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and multiple pustules and crusts &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; During the summer or before menstruation&#44; her symptoms became severe and were characterized by more papules and pustules visible on her forearm with a burning sensation and intense itching that made it impossible to sleep&#46; The patient had no relevant medical or family background&#46; The results of laboratory tests showed markedly increased levels of serum IL-6 24&#46;40&#8239;pg&#47;mL &#40;normal&#58; &#60; 3&#46;0&#8239;pg&#47;ML&#41; and TNF-&#945; 6&#46;71&#8239;pg&#47;mL &#40;normal&#58; &#60; 3&#46;10&#8239;pg&#47;ML&#41;&#44; but IL-4 0&#46;1&#8239;pg&#47;mL &#40;normal&#58; &#60; 3&#46;0&#8239;pg&#47;ML&#41; and IL-10 3&#46;37&#8239;pg&#47;mL &#40;normal&#58; &#60; 4&#46;1&#8239;pg&#47;ML&#41; were in normal range&#46; The light microscopy showed isolated dyskeratotic cells and spicules with hyperkeratosis&#44; and focal hyperkeratosis suggestive of DD &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; In addition&#44; skin immunohistochemistry showed weak positivity for IL-6 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; Mutation &#40;c&#46;193T&#62;G&#58;p&#46;L65V&#41; in the ATP2A2 gene was identified using whole-exome sequencing&#46; Finally&#44; she was diagnosed with DD&#46; Isotretinoin led to a slight improvement&#44; but even at small doses&#44; there were intolerable side effects&#46; She was distressed by itching and desired more treatment&#46; After signing the informed consent form&#44; she received treatment with Tocilizumab &#40;8&#8239;mg&#47;kg&#44; repeated at 2-week intervals&#41;&#46; During that time&#44; she used emollients to supplement treatment&#46; After 2-months of follow-up&#44; forearm lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> A&#8210;D&#41; and itching were reduced&#44; and sleep quality improved significantly&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In in vitro experiments&#44; UV light decreased the expression of the ATP2A2 gene&#44; which is consistent with DD exacerbated by heat and UV light&#44; and the gene expression of ATP2A2 was increased after the use of an IL-6 antibody&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> IL-6 antibodies have been proposed in the literature for the treatment of DD patients with summer exacerbations&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Nevertheless&#44; no cases of clinical use have been reported&#46; Here&#44; we found that Tocilizumab alleviates pruritus in summer exacerbations in DD patients and controls the further progression of skin inflammation&#46; Biologicals can improve genodermatoses acting in the secondary inflammation and not in the mutation per se&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0020" class="elsevierStylePara elsevierViewall">This work was supported by <span class="elsevierStyleGrantSponsor" id="gs0005">the Zhejiang Provincial Natural Science Foundation of China</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs0005">LY22H160030</span>&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#39; contributions</span><p id="par0025" class="elsevierStylePara elsevierViewall">Lele Chen&#58; Writing of the manuscript or critical review of important intellectual content&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Wenwen Wang&#58; Data collection&#44; or analysis and interpretation of data&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Sen Zhou&#58; Statistical analysis&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Zhiming Li&#58; Final approval of the final version of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Letter - Therapy
The first report of Tocilizumab for Darier disease with summer exacerbations
Lele Chen, Wenwen Wang, Sen Zhou, Zhiming Li
Corresponding author
wylzm1@163.com

Corresponding author.
The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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and multiple pustules and crusts &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; During the summer or before menstruation&#44; her symptoms became severe and were characterized by more papules and pustules visible on her forearm with a burning sensation and intense itching that made it impossible to sleep&#46; The patient had no relevant medical or family background&#46; The results of laboratory tests showed markedly increased levels of serum IL-6 24&#46;40&#8239;pg&#47;mL &#40;normal&#58; &#60; 3&#46;0&#8239;pg&#47;ML&#41; and TNF-&#945; 6&#46;71&#8239;pg&#47;mL &#40;normal&#58; &#60; 3&#46;10&#8239;pg&#47;ML&#41;&#44; but IL-4 0&#46;1&#8239;pg&#47;mL &#40;normal&#58; &#60; 3&#46;0&#8239;pg&#47;ML&#41; and IL-10 3&#46;37&#8239;pg&#47;mL &#40;normal&#58; &#60; 4&#46;1&#8239;pg&#47;ML&#41; were in normal range&#46; The light microscopy showed isolated dyskeratotic cells and spicules with hyperkeratosis&#44; and focal hyperkeratosis suggestive of DD &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; In addition&#44; skin immunohistochemistry showed weak positivity for IL-6 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; Mutation &#40;c&#46;193T&#62;G&#58;p&#46;L65V&#41; in the ATP2A2 gene was identified using whole-exome sequencing&#46; Finally&#44; she was diagnosed with DD&#46; Isotretinoin led to a slight improvement&#44; but even at small doses&#44; there were intolerable side effects&#46; She was distressed by itching and desired more treatment&#46; After signing the informed consent form&#44; she received treatment with Tocilizumab &#40;8&#8239;mg&#47;kg&#44; repeated at 2-week intervals&#41;&#46; During that time&#44; she used emollients to supplement treatment&#46; After 2-months of follow-up&#44; forearm lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> A&#8210;D&#41; and itching were reduced&#44; and sleep quality improved significantly&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In in vitro experiments&#44; UV light decreased the expression of the ATP2A2 gene&#44; which is consistent with DD exacerbated by heat and UV light&#44; and the gene expression of ATP2A2 was increased after the use of an IL-6 antibody&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> IL-6 antibodies have been proposed in the literature for the treatment of DD patients with summer exacerbations&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Nevertheless&#44; no cases of clinical use have been reported&#46; Here&#44; we found that Tocilizumab alleviates pruritus in summer exacerbations in DD patients and controls the further progression of skin inflammation&#46; Biologicals can improve genodermatoses acting in the secondary inflammation and not in the mutation per se&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0020" class="elsevierStylePara elsevierViewall">This work was supported by <span class="elsevierStyleGrantSponsor" id="gs0005">the Zhejiang Provincial Natural Science Foundation of China</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs0005">LY22H160030</span>&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#39; contributions</span><p id="par0025" class="elsevierStylePara elsevierViewall">Lele Chen&#58; Writing of the manuscript or critical review of important intellectual content&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Wenwen Wang&#58; Data collection&#44; or analysis and interpretation of data&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Sen Zhou&#58; Statistical analysis&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Zhiming Li&#58; Final approval of the final version of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Article information
ISSN: 03650596
Original language: English
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