Clinical and laboator y st ud y Jmpact of systemic psoriasis treatment on the lesional T- lymphocyte subtypes 
K E Y 
WORDS 
psoriasis, 
PASlscore, 
cyclosporin 
A treatment, 
lesional 
CD4,CD8 
lymphocytes 
Impact of systemic psorias-is treatment on 
the lesional T-lymplwcyte subtypes 
K. Adamicova, Ž. Fetisovova, J. Peč, P. Cingel, K. Parobekova and I. Chromej 
ABSTRACT 
Objective In 19 patients suffering from severe psoriasis and who were treated by Cyclosporin A (CyA), 
CD4 and CD8 positive T-cells were studied. 
Materials and methods. Skin from affected areas was examined by immunohistopathology tor the 
presence of CD4 and CD8 positive T-cells before and 4 weeks after the start of treatment. 
Results. Significant decrease in CD4 positive T-cells and a non-significant decrease in CD8 positive T-
cells were observed after the initiation of treatment. CD4/CD8 ratio dropped from the values of 2.1 O to 
1.68. Dramatic decrease in PASI score was observed, from the average value of 23.34 to that of 11.97. 
Discussion. The authors compare and discuss the results of a few similar cytophotometric studies 
found in the available literature. The decreases in T-lymphocyte subsets correlate with clinically well-
known treatment effect of CyA and suggest underlying immunopathologic process. 
Introduction 
Pathogenesis of psoriasis stil! remains unclear. At-
tention has been traditionally focused on abnormali-
ties ofkeratinocyte proliferation and differentiation. In-
flammat01y and immunological reactions in the affected 
skin have been proposecl as a suspectecl trigger only 
recently (1). The !atest knowledge in the field of immu-
nology of psoriasis and interaction processes between 
the cells at the site of inflammation suggest a possible 
autoimmune backgrouncl of this disease (2) . 
The cells of the immune system bear on their sur-
faces hundrecls of molecules specific for particular de-
velopment stage and functional state. Until now, more 
than 260 various types of molecules have been identi-
fied on the surface of human leucocytes, but only a few 
clecacles of these are associated with a know n structure 
and function. Sets of monoclonal antib? dies were pro-
cluced to target antigenic glycoprotein molecules on the 
surface of cells involved in immune response. In 1982, 
the Paris nomenclature of these glycoprotein molecules, 
denoted as CD (cluster of differentiation) markers, was 
approved (3,4). 
Healthy dermis contains a certain number ofT-lym-
Acta Dermatoven APA Vol 11, 2002, No 2 --------------- - - JJ 
lmpact of systemic psoriasis treatment on the lesional T- lymphocyte subtypes Clinical an d laboat o r y study 
Tab 1 CD4 and CD 8 positive T-cells measured before (1 st excision) and after (2nd excision) the start 
of treatment with CyA in 19 patients suffering from severe form of psoriasis. The ratio CD4/CD8 
was calculated and the clinical status was expressed as PASI score. 
1 st excision 
No. CD4 -1 CD8-1 CD4:CD8 PASI - 1 
1 24 8 3 38,8 
2 104 41 2,53 26 
3 68 83 0,81 28,8 
4 100 20 5 25 
5 25 11 2,27 15,3 
6 27 35 0,77 42 
7 30 30 1 6,3 
8 100 70 1,42 13 
9 40 40 1 25,8 
10 22 10 2,2 25,8 
11 21 12 1,75 14 
12 84 62 1,35 13,9 
13 96 42 2,28 17,4 
14 31 26 1,19 15,6 
15 97 36 2,7 27,5 
16 120 45 2,66 22,4 
17 93 49 1,9 29,9 
18 178 54 3,29 13,2 
19 162 58 2,79 42,8 
Mean: 74,84 38,52 2,1 23,3 
phocytes w hich can multiply significantly under patho-
logic (inflammatory) conditions (5) . Major pathologi-
cal abnormalities in psoriasis occur in epidermis with 
clisturbed balance in proliferation and differentiation of 
keratinocytes. Hyper-and parakeratosis in the psoriatic 
sites is accompanie<l by inflammation in the <lermis. 
Related to development of psoriasis and the effects of 
some systemic drugs used in the treatment, the dynam-
ics ofT-lymphocytes and their subpopulations of helper 
(CD4) T-cells and suppressor/ eytotoxic (CD8) T-cells 
might be closely connected with disease progression 
and a long-term outcome. In our pilot study, the abso-
lute and relative presence of T-lymphocyte subtypes, 
CD4 ancl CD8 T-cells, has been monitored in situ , be-
TAB.2 Correlations coefficients of CD4, CD8 
count, CD4/CD8 ratio and PASI score in the 
course of treatment. 
CD4 
CD8 
CD4:CD8 
PASI 
0,8389 
0,5456 
0,299 
0,6561 
2nd eXCiSiOn 
CD4 -2 CD8-2 CD4:CD8 PASI -2 
40 10 4,00 18,8 
26 23 1,13 14,9 
48 33 1,45 15,5 
74 49 1,51 3,6 
20 14 1,42 9,3 
21 18 1,16 18,2 
25 27 0,92 4,6 
69 45 1,53 9,6 
29 18 1,61 22,2 
20 12 1,66 10,4 
18 21 0,85 6,0 
57 29 1,96 6,0 
82 31 2,64 5,8 
27 19 1,42 13,3 
51 22 2,31 15,2 
36 31 1,16 5,1 
94 58 1,62 21,1 
125 78 1,60 12,6 
142 69 2,05 15,6 
52,8 31,9 1,68 11,97 
fore ancl during the treatment of severe forms of pso-
riasis w ith cyclospo rin A (CyA) . CyA (Sandimmun 
Neoral, Novartis) is a lipophilic unclecapeptide isolated 
from Tolypocladium inflatum. It is an effective immu-
nosuppressive drug with selective and reversible inhibi-
to1y effect on the T-lymphocyte functions mainly clue 
to the inhibition of interleukin-2 production, ancl has 
been proved as effective in the prophylaxis ancl treat-
ment of autoimmune dermatoses including psoriasis 
vulgaris (6). It has been used in the treatment of psori-
atic a11hropathy, moderate and severe forms of psoriasis, 
including psoriatic erythrodermia and pustular psoriasis. 
Material and Methods 
19 patients (11 males, 8 females) with severe pso-
riasis were included into the study. The age of patients 
varied from 32 to 58 years with an average of 42. The 
extent and severity of disease were measured by means 
of PASI score (psoriasis area and severity index). The study 
protocol was approved and monitored by the Ethical com-
mittee at Martin Faculty Hospital. The procedure was ex-
plained to the patients and their consent was obtained . 
The skin specimens were excised from the lesion 
.52 -------- ---- - ----- - ----- - ---------Acta Dermatoven APA Vol 11, 2002, No 2 
Clin ic al a nd laboator y s tud y lmpact of systemic psoriasis treatment on the lesional T-lymphocyte subtypes 
margins using 5 mm needle, the tissue was processed 
by the method of frozen cuts and monoclonal antibod-
ies specific against CD4 marker of helper/ inducer T-
cells, and CD8 marker of suppressor/cytotoxic T-cells 
(Dako Co. ) were applied. Under magnification of 480x, 
fixed number of 10 visual fields of the dermis was evalu-
ated by a semi quantitative method. After morphologi-
cal evaluation ofT-lymphocytes w ith positive reaction 
to the added antibody, the cells were counted . The skin 
specimens were processed and evaluated under the 
same conditions before the start of systemic treatment, 
and at four weeks after starting CyA therapy in the ini-
tial dosage of 3mg/ kg/ day. The fina! evaluation con-
sisted of comparing clinical outcome of treatment with 
CyA measured by PASI and relative and absolute pres-
ence of CD4 and CD8 positive T-cells in the psoriatic 
lesions. Two selection paired t-test was used as statis-
tics for the leve! of significance of observed data. 
Results 
Table 1 is a summary of data obtained in the group of 
19 patients divided according to the tirne of excision. 
Before the start of CyA treatment, the number of CD4 
positive T-cells was within the range of 22-178, w ith 
the average of74.8 per 10 fields of vision. CD8 positive 
T-cells were less, their values ranged from 8 to 83, w ith 
the average of 38.5 per 10 fields of visi01{ The CD4/ 
CD8 ratio at the ti.me of the pretreatment excision was 
about 2.1. PASI score was 23.3 on average, ranging from 
6.3 up to 42.8. 
After 4 weeks of CyA treatment, the number of T-
cells and their subtypes were decreased. The CD4 posi-
tive T-cells decreased to the value of 52.8 on average, 
the CD8 positive T-cells decreased to the value of 31.9 
on average . The decrease of CD4 positive T-cells was 
statistically significant at the leve! of p < 0.05. The de-
crease of CD8 positive T-cells was not statistically sig-
nificant. Decrease in CD4/ CD8 ratio from the value of 
2.10 to 1.68 was slightly exceeding the limit of signifi-
cance, staying within the limits of trend with p=0,055. 
The remarkable decrease in PASI score from the aver-
age value of 23.34 to the average value of 11.97 was 
statistically significant at the leve! of p = 0.00000292. 
Discussion 
The assumption of the autoimmune origin of pso-
riasis is mainly due to the conspicuous presence of an 
increased number of T-lymphocytes in lesions and to 
the observation of disease transfer by bone marrow 
transplantation or its cure by the same procedure (7). 
In a well-developed psoriatic lesion, the focal T-lym-
phocytes and their subsets multiply. The CD4 positive 
T-cells are mostly auxili aty T-lymphocytes engaged in 
Thl type of immunoreaction. They interact with anti-
gen-presenting cells and are connected with class II 
histocompatibility complex (MHC). They might play an 
important role in predse determination of epitopes trig-
gering the immune response. T-lymphocytes positive for 
CD8 on their sU1face belong to the MHC I class and play 
a role in principal recognition of self and non-self anti-
gens as a part of the first defense reaction against infec-
tions and in maintaining integrity of the epithelium layer. 
Dermal infiltrate consists mostly of CD4 positive T-
cells, while the T-lymphocyte infiltrate found among 
epidermal cells consists mostly of CD8 positive T-cells 
(8). Retention of the lymphocytes in the epidermis is 
due to their bond with keratinocytes which express 
adhesive ICAM-1 molecule (7). In our specimens, lym-
phocytes were found in the epidermis only occasion-
ally and in insignificant quantity, therefore we did not 
evaluate them further. This condition may be the result 
of local therapy with corticosteroids used by psoriatic 
patients. In a recent study, cytomorphometry of periph-
eral blood of psoriatic patients revealed the relative pres-
ence of CD4 positive T-cells in the range of 64-85% and 
CD8 positive T-cells of 10-32% (8) which is in apparent 
contrast with their values in a healthy population. Ref-
erential normal range for CD4 positive T-cells is 33-53% 
and for CD8 positive T-cells is 24-50% (11). Neverthe-
less , the relative increase in CD4 positive and the de-
crease in CD8 positive T-cells in the peripheral blood 
of psoriatics is also reflecting the stage of disease pro-
gression, remission or re lapse, as well as the effects of 
systemic treatment (5) . 
The differences in published data on the presence of 
activated T-lymphocytes in the peripheral blood of pso-
riatic patients may be also due to confounding effects of 
other immunologic reactions evolving in the body (9). 
Only few authors studied CD4 and CD8 positive T-
cells in situ, in the lesions of psoriatic patients. Baker et 
al. (1) have found 204 ( +/ - 24) CD4 positive T-cells and 
119 ( +/ - 18) CD8 positive T-cells, with their ratio of 2.05 
C+/ - 0.26) , in 50 fields of vision of frozen slices taken 
from the margins of psoriatic sites. CD4 / CD8 ratio of 
1.28 was higher than that found in a healthy popula-
tion. In the psoriatic lesions of patients with AIDS, CD4/ 
C8 ratio was ve1y low, only 0.5-0.8. Remarkable increase 
in the number of CD8 lymphocytes in the specimens 
has not been explainecl yet (9) . The present study of-
fers additional data on the in situ dynamics of T-lym-
phocyte subsets in psoriatic patients treated by CyA. 
The CD4/ CD8 ratio measured before the treatment was 
similar to that of Barker et al. (2.1 vs. 2.5) (10) . The 
decrease of absolute values in both studied T-lympho-
cyte subgroups can be explained by immunosuppres-
sive effect of CyA and was reflected also in the change 
of their relative proportion. 
It was hypothesized , that during remission of clini-
cal manifestations of psoriasis , activated CD8 cells rela-
Acta Dermatoven APA Vol 11, 2002, No 2 --- - ----- - ----- - - 53 
lmpact ofsystemic psoriasis treatment on the lesional T- lymphocyte subtypes Clinic al and laboator y study 
tively prevail and produce cytokines which help inhibit 
the disease process (12). Our results showed that de-
spite of dramatic drop in PASI , no increase in CD8 posi-
tive T-cells was observed after 4 weeks of CyA treat-
ment. Decrease in CD4/ CD8 ratio after CyA treatment 
shows more rapid decrease in CD4 than CD8. Improved 
clinical status reflected in PASI decrease after 4 weeks 
of CyA treatment was accompanied by returning the 
relative numbers ofT-lymphocyte subsets close to those 
found in healthy persons - 52.8% of CD4 p ositive T-
cells within the reference range 33-53% (13) and 31.9% 
of CD8 positive T-cells within the same of 24-50% (13). 
The rapid and favorable effect of CyA in the treatment 
of psoriasis was repeatedly stressed in the literature (14, 
15). The observed changes _in the CD4 and CD8 posi-
tive T-cell subsets correlate with the treatment outcome 
and may strongly suggest underlying immunopathol-
ogy in the development ofthe disease (16, 17, 18). 
REFERENC.ES 
l. Hatta N, Takata M, Kawa.ra, Hirone T, Takehara K. Tape stripping induces marked epidermal prolifera-
tion and altered TGF-alpha expression in non-lesional psoriatic skin. J Dermatol Sci 1997; 14: 154 - 61. 
2. Camp RDR. Psoriasis in: Textbook of Dermatology. Eds RH Champion, JL Burton, DA Burns, SM 
Breathanach. Vol 2, 6th ed Blackwell Science, Oxford 1998; 1589 - 649. 
3. Ferenčfk M, Rovensky J, Nyulassy Š. Imunol6gia- zakladne termfny a definfcie. SlovakAkademic Press 
sro, Bratislava 1999; 195. 
4. Lukaš Z, Drabekova E, Feit J, Vojtlšek B. Imunohistochemiske metody v biologii a biopticke diagnostice. 
Sbornfk p.racf Leka0ske fakulty v Brnl. Leka0ska fakulta Masarykovy univerzity, Brno, 1997; 14 7. 
5. McKee PH. Pathology of the Skin. 2nd ed Mosby- Wolf, London. Wiesbaden 1996; 14 -7. 
6. Picascia DD. Treatment of severe resistant psoriasis with systemic cyclospori..11. J Amer Acad Derm 
1987; 17: 408 - 14. 
7. Griffits ChEM, Kirby B. Psoriasis. M Dunitz, London, 1999; 1 - 6. 
8. Brown DW, Baker BS, Ovigne JM, Hardman C, Powles AV, Fry L. Skin CD4+ T cells produce interferon -
gamma in vitro in response to streptococcal antigenes in chronic plaque psoriasis. J Invest Dermatol 
2000; 114: 576 - 80. 
9. Steigleder GK, Rasokat H, Wermmer V. Psoriasis in immunodeficiency related to HLTV - III - ceUular 
immunity and immunohistochemical findings. Z Hautkr 1986; 61: 1971 -8. 
10. Baker BS, Swain AF, Griffits,CEM. Epidermal T lymfocytes and dendritic cells in chronic plaque psoria-
sis: The effects of PINA treatment. Clin Exp lmmunol 1985; 61: 526 - 34. 
11. Barrett JT. Textbook of Immunology ai1 Introduction to Immunochemistry and Immunobiology. CV 
Mosby Comp, St Louis Washington, Toronto, 1988; s 121 - 44. 
12. Fry L. Psoriasis: immunopathology and long - term treatment with cyclosporin. J Autoimmunity 1992; 
5 (Suppl A): 277 - 83. 
13. PetriskovaJ. Vyznam prietokovej cytometrie kože v diagnostike dermatologickych ochoreni. Atestačna 
praca, Martillske centrum imunol6gie, Martin 2001 ; 30. 
14. Buchvald J, Šimaljakova, M. Cyklosporin A v terapii psoriazy. Čs Derm 1994; 69: 179 - 81. 
15. Novotny E Cyclosporin A v terapii psoriazy a atopickeho ekzemu. Čs Derm 1999; 74: 61 - 3. 
16. Glad CP, van Erp, PE, Boezman L, van de Kerkhof PC. Multiparaineter flow cytometry as a tool to 
evaluate antipsoriatic therapy. Br J Dermatol 1997; 137: 367 - 75. 
17. Griffiths ChEM. Systemic aJJd local administration of cyclosporin iil the treatment of psoriasis. J Amer 
Acad Derm 1990; 23: 1242 - 6. 
18. Malu·le G, Schulze HJ, Brautigain M and other multicenttic contributors. Anti - mflainmatory efficacy of 
low- dose cyclosporill A in psodatic arthritis. A prospective multicentdc study. BrJ Denn 1996; 135: 752 -7. 
A U T H O R s ' KatarinaAdamicova, MD, PhD, assist. projessor, Department oj 
A D D R E S S E S Pathology, Jessenius Faculty ojA1edicine, Comenius Vniversity, Martin 
(JFM CV), Kollarova 2, 036 59 Martin. 
Želmira Fetisovova, MD, Department oj Dermatovenerolof!,y JFM CV 
Jura} Peč MD, PhD, projessor and chairman, same address 
Peter Cingel, Computer Centre JFM CV 
Katarina Parobekova, same address 
Ivan Chromej, Division oj Immunology and Oncology, Novartis Bratislava 
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