Concurrent inhibition of TGF-β and mitogen driven signaling cascades in Dupuytren's disease - non-surgical treatment strategies from a signaling point of view.

Dupuytren's disease (DD) is a benign progressive fibro-proliferative disorder of the fascia palmaris of the hand. Currently, treatment consists of surgical excision with a relatively high recurrence rate and risk of complications. To improve long-term outcome of DD treatment, research focus has shifted towards molecular targets for DD as an alternative to surgery. Therefore, complete and exact understanding of the cause of DD is needed. Transforming growth factor (TGF)-β is considered a key player in DD. We recently showed that increased TGF-β expression in DD correlates not only with elevated expression and activation of downstream Smad effectors, but also with overactive ERK1/2 MAP kinase signaling. Both TGF-β/Smad and non-Smad signaling pathways increase expression of key fibrotic markers and contractility of Dupuytren's myofibroblasts. What is not yet known is whether these two signaling cascades each accelerate DD autonomously, successively or in conjunction. Elucidation of this mechanism will help develop new potential non-surgical treatments. We hypothesize that TGF-β-induced short-term activation of the MAPK pathway leads to an autonomous non-Smad driven fibrosis. Therefore, successful treatment strategies will target not only TGF-β/Smad, but also intracellular MAPK signaling. In this review we discuss possible scenarios in which such a drift from TGF-β induced Smad signaling to autonomous non-Smad signaling could be observed in DD. The potential therapeutic effects of small cytokine signaling cascades inhibitors, such as TGF-β type I receptor-, (pan-) tyrosine- or ERK1/2 MAP-kinase inhibitor will be highlighted. To abrogate the fibrotic trait and the recurrence of DD, we speculate on sequential and co-application of such molecules in order to provide possible new non-operative strategies for DD.