British Journal of Dermatology (1975) 92, 631.
Epidermal antigens in lichen planus E. ABELL AND D. RAMNARAIN St. John's Hospital for Diseases of the Skin, Lisle Street, London WC2 Accepted for publication 21 October 1974
SUMMARY
The loss of intercellular and basement membrane antigens has been associated with the development of epidermal cell dysplasia and neoplasia. The antigenic components of the epidermis have been investigated in lichen planus., lupus erythematosus and eczema, using pemphigoid and pemphigus sera by the indirect immunofluorescent staining method. In areas of active lichen planus there was extensive reduction or complete absence of basement membrane antigen. Intercellular antigen was preserved in lichen planus although in some damaged rete ridges it appeared to be reduced. Both these antigens were well preserved in lupus erythematosus and eczema. Loss of epithelial antigens is therefore not confined to the development of neoplasia.
Using the indirect immunofluorescent (IF) staining technique the majority of patients with pemphigus and pemphigoid can be shown to have circulating antibodies to the intercellular and basement membrane areas, respectively, of mammalian stratified squamous epithelium. The antibodies of these bullous diseases have been employed to detect alteration of epidermal antigenicity occurring in human skin cancer (De Moragas, Winkelmann & Jordan, 1970 a & b) and also in experimentally induced skin dysplasia and neoplasia in mice (Muller & Sutherland, 1971J. Both these studies indicated that intercellular (IC) antigen was apparently diminished or lost with increasing dysplasia of the epidermal cells. Basement membrane (BM) antigen staining was also reduced as the cell became more dysplastic; and particularly in association with deep invasive squamous cell carcinoma might be completely absent. Similar studies on squamous cell neoplasms of non-cutaneous origin, however, showed that the majority of both primary and secondary tumours retained IC and BM antigen staining (Pertschuk & Rosen, 1973) but the reason for this disparity was not clear. The same methods have been used to study the development of epidermal antigens in the fetus (Muller, Kalnins & Sutherland, 1973; Delpech-Stewart, 1971) and also the regeneration of the basement membrane region under migrating epidermal cells in an experimental in vitro model of wound healing (Marks, Abell & Nishikawa, 1975). Although the alteration or loss of epidermal antigens has been shown to be associated with cellular dysplasia, no study appears to have been undertaken to examine the changes produced by inflammatory reactions. While examining a series of biopsies of lichen planus papules by direct IF staining 631
632
E.Abell and D.Ramnarain
it was considered that such a study might prove of interest, particularly in this condition in which the inflammatory changes arc directed against the basal epidermal cells. Moreover, ultrastructural studies of lichen planus have shown that the basal lamina may be disrupted, lost or even reduplicated (Brody, 1969; Johnson & Fry, 1967; Ebner & Gebhart, 1972; Sarkany & Gaylarde, 1971), these changes presumably being brought about by the continued process of destruction and repair of this region which is thought to characterize the disease process. MATERIALS AND METHOD
Elliptical skin biopsies were obtained from nineteen cases of active lichen planus (LP), five cases of lupus erythematosus (LE), and seven cases of eczema. The specimens were divided, half being rapidly frozen in liquid nitrogen and stored at — 70 C, and half being fixed in formal-saline 10",, for routine histological processing. The frozen material was sectioned at 5 /im at — 25^0 within i week of collection, and stained by the indirect method as follows. After preliminary washing in phosphate buffered saline, sections were incubated in moist chambers at 37 C, with either normal human serum, pemphigoid, or pemphigus serum at 1:10 and 1:8o dilutions, for 30 min. After further washing, a second incubation was performed using a commercially obtained sheep antihuman IgG (Wellcome reagents) F/P ratio 41 molar, Ab/P 071 mg/ml, 4 units per ml, diluted to i :30. The sections were mounted in buffered glycerol at pH 8 and examined in a Leitz SM fluorescent microscope, illuminated by a HBO 200 lamp, using a BG 38 (red) and a KP 490 FITC primary filter, and secondary filters 510 or 530. Sera from two cases of pemphigoid and two cases of pemphigus were used in these experiments. Each serum had a titre of at least 11640 against normal human skin. Normal skin sections, stained in the same way, were incorporated as controls in all experiments. Histological confirmation of all diagnoses was obtained from the paraffin processed haematoxylin and eosin stained tissue. All biopsies included areas of uninvolved skin adjacent to the abnormal sites, except in the biopsies of eczematous skin. All nineteen cases of LP demonstrated globular or cytoid body deposits of immunoglobulins (mainly IgM) together with fibrin deposition in the papillary dermis, on direct IF staining. The five cases of LE were chosen because of the absence of IgG in the IE basement membrane band. IgM and IgA were demonstrated together with complement in the BM zones of three of these biopsies, and two had negative IF findings. All five had characteristic histological findings of LE, and four showed cytoid body depositsof IgM in the dermal papillae. Two of the five eczema cases had the histology of lichenification, and the rest were of the subacute type. RESULTS (a) Basement membrane antigens
Continuous linear BM fluorescent staining was demonstrated in all the sections of normal skin, lupus erythematosus, and eczema. Only in two biopsies of subacute eczema were small breaks in the basement membrane seen. In the uninvolved areas of all the LP sections this same linear fluorescent band was preserved, but in tbe LP papules all demonstrated diminution of BM staining. Breaks in the BM were readily apparent in eighteen of these papules and were of variable extent. The most frequent pattern was of multiple small breaks or short gaps in areas of obvious LP activity but occasionally the BM was almost completely absent over a whole rete ridge (Eig. i). No other specific staining was seen other than at the epidermo-dermal junction. Hyaline, or IE cytoid bodies were not visualized.
Epidermal antigens in lichen planus
633
1. Indirect IF of LP with pemphigoid serum. BM staining is almost completely absent from rete ridge (>< 125)-
(b) Intercellular antigens
The antigenicity of the intercellular area was preserved in all the specimens, whether from normal skin, LE, eczema, or LP. As is the usual pattern, IC staining tended to be weaker around the basal cells, and this was also the case in the LE and LP biopsies. In four biopsy specimens of LP., however, the IC staining pattern was reduced at the tips of some saw-toothed rete ridges (Fig. 2). Hyaline or cytoid IF bodies were not demonstrated by this method. DISCUSSION
Extensive deficiency of stainable BM antigen in these experiments was confined to LP papules. The short breaks seen in two biopsies of subacute eczema were of a localized type and were not associated with the marked reduction of BM staining in the adjacent areas seen in LP lesions. Despite the similarity of histological localization of tissue damage in LP and LE, the latter condition failed to show evidence of alteration or destruction of BM antigens. These initial experiments on LE were performed upon cases failing to show IgG deposition at the BM zone on direct IF staining. IgG, deposited at this site in LE biopsies, interferes with the demonstration of BM antigens by this indirect method. Prior elution of this IgG antibody would probably enable all LE lesions to be used, but this does introduce an unnecessary additional reaction to the method. It has been suggested that the primary change in LP is that of basal epidermal cell degeneration (Thyresson & Moberger, 1957) and that the areas sustaining the damage are repopulated by migration
634
E.Abell and D.Ramnarain
FIGURE 2. Indirect IF of LP with pemphigus serum. The IC staining is preserved in this active papule but is much reduced in the rete ridges on the left of the micrograph ( x 300J.
of cells from the viable margins (Marks, Black & Wilson Jones, 1973; Presbury & Marks, 1974). There is some evidence to suggest that the basal cells elaborate basal lamina (Hay & Dodson, 1973) and possibly also basement membrane antigen (Marks et al. 1975) although these antigens have not been definitely shown to reside within the basal lamina. If the cells repopulating the lichen planus papule are responsible for the reduplication of the basal lamina seen by electron microscopy, they cannot be shown by this IF method to have elaborated BM antigens. However, it is probable that any newly formed BM antigen would be destroyed in the same way as the original material by the continued LP process. These experiments clearly demonstrate that BM antigen can be structurally altered or lost in at least one infiammatory dermatosis, as well as in association with epidermal cell dysplasia. At least two possible mechanisms might be responsible for these changes in LP. BM antigen may be damaged by the infiammatory cellular reaction or alternatively the damage to the epidermal basal cells may be sufiicient to prevent them elaborating BM antigenic material. Considering the preservation of the BM fiuorescent staining in eczema and LE it would seem that the latter process is the more likely. The hyaline or Civatte body in LP (and LE) is derived from the degeneration of basal epidermal cells (Thyresson & Moberger, 1957; Ueki, 1969; El-Labban, 1970) possibly during mitotic division (El-Labban & Kramer, 1974). These bodies arc probably the equivalent of the cytoid or globular deposits seen on direct IF staining (Ueki, 1969; Michel & Sy, 1973; Baart de la Faille-Kuyper & Baart de la Faille, 1974; Abell ei al. 1975). These bodies do not appear to retain the IC antigen, nor do they bind BM antibody, as might be expected if, as suggested by Ueki, some of these bodies (especially in LE) were derived from thickened basement membrane. The epidermal cells in LP, as well as in other dermatoses, are able to elaborate IC antigen. This
Epidermal antigens in lichen planus
635
antigen probably resides in the glycocalyx (Hashimoto et al., 1974) and this extracellular material appears to play a part in cellular cohesion. In a few sections the saw-toothed rete ridges, although showing diminished IC staining, did not lose this material completely. In severe LP reactions, clefts or frank bullae may develop in the basal cell layer, and it is interesting to speculate that the absence of histological acantholysis in such damaged epidermis is due to the preservation of this intercellular material. Ultrastructural studies of LE have not demonstrated loss of basal lamina although this has been described in lichen sclerosus et atrophicus (Mann & Cowan, 1973), bullous pemphigoid (SchaumburgLever, Orfanos & Lever, 1972),dermatitis herpetiformis (Fry & Johnson, 1969) and cicatrical pemphigoid (Caputo, Bellone & Crosti, 1973). More extensive testing of inflammatory dermatoses is required to determine whether the loss of BM antigen staining is confined to LP and also whether this reaction is shared by the other lichenoid conditions. ACKNOWLEDGMENT We wish to thank Mr SJ. Robertson and Staff of the Department of Medical Illustrations for their help in preparing the photomicrographs. REFERENCES ABELL, E., PRESBURY, D.G.C., MARKS, R.&R.A.MNARAiN,D. (1975) The diagnostic significance of immunoglobulin and fibrin deposition in Lichen Planus British Journal of Dermatology. (In press) BAAKT DE LA FAILLI'-KUYPER, E.H. & BAART DE LA FAILLE, H . (1974) An immimofluorescence srudy of lichen
planus. British Journal of Dermatology, 90, 365. BRODY, I. (1969) The ultrastructure of the epidermis in lichen ruber planus as revealed by electron microscopy. I. Journal of Ultrastructure research, 28, 161. CAPUTO, R . , BELLONE, A.G. & CROSTI, C . (1973) Pathogenesis of the blister in cicatricial pemphigoid and in bullous pemphigoid. Avchiv fiir Dermatahgische Forschtdng, 247, l8l. DELPECH-STEWART, A. (1971) An immunofluorescent study of aniigcnic structures in the development of human epidermis. Journal of Histochenn'stry and Cytochemistry, 19, 627. DE MOROGAS, J.M., WINKELMANN, R.K.& JORDON, R.E. (1970a) Immunofluorescence of epithelial skin tumours. I. Patterns of intercellular substance. Cancer., 25, 1399. DE MOROG.«, J.M., WINKELMAKN, R.K. & JORDON, R.E. (1970b) Immunofluorcsccncc ol epithelial skin tumours. II. Basement membrane. Cancer, 25, 1404. EBNER, H . & GEBHART, W . (1972) Die Ultrastrukrur der Epidermis-Cutis-Grenze bein Lichen Rubcr Planus Archivfiir Dcrmatohgische Forschung, 245, 285. EL-LABBAN, N . G . (1970) Light and electron microscopic studies of colloid bodies in lichen p\a.nu%. Journal of Periodontal Research, 5, 315. EL-LABBAN, N.G. & KRAMER, I.R. (1974) Civatte bodies and the actively dividing epithelial cell in oral lichen planus. British Journal of Dermatology, 90, 13. FRY, L . & JOHNSON, F . R . C1969) Electron microscopic study of dermatitis herpetiformis. British Journal of Dermatology, 81, 44. HASHIMOTO, K . , KING, L.E., YAMANISHI, Y., BEACHEY, E.M. & MAEYENS, E. (1974) Identification of the substance
binding pemphigus antibody and concanavalin A in the skin. Journal of Investigative Dermatology, 52, 423. HAY, E . D . & DODSON, J.W. (1973) Secretion of collagen by cornea! epithelium. Journal of Cell Biology., 57, 190. JOHNSON, F.R. & FRY, L . (1967) Uttrastructural observations on lichen planus. Archives of Dermatology, 95, 596. MANN, P.R. & COWAN, M . A . (1973) Ultrastructurai changes in four cases of lichen sclerosus et atrophicus, British Journal of Dermatology, 89, 223. MARKS, R., ABELL, E.& NISHIKAWA, T . (1975) The functional zone beneath epidermis. British Journal of Dermatology, 92, 311. MARKS, R., BLACK, M . M . & WILSON JONES, E. (1973) Epidermal cell kinetics in lichen planus. British Journal of Dermatology, 88, 37.
636
E.Abell and D.Ramnarain
MICHEL, B. & Sv, E.K. C1973) Tissue fixed immunoglobulin in lichen planus. In: Immunopathohgy of the skin (Ed. by E.H.Beutner, T.P.Chorzelsky, S.F.Bean and R.E.Jordon) p. 182. Dowden, Hutchinson & Ross Inc. Stroudsburg. MuLLER, H.K. & SUTHERLAND, R . C . (1971) Epidermal antigens in cutaneous dysplasia and neoplasia. Nature, 230, 384. MuLLER, H.K., KALNINS, R. & SUTHERLAND, R.C. (1973) Ontogeny of pemphigus and bullous pemphigoid antigens in human skin. British Journal of Dermatology, 88, 443. PRESBURY, D.G.C. & MARKS, R. (1974) The epidermal disorder in lichen planus: An in vitro study. Britishjournal of Dermatology, 90, 373. PERTSCHUK, L.P. & ROSEN, Y. (1973} An immunofluorescent study of tumours with specific antisera for squamous epithelial intercellular substance and basement membrane. American Journal of Clinical Pathology, 60, 601. SARKANY, I. & GAYLARDE, P . M . (1971) Ultrastructural and light microscopic changes of the epidermo-dermal junction. Transactions of St. John's Hospital Dermatological Society, 57, 139. SCHAUMBERG-LEVER, G., ORFANOS, C.E. & LEVER, W . F . (1972) Electron microscopic study of bullous pemphigoid. Archives of Dermatology, 106, 662. THYRESSON, N . & MOBERGER, G . (1957) Cytologic studies in lichen ruber planus. Acta Dermato-venereologica, 37, 191. UEKI, H . (1969) Hyaline bodies in subepidermal papillae. Archives of Dermatology, 100, 610.
Epidermal antigens in lichen planus E. ABELL AND D. RAMNARAIN St. John's Hospital for Diseases of the Skin, Lisle Street, London WC2 Accepted for publication 21 October 1974
SUMMARY
The loss of intercellular and basement membrane antigens has been associated with the development of epidermal cell dysplasia and neoplasia. The antigenic components of the epidermis have been investigated in lichen planus., lupus erythematosus and eczema, using pemphigoid and pemphigus sera by the indirect immunofluorescent staining method. In areas of active lichen planus there was extensive reduction or complete absence of basement membrane antigen. Intercellular antigen was preserved in lichen planus although in some damaged rete ridges it appeared to be reduced. Both these antigens were well preserved in lupus erythematosus and eczema. Loss of epithelial antigens is therefore not confined to the development of neoplasia.
Using the indirect immunofluorescent (IF) staining technique the majority of patients with pemphigus and pemphigoid can be shown to have circulating antibodies to the intercellular and basement membrane areas, respectively, of mammalian stratified squamous epithelium. The antibodies of these bullous diseases have been employed to detect alteration of epidermal antigenicity occurring in human skin cancer (De Moragas, Winkelmann & Jordan, 1970 a & b) and also in experimentally induced skin dysplasia and neoplasia in mice (Muller & Sutherland, 1971J. Both these studies indicated that intercellular (IC) antigen was apparently diminished or lost with increasing dysplasia of the epidermal cells. Basement membrane (BM) antigen staining was also reduced as the cell became more dysplastic; and particularly in association with deep invasive squamous cell carcinoma might be completely absent. Similar studies on squamous cell neoplasms of non-cutaneous origin, however, showed that the majority of both primary and secondary tumours retained IC and BM antigen staining (Pertschuk & Rosen, 1973) but the reason for this disparity was not clear. The same methods have been used to study the development of epidermal antigens in the fetus (Muller, Kalnins & Sutherland, 1973; Delpech-Stewart, 1971) and also the regeneration of the basement membrane region under migrating epidermal cells in an experimental in vitro model of wound healing (Marks, Abell & Nishikawa, 1975). Although the alteration or loss of epidermal antigens has been shown to be associated with cellular dysplasia, no study appears to have been undertaken to examine the changes produced by inflammatory reactions. While examining a series of biopsies of lichen planus papules by direct IF staining 631
632
E.Abell and D.Ramnarain
it was considered that such a study might prove of interest, particularly in this condition in which the inflammatory changes arc directed against the basal epidermal cells. Moreover, ultrastructural studies of lichen planus have shown that the basal lamina may be disrupted, lost or even reduplicated (Brody, 1969; Johnson & Fry, 1967; Ebner & Gebhart, 1972; Sarkany & Gaylarde, 1971), these changes presumably being brought about by the continued process of destruction and repair of this region which is thought to characterize the disease process. MATERIALS AND METHOD
Elliptical skin biopsies were obtained from nineteen cases of active lichen planus (LP), five cases of lupus erythematosus (LE), and seven cases of eczema. The specimens were divided, half being rapidly frozen in liquid nitrogen and stored at — 70 C, and half being fixed in formal-saline 10",, for routine histological processing. The frozen material was sectioned at 5 /im at — 25^0 within i week of collection, and stained by the indirect method as follows. After preliminary washing in phosphate buffered saline, sections were incubated in moist chambers at 37 C, with either normal human serum, pemphigoid, or pemphigus serum at 1:10 and 1:8o dilutions, for 30 min. After further washing, a second incubation was performed using a commercially obtained sheep antihuman IgG (Wellcome reagents) F/P ratio 41 molar, Ab/P 071 mg/ml, 4 units per ml, diluted to i :30. The sections were mounted in buffered glycerol at pH 8 and examined in a Leitz SM fluorescent microscope, illuminated by a HBO 200 lamp, using a BG 38 (red) and a KP 490 FITC primary filter, and secondary filters 510 or 530. Sera from two cases of pemphigoid and two cases of pemphigus were used in these experiments. Each serum had a titre of at least 11640 against normal human skin. Normal skin sections, stained in the same way, were incorporated as controls in all experiments. Histological confirmation of all diagnoses was obtained from the paraffin processed haematoxylin and eosin stained tissue. All biopsies included areas of uninvolved skin adjacent to the abnormal sites, except in the biopsies of eczematous skin. All nineteen cases of LP demonstrated globular or cytoid body deposits of immunoglobulins (mainly IgM) together with fibrin deposition in the papillary dermis, on direct IF staining. The five cases of LE were chosen because of the absence of IgG in the IE basement membrane band. IgM and IgA were demonstrated together with complement in the BM zones of three of these biopsies, and two had negative IF findings. All five had characteristic histological findings of LE, and four showed cytoid body depositsof IgM in the dermal papillae. Two of the five eczema cases had the histology of lichenification, and the rest were of the subacute type. RESULTS (a) Basement membrane antigens
Continuous linear BM fluorescent staining was demonstrated in all the sections of normal skin, lupus erythematosus, and eczema. Only in two biopsies of subacute eczema were small breaks in the basement membrane seen. In the uninvolved areas of all the LP sections this same linear fluorescent band was preserved, but in tbe LP papules all demonstrated diminution of BM staining. Breaks in the BM were readily apparent in eighteen of these papules and were of variable extent. The most frequent pattern was of multiple small breaks or short gaps in areas of obvious LP activity but occasionally the BM was almost completely absent over a whole rete ridge (Eig. i). No other specific staining was seen other than at the epidermo-dermal junction. Hyaline, or IE cytoid bodies were not visualized.
Epidermal antigens in lichen planus
633
1. Indirect IF of LP with pemphigoid serum. BM staining is almost completely absent from rete ridge (>< 125)-
(b) Intercellular antigens
The antigenicity of the intercellular area was preserved in all the specimens, whether from normal skin, LE, eczema, or LP. As is the usual pattern, IC staining tended to be weaker around the basal cells, and this was also the case in the LE and LP biopsies. In four biopsy specimens of LP., however, the IC staining pattern was reduced at the tips of some saw-toothed rete ridges (Fig. 2). Hyaline or cytoid IF bodies were not demonstrated by this method. DISCUSSION
Extensive deficiency of stainable BM antigen in these experiments was confined to LP papules. The short breaks seen in two biopsies of subacute eczema were of a localized type and were not associated with the marked reduction of BM staining in the adjacent areas seen in LP lesions. Despite the similarity of histological localization of tissue damage in LP and LE, the latter condition failed to show evidence of alteration or destruction of BM antigens. These initial experiments on LE were performed upon cases failing to show IgG deposition at the BM zone on direct IF staining. IgG, deposited at this site in LE biopsies, interferes with the demonstration of BM antigens by this indirect method. Prior elution of this IgG antibody would probably enable all LE lesions to be used, but this does introduce an unnecessary additional reaction to the method. It has been suggested that the primary change in LP is that of basal epidermal cell degeneration (Thyresson & Moberger, 1957) and that the areas sustaining the damage are repopulated by migration
634
E.Abell and D.Ramnarain
FIGURE 2. Indirect IF of LP with pemphigus serum. The IC staining is preserved in this active papule but is much reduced in the rete ridges on the left of the micrograph ( x 300J.
of cells from the viable margins (Marks, Black & Wilson Jones, 1973; Presbury & Marks, 1974). There is some evidence to suggest that the basal cells elaborate basal lamina (Hay & Dodson, 1973) and possibly also basement membrane antigen (Marks et al. 1975) although these antigens have not been definitely shown to reside within the basal lamina. If the cells repopulating the lichen planus papule are responsible for the reduplication of the basal lamina seen by electron microscopy, they cannot be shown by this IF method to have elaborated BM antigens. However, it is probable that any newly formed BM antigen would be destroyed in the same way as the original material by the continued LP process. These experiments clearly demonstrate that BM antigen can be structurally altered or lost in at least one infiammatory dermatosis, as well as in association with epidermal cell dysplasia. At least two possible mechanisms might be responsible for these changes in LP. BM antigen may be damaged by the infiammatory cellular reaction or alternatively the damage to the epidermal basal cells may be sufiicient to prevent them elaborating BM antigenic material. Considering the preservation of the BM fiuorescent staining in eczema and LE it would seem that the latter process is the more likely. The hyaline or Civatte body in LP (and LE) is derived from the degeneration of basal epidermal cells (Thyresson & Moberger, 1957; Ueki, 1969; El-Labban, 1970) possibly during mitotic division (El-Labban & Kramer, 1974). These bodies arc probably the equivalent of the cytoid or globular deposits seen on direct IF staining (Ueki, 1969; Michel & Sy, 1973; Baart de la Faille-Kuyper & Baart de la Faille, 1974; Abell ei al. 1975). These bodies do not appear to retain the IC antigen, nor do they bind BM antibody, as might be expected if, as suggested by Ueki, some of these bodies (especially in LE) were derived from thickened basement membrane. The epidermal cells in LP, as well as in other dermatoses, are able to elaborate IC antigen. This
Epidermal antigens in lichen planus
635
antigen probably resides in the glycocalyx (Hashimoto et al., 1974) and this extracellular material appears to play a part in cellular cohesion. In a few sections the saw-toothed rete ridges, although showing diminished IC staining, did not lose this material completely. In severe LP reactions, clefts or frank bullae may develop in the basal cell layer, and it is interesting to speculate that the absence of histological acantholysis in such damaged epidermis is due to the preservation of this intercellular material. Ultrastructural studies of LE have not demonstrated loss of basal lamina although this has been described in lichen sclerosus et atrophicus (Mann & Cowan, 1973), bullous pemphigoid (SchaumburgLever, Orfanos & Lever, 1972),dermatitis herpetiformis (Fry & Johnson, 1969) and cicatrical pemphigoid (Caputo, Bellone & Crosti, 1973). More extensive testing of inflammatory dermatoses is required to determine whether the loss of BM antigen staining is confined to LP and also whether this reaction is shared by the other lichenoid conditions. ACKNOWLEDGMENT We wish to thank Mr SJ. Robertson and Staff of the Department of Medical Illustrations for their help in preparing the photomicrographs. REFERENCES ABELL, E., PRESBURY, D.G.C., MARKS, R.&R.A.MNARAiN,D. (1975) The diagnostic significance of immunoglobulin and fibrin deposition in Lichen Planus British Journal of Dermatology. (In press) BAAKT DE LA FAILLI'-KUYPER, E.H. & BAART DE LA FAILLE, H . (1974) An immimofluorescence srudy of lichen
planus. British Journal of Dermatology, 90, 365. BRODY, I. (1969) The ultrastructure of the epidermis in lichen ruber planus as revealed by electron microscopy. I. Journal of Ultrastructure research, 28, 161. CAPUTO, R . , BELLONE, A.G. & CROSTI, C . (1973) Pathogenesis of the blister in cicatricial pemphigoid and in bullous pemphigoid. Avchiv fiir Dermatahgische Forschtdng, 247, l8l. DELPECH-STEWART, A. (1971) An immunofluorescent study of aniigcnic structures in the development of human epidermis. Journal of Histochenn'stry and Cytochemistry, 19, 627. DE MOROGAS, J.M., WINKELMANN, R.K.& JORDON, R.E. (1970a) Immunofluorescence of epithelial skin tumours. I. Patterns of intercellular substance. Cancer., 25, 1399. DE MOROG.«, J.M., WINKELMAKN, R.K. & JORDON, R.E. (1970b) Immunofluorcsccncc ol epithelial skin tumours. II. Basement membrane. Cancer, 25, 1404. EBNER, H . & GEBHART, W . (1972) Die Ultrastrukrur der Epidermis-Cutis-Grenze bein Lichen Rubcr Planus Archivfiir Dcrmatohgische Forschung, 245, 285. EL-LABBAN, N . G . (1970) Light and electron microscopic studies of colloid bodies in lichen p\a.nu%. Journal of Periodontal Research, 5, 315. EL-LABBAN, N.G. & KRAMER, I.R. (1974) Civatte bodies and the actively dividing epithelial cell in oral lichen planus. British Journal of Dermatology, 90, 13. FRY, L . & JOHNSON, F . R . C1969) Electron microscopic study of dermatitis herpetiformis. British Journal of Dermatology, 81, 44. HASHIMOTO, K . , KING, L.E., YAMANISHI, Y., BEACHEY, E.M. & MAEYENS, E. (1974) Identification of the substance
binding pemphigus antibody and concanavalin A in the skin. Journal of Investigative Dermatology, 52, 423. HAY, E . D . & DODSON, J.W. (1973) Secretion of collagen by cornea! epithelium. Journal of Cell Biology., 57, 190. JOHNSON, F.R. & FRY, L . (1967) Uttrastructural observations on lichen planus. Archives of Dermatology, 95, 596. MANN, P.R. & COWAN, M . A . (1973) Ultrastructurai changes in four cases of lichen sclerosus et atrophicus, British Journal of Dermatology, 89, 223. MARKS, R., ABELL, E.& NISHIKAWA, T . (1975) The functional zone beneath epidermis. British Journal of Dermatology, 92, 311. MARKS, R., BLACK, M . M . & WILSON JONES, E. (1973) Epidermal cell kinetics in lichen planus. British Journal of Dermatology, 88, 37.
636
E.Abell and D.Ramnarain
MICHEL, B. & Sv, E.K. C1973) Tissue fixed immunoglobulin in lichen planus. In: Immunopathohgy of the skin (Ed. by E.H.Beutner, T.P.Chorzelsky, S.F.Bean and R.E.Jordon) p. 182. Dowden, Hutchinson & Ross Inc. Stroudsburg. MuLLER, H.K. & SUTHERLAND, R . C . (1971) Epidermal antigens in cutaneous dysplasia and neoplasia. Nature, 230, 384. MuLLER, H.K., KALNINS, R. & SUTHERLAND, R.C. (1973) Ontogeny of pemphigus and bullous pemphigoid antigens in human skin. British Journal of Dermatology, 88, 443. PRESBURY, D.G.C. & MARKS, R. (1974) The epidermal disorder in lichen planus: An in vitro study. Britishjournal of Dermatology, 90, 373. PERTSCHUK, L.P. & ROSEN, Y. (1973} An immunofluorescent study of tumours with specific antisera for squamous epithelial intercellular substance and basement membrane. American Journal of Clinical Pathology, 60, 601. SARKANY, I. & GAYLARDE, P . M . (1971) Ultrastructural and light microscopic changes of the epidermo-dermal junction. Transactions of St. John's Hospital Dermatological Society, 57, 139. SCHAUMBERG-LEVER, G., ORFANOS, C.E. & LEVER, W . F . (1972) Electron microscopic study of bullous pemphigoid. Archives of Dermatology, 106, 662. THYRESSON, N . & MOBERGER, G . (1957) Cytologic studies in lichen ruber planus. Acta Dermato-venereologica, 37, 191. UEKI, H . (1969) Hyaline bodies in subepidermal papillae. Archives of Dermatology, 100, 610.
