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Vol 10, No l, Jamnry -

March 2001 Immunohistopathological featues of prurigo H ebra

The immunohistopathological features of prurigo HebraSiti Aisah Boediardja,x Achmad Tjarta,x* Santoso Comain,** Unandar Budimulja,* Adhi Djuanda, xEndang.S.Roostini,*x Meny Hartati**

Abstrak

Sampai saat ini meknnisme pruigo Hebra (PH) belum diketahui secara pasti. Namun, berdasarkan adanya riwayat dalam keluargayang menderita penyakit serupa serta riwayat alergi terhadap gigitan nyamuk, besar kemungkinan mekanismenya merupaknnmekanisme hipersensitivitas. Penelitian ini bertujuan mengevaluasi gambaran imunohistopatologik PH khususnya sebukan selinflamasi umum dan spesifik pada lesi awal dan lesi kronik. Penelitian dilakuktn terhadap 50 spesimen yang berasal dari biopsi lesiawaL dan 50 lesi lanjut. Setelah diproses sediaan tersebut diwamaknn dengan HE dan imunoperoksidase (lP) menggunakan antibodimonoklonal terhadap sel inJlamasi spesifik, yaitu sel B, sel T, sel T-helper CD4+(sel CD4+), sel T-supresor CD8+ (sel CD9+), selktngerhans, dan sel penyaji antigen (SPA) yang mengel0.05), kecuali CD4+. Pada sediaan lesi awalmaupun Lesi lanjut sebukan sel CD4+ Lebih banyakjumlahnya daripada sel CD8+ dengan ratio 3:l dan 2:1. Sel B yang normalnyatidak dijumpai di kulit, ditemukan dalam jumlah sedikit, serta tidak berhubungan dengan banyaknya eosinofil dan sel T. JumLah seLI'angerhans (SL) di epidermis pada lesi Lanjut Lebih banyak daipada awal. Secara statistik ditemukan korelasi kuat (0.39) antarajumlah sel T dan SPNHLADR. berdasarkan hal tersebut dapat disimpulkan bahwa pasien prurtgo selalu terpajan faktor ekstrinsik.Analsis menunjukkan pada pPH yang memiliki HIA,-AI) atau HLA-Al0-spIit, makin berat penyakitnya makin banyak jumlah sebukaneosinofil (X2 for trend

IBoediardja et al

disease in Vienna, Austria. Its clinical manifestations,rtchrng, prurigo papules, hyperpigmentation andhyperkeratotic skin, greatly inhibit patient's rlcrivityand aesthetic p.erformance.l-6 In Inclonesia. prurigoHebra cases are very common. even in a referralhospital like Dr. Cipto Mau_rnnkusumo GeneralHospital, Jakarta.T 8

The diagnosis is not especially difficult; the disease iseasily recognized by its specific locations: theextensor surface of lower and upper extremities, face,buttocks and abdomen. Patients generally complain ofsevere itching. The manifestation is limited to theskin, appearing as polymorphic lesions such aserythema and dome-shaped papules with tiny vesicleon its top. The vesicles are immediately ruptured byscratching then the lesions become eroded andexcoriated.r-6 Agents of hypersensitivity, such as bedbugs, ants, mosquitoes. and certain drugs and foods,as well as bad hygiene and poor nutrition, areclaimed as the factors that trigger or influence thedevelopment of the disease. e'lo

Until now, the mechanism of the disease has not beenfully understood. Occampo 1975, Australian, fourldthat the histopathological specimens stained with HEof early infantile prurigo Hebra lesions showed acuteinflammatory infiltration consisting of polymorpho-nuclear cells and eosinophils. This feature was similarto that of insect bite reaction.'o On the other hand,Boediardja, 1987, Indonesian, found that the histo-pathological examination on 159 HE biopsyspecimens of chronic prurigo Hebra lesions showedchronic inflammatory infiltration predominated bylymphocytes, histiocytes and eosinophils. This findingcould not be concluded wether the underlyingmechanism was a general or specific immunologicalreaction, even though the presence of eosinophilssuggested immediate (type I) hypersensitivity reaction.Boediardja, 1987, also found an increase of total IgElevels in 50Vo of 159 patients.n O""u-po, 1915,confirmed the hypersensitivity to insect bite in prurigoHebra, his study on 100 infantile prurigo cases foundpositive prick test reaction to insect allergens.l0

The airn of this study is to identify the localimmunologic mechanism of the disease usinghistopathological examination with HE and IPstainings.

Med J lndones

I\,IETHODS

A descriptive-analytic study was designed to comparethe intlammatory cells infiltration in the early (A) andlate (chronic) lesions (B). Fifty cases of prurigo Hebrawere included in the study. Skin biopsy was takenfrom an early lesion (red papule that appeared within48 hours) and a late lesion (old papule onliyperpigmented area or hyperkeratotic lesions) oneirch subject.

All skin biopsies were sliced wrth a microtome to 3-4 pm thickness; 3 or more slices of the same lesion(A or B) were prepared on an objective glass (slide).Fifty slides of each early and late lesions were therrstained with HE and IP using monoclonal antibodiesa-{ainst T cells, T-helper (CD4+) cells, T-supressor/cytotoxic (CDS+) cells, B cells, Langerhans cellsand antigen-presenting cells which expressed the q.-and B-chain of HLA-DR (APCs/HLA-DRu or'APCs/HLA-DnB).To identify specific cells (T-cells, CD4+ cells, CDtj+cells, B cells, Langerhans cells, and APCs), themonoclonal antibodies UCHL- I (CD45RO), antihuuranCD4+ cells, antihuman CD8+ cells, CD20 or L26.protein S-100. antihllman HLA-DRa and antilrunrarrHLA-DRP or CR3/213, respectively were nsed. Thesemonoclonal antibodies were made by DakoCorporation.

The substrate fbr all lP staining was 3'3'diaminoben-zidine (DAB), ')-r+ except fbr epidermal Langerhar.rscells (LCs) was 3'amino-9'aethylcarbazone (AEC;. r5'r('From skin biopsy 100 were eligible for the study, eachlesion had one HE-stained slitle and seven IP-stained sfides, one for each type of cells. The positivecontrol specimens were taken tl'om the tonsil/appendix tissue while negative (Lrnstained) contlolspecimens were fiom the sarne lesions.

Non-specrtic int'larnrnatory cells (lyrrphocytes,histiocytes, eosinophils, basophils, mast cells), andspecific inf'lammatory cells (B cells, T cells, CD4+cells, CD8+ cells, Langerhans cells, HLA-DRor/APCsand HLA-DRB/APCs), in the two rnost representativeslices on each slide were examined. The total absolutenumbers of cells per I cm2 and the proportions ofthose inflammatory cells in 2 parts of the lesion (thecentral and the edge) were calculated. The slides wereexamined by using 1 cm2 net-grid eyepiece placecl onthe ocular lens, under 400x magnification. The

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March 2001

average (mean t standard deviation) number ofinfiltrating cells was calculated from the totalnumber/l cm2 of that particular cell. The averagenumber of a particular cell in the central part of thelesions was the total numberll cmz of that cells inthree parts of each slice divided by six (3x 2 slices).Mann-Whitney statistical method (U tesQ was used tocompare the quantity of inflammatory cell infiltrationat the central part and the edge ofearly and late lesions.

The immunogenetic factors of human leukocyteantigen (HLA) were performed in 4l cases by usingHlA-class I Asian dry traylot # 1A based onmicrolymphocytotoxic reaction.

RESULTS

The histopathological characteristics of Ifi stainingHistopathological examinations revealed thecharacteristics of corneal layer in early and latelesions and are presented in Table 1. Normal corneallayer was seen in 80% cases of early lesions and l2%oof late lesions. On the contrary, orthokeratosis wasnoted in 887o cases of late lesions and appeared inonly 2OVo cases of early lesions. The basket weaveconfiguration of corneal layer was pronounced inearly lesions (48Vo). All findings were statisticallysignificant (p

Boediardja et aI

early-lesion and 9 of 50 late-lesion specimens. Thenumber of PMNs in early lesions was greater than inthe late ones. Lymphocytes and histiocytes wereabundant, their number in the late lesions were greaterthan in the early ones, statistically these findings werenot significant (p>0.05). [n the early lesions,eosinophils were more pronounced; their number wasgreater than that in the late lesions with a highlysignificant difference (p0.05). The absolute

Type of cells Early lesions (n=50)N#) MeantSD Med. Late lesions (n=50) PN#) MeaniSD Med.

l. PMNs2. Lymphocytes3. Histiocytes4. Eosinophils5. Other cells ##)

8+ 2 089t 59 6540+ 24 36l0+ ll 9

9 l+ 350 85+ 3650 48+ 2530 5+ 9

l3505046

07343

3

> 0.05> 0.05> 0.05< 0.01 **

Note: N#) =nurn6st of positive specimens, Mean = average,'SD= standard deviation, Med. = median,##) Mast cells, basophils, plasma cells were not found.Significant different at p < 0.05, ** highly signihcant difference at p< 0.01

Table 4. The absolute numbers of T,CD4+ cells ,CD8+ cells, and B cells in the central part of prurigo Hebra lesions

The absolute number ofcells /l cm2

Early lesions (n1=59;Mean t SD Median

Late lesions (n2=50)Mean t SD Median

U test

1. T cellsLymphocyes

Histiocytes+lymphocytes

2. CD4+ cellsLymphocytes

Hi sti ocytes+lymphocytes

3. CD8+ cellsLymphocytes

Histiocytes+lymphocytes

4. B cellsLymphocytes

Hi stiocytes+lymphocytes

5. RatioCD4+ cells:CD8+ cells

72.68 X44.2255.06 t 28.3891.94 + 4t .43

41.40 + 35.4460.18+31.0197.79 t 45.3820.84 t 15.8668.52 t35.32

105.68 + 48.88

4.57 + 3.8393.73 + 43.6237.00 r 57.00

2.90 I 1.89

57.24 + 33.5951.66 + 25.9687.30 + 41.78

27.70 + 18.0062.04 + 27.02

102.94 + 41.7',1

20.00 I 16.0067.96 + 28.O4

108.98 + 46.56

5.76 r 3.00'73.43 !33.88

119.81!43.52

I .847+ l.l8

58.5053.5086.50

28.0060.0094.00

17.5070.50

108.00

4.0092.00

130.00

3. t0

5t.5050.5586.50

22.2965.5099.00

17.0070.50

107.50

5.7 |74.00

t24.00

1.58

p > 0.05p > 0.05p > 0.05

p > 0.05p > 0.05p > 0.05

p > 0.05p > 0.05p > 0.05

p > 0.05p > 0.05p > 0.05

p < 0.05*

Note: SD = standard deviation, U test with significant difference at p

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March 2001

number of CD8+ cells in the early lesions was similarto the late ones. No specific arrangement distributionsof CD4+ and CD8+ cells were seen in the patchyinfiltrates. The CD4+: CD8+ ratio in the early lesionswas higher than that in late lesions, statisticallysignificant at p0.05). The absolute numbers of lymphocytes andhistiocytes in the early lesions were greater than thosein late lesions, but not statistically significant (p > 0.05).

The proportion meaning the percentage of theabsolute number of T, CD4+, CD8+ cells and Bcells in the central part of the specimens to the totalnumber of lymphoytes in each slides/l cm2. Theproportions were presented in Table 5. The CD4+cell proportion in the early lesions was statistically

Immunohistopathological featues of prurigo Hebra

greater than that in the late Iesions (p 0.05

p < 0.01't*

p > 0.05

p > 0.05

p>0.05

30.10 t 15.0422.60 ! t2.t0

9.10 + 1.17

1.14+ 6.69

Note: SD = standard deviation, significant difference at p

Boediardja et al

The absolute numbers of HlA-DR-expressing APCsare showed in Table 7. The absolute numbers ofHLA-DR (o and B chains)-expressing APCs in theearly lesions were greater than those in late lesions,but were not statistically significant (p> 0.05).

The expression of HLA-DR-o and HLA-DR-B onAPCs in the central part of early lesions were as seenin the part of early lesions were as seen in theScatter-diagram 1. There was a positive correlationbetween the expressions of HLA-DRcI and B in APCs,

Med J Indones

the coefficient correlation ( r) was 0.618 with 95VoC.I.= 0.410-0.765. This correlation was calculated bystatistics with confidence/C.I.A. program. HLA-DRexpressed the B chain more stronger than the o chainin dermal APCs, but in epidermal LCS, the expressionof B chain was as good as u chain.

The proportion of HLA-DR-cI- and HLA-DR-p-expressing APCs were the ratio of the absolutenumbers of each APCs to the total number (sum) oflymphocytes + histiocytes + APC/I

" .' The

Table 7. The absolute numbers of HlA-DR-expressing APCs in the central part of early and late lesions of prurigo Hebra

Cells Early lesions (n1=50) Late lesions (n2=50) U test

Mean + SD Median Mean * SD MedianAPCs/HLA-DRcrLymphocytesHistiocytes+l ymphocytes

APCs/HLA-DRpLymphocytesHistiocytes+lymphocytes

70.42 ! 38.0953.14 ! 29.5378.24 ! 42.t979.42 t 38.0950.56 t 27.8675.16 + 38.35

67.98 r 31,5648.18 t 26.4078.92 t 40.1577.94 + 39.0941 .78 + 3l.3772.94 X 39.09

p > 0.05p > 0.05p > 0.05

p > 0.05p > 0.05p > 0.05

75 0048 0076 50

83 0050 0070 00

65.5044.5078.00

78.0042.0078.00

Note: SD = standard deviation, APCs = antigen-presenting cellsU test with signihcant difference at p

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proportion of of HLA-DR-a- and HLA-DR-P-e4pressing APCs in the central part of the lesions ispresented in Table 8. The proportion of both HLA-DR-cr- and HlA-DR-B-expressing APCs in the latelesions were greater than that in early lesions, but notstatistically significant (p>0.05).

The correlation between inflammatory cells,severity, and human leukocyte antigen

In order to improve the correlation betweeninflammatory cells in early lesions, the severity of thedisease and immunogenetic factors of human leukocyteantigen (HLA), were performed in 4l of 50 subjects

Immuno hist op atho Lo gic a L featue s of pruri go H e b ra

with prurigo Hebra. Forty one prurigo Hebra casesconsisting of 17 mild and 24 severe condition.Female was the majority (28 cases).

The amounts of cell infiltrate in early and late lesionsof 41 prurigo Hebra is shown in Table 9. Statisticallythe distributions of non-specific and specific cellswere not normal, Mann Whitney method was used forstatistical analysis. There is no significant differencebetween the specific inflammatory and nonspecificcells in early and late lesions. Correlation between Band T cells, B and eosinophil, LCs and T, CD4+, andCD8+ cells were weak and were not statisticallysignificant.

Table 8. The proportions of HLA-DR-o and HLA-DR-B expressing APCs in the central part of prurigo Hebra lesions

Antigen- presentingcells

early lesions (n=50) late lesions (n=50)

Mean + SD Median Mean + SD MedianU test

APCs/HLA-DRcr

APCs /HLADRp

47.20 + 15.60

50.10+ 16.80

45.40

-54.1 0

46.30 + t3.70 48.30. 52.00 + 18.10 54.60

p > 0.05

p > 0.05

Note: SD = standard deviation, U test with significant difference p

-t

Boediardia et al

Correlation between T, CD4+, CD8+ cells, APCsand eosinophils

Table 10. shows that correlation between APCs andT cells and subsets were strong (r = 0.32-0.49), andsignificant with 95Vo C. I, save for the correlationbetween APCs/HLA-DRB and CDS+ cells (r=0.24).The strong correlation between APCs and T cells andtheir subsets suggesting that this condition might leadto chronic inflammation of prurigo Hebra. Theabundance of APCs meant that a person with prurigoHebra was exposed to antigens or triggering factorsfor a long time and thus the interaction with T cellsand their subsets did follow. The correlation betweenT cells and APCs/HLA-DRP was positive as shown inScatter diagram 2.

In this analysis, the correlation between eosinophilsand T cells (r=- 0.05, 95VoC.I.= - 0.385;0.255), CD4+cells (r=- 0.09,95Vo C.I.=- 9.399 ;0.221), and CD8+cells (r=-0.19 with 95Vo C.I. - 0.469 ; 0.126) wereweak. It was doubted whether the presence ofeosinophils was due to a collaboration between type-lV and type-I hypersensitivity, or to insect bitereaction itself. Statistical analysis also showed thatthe correlation between eosinophils and APCs/HL-DRcr (r=0.16 with 95Vo C.I. - 0.367 ;0.246) and thecorrelation between eosinophils and APCs/HLA-DRP(r=0.14 with 95Vo C.L = -0.180 ;0.425) were borhweak.

Med J Indones

Table 10. The correlations between APCs and T, CD4+, andCDS+ cells

Correlationbetween Correlation"'r;i:#,!:'

correlation

95Vo C.L

APCs/HLA-DRa andT cellsAPsC/HLA-DRcI andCD4+ cellsAPCs/HLA-DRq andCD8+ cellsAPCs/HLA-DRB andT cellsAPCs/HLA-DRp andCD4+ cellsAPCs/HLA-DRp andCDS+ cells

0.39

0.32

0.49

0.49

0.46

o.24

0.090

0.010

0.188

0.217

0.179

-0.06

0.624 "

0.578 *

0.678 *

0.694 "

0.674 *

0.523

Note: APC= ntigen-presenting cells, 95Va C.l. = 95Voconfidence interval

Correlation between severtty of prurigo Hebra andinflnmmatory cells

Table 11 shows the quantity of non-specific andspecific inflammatory cells in 24 severe cases and 17mild cases of prurigo Hebra. There was no significantdifference between the amount of non-specific andspecific cell infiltration in severe and mild cases,except for the eosinophils. In severe cases,eosinophlis were predominant (p< 0.05).

The correlation between Tcells and

oCL6cc)o.soEo

HLA-DRalfa-Antigen presenting cells (central part)'Scatter diagram -2. The correlation between T ceLls and APC/HI-A-DRP

HLA-DR expressing APCs in prurigo Hebra

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The analysis showed that correlation between severityof prurigo Hebra and the quantities of T cells (r=0.18), CD4+ cells (r= 0.19), CDS+ cells (r= 0.20),and LCs (r= - 0.22) were not statistically significant.However, the correlation between severity of prurigoHebra and eosinophils (r= 0.25) was strong. It isassumed that the more the number of eosinophilspresent, the more severe the condition would be.

Correlation between severity of prurigo Hebra,eosinophils and HLA

Eosinophils in severe cases was more pronouncedthan that in mild ones, and was statistically significant(p 0.05

> 0.05

> 0.05

> 0.05

> 0.05

> 0.05

> 0.05

< 0.05*

60.0

22.0

11.0

2.0

70.0

75.0

4.0

6.0

Note: APCs = antigen-presenting cells. LCs= Langerhans cells. Significant difference at p < 0.05U test = Mann Whitney test

Table I 2. The amount of eosinophils in severe cases of prurigo Hebra (n=24)

Groups(eosinophils/cm2)

Nos. of Expectedspecimens

TotalPH

RR 959n C.I. Score testX2 for trend

r. (0-s)

il. (6-rs)III. > I6

9 1t.7 20

t3'7.60

4.68

0.745

1.1'7

1.21

0.383 ; 1.450

0.614 : 2.240

0.597 : 2.470

Note: Significant difference at p < 0.05 95Vo C. I. = confidence interval

1.129, >0.05

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The Immunohistopthalogical features showed that thenumbers of cells in early and late lesions were notsignificant difference, except for CD4+ cells, whichwere found significantly greater number in earlylesions. In both the early and late lesions, the T,CD4+, CDS+ cells and APCs were found in greatquantities. This finding was compatible with thefature of type-IV hypeensitivity. '/''tThe abundance of APCs and T cells and its strongcorrelation probably indicates that the prurigo_ lebrapatients always exposure to extrinsic factors.lT'18

Protein 5-100 and monoclonal antibodies of HLA-DR-cr and p were both potential to use for epidermalLC identification. Langerhans epidermal cells stainedwith monoclonal antibodies of HLA-DRcr or p andprotein 5-100 with AEC substrate was seen in goodconfiguration with its dendrite processus. Thenumber rn late lesions was significantly moreprofound than in early lesion, but the number waswithrn normal limits (2-87o).

B cells, which normally were not found in normalskin,'?'18 were surprisingly found in few number Thetct, that eosinophils were found in large amountsmight have been related to CD4+ cells' domination,although statistically the correlation between T helper(Th) or CD4+ and eosinophils was not sigificant. Asit is been known that T helper (CDa+) cells consist 2subsets, T helper -l (Th-l) and Th-2. TheoreticallyTh-2 cells collaborate with type-I hypersensitivityreactions. Th-2 cells produce IL-3 and IL-5, cytokinesthat act as attracting mediator to eosinophils andpotentially stimulate eosinophil migration to theinflammatory site.rT'r8 In this study Th-l and Th-2were not examined.

In this study the severity of prurigo Hebra wassignificantly correlated with hypereosinophils rn skinlesions of prurigo Hebra patients with HLA-410 andits splits.

CONCLUSIONS

The immunohistopathological feature revealednumerous inf'lammatory cells consisting T cells,CD4+ cells, CD8+ cells, T suppressor cells, LC cellsand HlA-DR-expressing APCs. However thenumbers of cells in early and late lesions were notstatistically different, except for CD4+ cells, whichwere found in significantly greater number in early

Immunohistopathological featues of pruigo Hebra I I

lesions. CD4+ cells were significantly predominantthan CD8+ cells. The eosinophils were found inabundance, independent on the presence of mastcells, plasma cells, basiphils and B cells. The presencemight be correlatd with CD4+ cells' domination. Thenumbers of LC were within normal limits. Thecorrelation between T cells and APCs were strong, itis indicated that prurigo Hebra patients alwaysexposure to the extemal factors, especially insectsbite. The severe cases may correlate with HLA-AIOand hypereosinophils in skin lesions. Considering theimmunohistopathological findings it is assurned thatthe mechanisms of prurigo Hebra was a mixturebetween type-IV and type-I hypersensitivity reactions.

Acknowledgement

We would like to thank the head of the PathologyDepartment for the possibility of the study inimmunohistochemistry. We are debtfull to Ms. NunukKurniati and Ms. Neneng Komariah analysts, fortheir keen work in staining the immunoperoxydasespecimens. Personally, I would like to thank Dra.Corry Wawolumaya, PhD, MPH for statisticalconsultations.

REFERENCES

1. von Hebra F. Erythema multiforme, lichen simplex,prurigo, pityriasis rosea, rhinosklerosis. In: Shelley WB,Crissey JT, Stokes JH, Eds. Classics in clinicaldermatology with biographical scketches. Oxford:Blackwell Scientific Publication; 1953. p. ll0-2.

2. McKenna RW, Mc Kenna MW. Diseases of the skin. 6thed. London: Billaire lndall and Cox; 1952. p.331-52.

3. Ormsby DS, Montgomery H. Diseases of the skin. 6th ed.Philadelphia: Lea & Febriger;1954. p. 191-203.

4. Rook A, Wilkinson DS, Ebling FJG. Eczema, lichensimplex and prurigo. In: Rook A, Ed. Rook's Textbook ofDermatology. London: Blackwell Scientific Publication;1972. p.84-9,291-8

5. Arnold HL, Odomm RB, James WD. Andrew's diseasesof the skin: clinical dermatology, 8'h ed. Philadelphia: WBSauders Company; 1 990. p. 1 57-8.

6. Kocsard E. The problem of prurigo. Austr J Derm 1962;6:156-66.

7. Boediardja SA. lncidence of skin diseases in Indonesianchildren fiom l98l-1985. In: Urabe H, Kimura M,Yamamoto K, Ogawa H, Eds. Proceeding of the 4thlnternational Congress of Pediatric Dermatology. Tokyo:University Press ofTokyo; 1986. p. 371-82.

8. Medical record liom Sub-Dept. of Pediatric Dermatology,Department of Dermato-Venereology, Dr. Cipto Mangun-kusumo Hospital, Jakarta (1990-1997, in press.).

9. Boediardja SA, Soelarsito SA, Wisnu IM. Gambaranklinis dan histopatologi pada 159 penderita prurigo Hebra"

t2 Boediardja et al

Kumpulan makalah Ilmiah, Kongres PADVI ke-4. UjungPandang: 1986. h. ll58-65.Occampo FA, Collade CM. Acute infantile prurigo.Clinico pathological correlation in 100 cases. Austr JDerm 1975; 16:169-73.Jasani B, Schmid Kw. Immunocytochemistry in diagrostichistopathology. London: Churchill Livingstone; 1993.p.l-27.Yaoita H. Enzyme labelled antibody method. In: Ueki H,Yaoita H, Eds. A colour atlas of dermatohistocytology.Tokyo: Wolfe Medical Publications Ltd; 1989. p. 8-10.Takezaki S, Nishiyama S. Application of monoclonalantibodies. In: Ueki H, Yaoita H, Eds. A colour atlas ofdermatohistocytology. Tokyo: Wolfe Medical PublicationsLrd.; 1989. p.18-23Hsu S-M, Raine L The use of avidin-biotin-peroxidasecomplex (ABC) in diagnostic and research pathology. In:

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Ueki H, Yaoita H, Eds. A colour atlas of dermato-histocytology. Tokyo: Wolfe Medical Publications Ltd;1989. p. 3l-42.Boenish T. Staining methods. In: Naish Sj. Handbook:immunological staining methods. Califomia: Dakocooperation; 1989. p. l3-23.Farmilo AJ. Stead RH. Fixation in immunocytochemistry.In: Naish Sj. Handbook: immunological staining methods.California: Dako cooperation; 1989. p.24-9.Bos JD, Das PK, Kapsenberg ML. Skin immune system.In: Bos JD, Ed. Skin immune systenl l't ed. Boca Raton:CRP Press; 1990. p. 4-7.Bos JD and Kapsenberg ML. Skin immune system:progress in cutaneous biology. Immunology to day 1993;l4:75-8.Boediardja SA. The role of immunogenetic factors ofHLA in Prurigo Hebra. Disertation, Jakarta 1999.

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1.6

77.

18

1.9

10

11

L2

13

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Figure l. Prurigo Hebra ih a chiW with severe condition,the skin lesions were seen on the extensor part of the

el

t4 Boediardja et al

Figure 5. The expression of UHCL in T cells in an earlylesion of cases No 19. , were clearly seen (brownish incolour), within lymphocytes and histiocytes (lP, I20x).

Figure 7. The expression of CD8+ monoclonal antibody inCD8+ cells of an early lesion of cases No. 19., were lessamowt than CD4+ cells (lP, l20x).

Figure 6. The expression ofCD4+ monoclonal antibody inCD4+ cells of an early lesion of cases No.l9., were seen lessamount than T cells (lP, 120x).

Med J Indones

Figure 8. The expression of L-26/CD20 monoclonal antibodyin B cells of an early lesion of cases No.27., only one B cellwas seen. (1P,240x).

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Figure 9. The expression qf HU-DRa monoclonal antibodyin dermal antigen presenting cells (APC) (brownish in colour)ofan early Lesion ofprurigo Hebra. The interaction betvveenlymphocytes and APC was seen (lP, 240x)

Immunohistopathological featues of prurigo Hebra l5

Figure 10. The expression of Hl,A-DRp monoclonal antibodyin dermal antigen presenting cells (APC) (brownish in colour)of an earLy lesion of prurigo Hebra. The interaction betweenlymphocytes and APC was seen (lP,240x)