Satria Adi

4.1 Introduction

Irritant contact dermatitis is an eczematous reactionin the skin of external origin. In contrast to allergiccontact dermatitis, no eliciting allergens can be iden-tified. The spectrum of irritant reactions includessubjective irritant response, acute irritant contactdermatitis, chronic irritant contact dermatitis, andchemical burns (Table 1). Irritant contact dermatitisis in its acute form characterized by erythema, infil-

tration, and vesiculation. In its more chronic form,dryness, fissuring, and hyperkeratosis are more pro-nounced. It is thus clear that the clinical reaction pat-tern of mild to moderate irritant contact dermatitisis often indistinguishable from the allergic contactdermatitis reaction. Thus, differentiation betweenthese two reaction types is often based solely on pa-tient history and skin allergy tests. Despite the com-mon hallmarks of irritant contact dermatitis, theclinical manifestation of the skin lesions developingfollowing contact with different irritants varies. Fac-tors that may influence the outcome of skin contactwith irritants can be divided as follows:

Exogenous: such as structural and chemicalproperties of the irritant, exposure to otherirritants, and environmental conditions, e.g.,temperature and humidity.

Endogenous: such as body region that isexposed (the scrotum is much more sensitivethan, e.g., the upper back), age [1], race [2],and pre-existing skin disease.

Moreover, in addition to the capacity of different irri-tants to induce clinically different reactions, it hasbeen reported that marked interindividual variationin the threshold for eliciting clinical irritant reactionin skin is present [3].

In the past, the pathogenesis of irritant contactdermatitis was thought to be nonimmunological.However, today it is generally accepted that the im-mune system plays a key role in eliciting irritant re-actions. This has been underscored by human andanimal studies demonstrating the importance of sig-

Chapter 4

Mechanisms of Irritant ContactDermatitisSteen Lisby, Ole Baadsgaard

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Table 1. Type of irritant reactions

Subjective irritant reaction (stinging)Acute irritant contact dermatitisChronic irritant contact dermatitisChemical burn

Contents

4.1 Introduction . . . . . . . . . . . . . . . . . . 69

4.2 Clinical Spectrum of Irritant Skin Reactions 704.2.1 Subjective Irritant Reaction . . . . . . . . . . 704.2.2 Acute Irritant Contact Dermatitis . . . . . . 704.2.3 Chronic (Cumulative) Irritant Contact

Dermatitis . . . . . . . . . . . . . . . . . . . 704.2.4 Chemical Burn . . . . . . . . . . . . . . . . . 71

4.3 Skin the Outpost of the Immune System . 714.3.1 Immunocompetent Cells of the Skin . . . . . 714.3.2 Skin Infiltrating T Lymphocytes . . . . . . . 72

4.4 Pathogenesis of Acute Irritant Contact Dermatitis . . . . . . . . . . . . . . . . . . . 73

4.4.1 Skin Barrier Perturbation . . . . . . . . . . . 734.4.2 Cellular Immunological Changes

in Irritant Contact Dermatitis . . . . . . . . 744.4.3 Epidermal Cytokines Involved

in Irritant Contact Dermatitis . . . . . . . . 75

4.5 Irritant-induced Interleukin-1 . . . . . . . . 76

4.6 Irritant-induced TNF- . . . . . . . . . . . . 76

4.7 Mechanisms of Irritant-induced TNF-in Keratinocytes . . . . . . . . . . . . . . . . 77

4.7.1 Regulation of the Inflammatory Milieu Locally in Inflamed Skin . . . . . . . . . . . . 78

4.8 Hypothesis of the Immunological Events Leading to Irritant Contact Dermatitis . . . . 79

Suggested Reading . . . . . . . . . . . . . . . 80

References . . . . . . . . . . . . . . . . . . . 80

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nal molecules, e.g., cytokines, in eliciting the irritantreaction.

Irritant contact dermatitis is an eczema-tous reaction in the skin caused by expo-sure to external agents/chemicals. Clinical-ly the reaction manifests similar to the allergic contact dermatitis reaction.

4.2 Clinical Spectrum of Irritant Skin Reactions

The spectrum of the clinical appearances of irritantcontact dermatitis is extremely broad. It is thereforewidely accepted that no single mechanism underly-ing the development of this disease entity exists. Inthis chapter, we briefly outline the different clinicalreaction types. For more extensive description, thereader is referred to Chap. 15.

Irritant contact dermatitis can be dividedinto different reaction types, includingstinging, acute irritant reaction, chronic irritant reaction, and chemical burn.

4.2.1 Subjective Irritant Reaction

The hallmark of this type of irritation is the lack ofclinical manifestation. Subjective registration of aburning or stinging feeling following contact withcertain chemicals is diagnostic (Table 2). Despite noclinical manifestation, the reaction can be repro-duced. Typically, symptoms occur rapidly followingexposure (i.e., within seconds to minutes). Thereseem to be interindividual differences in eliciting thistype of reaction, and several studies have classed in-dividuals as sensitive (stingers) and nonsensitive(nonstingers) [4]. One example of immediate sting-ing is the appliance of a mixture of chloroform andmethanol to the skin. In stingers, even when appliedto intact skin, a sharp pain develops within secondsto minutes following exposure to the chloroform/methanol mixture [5].

4.2.2 Acute Irritant Contact Dermatitis

This type of reaction is often the result of a single ex-posure to an irritant. The clinical appearance is veryvariable and often indistinguishable from the allergiccontact dermatitis reactions. The manifestation mayvary from a little dryness and redness to severe reac-tions with edema, inflammation, and vesiculation.Often the clinical reactions are located to areas of ex-posure and the skin manifestations often disappearwithin days to weeks.

4.2.3 Chronic (Cumulative) Irritant ContactDermatitis

This type of reaction develops as a result of cumula-tive exposures of the skin to irritants. Clinically, thistype of reaction is characterized by dryness, redness,infiltration, scaling, fissuring, and vesiculation to on-ly a minor degree. Often this type of irritant contactdermatitis is located on the hands. A hallmark of thistype of reaction is its chronicity. Despite removal ofirritant exposure, the clinical reaction may continuefor several years. Several external factors are knownto contribute to elicitation of chronic irritant eczema.These agents include water, detergents, organic sol-vents, oils, alkalis, acids, oxidizing agents, heat, cold,friction, and multiple microtrauma.

Steen Lisby, Ole Baadsgaard70

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Table 2. Chemicals involved in subjective skin reactions(adapted from [4])

Immediate stinging potentialChloroformMethanolHydrochloric acidRetinoic acid

Delayed stinging potential

Weak:Aluminum chlorideBenzenePhenolPhosphoric acidResorcinolSalicylic acid

Moderate:Propylene glycolDimethylsulfoxideBenzoyl peroxide

Severe:Crude coal tarLactic acidHydrochloric acidSodium hydroxideAmyldimethyl-p-aminobenzoic acid

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4.2.4 Chemical Burn

Reactions are induced by highly alkaline or acid com-pounds. These agents can result in severe damage ofthe skin. The reaction often develops within minutes,and frequently manifests with the appearance of apainful erythema, followed by vesiculation, and theformation of necrotic scars. This type of reaction isoften sharply demarcated and may lead to deep tissuedestruction even after only a short exposure.

4.3 Skin the Outpost of the Immune System

To understand the pathogenic mechanisms involvedin irritant contact dermatitis, it is important to ad-dress the involvement of the different cell types con-stitutively present within the skin, and the cell typesthat can be recruited to the site of the irritant reac-tion as well as the proinflammatory and inflammato-ry mediators induced by the different cell popula-tions following irritant exposure.

4.3.1 Immunocompetent Cells of the Skin

The outermost part of the skin is the epidermis. Epi-dermis is mainly composed of keratinocytes, Langer-hans cells, and melanocytes. Both keratinocytes andLangerhans cells are involved in immunological pro-cesses. In contrast, the immunological importance ofthe epidermal melanocyte, if any, is not known.

The involvement of the keratinocyte in the skinimmune system was first indicated in 1981/1982 byLuger et al. and Sauder et al. who described a keratin-ocyte-derived cytokine, epidermal-derived thymo-cyte activating factor (ETAF) [6, 7]. The majority ofETAF activity was later confined to interleukin-1 (IL-1). It has now been demonstrated that the keratino-cyte is capable of producing a variety of immunolog-ical active cytokines/factors (Table 3), including IL-1,IL-6, IL-8, IL-10, IL-12, granulocyte-macrophage col-ony-stimulating factor (GM-CSF), tumor necrosisfactor-alpha (TNF-), and transforming growth fac-tor-beta (TGF-). The involvement of some of thesefactors in irritant contact dermatitis is reviewed laterin this chapter. Beside cytokine expression, kerati-nocytes can be induced to express or increase expres-sion of major histocompatibility complex (MHC)molecules [8, 9] and cell adhesion molecules such asintercellular adhesion molecule-1 (ICAM-1) [10, 11].Expression of these molecules, in combination withthe release of chemotactic cytokines, and factors in-volved in the upregulation of E-selectin and vascular

cell adhesion molecule-1 (VCAM-1) on dermal endo-thelial cells [12], makes the keratinocyte an impor-tant player in the induction and maintenance of in-flammatory cells within the skin.

The epidermal Langerhans cell is the only celltype in normal epidermis that exhibits all accessorycell functions and thus acts as a complete antigen-presenting cell. The epidermal Langerhans cell wasoriginally described in 1868 by Paul Langerhans [13]and comprises 25% of the total epidermal cell popu-lation. It is constitutively present in the skin and is lo-calized to the suprabasal part of the epidermis. TheLangerhans cell is a dendritic, bone marrow-derivedcell characterized by surface expression of type-1acluster of differentiation (CD1a) antigen, as well asMHC class I, and MHC class II (HLA-DR, -DP, -DQ)molecules. Ultrastructurally, the Langerhans cellcontains characteristic intracytoplasmic Birbecksgranules. Beside its capacity to present antigens to T-cells, the Langerhans cell is capable of secreting cyto-kines such as IL-1, IL-6, IL-10, IL-12, and TNF- [14].The Langerhans cell has been implicated in the im-mune surveillance of the skin; it is also required forinduction of primary immune responses in skin, andas such is suggested to be a key player in allergic con-tact dermatitis. In addition, recent research has asso-ciated this cell type with events occurring during thedevelopment of irritant contact dermatitis.

Several dermal antigen-presenting cell subsetshave been described including macrophages anddendritic cells. Macrophages are bone marrow-de-

Chapter 4Mechanisms of Irritant Contact Dermatitis 71

Table 3. Keratinocyte-derived cytokines

Interleukin-1Interleukin-1Interleukin-3Interleukin-6Interleukin-7Interleukin-8Interleukin-10Interleukin-12Interleukin-15Interleukin-18Tumor necrosis factor-Transforming growth factor-Transforming growth factor-Granulocyte colony-stimulating factorGranulocyte-macrophage colony-stimulating factorPlatelet-derived growth factorEpidermal cell-derived lymphocyte differentiation

inhibiting factorKeratinocyte lymphocyte inhibitory factor

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rived cells with a broad range of functions, includingantimicrobial activity, anti-tumor activity, regulationof B and T lymphocytes, release of cytokines andprocessing antigens thereby functioning as anti-gen-presenting cells. These cells are characterized bysurface expression of Fc-receptors, including CD16and CDw32, and MHC class II molecules. Further-more, these cells express LFA-1 (CD11a) and when ac-tivated also CD11b.

In ultraviolet-irradiated skin, dermal and epider-mal monocyte/macrophage-like cells expressing aHLA-DR+, CD11b+, CD36+ phenotype have been ob-served [15]. These cells are involved in downregula-tion of the immune response, revealed by their ca-pacity to preferentially activate CD4+ suppressor-in-ducer T lymphocytes [16, 17]. In addition, theseCD11b+, MHC class II+ cells were found to secretelarge amounts of IL-10, in contrast to the residual epi-dermal Langerhans cells, which secrete mainly IL-12[18]. Thus, different bone marrow-derived cells of themacrophage or dendritic cell lineage are differentlyinvolved in the ongoing immune regulation withinthe skin during an inflammatory reaction.

In skin diseases, such as mycosis fungoides andcontact dermatitis, cells with a similar HLA-DR+,CD36+ phenotype have been detected within the epi-dermis [19, 20]. Their functional role is underscoredby observations that depletion of the epidermalLangerhans cells only partially inhibits an autologousepidermal lymphocyte reaction. Furthermore, whenisolated from involved epidermis, HLA-DR+, CD36+

cells exhibit the capacity directly to stimulate autolo-gous T lymphocytes in vitro [21]. In addition, HLA-DR+, CD36+ cells have been observed in the irritantreaction [22]. However, their functional role in the de-velopment of an irritant reaction is still unknown.

Immunocompetence of normal epidermisis restricted to the epidermal Langerhanscell. In irritant contact dermatitis, otherdendritic cells are present, and the kerati-nocytes develop immunoregulatory func-tions, including but not limited to MHCclass II and ICAM-1 expression.

4.3.2 Skin Infiltrating T Lymphocytes

It has been known for several years that many skindiseases are characterized by skin infiltration by T

lymphocytes. These T lymphocytes often express aCD3+, CD4+ phenotype, although CD8+ T lympho-cytes are also present. While trafficking the skin,these T lymphocytes are capable of releasing a varie-ty of cytokines, including IL-2, IL-4, IL-10, interferon- (IFN-) and TNF-. Based on their cytokine secre-tion, T lymphocytes can be divided into T helper-1-like (Th1-like), Th2-like or Th0-like cells (Table 4).This division was originally suggested in 1986 byMosmann et al. based on investigation of murine Tlymphocyte clones [23]. He distinguished two differ-ent subsets of T lymphocyte clones. The first wasnamed Th1 and comprised clones preferentially pro-ducing IL-2 and IFN-, while the other group ofclones was termed Th2 and produced large amountsof IL-4 and IL-5. Following this observation, severalstudies have included more cytokines in this subdivi-sion and furthermore suggested a similar division ofhuman T lymphocytes. Many of the T lymphocyte-derived cytokines are involved in regulation of in-flammatory processes. IL-2 is known as a T lympho-cyte growth factor, another cytokine like IFN- is in-volved in the induction or upregulation of cell adhe-sion molecules [10], and IL-10 downregulates Th1-type cytokine secretion [24] and thus acts as an in-hibitory molecule.

In humans, a disease such as atopic eczema is char-acterized by skin infiltration by T lymphocytes ex-pressing a Th2 like profile in its acute phase whetherthe skin-infiltrating T lymphocytes in allergic contactdermatitis, psoriasis, and late-phase chronic atopicdermatitis express a Th1 like profile. In irritant con-tact dermatitis, studies investigating cytokine profilesin the acute reactions have mainly detected increasedlevels of IL-2 and IFN-, thereby indicating a Th1-cy-tokine profile, as discussed in this chapter.

Recent, it has been demonstrated that T lympho-cytes entering the skin often are characterized by in-creased expression of a surface molecule cutaneouslymphocyte-associated antigen (CLA) [25]. Thismolecule participates directly in transendothelialmigration of T lymphocytes. The ligand for CLA is E-


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Core Message

Table 4. T helper (Th) lymphocyte cytokine profiles: cytokinespredominant in the different groups

Th1 Th2 Th0

IFN- IL-4 INF-IL-2 IL-5 IL-2TNF- IL-6 IL-4TNF- IL-9 TGF-

IL-10IL-13

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selectin, which is found to be upregulated in variousskin diseases, including contact dermatitis. Other re-ceptor-ligand pairs, such as lymphocyte function-as-sociated antigen (LFA)-1/ICAM-1 and very late anti-gen-4 (VLA-4)/VCAM-1, are also involved in this pro-cess [26]. The importance of CLA has been demon-strated by blocking CLA in vitro, which resulted ininhibition of transendothelial T lymphocyte migra-tion [26]. Furthermore, studies on T lymphocytesfrom individuals with contact allergic dermatitishave revealed that preferentially CLA+ cells are acti-vated and recruited to the skin [27]. Thus, the impor-tance of CLA as a selective skin homing receptor forT lymphocytes has been established and this mole-cule seems to play an important role in the recruit-ment of T lymphocytes to the local inflammatory re-action site in the skin. Despite these observations, therole of CLA expression in irritant contact dermatitisis still not clarified.

Inflammatory skin diseases, including irri-tant contact dermatitis, are characterizedby influx of activated T lymphocytes. Ingeneral the skin-infiltrating T lymphocytesexpress CLA; however, their role in irritantcontact dermatitis is unknown. In irritantcontact dermatitis, studies investigating cy-tokine profiles are preferentially performedin the acute reactions and these investiga-tions have detected increased levels of IL-2and IFN- and thereby indicate a Th1-cyto-kine profile.

4.4 Pathogenesis of Acute Irritant Contact Dermatitis

Research within the field of irritant contact derma-titis has primary been focused on the development ofthe acute irritant reaction and only to a lesser degreethe chronic irritant reaction. For many years re-searchers have tried to differentiate between the al-lergic and irritant skin reactions by the means of his-topathology or immunohistopathology [28, 29] asdescribed in Chapter 8. However, only minor differ-ences have been revealed. Until recently, skin irrita-tion was thought to be a nonimmunological reactionin the skin; however, recent work has indeed impli-cated the immune system in the development andmaintenance of irritant-induced skin reactions. In

contrast to allergic skin reactions, no immunologicalmemory seems to be involved in eliciting irritantcontact dermatitis and the development of irritantskin reactions does not require prior sensitization.

Although chemical differences exist between dif-ferent irritants, exposure of the skin to irritants oftenlead to skin barrier perturbation, skin infiltration byimmunocompetent cells, and induction of inflamma-tory signal molecules.

4.4.1 Skin Barrier Perturbation

One major finding following exposure to skin irri-tants is perturbation of the skin barrier. The skinbarrier is composed of the outermost layer of the epi-dermis the stratum corneum. The stratum corne-um consists of protein-rich cells, the corneocytes,which are embedded within a continuous lipid-richmatrix. Within the stratum corneum, the barrierfunction is mainly confined to the inner one-third included within the compact part of the stratum cor-neum [30]. The dynamic process of damaging andre-normalization of the skin barrier can be quanti-fied using a noninvasive technique based on themeasurement of transepidermal water loss (TEWL).This method has today been accepted as a reliablemarker of skin barrier disruption. Much research hasbeen conducted using the anionic surfactant sodiumlauryl sulfate (SLS).Application of SLS to human skinresults in perturbation of the skin barrier and an in-creased TEWL measurement as compared to controlvalues [31]. This effect is not only a transient phe-nomenon. Increased TEWL values have indeed beenobserved more than 6 days following exposure to SLS[32]. In addition, another study demonstrated thatcomplete recovery of the skin barrier was first ob-tained more than 3 weeks after irritant challenge [33].This was demonstrated by re-testing the irritant-treated skin area with the same irritant. Thus, long-lasting perturbation of the skin barrier is observedfollowing SLS challenge of the skin in vivo.

The mechanisms behind the irritant-induced bar-rier perturbation are not fully understood; however,increased hydration [34] and disorganization of thelipid bilayers of the epidermis [35] have been report-ed. Although one could argue that disruption of theskin barrier is merely a mechanical change of theskin, several studies have demonstrated the impor-tance of an intact stratum corneum. Disruption ofthe barrier could actually result in the induction of adanger signal. In support of this, it has been demon-strated that acetone treatment or impeachment ofthe skin barrier by tape stripping results in increasedmitotic activity in the basal keratinocytes [36]. Fur-


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thermore, studies have indicated that, following dis-ruption of the skin barrier, increased levels of immu-nological active signal molecules, in particular IL-1,IL-1, TNF- and GM-CSF, are present within theskin [37]. Thus, taken together, perturbation of theskin barrier itself could actually initiate an immuno-logical stress signal leading to the subsequent devel-opment of an inflammatory reaction locally in theskin.

Finally, an impaired skin barrier also facilitatesskin penetration by the irritant itself, or by other ex-ternal agents including allergens and bacteria. Thus,perturbation of the skin barrier is thereby implicatedin many skin diseases and thought to be a majorplayer in the induction of irritant contact dermatitis.

One hallmark of irritant exposure is per-turbation of the skin barrier. This facili-tates penetration by external agents and byitself induces inflammatory signals locallyin challenged skin.

4.4.2 Cellular Immunological Changes in Irritant Contact Dermatitis

As described above, the skin, which is the outermostoutpost of the immune system, is an organ essentialfor the initiation and maintenance of contact derma-titis.Although much research has been focused on al-lergic contact dermatitis, numerous studies havecharacterized the cellular infiltrate in irritant contactdermatitis, especially the experimentally inducedacute irritant reaction. The histological manifesta-tion of the irritant reaction is often impossible to dis-tinguish from the manifestation observed in the con-tact allergic reaction [28, 29]. In addition, diversity ofthe histopathological changes is seen following skinexposure to different irritants [38]. However, the cel-lular infiltrate is characterized mainly by mononu-clear cells in particular T lymphocytes belonging tothe CD4+ subset [39, 40]. These T lymphocytes de-tected in irritant contact dermatitis seem to belongto a Th1-like subpopulation, as the major T lympho-cyte cytokines detected are IFN- and IL-2 [41]. Thisobservation parallels findings in allergic contact der-matitis. Furthermore, a study has shown that in bothallergic and irritant skin reactions, an increase innumber of CLA+ T lymphocytes is observed in theskin [42]. This study was, however, performed on

atopic individuals. Another study also found an in-crease in CD3+ cells in skin biopsy samples from irri-tant reactions, however in this study they actually ob-served a decreased percentage of CLA+ cells as com-pared to samples from atopic dermatitis skin [43].Furthermore, the same study found marked expres-sion of integrin 47 by T lymphocytes present inthe skin [43]. 47 is a gut homing marker and skinexpression of this molecule suggests that a nonspe-cific influx of T lymphocytes has occurred and thatCLA is not a prerequisite for cutaneous T lympho-cyte infiltration [43, 44]. Thus, the precise role of CLAin irritant contact dermatitis is still not clearlyunderstood.

In addition to CLA-positive T cells, new informa-tion has implicated cells expressing IL-2 receptor(CD25) in the regulation of inflammation in tissues,including the skin. The CD25-positive T cells seem tobe downregulators of inflammation and thus in-volved in the regulation and termination of inflam-matory processes. In allergic contact dermatitis, a de-creased number of CD25-positive cells has been ob-served in involved skin (nickel allergic patch tests)compared to normal skin. However, it is imperativeto state that a role for CD25-positive T cells in the de-velopment and maintenance of the irritant reactionis currently unknown.

Many studies have implicated the keratinocyte asan important player in the induction of immunolog-ical changes observed in irritant contact dermatitis(Fig. 1). The effect of irritants on the epidermal kerat-inocytes varies depending on the exposure. Strongacids or alkalis often result in necrosis of keratinocy-tes. In contrast, following damage to the skin barrierby tape-stripping or irritant challenge using SLS, anincreased mitotic activity in keratinocytes has beenobserved [36, 45]. At the histopathological level, irri-tants exhibit different effects on keratinocyte mor-phology. Willis et al. [38] evaluated clinical and histo-logical changes in skin following 48 h of exposure todifferent irritants [38]. Nonanoic acid induced eosin-ophilic degeneration of keratinocytes with nucleardegeneration and only minimal spongiosis. Crotonoil produced considerable spongiosis, and the pres-ence of intracytoplasmic vesicles in the upper dermiswas observed. SLS induced minor morphologicalchanges in the keratinocytes and induced parakerat-osis, suggesting increased epidermal turnover. Final-ly, ditranol induced a marked swelling of the kerati-nocytes in the upper epidermis. Thus, specific chang-es of keratinocytes can be observed following expo-sure to structurally different irritants. In addition toinducing morphological changes in the skin, irritantsare also capable of upregulating cell surface mole-cules on epidermal cells. One important observation


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is the capacity to upregulate MHC class II expressionon keratinocytes [46]. This upregulation is also ob-served in the contact allergic reaction. Furthermore,induction of adhesion molecules such as ICAM-1 onkeratinocytes has been demonstrated [47] and thismolecule, possibly in combination with irritant-in-duced upregulation of E-selectin on endothelial cells[48], is known to be involved in T lymphocyte accu-mulation within the skin. Finally, irritant challengeresults in the release of several keratinocyte-derivedcytokines, as discussed later.

The involvement of the epidermal Langerhans cellin irritant contact dermatitis is still unclear. Somestudies have indicated that the number of epidermalLangerhans cells remain unaltered in the skin. Incontrast, other studies have demonstrated a decreasein epidermal Langerhans cell numbers following ir-ritant challenge [22, 4951]. The effect of irritants onLangerhans cell number was long lasting, and full re-covery was first obtained 4 weeks following irritantchallenge [22]. In support of the latter observation,increased numbers of Langerhans cells have beenidentified in the afferent lymphatic system followingirritant challenge of human skin [52, 53]. However,one must consider that chemically different irritantsmight have different capacities to modulate Lange-rhans cell numbers. Accordingly, different effects onLangerhans cell numbers have been observed whencomparing SLS and nonanoic acid (NAA) [54].

The histological manifestation of the irri-tant reaction is often impossible to distin-guish from the contact allergic reaction.Furthermore, diverse histopathological

changes are seen following skin exposureto different irritants. In general, during theacute phase of the irritant reaction, a de-crease in epidermal Langerhans cells num-ber is observed, and upregulation of MHCclass II and ICAM-1 on keratinocytes isdemonstrated.

4.4.3 Epidermal Cytokines Involved in Irritant Contact Dermatitis

As discussed before, both keratinocytes and Lange-rhans cells exhibit the capacity to secrete a variety ofimmunologically active cytokines. In irritant contactdermatitis many cytokines have been found to be up-regulated as compared to normal, uninvolved skin(Table 5).Although demonstration of increased levels


Fig. 1.Keratinocyte responses toskin irritants

Core Message

Table 5. Cytokines upregulated in irritant contact dermatitis

In vivo In vitro

Interleukin-1 [41, 55]Interleukin-1 [56, 57]Interleukin-2 [41]Interleukin-6 [57, 58]Interleukin-8 [59]Interleukin-10 [56]Tumor necrosis factor- [60, 61] [62]Granulocyte-macrophage colony [60]stimulating factorInterferon- [41, 60]

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of cytokines in the irritant reaction is well estab-lished both in vivo and in vitro, different results arepublished in the literature as to which cytokines ac-tually are increased. Many studies have investigatedone or two irritants, and generalized from these data.However, today it is known that the application ofdifferent irritants to the skin results in the inductionof different cytokine profiles. One example is a studyby Grngsj et al. demonstrating that in contrast toSLS, NAA is capable of upregulating IL-6 mRNA inhuman skin [63]. Similar, several irritants includingSLS, but not benzalkonium chloride, have been dem-onstrated to upregulate TNF- [58]. The complexityof irritant-induced cytokine profiles in skin is fur-ther underscored by the findings that SLS, phenol,and croton oil all upregulate IL-8 whereas only cro-ton oil upregulates GM-CSF [64]. Thus, differencesexist in the capability of irritants to induce cyto-kines. Of the many irritant-inducible cytokines (seeTable 5), the pro-inflammatory cytokines IL-1, IL-1, and TNF- are of particular interest.

4.5 Irritant-induced Interleukin-1

Interleukin-1, which was first isolated from monocy-tes, is now known to be synthesized in several celltypes, including keratinocytes. IL-1 exists in twofunctionally active forms: IL-1 and IL-1.

In normal skin, IL-1 is constitutively producedby the keratinocytes, and damaging the cell mem-brane can result in the release of pre-formed IL-1 tothe intercellular space. IL-1 is the major form ofIL-1 produced by keratinocytes and is secreted as anactive molecule. In contrast, IL-1 is secreted as a 31-kDa biologically inactive precursor, which has tobe cleaved into an active 17.5-kDa molecule by a pro-tease, not present in resting human keratinocytes.However, in activated keratinocytes, mRNA of IL-1-converting-enzyme was readily detected followingincubation with the hapten urushiol or the irritantsphorbol myristate acetate (PMA) or SLS [65]. Thus,even though the keratinocyte is not capable of syn-thesizing immunological active IL-1 in intact skin,this capacity can be induced by external inflammato-ry signals. The mechanism for this induction re-mains unclear. IL-1 is a multifunctional cytokine[66], implicated in T lymphocyte activation and IL-2production. In addition, IL-1 is involved in upregula-tion of IL-2 receptors on activated T lymphocytesand is chemotactic for T lymphocytes. IL-1 is alsoproduced by the Langerhans cell and involved inantigen presentation and Langerhans cell migration.Furthermore, IL-1 is capable of inducing other kerat-inocytes to release or synthesize IL-1 in a paracrine

or even autocrine fashion [67] as well as upregulatingother cytokines including epidermal growth factor,IL-6, IL-8, and GM-CSF [68]. Thus, the release of IL-1can lead to amplification of the ongoing immunolog-ical process. In addition to its capacity to regulateother cytokines, IL-1 upregulates cell adhesion mole-cules on the keratinocyte. In vitro analyses havedemonstrated that IL-1 upregulates ICAM-1 expres-sion on keratinocytes, thereby further contributingto the maintenance of the inflammatory cells in theskin.

When analyzing cytokine profiles in the earlyphases of the allergic as well as irritant reaction inmice, Enk and Katz demonstrated that IL-1 is upreg-ulated as early as 15 min following application of anallergen but not an irritant. Cell depletion studies re-vealed the Langerhans cell as the cellular source [60].Furthermore, blocking IL-1 inhibited the elicitationof the allergic reaction, thereby substantiated by theimportance of IL-1. Similar, injection of recombi-nant IL-1 in vivo led to the development of a clinicalreaction, indistinguishable from the contact derma-titis reaction. This observation has supported the hy-pothesis that expression of IL-1 could differentiatebetween contact allergic and irritant reactions. How-ever, later studies have indeed found IL-1 in the irri-tant reaction, though at later time points [56, 57].Thus, early synthesis of IL-1 seems to be an impor-tant initial step in the induction of allergic contactdermatitis, but is not specific for allergic reactions.

Both IL-1 and IL-1 have been found to beupregulated in the contact irritant reaction.In murine studies, IL-1 was the first cyto-kine upregulated and injection of IL-1 invivo resulted in clinical eczema indistin-guishable from the irritant reaction.

4.6 Irritant-induced TNF-

TNF- was first described as a molecule exhibitinganti-tumor activity in vivo and in vitro. TNF- is ahighly pleomorphic cytokine [66], produced by a va-riety of cell types, including T lymphocytes, monocy-tes, Langerhans cells, fibroblasts, and keratinocytes.TNF- is synthesized as a 26-kDa pro-peptide. Be-fore secretion the pro-peptide is converted into a 17-kDa protein by metalloproteases [69]. In its activeform, TNF- is composed of three 17-kDa subunits.


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TNF- exerts its function by binding to specificcell surface receptors. Two distinct TNF- receptorsare described. TNF-R1 (414 amino acids) has a mo-lecular weight of approximately 5560 kDa and TNF-R2 (461 amino acids) is a 75- to 80-kDa receptor.These receptors have similar extracellular structuresbut distinct cytoplasmic domains. The TNF receptorsare expressed on a variety of cells, however mainlythe TNF-R1, which is involved in metabolic altera-tions, cytokine production, and cell death, is ex-pressed on the keratinocytes [70]. TNF- stimulatesthe production of collagenase and prostaglandin E2by synovial cells and dermal fibroblasts and thuscontributes to inflammation and tissue destructionin general. TNF- increases both MHC class II anti-gen expression and upregulates the surface expres-sion of ICAM-1 on keratinocytes [71, 72]. Thus, TNF- is an important cytokine involved in the mainte-nance of inflammatory processes in the skin. Thepro-inflammatory role of TNF- is stressed by its ca-pacity to induce other inflammatory markers, in-cluding IL-1, IL-6, and the chemoattractant IL-8[66].

Finally, it has been demonstrated that blockingTNF- results in inhibition of Langerhans cell mi-gration towards the local lymph nodes following epi-cutaneously applied allergens or irritants [73, 74].The importance of TNF- in irritant contact derma-titis has been further emphasized by studies by Pi-guet et al. demonstrating that primary irritant reac-tions to trinitrochlorobenzene (TNCB) could be in-hibited in vivo by injection of antibodies to TNF orrecombinant soluble TNF receptors [61]. Thus, TNF- seems to be a key player in the induction of irritantreactions in the skin.

Several irritants exhibit the capacity to upregulateTNF- in skin. These irritants include dimethylsul-foxide (DMSO), PMA, formaldehyde, phenol, tribu-tylin, and SLS [56, 62, 75]. The list of skin irritants thatupregulate TNF- is still growing, and studies revealthat this upregulation is also found by application ofallergens to the skin and when analyzing the irritantcapacity of sensitizers, e.g., TNCB, DNTB, and nickel[61, 62]. Although many irritants upregulate TNF-in skin, no increase in TNF- expression has beenobserved following skin application of benzalkoni-um chloride [58]. Thus, as previously discussed, dif-ferent irritants interact or regulate the immune sys-tem at different levels.

Several irritants can induce keratinocyteexpression of TNF- both in vitro and invivo. The importance of irritant-inducedTNF- is stressed by observations by Piguet et al. [61], who could block elicita-tion of irritant reactions by administrationof anti-TNF antibodies.

4.7 Mechanisms of Irritant-induced TNF-in Keratinocytes

Most previous studies addressing the upregulation ofcytokine expression in skin have focused on proteinmeasurements often by ELISA. In addition, cyto-kine mRNA expression has been determined by ei-ther Northern blotting or reverse transcriptase poly-merase chain reaction (RT-PCR). Increased proteinand mRNA expression has been interpreted as an in-crease in synthesis of the investigated cytokine. How-ever, increased mRNA stability or other posttran-scriptional modifications have hardly been ad-dressed. The importance of such investigations isstressed by findings that both transcriptional andtranslational mechanisms were involved the lipopol-ysaccharide-induced upregulation of TNF- mRNAin macrophages [76]. Recently it was determinedwhether transcriptional or posttranscriptionalmechanisms are involved in the irritant-induced up-regulation of TNF- in keratinocytes [62]. This studywas performed on murine keratinocytes that weretransfected with a chloramphenicol acetyl transfe-rase (CAT) reporter construct containing the full-length TNF- 5-promoter region. Increased TNF-promoter activity was indeed observed following invitro exposure to the irritants PMA and DMSO,strongly suggesting that the PMA- and DMSO-in-duced upregulation of TNF- mRNA in keratinocy-tes is due to increased transcription of the TNF-gene. These findings were further substantiated bythe observation that no significant difference inTNF- mRNA stability was observed between un-stimulated and stimulated keratinocytes [62]. It isgenerally accepted that the irritant PMA mediatesmost of its effects via PKC-dependent signal trans-duction pathways. Accordingly, it was found thatPMA, as well as the common irritants DMSO andSLS, induced an increase in TNF- mRNA in kerati-nocytes via a PKC-dependent signaling pathway(Fig. 2).


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It is known that nickel, in addition to being a fre-quent contact sensitizer, can act as an irritant in non-sensitized animals. Furthermore, nickel exhibits thecapacity to upregulate TNF- mRNA and protein inpurified keratinocytes. Inhibitors of PKC and of thecyclic nucleoside-dependent protein kinase were re-ported not to block this nickel-induced increase inTNF- mRNA. In addition, this study demonstratedno increase in TNF- promoter activity followingstimulation with nickel. Of particularly interest wasthe finding that nickel stimulation of keratinocytesin vitro resulted in a pronounced increase in thestability of TNF- mRNA as compared to unstimu-lated control cultures [62]. The precise mechanism ofthe nickel-induced increased stability of TNF-mRNA remains unclear. One possibility is modifica-tion of peptides binding to an AUUUA-sequence inthe 3-region of the mRNA thereby blocking/inhibit-ing degradation of the mRNA transcript. Anotherpossibility is that nickel stimulation could result insequestering TNF- mRNA in the ribosomal com-partment, thereby stabilizing the mRNA. Indepen-dently of the mechanism, the overall result was an in-crease in the release of biologically active TNF pro-tein.

Thus, when comparing the irritant effect of nickelin nonsensitized animals with irritants such asDMSO and PMA, different intracellular signalingmechanisms are involved in upregulation of TNF-peptide expression (Fig. 2).

Not all skin irritants induce measurableTNF-. Furthermore, different signalingmechanisms have been described, includ-ing direct gene activation (transcription)and stabilization of the TNF- mRNA(posttranscriptional regulation).

4.7.1 Regulation of the Inflammatory Milieu Locally in Inflamed Skin

As described in this chapter, an upregulation of pro-and inflammatory cytokines is present in the irritantreaction. It is noteworthy that this type of reactionoften tends to exhibit a prolonged course, even de-spite removal of the irritant exposure. Thus, the clin-ical reaction may continue for several years. Until re-cently, no explanation for this phenomenon has beenforwarded. However, data are now available suggest-ing that elements in the local inflammatory milieumay actually contribute to the persistence of skin in-flammation. Previous, it was shown that autocrineregulation of IL-1, both IL-1 and IL-1, is present invitro [77, 78]. Therefore, a study was enforced to de-scribe whether such autocrine regulation of the pro-inflammatory cytokine TNF was present in ke-ratinocytes. Indeed, it was found that stimulating ke-ratinocytes with TNF- in vitro led to an increase in


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Fig. 2. Mechanisms of irritant-induced TNF- in keratinocy-tes. Irritants (e.g., PMA, DMSO, SLS) upregulate TNF- mRNAin keratinocytes via a PKC-dependent signaling pathway re-sulting in increased mRNA transcription. In contrast, nickelsalts mediate their effects by increasing the stability of TNF-

mRNA. Both pathways ultimately lead to increased release ofTNF protein. (DMSODimethylsulfoxide,PKC protein kinase C,PMA phorbol myristate acetate,SLS sodium lauryl sulfate,TNFtumor necrosis factor)

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TNF- mRNA expression [79]. This potential, inter-esting signaling pathway was critically dependentupon signaling through PKC-dependent pathwaysand involved increased gene transcription. Thus, itwas shown that induction of the pro-inflammatorycytokine TNF-, e.g., by skin irritants, could lead toinduction of an autocrine signaling pathway locallyin the skin, thereby substantiating the inflammatoryreaction and as such contributing to the persistenceof the clinical irritant skin reaction.

Skin irritants can induce an inflammatorymilieu, following which further amplifica-tion is possible. Today, data exist demon-strating autocrine regulation of both IL-1and TNF- in keratinocytes.

4.8 Hypothesis of the Immunological Events Leading to Irritant Contact Dermatitis

Following application of irritants to the skin, pene-tration of the stratum corneum is the primary event.During this, perturbation of the skin barrier occurs.This further facilitates the penetration of the skin bythe irritant and other external agents. Following pen-etration of the stratum corneum, the irritant mostlikely induces the release of pre-formed IL-1 fromthe keratinocytes, and induces the synthesis of sever-al other immunoregulatory keratinocyte-derived cy-

tokines (Fig. 3). TNF- in particular seems essential,because in a murine system injection of antibodies toTNF in vivo completely blocks the development of ir-ritant reactions [61]. The mechanism of irritant-in-duced upregulation of TNF- seems to involve in-creased transcription of the gene; however, irritant-induced stabilization of cytokine mRNA may alsocontribute [62]. Next, induction of cell adhesionmolecules such as ICAM-1 on the keratinocytes andE-selectin on the endothelial cells facilitates the ex-travasation of inflammatory T lymphocytes to theskin. This process may be enforced by the release ofthe chemoattractant IL-8 by the keratinocytes [80].During the first 2472 h, an epidermal influx on non-Langerhans cell-derived antigen-presenting cells oc-curs. In addition, the number of epidermal Lange-rhans cells decreases and these cells possibly migratetowards the draining local lymph node. A cellular in-filtrate comprised mainly of mononuclear cells, inparticular CD4+ T lymphocytes, is then seen in theinvolved skin area. These cells are activated and theyrelease inflammatory cytokines. In particular, in-creased levels of IFN- and IL-2 have been observed[41]. Ultimately, these events lead to the histologicalpicture of acute irritant contact dermatitis.

The often-observed chronicity of irritant contactdermatitis is elusive. However, the irritant-inducedinflammation may expose the immune system to im-munogenic skin peptides that it does not normallysee. The chronicity may therefore involve presenta-tion of such self-peptides to the immune system re-sulting in the development of an autoimmune skindisease. Alternative, the irritant-induced TNF- isregulated in an autocrine way and thereby involvedin the maintenance of an inflammatory milieu local-ly in the skin. The resulting irritant contact derma-titis reaction may continue for years.


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Fig. 3.Epidermal changes followingexposure to irritants

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Suggested Reading

1. Piguet PF, Grau GE, Hauser C, Vassalli P (1991) Tumor ne-crosis factor is a critical mediator in hapten-induced irri-tant and contact hypersensitivity reactions. J Exp Med173 : 673679This paper describe in detail the presence and significanceof TNF-a in the contact irritant reaction as well as elicita-tion of the contact allergic reaction. Using the in situ hy-bridization technique, the authors directly demonstrate animportant role of the keratinocyte in this induction, thusimplicating the keratinocyte as an important player in theinduction of the contact irritant reaction in skin.

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