Clinical efficacy and IL-17 targeting mechanism of Indigo naturalis as a topical agent in moderate psoriasis

Hui-Man Cheng, Yang-Chang Wu, Qingmin Wang, Michael Song, Jackson Wu, Dion Chen, Katherine Li, Eric Wadman, Shung-Te Kao, Tsai-Chung Li, Francisco Leon, Karen Hayden, Carrie Brodmerkel, C Chris Huang, Hui-Man Cheng, Yang-Chang Wu, Qingmin Wang, Michael Song, Jackson Wu, Dion Chen, Katherine Li, Eric Wadman, Shung-Te Kao, Tsai-Chung Li, Francisco Leon, Karen Hayden, Carrie Brodmerkel, C Chris Huang

Abstract

Background: Indigo naturalis is a Traditional Chinese Medicine (TCM) ingredient long-recognized as a therapy for several inflammatory conditions, including psoriasis. However, its mechanism is unknown due to lack of knowledge about the responsible chemical entity. We took a different approach to this challenge by investigating the molecular profile of Indigo naturalis treatment and impacted pathways.

Methods: A randomized, double-blind, placebo-controlled clinical study was conducted using Indigo naturalis as topical monotherapy to treat moderate plaque psoriasis in a Chinese cohort (n = 24). Patients were treated with Indigo naturalis ointment (n = 16) or matched placebo (n = 8) twice daily for 8 weeks, with 1 week of follow-up.

Results: At week 8, significant improvements in Psoriasis Area and Severity Index (PASI) scores from baseline were observed in Indigo naturalis-treated patients (56.3% had 75% improvement [PASI 75] response) compared with placebo (0.0%). A gene expression signature of moderate psoriasis was established from baseline skin biopsies, which included the up-regulation of the interleukin (IL)-17 pathway as a key component; Indigo naturalis treatment resulted in most of these signature genes returning toward normal, including down-regulation of the IL-17 pathway. Using an in vitro keratinocyte assay, an IL-17-inhibitory effect was observed for tryptanthrin, a component of Indigo naturalis.

Conclusions: This study demonstrated the clinical efficacy of Indigo naturalis in moderate psoriasis, and exemplified a novel experimental medicine approach to understand TCM targeting mechanisms.

Trial registration: NCT01901705 .

Keywords: Gene expression; Indigo naturalis; Mechanism of action; Psoriasis.

Conflict of interest statement

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of China Medical University Hospital, Taiwan, and conducted at this institute. The protocol followed Declaration of Helsinki and detailed information can be found at the Consent for publication

Patients provided written consent for their photographs to be used in this study and publication.

Competing interests

Q. Wang, M. Song, D. Chen, K. Li, E. Wadman, F. Leon, K. Hayden, C. Brodmerkel, and C. C. Huang are all employees of Janssen Research & Development, LLC, a subsidiary of Johnson & Johnson, and Q. Wang, M. Song, D. Chen, K. Li, F. Leon, C. Brodmerkel, and C. C. Huang own stock in Johnson & Johnson.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Study design. (a) Patient disposition; (b) study design; (c) study agent and placebo. The Indigo naturalis ointment used was a mixture (1:10) of Indigo naturalis powder and vehicle (Vaseline, microcrystalline wax, and olive oil [5:6:9]). Placebo preparation used was a mixture of blue dye powder (Indigo carmine aluminum lake [Blue #2] and Allura red AC aluminum lake [Red #40]) and vehicle
Fig. 2
Fig. 2
Efficacy assessments. (a) Mean PASI scores; (b) proportion of placebo- and Indigo naturalis-treated patients achieving a PASI 75 response (PASI 75 responders); (c) mean PGA scores; (d) and mean OTPSS in placebo- and Indigo naturalis-treated patients by study visit; (e) photo of a patient prior to Indigo naturalis treatment at week 0 (baseline) (left panel) and at week 8 following Indigo naturalis treatment (right panel). *p < 0.05 and **p < 0.005 vs. placebo. OTPSS, Overall Target Plaque Severity Score; PASI, Psoriasis Area and Severity Index; PGA, Physician's Global Assessmen t; SD, standard deviation
Fig. 3
Fig. 3
Moderate psoriasis signature. (a) Hierarchical clustering diagram of a moderate psoriasis signature generated from biopsies taken from lesional skin (LS; blue bar) and nonlesional skin (NS; green bar at the bottom) of the same patients at baseline; genes are represented as rows and samples as columns. Upregulated genes are shown in yellow and downregulated in blue; (b) enrichment of ingenuity pathways by moderate psoriasis gene signature. The stacked bar chart displays the number of up-regulated (red) and down-regulated (green) genes in each Ingenuity Canonical Pathway. The pathways are ranked by the p-value of a Fisher exact test from top to bottom (orange line; p-value listed in Additional file S1)
Fig. 4
Fig. 4
Indigo naturalis treatment signature. (a) Hierarchical clustering diagram of baseline and post-Indigo naturalis treatment (week 8) samples of the entire study cohort; genes are represented as rows and samples as columns. Upregulated genes are shown in yellow and downregulated in blue. Samples from four different groups are denoted as follows: baseline lesional (BL_LS; blue), baseline nonlesional (BL_NL; green), week-8 Indigo naturalis-treated lesional (W8_LS_IND; purple), and week-8 placebo-treated (W8_LS_PLB; yellow); (b) a Venn diagram comparing moderate psoriasis gene signature (dark blue circle on the left) and Indigo naturalis treatment signature (light blue circle on the right); (c) enrichment of Ingenuity pathways by Indigo naturalis treatment gene signature. The stacked bar chart displays the number of up-regulated (red) and down-regulated (green) in each Ingenuity Canonical Pathway. The pathways are ranked by the p-value of a Fisher exact test from top to bottom (orange line; p-value listed in Additional file 3); (d) the “Role of IL-17A in psoriasis” pathway overlaid with the gene expression pattern and each circle represents one gene. Differential expression between lesional and nonlesional sample at baseline is shown in left-half of each circle, and differential expression between week 8 and baseline samples is shown in right- half of circles. Yellow = up-regulated, blue = down-regulated, IL = interleukin, RA, receptor A, RC, receptor C
Fig. 5
Fig. 5
Indigo naturalis’ impact on the IL-17 pathway. (a) Down-regulation of interleukin (IL)-17A mRNA in the lesional skin (LS). Indigo naturalis-treated samples (blue filled-circle) are the left columns (week 0 [WK 0]: n = 16; week 8 [WK 8]: n = 14); placebo-treated samples (green triangles) are the middle two columns (WK 0: n = 8; WK 8: n = 7), and baseline nonlesional (NL) samples (gray square) are the right column (n = 23); (b) inhibition of IL-17-induced IL-6 secretion in cultured human keratinocytes. 100 mg/mL of IL-17 is present in all samples except media alone (first column). Compounds are tested in the following order: PD 0325901 1 μg (n = 2), 10 μg (n = 2); Tryptanthrin 0.3 μg (n = 7), 2.5 μg (n = 7) and 10 μg (n = 7). *T-test p-value ≤0.05; (c) inhibition of IL-17-induced IL-8 secretion in cultured human keratinocytes. 100 mg/mL of IL-17 is present in all samples except media alone (first column). IL, interleukin; mRNA, messenger RNA; SEM, standard error of mean

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