPRI system as a high throughput screening system in clinical diagnosis, such as type I hypersensitivity and drug hypersensitivity, and as a tool to reveal novel phenomena in evanescent fields around plasma membranes.

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Asthma is a heterogeneous disease with varying phenotypes and numerous risk factors. This condition results from complex interactions between genetic and environmental factors, and active smoking is one of these risk factors. The effects of aging should also be taken into account in these interactions. From an epidemiological standpoint, smokers and/or elderly patients with asthma are not small part in the total population with asthma. Furthermore, both smoking and aging are important risk factors for severe asthma. This review discusses the potential effects of smoking and aging on healthy subjects and patients with asthma, particularly from the perspective of inflammatory changes. First we show evidence that smokers and the elderly have increased neutrophil counts in their airways, which may have impacts on their clinical characteristics of elderly smokers with asthma. Secondly, on the basis of our recent findings on the interactions between smoking and aging in patients with asthma, we propose that IgE/eosinophilic inflammation should not be underestimated in elderly smokers with asthma, particularly those who are atopic. This review may expand our understanding of the effects of smoking and aging on asthma with a new perspective of an old issue.

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Background: This study intended to assess the severity of Japanese cedar pollinosis using the Practical Guideline for the Management of Allergic Rhinitis in Japan (PG-MARJ) and the Allergic Rhinitis and its Impact on Asthma (ARIA) Guideline.
Methods: An Internet questionnaire survey of patients with pollinosis was conducted in mid-May 2011 and responses were obtained from 3382 individuals who had potential symptoms of Japanese cedar pollinosis from February to early May 2011 and who had experienced such symptoms for at least two pollen seasons.
Results: According to PG-MARJ, 23.5% of the respondents had severest rhinitis, 29.4% severe rhinitis, 31.3% moderate rhinitis, 13.8% mild rhinitis and 2.0% asymptomatic rhinitis. According to ARIA, 67.2% of them had moderate/severe persistent rhinitis, 23.8% moderate/severe intermittent rhinitis, 4.4% mild persistent rhinitis and 4.6% mild intermittent rhinitis.
Conclusions: Moderate to severe rhinitis was diagnosed in more than 80% of the respondents according to PG-MARJ, while moderate/severe rhinitis was diagnosed in more than 90% of the respondents according to ARIA. Most of the respondents suffered relatively severe pollinosis. More than 80% of the respondents had all the three major symptoms (i.e., sneezing, rhinorrhea and nasal blockage). Disagreement in the severity assessment between the two guidelines was noted in approximately 20% of the respondents.

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Background: Anisakis simplex sensitization has been associated with acute, but also with chronic urticaria. The objective of this study is to characterize chronic urticaria with (CU+) and without sensitization (CU-) against the ubiquitous fish parasite A. simplex in a transversal and longitudinal evaluation.
Methods: 16 CU+ and 22 CU- patients were included and assessed for Urticaria activity score (UAS), fish-eating habits by standardized questionnaire and cytokine production (assessed by flow cytometric bead-based array) of peripheral blood mononuclear cells after stimulation with A. simplex extract or Concanavalin A (Con A). Patients were randomly put on a fish-free diet for three months and UAS, as well as cytokine production were again assessed. A difference of ≥1 in UAS was defined as improvement.
Results: There was no difference in UAS in both groups. Anisakis induced IL-2, IL-4 and IFN-γ production was higher in CU+. Con A induced IL-6 and IL-10 production was higher in CU+. CU+ was associated with higher total fish intake, whereas CU- was associated with oily fish intake. The correlation of UAS was positive with oily fish, but negative with total fish intake.
There was a better UAS-based prognosis in CU+ without diet. Improvement was associated with higher Con A induced IL-10/IFN-γ as well as IL-10/IL-6 ratios. Further, previous higher oily fish intake was associated with improvement.
Conclusions: Our data confirm the different clinical and immunological phenotype of CU+. Our results show a complex relationship between fish-eating habits, cytokine production and prognosis, which could have important consequences in dietary advice in patients with CU. When encountering A. simplex sensitization, patients should not be automatically put on a diet without fish in order to reduce contact with A. simplex products.

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Background: Details of the comparisons between airway and peripheral blood regulatory T cells (Tregs) in patients with atopic asthma are still unclear. The objective of this study is to investigate the profiles of both airway and circulating Tregs in atopic asthma.
Methods: We measured the numbers of Tregs and eosinophils in induced sputum and peripheral blood in 28 patients with mild atopic asthma and compared these with numbers in 18 healthy controls. The frequency (%) of Tregs (surface CTLA4⁺, intracellular Foxp3⁺, and CTLA4⁺Foxp3⁺ on CD25^highCD4⁺ T cells) in sputum and blood was determined by intracellular 5-color flow cytometry. We also correlated the numbers with the level of airway hyperresponsiveness (AHR) in asthmatics.
Results: The mean frequencies of cells expressing CTLA4⁺ (19.4 ± 2.1%, p = 0.075), Foxp3⁺ (16.4 ± 3.3%, p = 0.001), and CTLA4⁺Foxp3⁺ (7.0 ± 1.1%, p = 0.008) in induced sputum from asthmatics were significantly lower than controls (27.2 ± 3.7%, 37.4 ± 4.7%, and 18.2 ± 3.6%, respectively), whereas in peripheral blood, there was no inter-group difference in the frequencies of cells expressing CTLA4⁺ (7.1 ± 1.5% vs 5.7 ± 1.7%, p > 0.05), Foxp3⁺ (35.7 ± 3.2% vs 21.1 ± 3.9%, p > 0.05), and CTLA4⁺Foxp3⁺ (6.6 ± 1.5% vs 4.2 ± 1.0%, p > 0.05). Moreover, the frequency of CD25^highCD4⁺ cells expressing CTLA4⁺, but not Foxp3⁺, in induced sputum was associated with AHR (r = 0.60, p = 0.009) and airway eosinophilic inflammation (r = -0.60, p = 0.008) in asthmatics.
Conclusions: Airway, but not circulating, Tregs are decreased in mild atopic asthmatics, and are negatively correlated to an increase of airway eosinophilic inflammation and AHR.

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Background: Allergic rhinitis represents a worldwide health problem. The prevalence is increasing. The aim of this study was to analyse the correlation between the severity of allergic rhinitis and an adequate treatment dose of modern oral antihistamines.
Methods: From a comprehensive databank containing data from ten different open-label prospective observational studies including raw data of 140,853 patients with allergic rhinitis, symptomatology variables were analysed and scored to study the effects of treatment with four antihistamines (Desloratadine, Ebastine, Fexofenadine, Levocetirizine) alone or in combination with intranasal corticosteroids. The patient data were collected in 23,606 study centres from Germany, mostly medical specialist and some primary care physicians in private practice. The analyses were performed via individual patient data meta-analysis techniques.
Results: Finally 92,900 patient data from nine of ten studies could be analysed. One study with data of 47,953 patients was excluded due to incomplete treatment documentation. Both monotherapy analysis subgroups (Total Symptom Score and Total Nasal Symptom Score) were significantly better than those of their combinations with intranasal steroids. Monotherapy with levocetirizine was determined to be significantly more effective in lowering the Total Symptom Score (p < 0.001) and the Total Nasal Symptom Score (p < 0.05) than the other antihistamines. In the next stage, a greater positive effect of levocetirizine was demonstrated in relation to the severity of the clinical symptoms of allergic rhinitis (Total Nasal Symptom Score in cases with severe symptomatology [effect size = -0.09]).
Conclusions: Levocetirizine asserted itself as the only antihistamine compared with the others as significant in this analysis. The study authors recommend monotherapy with the new-generation antihistamine levocetirizine, especially in severe cases of allergic rhinitis.

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Background: Cysteinyl leukotrienes (CysLTs) are lipid mediators that have been implicated in the pathogenesis of allergic rhinitis. Pharmacological studies using CysLTs indicate that 2 classes of receptors exist, namely, CysLT₁ and CysLT₂ receptors. The former class of receptors is sensitive to the CysLT₁ antagonists currently used to treat asthma and allergic rhinitis, and its localization has been previously examined by our group using immunohistochemistry and in situ hybridization techniques. We investigated the expression and localization of the CysLT₂ receptor in human nasal mucosa by western blot and immunohistochemical analyses.
Methods: Human turbinates were obtained after turbinectomy from 16 patients with nasal obstruction refractory to medical therapy. To identify the cells expressing the CysLT₂ receptor, double immunostaining was performed by using anti-CysLT₂ receptor antibody and anti-CD31 (endothelial cell) antibody or anti-smooth muscle actin antibody.
Results: A 39 kDa band was detected on the western blots of human turbinates samples by using the anti-CysLT₂ receptor antibody. The expression level of the CysLT₂ receptor in patients with nasal allergy was higher than that in patients with non-allergic rhinitis. The immunohistochemical study also showed an intense immunoreactivity for CysLT₂ receptor in both vascular endothelial cells and vascular smooth muscles.
Conclusions: The results indicated that the CysLT₂ receptor plays a primary role in the vascular responses in the upper respiratory tract.

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Background: Challenge testing with wheat plus exercise and/or aspirin is a gold standard for the diagnosis of wheat-dependent exercise-induced anaphylaxis (WDEIA); however, the test may often yield false-negative results. Our previous study suggested that an increase in serum wheat gliadin levels is required to induce allergic symptoms in patients with WDEIA. Based on this knowledge, we sought to extract the patients with false negative results in the challenge tests of WDEIA.
Methods: Thirty-six patients with suspected WDEIA were enrolled. First, group categorizations—Group I, challenge tests were positive; Group II, challenge tests were negative and serum gliadin were undetectable; Group III, challenge tests were negative and serum gliadin were detectable—were given according to the results of wheat plus exercise and/or aspirin challenge testing and serum gliadin levels. Second, diagnoses were made using retests and/or dietary management in Group II and III.
Results: Positive results for wheat plus exercise and/or aspirin challenge tests gave a diagnosis of definite WDEIA in 17 of 36 patients (Group I). Of the remaining 19 challenge negative patients, serum gliadin was undetectable in ten patients (Group II). Of the ten patients (Group II), three of them were diagnosed as definite WDEIA by retesting and six of them were diagnosed as probable WDEIA using a wheat elimination diet, whereas one patient was non-WDEIA. In the rest of the nine challenge negative patients, serum gliadin was detectable (Group III). No allergic episodes with a normal diet provided a diagnosis of non-WDEIA in seven of the nine patients, whereas the remaining two patients were probable WDEIA or had another food allergy because of repeated episodes.
Conclusions: Our study revealed that serum gliadin monitoring during challenge testing is useful.

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Background: Extracellular nucleotides such as ATP and UTP are released from essentially all cells, and they interact with cell surface P2 receptors to produce a broad range of physiological responses. P2Y₁₂ receptor is the major platelet receptor that mediates ADP-induced aggregation, P2Y₁₂ receptor inhibitors such as clopidogrel and prasugrel inhibit platelet aggregation, and thus, they are used in the treatment and prevention of coronary artery disease. Recently, studies have focused on the P2Y₁₂ receptor as a receptor for leukotriene E₄ (LTE₄), because this receptor is required for LTE₄-mediated pulmonary inflammation. To establish the presence of P2Y₁₂ receptor in human nasal mucosa, we investigated the expression and the localization of the P2Y₁₂ receptor in human nasal mucosa.
Methods: Human turbinates were obtained by turbinectomy from 12 patients with nasal obstruction refractory to medical therapy. The expression of P2Y₁₂ receptor was evaluated by RT-PCR, western blotting, and immunohistochemical analysis.
Results: RT-PCR analysis of total RNA extracted from human nasal turbinate, primary cultured human nasal epithelial cells and nasal vascular endothelial cells demonstrated the expression of P2Y₁₂ receptor mRNA. A band of approximately 55 kDa was detected in human turbinates by western blot analysis using anti-P2Y₁₂ receptor antibody. We could not find any differences between P2Y₁₂ receptor levels in allergic and non-allergic nasal mucosa. An immunohistochemical study revealed that epithelial cells, submucosal glands and vascular endothelial cells showed intense immunoreactivity for the P2Y₁₂ receptor.
Conclusions: The results may have important clinical implications for understanding the role of P2Y₁₂ receptor in upper airway diseases such as allergic rhinitis and non-allergic rhinitis.

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Background: There are few reports on the effects of intranasal Botulinum Toxin-A (BTX-A) as a treatment of allergic rhinitis (AR). In this study, we compared the efficacy of intranasal BTX-A to cetirizine in the treatment of AR.
Methods: Fifty AR patients at the age of 26.2 ± 9.1 years (64% females), were recruited to the trial according to the Allergic Rhinitis and its Impact on Asthma (ARIA) criteria. Participants randomly received either intranasal injection of BTX-A (75IU Dysport^®) or cetirizine (10mg/day). Symptoms (based on the ARIA) and side effects were assessed every two weeks for two months. Quality of life was evaluated before and after the study using the Rhinasthma questionnaire.
Results: Total symptom severity score of patients significantly decreased (P < 0.001) and quality of life significantly improved (P < 0.001) at the same level in both groups. Side effects included nasal dryness (4%) and epistaxis (4%) in the BTX-A group. In the cetirizine group 44% sleepiness and 4% blurred vision was reported.
Conclusions: Nasal injection of BTX-A shows the same therapeutic effects as cetirizine in the management of AR. Since BTX is expensive, we do not suggest it in the first line of treatment for AR. However, BTX-A is a potential treatment for patients who are resistant or not compliant to the routine medications of AR. Further studies are required to investigate implications and limitations of BTX-A in the treatment of AR.

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Background: Fractional exhaled nitric oxide (FeNO) is known to be a good marker of airway eosinophilic inflammation in bronchial asthma. Recently, serum high sensitivity C-reactive protein (hs-CRP) has been shown to be also useful to detect the airway inflammation.
Methods: Newly diagnosed 90 cough variant asthma and 92 bronchial asthma patients were enrolled. FeNO, serum hs-CRP, pulmonary function tests, bronchial hyperresponsiveness, IgE and sputum eosinophils ratio were compared. Ninety healthy control subjects were set for FeNO and serum hs-CRP normal range reference. We have compared the clinical utilities of FeNO and serum hs-CRP to differentiate bronchial asthma and cough variant asthma.
Results: FeNO was significantly higher in bronchial asthma (92.6 ± 85.5ppb) than in cough variant asthma (35.6 ± 43.3; p < 0.001) and both were significantly higher than normal range (18.0 ± 6.4, p < 0.001, respectively), and in differentiating between the two groups showed a sensitivity of 0.69 and a specificity of 0.73 at the cutoff value of 28 ppb. Serum hs-CRP did not differ significantly between bronchial asthma (723 ± 1162ng/ml) and cough variant asthma (558 ± 758) even if both were significantly higher than normal range (345 ± 401, p < 0.01 and p < 0.05 respectively).
Conclusions: FeNO is more useful than serum hs-CRP in differentiating patients with bronchial asthma from those with cough variant asthma, and healthy persons.

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