Petrolatum: Barrier repair and antimicrobial responses underlying this “inert” moisturizer Tali Czarnowicki, MD, Dana Malajian, BA, Saakshi Khattri, MD,

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Petrolatum: Barrier repair and antimicrobial responses underlying this “inert” moisturizer Tali Czarnowicki, MD, Dana Malajian, BA, Saakshi Khattri, MD, Joel Correa da Rosa, PhD, Riana Dutt, ScB, Robert Finney, MD, Nikhil Dhingra, MD, Peng Xiangyu, MSc, Hui Xu, MSc, Yeriel D. Estrada, BS, Xiuzhong Zheng, MSc, Patricia Gilleaudeau, NP, Mary Sullivan- Whalen, NP, Mayte Suaréz-Fariñas, PhD, Avner Shemer, MD, James G. Krueger, MD, PhD, Emma Guttman-Yassky, MD, PhD Journal of Allergy and Clinical Immunology Volume 137, Issue 4, Pages 1091-1102.e7 (April 2016) DOI: 10.1016/j.jaci.2015.08.013 Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 1 Study design. Two cohorts were enrolled in this study. Cohort 1 included 29 (13 patients with AD and 16 subjects without AD) subjects, and cohort 2 included 20 healthy volunteers. Patch tests were applied for 48 hours in cohort 1 and 72 hours in cohort 2, and biopsy specimens were obtained at 72 hours. Five subjects from cohort 2 had another 3 biopsy specimens taken at 48 hours. Journal of Allergy and Clinical Immunology 2016 137, 1091-1102.e7DOI: (10.1016/j.jaci.2015.08.013) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 2 Unsupervised hierarchic clustering of DEGs across petrolatum-occluded and control skin samples (red, upregulated; blue, downregulated). Expression of the AMPs HBD2/DEFB4A, LCN2, elafin/PI3, S100A8, S100A9, CXCL1, and CXCL2 was increased significantly by petrolatum occlusion. The right column shows FCHs of petrolatum compared with control values. **P < .05 and ***P < .01. Journal of Allergy and Clinical Immunology 2016 137, 1091-1102.e7DOI: (10.1016/j.jaci.2015.08.013) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 3 Expression of AMPs, innate immune genes, and major cytokines, as determined by using RT-PCR, in control, occlusion-only, and occlusion with petrolatum skin. Mean expression estimates normalized to hARP are represented in a (log2[expression/hARP]) scale. Data were grouped according to the major immune pathways represented. Increased expression of significant AMPs, innate immune genes, and cytokines was observed with petrolatum occlusion. P values are indicated if significant. *P < .1, **P < .05, and ***P < .01. Journal of Allergy and Clinical Immunology 2016 137, 1091-1102.e7DOI: (10.1016/j.jaci.2015.08.013) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 4 Representative H&E (A-C) and IHC staining of S100A8/A9 (D-F), lipocalin/LCN2 (G-I), and CCL20 (J-L) in control, occluded, and petrolatum-occluded skin samples, demonstrating increased expression of AMPs in petrolatum-occluded skin (histologic magnification ×10). Note also increased thickness of the SC in H&E-stained samples (Fig 4, A-C), with intercellular clefts most notable in petrolatum-occluded skin (Fig 4, C). Journal of Allergy and Clinical Immunology 2016 137, 1091-1102.e7DOI: (10.1016/j.jaci.2015.08.013) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 5 Heat map showing average RT-PCR expression values for control and petrolatum AD and non-AD groups. A, Mean RT-PCR expression values in control non-AD and control AD skin. Large TH2 pathway gene (ie, IL4, IL13, IL10, and CCL26) expression increases in control skin were observed in patients with AD. B and C, Mean RT-PCR expression values in control and petrolatum non-AD (Fig 5, B) and AD (Fig 5, C) skin, showing greater increases in AMP (S100A7-9, LCN2, CCL20, and PI3) and immune gene (IL12/IL23p40, IL23p19, IL22, IFNG, and IL17F) expression in subjects without AD. FCH values are shown in the columns to the right. *P < .1, **P < .05, and ***P < .01. Journal of Allergy and Clinical Immunology 2016 137, 1091-1102.e7DOI: (10.1016/j.jaci.2015.08.013) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 6 Representative staining of H&E (A-D), LOR (E-H), and FLG (I-L) in control skin and petrolatum-occluded skin from patients with AD and subjects without AD. AD skin shows parakeratosis and focal disruptions of the granular layer Fig 6, C), with restoration of orthokeratosis with petrolatum (Fig 6, D). Weak and discontinuous LOR (Fig 6, G) and FLG (Fig 6, K) staining was observed in control AD skin, with increased intensity and restoration of continuous expression of both markers after occlusion with petrolatum (Fig 6, H and L; histologic magnification ×10). Journal of Allergy and Clinical Immunology 2016 137, 1091-1102.e7DOI: (10.1016/j.jaci.2015.08.013) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig E1 RT-PCR log2 expressions normalized to hARP for 5 key AMPs. To assess the point of maximum gene induction for petrolatum and occlusion, we compared gene expression at different time points. S100A7, LCN2, S100A8, and PI3 all showed significant increases in expression from baseline at 72 hours of occlusion with petrolatum but not at 48 hours. Bar plots represent means ± SDs. *P < .1, **P < .05, and ***P < .01. Journal of Allergy and Clinical Immunology 2016 137, 1091-1102.e7DOI: (10.1016/j.jaci.2015.08.013) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig E2 A, Thickness (in micrometers) of the SC in control, occlusion-only, and occlusion with petrolatum skin. Occluded and petrolatum-occluded SC showed significant thickness increases compared with baseline, and petrolatum also significantly increased SC thickness compared with occlusion alone. B-D, Immunofluorescence staining with Nile Red for neutral lipids in control (Fig E2, B), occlusion-only (Fig E2, C), and occlusion with petrolatum skin in a representative subject (Fig E2, D). Intercellular lipid clefts are observed after occlusion with petrolatum, which, in Fig E2, B and C, were not observed in control and occlusion-only skin, probably accounting for the increased SC thickness observed. Bar plots represent means ± SEMs. **P < .05 and ***P < .01. Journal of Allergy and Clinical Immunology 2016 137, 1091-1102.e7DOI: (10.1016/j.jaci.2015.08.013) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig E3 Neutrophil elastase cell counts of control, occluded, and petrolatum-occluded skin. There were no statistically significant increases in neutrophil elastase–positive infiltrates in occluded or petrolatum-occluded skin. Bar plots represent means ± SEMs. Journal of Allergy and Clinical Immunology 2016 137, 1091-1102.e7DOI: (10.1016/j.jaci.2015.08.013) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig E4 Cell counts for CD8, dendritic cell lysosome-associated membrane glycoprotein (DC-LAMP), CD11c, CD3, CD1a, CD1c, maltose-binding protein (MBP), and Langerin for control and occlusion with petrolatum skin in patients with AD and subjects without AD, demonstrating significantly decreased CD8 infiltrates for patients with AD and subjects without AD and decreases in CD1c and CD3 for patients with AD only. Bar plots represent means ± SEMs. *P < .1 and **P < .05. Journal of Allergy and Clinical Immunology 2016 137, 1091-1102.e7DOI: (10.1016/j.jaci.2015.08.013) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions