IJD_1452.fm Page 768 Wednesday, November 6, 2002 10:05 PM
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`Blackwell Science, LtdOxford, UKIJDInternational Journal of Dermatology0011-9059Blackwell Science, 2002411000
`
`
`
`Report
`
`in acne rosacea
`Œ
`Professor Mehmet Ali G(cid:159)rer, Associate Professor Arzu Erel, Professor Deniz Erba
`,
`g
`g
`Associate Professor Kayhan (cid:130)a
`lar, and Assistant Doctor (cid:130)i
`dem Atahan
`
`
`
`
`
`The seroprevalence of Helicobacter pylori and nitric oxide
`
`H. pylori and NO in acne rosaceaGürer et al.
`
`From the Departments of Dermatology,
`Physiology, and Clinical Microbiology, Faculty
`of Medicine, Gazi University, Besevler,
`Ankara, Turkey
`
`
`Correspondence
`
`Arzu Erel,
`MD
`Bilkent University
`Lojman No: 22/4
`06533 Bilkent, Ankara
`Turkey
`E-mail: aerel@med.gazi.edu.tr
`
`Abstract
`Background
`Acne rosacea is a dermatosis with unknown etiology. Some studies have
`
`
`reported a high prevalence of Helicobacter pylori infection in acne rosacea. Other studies have
`
`
`reported a decrease in the severity of the lesions of acne rosacea after eradication of H. pylori.
`
`H. pylori is a Gram-negative bacterium which colonizes the gastric mucosa and increases the
`synthesis of oxygen radicals, such as superoxide and proinflammatory cytokines. These cytokines
`have been demonstrated to stimulate the synthesis of the inflammatory species nitric oxide
`
`
`(NO). In this study, we examined the role of NO in the possible effect of H. pylori in acne rosacea.
`Methods
`Thirty-three acne rosacea patients were included in the study and the control group
`
`
`comprised 20 healthy individuals. The levels of immunoglobulin G antibodies against H. pylori
`in the serum samples were measured using the enzyme-linked immunoabsorbent assay
`method. Measurement of nitrate was performed using chemiluminescence in accordance with
`the method described by Braman and Hendrix (Braman RS, Hendrix SA. Nanogram nitrite and
`iii
`nitrate determination in environmental and biological materials by vanadium(
`) reduction with
`
`
`chemiluminescence detection. Anal Chem 1989; 61: 2715–2718). For statistical analysis, the
`
`
`
`t-test was used.
`Results
`The seropositivity of H. pylori in acne rosacea patients was found to be high; however,
`
`
`the serum nitrate levels were found to be normal.
`Conclusions
`The results of the study indicate that the inflammatory species NO, which has
`
`
`been hypothesized to be associated with H. pylori, has no role in the inflammatory mechanism
`of acne rosacea.
`
`Introduction
`
`Acne rosacea is an inflammatory skin disease that affects the
`central parts of the face. It is characterized clinically by
`papules and papulopustules, erythema, telangiectasia, and
`flushing episodes. The flushing episodes are seen generally in
`the initial stages of the disease and turn into permanent dark-
`red erythema in the later stages. The etiopathogenesis has not
`yet been clarified. Various factors are thought to affect the
`course of the disease, including the genetic predisposition of
`the individual, gastric hypochlorhydric dyspepsia, gastro-
`intestinal system infections, hypertension,
`Demodex folliculo-
`1—3
`, and psychogenic factors.
`
`
`Helicobacter pylori is the
`rum
`pathogenic bacterium responsible for the etiology of gastro-
`intestinal system infections from non-ulcer dyspepsia to the
`activation of peptic ulcer. Recent studies have shown that the
`prevalence of
`
`H. pylori infection is higher in acne rosacea
`4—6
`patients than in control groups.
` In another study,
`7
`s
`
`.
`Uta
` found that the seroprevalence of
`et al
`H. pylori
`
`768
`
`was the same as that of the control group, but a statistically
`significant decrease in the severity of the disease was reported
`with the treatment of seropositive acne rosacea patients with
`a combination of metronidazole, amoxicillin and bismuth
`compounds.
`
`H. pylori increases the synthesis of oxygen metabolites,
`such as superoxide and proinflammatory cytokines. These
`cytokines have also been shown to stimulate the synthesis of
`8—11
`the inflammatory species nitric oxide (NO).
`In this study, we investigated the role of NO in the possible
`effect of
`
`H. pylori in acne rosacea patients. The seropreval-
`
`H. pylori and the serum nitrate levels in a group of
`ence of
`acne rosacea patients were measured and compared with
`those of a control group consisting of healthy individuals.
`
`Materials and methods
`
`Thirty-seven acne rosacea patients (between the ages of 26 and
`67 years; 27 women and 10 men), who were seen at the Polyclinic
`
`
`
`International Journal of Dermatology 2002,
`, 768–770
`41
`
`
`
`© 2002 The International Society of Dermatology
`
`1
`
`Galderma Laboratories, Inc. Ex 2008
`Dr. Reddy's Labs v. Galderma Labs., Inc.
`IPR2015-01778
`
`

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`IJD_1452.fm Page 769 Wednesday, November 6, 2002 10:05 PM
`
`
`
`Gürer et al.
`
`
`
`H. pylori and NO in acne rosacea
`
`Report
`
`769
`
`Table 1 Helicobacter pylori (HP) immunoglobulin G (IgG) results
`
`
`
`HP IgG (+)
`
`HP IgG (suspect)
`
`HP IgG (–)
`
`Total
`
`Patients
`Controls
`
`29
`9
`
`1
`3
`
`3
`8
`
`33
`20
`
`patient and control groups: both groups contained 75%
`women.
`H. pylori were positive in 29 (95.7%)
`
`IgG antibodies against
`of the acne rosacea patients, whereas in one (3.3%) patient
`they were found to be probably positive. Among individuals
`in the control group, nine (45%) were positive, whilst three
`(15%) were probably positive (Table 1). The seropositivity
`
`
`of H. pylori in the patient group was found to be statistically
`significantly higher than that of the control group (
`
`p < 0.005).
`The average nitrate level of the serum samples from the patients
` 9.85
`mol/L, whereas that of the control group
`was 49.27
`was 46.06
` 18.44
`mol/L. No statistically significant differ-
`ence was found between the nitrate levels of the two groups
`(
`
`p > 0.5).
`
`Discussion
`
`Acne rosacea is a dermatosis with unknown etiology. The dis-
`ease is associated with hypochlorhydria, gastritis and jejunal
`mucosal abnormalities, such as gastrointestinal system distur-
`
`H. pylori infection plays an etiologic role in the devel-
`bances.
`opment of chronic active gastritis, peptic ulcer disease, and
`gastric malignancy.
`
`H. pylori is a Gram-negative bacterium
`that colonizes the gastric mucosa. In various studies, it has
`been shown that inducible nitric oxide synthetase protein is
`expressed in the gastric mucosa of patients with active gast-
`ritis and
`
`H. pylori infection, and that large amounts of NO
`8—11
`are excreted from the gastric mucosa of these patients.
`NO is a colorless paramagnetic gas. It has radical charac-
`teristics due to the uncoupled single electron it carries in its
`outer orbital. In fluid media, it diffuses freely and passes
`through cell membranes easily. The half-life in tissues varies
`between 10 and 60 s. In water and plasma, it reacts with
`oxygen to form the nitrite, whilst in whole blood it reacts with
`hemoglobin to form the nitrate which is excreted in urine. The
`nitrites and nitrates have no biological activity. In biological
`systems, the measurement of NO is generally performed indir-
`ectly via its physiological activity. To determine the amount
`of NO in an organism, the serum or plasma nitrate and nitrite
`13,14
`levels, the end-products of NO, are used.
` NO is thought
`to play a role in vasodilatation, inflammation, and immuno-
`13,14
`modulation in the skin.
`Knowledge of the etiopathogenesis of acne rosacea is still
`very limited, and treatment is performed on a symptomatic
`basis. Studies on
`
`H. pylori in acne rosacea suggest that this
`
`or admitted to the ward of the Dermatology Department of Gazi
`University, Faculty of Medicine, between January 1998 and July
`1999, were included in the study. The patients had a disease
`duration varying between 4 months and 13 years. Twenty healthy
`individuals of similar gender and age distribution (20–69 years;
`15 women and five men) were selected as the control group.
`Acne rosacea can be clinically classified into four stages: stage
`I, episodic erythema and flushing attacks on the central areas of
`the face, the neck, and the V-shaped area of the chest (rosacea
`diathesis); stage II, persistent erythema and telangiectases; stage
`III, persistent erythema, telangiectases, and papules and pustules;
`stage IV, persistent erythema, telangiectases, papules, pustules,
`and nodules, and tissue hypertrophy (rhinophyma).
`The clinical diagnosis of acne rosacea was made according to
`the above stages. Patients in stages II, III, and IV were included in
`the study. All patients were also diagnosed histopathologically
`according to the clinical stage. The histopathologic diagnoses
`had been made previously in 13 patients, whereas the diagnoses
`were made during the study in 20 patients.
`Before blood samples were taken from the patients, it was made
`certain that they had not received topical or systemic drugs for acne
`rosacea for at least 1 week. This period was determined from the
`half-lives of the drugs used in the treatment of acne rosacea to avoid
`the influence of the possible anti-inflammatory effects of these drugs.
`Four blood samples (three women and one man) could not be
`analyzed because of hemolysis. From the blood samples of both the
`3
`patient and control groups, 5 cm
` portions were drawn into test tubes
`containing gel and centrifuged. These samples were stored
`at
`20
`C until analysis.
`The amount of total nitrate in the test samples was determined
`by a modification of the procedure described by Braman and
`12
`Hendrix
` using the purge system of a Sievers Instruments Model
`280A Nitric Oxide Analyzer. A standard curve was constructed
`using various concentrations of NO
`(10–100
`). The nitrate
`M
`levels of the samples were calculated using the standard curve.
`Results were expressed as the mean
` standard deviation (SD).
`
`The level of immunoglobulin G (IgG) antibodies against H.
`
`pylori in the serum samples was measured using the enzyme-linked
`immunoabsorbent assay (ELISA) method (International Immuno-
`Diagnostics, USA). The antibody titer of each serum sample was
`determined using the calibration curve. A sample was considered
`to be positive if the IgG value was equal to or greater than 100 EU/
`mL. If the value was between 91 and 99 EU/mL, it was considered
`to be equivocal. If the value was lower than 90 EU/mL, it was
`considered to be negative.
`
`3–
`
`Results
`
`Thirty-three acne rosacea patients were compared with the
`20 healthy individuals of the control group in terms of the
`average age (48.21 and 46.35 years, respectively) and no
`statistically significant difference was found between the groups.
`There was also no difference in terms of gender between the
`
`
`
`© 2002 The International Society of Dermatology
`
`
`
`International Journal of Dermatology 2002,
`, 768–770
`41
`
`2
`
`Galderma Laboratories, Inc. Ex 2008
`Dr. Reddy's Labs v. Galderma Labs., Inc.
`IPR2015-01778
`
`-
`(cid:176)
`m
`–
`–
`m
`–
`m
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`IJD_1452.fm Page 770 Wednesday, November 6, 2002 10:05 PM
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`770
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`Report
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`H. pylori and NO in acne rosacea
`
`
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`Gürer et al.
`
`
`
` D. Nitric oxide in health. Gazi Med J 1998; 9:
`
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`seroprevalence in patients with acne rosacea. (Abstract).
`
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`J Eur Acad Dermatol Venereol 1995; 5 (Suppl. 1): 151.
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`6 Jones MP, Knable AL, White MJ, Durning SJ. Helicobacter
`pylori in rosacea: lack of an association. (letter).
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`pylori eradication treatment reduces the severity of rosacea.
`
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`J Am Acad Dermatol 1999; 40: 3.
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`et al. Helicobacter pylori
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`8 Tsuji S, Kawano S, Tsujii M,
`extract stimulates inflammatory nitric oxide production.
`
`
`Cancer Lett 1996; 108: 195—200.
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`9 Franco L, Talamini G, Carra G, Doria D. Expression of
`COX-1, COX-2, and inducible nitric oxide synthase
`protein in human gastric antrum with Helicobacter pylori
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`Prostaglandins Other Lipid Med 1999; 58:
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`infection.
`9—17.
`et al. Inducible nitric
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`10 Mannick EE, Bravo E, Zarama G,
`oxide synthase, nitrotyrosine, and apoptosis in Helicobacter
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`11 Shapiro KB & Hotchkiss JP. Induction of nitric oxide
`synthesis in murine macrophages by Helicobacter pylori.
`
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`Cancer Lett 1996; 102: 49—56.
`
`12 Braman RS & Hendrix SA. Nanogram nitrite and nitrate
`determination in environmental and biological materials by
`
`iii) reduction with chemiluminescence detection.
`vanadium(
`
`
`Anal Chem 1989; 61: 2715—2718.
`
`$
`
`
`13 Erba
`1—36.
`
`
`14 Kiechle F,
`567—573.
`
`pathogen may be an aggravating factor rather than an
`1—3
`etiologic cause.
`In this study, we investigated the role of NO in the possible
`effect of
` in patients with acne rosacea. The sero-
`H. pylori
`positivity of
`
`H. pylori in acne rosacea patients was found to
`be significantly high, whereas the serum nitrate levels of the
`patients were normal. Based on the results of the study, we
`conclude that the inflammatory species NO, which has been
`
`H. pylori, has no role in
`hypothesized to be associated with
`the inflammatory mechanism of acne rosacea.
`
`Acknowledgments
`
`This study was supported by the Gazi University Research
`Fund.
`
`References
`
`1 Plewig G, Jansen T. Rosacea. In: Freedberg IM,
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`
`et al., eds. Dermatology in General
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`, 5th edn. Philadelphia: McGraw-Hill Company,
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`2 Wilkin JK. Rosacea pathophysiology and treatment.
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`
`Arch Dermatol 1994; 130: 359—362.
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`Retinoids 1998; 14: 117.
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`3 Griffiths WAD. Rosacea.
`4 Rebora A, Drago F, Picciotto A. Helicobacter pylori in
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`Am J Gastroenterol 1994; 89:
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`patients with rosacea.
`1603—1604.
`$
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`lter N, et al. Helicobacter pylori
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`Malinski T. Nitric oxide. Clin Chem 1993; 100:
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`International Journal of Dermatology 2002,
`, 768–770
`41
`
`
`
`© 2002 The International Society of Dermatology
`
`3
`
`Galderma Laboratories, Inc. Ex 2008
`Dr. Reddy's Labs v. Galderma Labs., Inc.
`IPR2015-01778