TH2 sensitization in the skin-gut-brain axis: How early-life Th2-mediated inflammation may negatively perpetuate developmental and psychologic abnormalities

We recently reported children with comorbid atopic dermatitis (AD), asthma, allergic rhinitis, and food allergies displaying a 2.7-fold increase in developmental delays.² To this end, we hypothesize unregulated increases in T helper-2 (Th2)-driven inflammation, such as those seen in atopic diseases, can exert deleterious effects on the developing brain. Recognizing that available information is incomplete and that many potential associations are not firmly established, we speculate these effects underlie the association between Th2 sensitization and cognitive dysfunction in children. In this review, we explore the role of Th2 sensitization in the skin-gut-brain axis and explain how it can lead to reduced connectivity and transmission in the developing brain. With a focus on AD, we explore the association between Th2 sensitization and developmental abnormalities such as developmental delays, memory impairment, autism spectrum disorder (ASD), and epilepsy/seizures. As such, we review the available literature to examine the impact of increased IL-4 exposure in early life on the brain. We explore the possible association between Th2 sensitization and psychologic dysfunction such as attention-deficit/hyperactivity disorder (ADHD), depression, anxiety, and suicidal ideation. We also examine the impact that increased exposure to glucocorticoids and neurotrophins in early life exerts on the developing brain. Last, we discuss future directions for the advancement of our knowledge as a scientific community including possible interventions to reduce developmental and psychologic aberrations in children.

Association of Varying Clinical Manifestations and Positive Anti-SARS-CoV-2 IgG Antibodies: A Cross-Sectional Observational Study

BACKGROUND

The complex relationship between clinical manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and individual immune responses is not fully elucidated.

OBJECTIVE

To examine phenotypes of symptomatology and their relationship with positive anti-SARS-CoV-2 IgG antibody responses.

METHODS

An observational study was performed of adults (≥18 years) from 5 US states. Participants completed an electronic survey and underwent testing to anti-SARS-CoV-2 nucleocapsid protein IgG antibody between May and July 2020. Latent class analysis was used to identify characteristic symptom clusters.

RESULTS

Overall, 9507 adults (mean age, 39.6 ± 15.0 years) completed the survey; 6665 (70.1%) underwent antibody testing for anti-SARS-CoV-2 IgG. Positive SARS-CoV-2 antibodies were associated with self-reported positive SARS-CoV-2 nasal swab result (bivariable logistic regression; odds ratio [95% CI], 5.98 [4.83-7.41]), household with 6 or more members (1.27 [1.14-1.41]) and sick contact (3.65 [3.19-4.17]), and older age (50-69 years: 1.55 [1.37-1.76]; ≥70 years: 1.52 [1.16-1.99]), but inversely associated with female sex (0.61 [0.55-0.68]). Latent class analysis revealed 8 latent classes of symptoms. Latent classes 1 (all symptoms) and 4 (fever, cough, muscle ache, anosmia, dysgeusia, and headache) were associated with the highest proportion (62.0% and 57.4%) of positive antibodies, whereas classes 6 (fever, cough, muscle ache, headache) and 8 (anosmia, dysgeusia) had intermediate proportions (48.2% and 40.5%), and classes 3 (headache, diarrhea, stomach pain) and 7 (no symptoms) had the lowest proportion (7.8% and 8.5%) of positive antibodies.

CONCLUSIONS

SARS-CoV-2 infections manifest with substantial diversity of symptoms, which are associated with variable anti-SARS-CoV-2 IgG antibody responses. Prolonged fever, anosmia, and receiving supplemental oxygen therapy had strongest associations with positive SARS-CoV-2 IgG.

Integrated Safety Analysis of Abrocitinib for the Treatment of Moderate-to-Severe Atopic Dermatitis From the Phase II and Phase III Clinical Trial Program

Background

Pivotal phase III studies demonstrated that abrocitinib, an oral, once-daily, JAK1-selective inhibitor, is effective treatment for moderate-to-severe atopic dermatitis (AD) as monotherapy and in combination with topical therapy.

Objective

The aim of this study was to evaluate the long-term safety of abrocitinib 200 mg and 100 mg in an integrated analysis of a phase IIb study, four phase III studies, and one long-term extension study.

Methods

Two cohorts were analyzed: a placebo-controlled cohort from 12- to 16-week studies and an all-abrocitinib cohort including patients who received one or more abrocitinib doses. Adverse events (AEs) of interest and laboratory data are reported.

Results

Total exposure in the all-abrocitinib cohort (n = 2856) was 1614 patient-years (PY); exposure was ≥ 24 weeks in 1248 patients and ≥ 48 weeks in 606 (maximum 108 weeks). In the placebo-controlled cohort (n = 1540), dose-related AEs (200 mg, 100 mg, placebo) were nausea (14.6%, 6.1%, 2.0%), headache (7.8%, 5.9%, 3.5%), and acne (4.7%, 1.6%, 0%). Platelet count was reduced transiently in a dose-dependent manner; 2/2718 patients (200-mg group) had confirmed platelet counts of < 50 × 10³/mm³ at week 4. Incidence rates (IRs) were 2.33/100PY and 2.65/100 PY for serious infection, 4.34/100PY and 2.04/100PY for herpes zoster, and 11.83/100PY and 8.73/100PY for herpes simplex in the 200-mg and 100-mg groups, respectively. IRs for nonmelanoma skin cancer, other malignancies, and major adverse cardiovascular events were < 0.5/100PY for both doses. Five venous thromboembolism events occurred (IR 0.30/100PY), all in the 200-mg group. There were three deaths due to gastric carcinoma (diagnosed at day 43), sudden death, and COVID-19.

Conclusion

Abrocitinib, with proper patient and dose selection, has a manageable tolerability and longer-term safety profile appropriate for long-term use in patients with moderate-to-severe AD.

Trial Registries

ClinicalTrials.gov: NCT02780167, NCT03349060, NCT03575871, NCT03720470, NCT03627767, NCT03422822.

Video abstract

Upadacitinib plus topical corticosteroids in atopic dermatitis: week-52 AD Up study results

BACKGROUND

Primary (week 16) results from the ongoing phase 3, double-blind AD Up study (NCT03568318) demonstrate a positive benefit-risk profile for upadacitinib+TCS in patients with moderate-to-severe AD.

OBJECTIVE

Evaluate efficacy and safety of UPA+TCS through 52 weeks.

METHODS

Patients (12-75y) with chronic AD (≥10% of body surface area affected, EASI ≥16, vIGA-AD™ ≥3, and WP-NRS score ≥4) were randomized 1:1:1 to once-daily upadacitinib 15mg+TCS, upadacitinib 30mg+TCS, or PBO+TCS (re-randomized at week 16 to upadacitinib+TCS). Safety and efficacy, including proportion of patients achieving ≥75% improvement in EASI (EASI-75), vIGA-AD of clear/almost clear with improvement ≥2 grades (vIGA-AD 0/1), and WP-NRS improvement ≥4, were assessed through week 52. Missing data were primarily handled by nonresponder imputation incorporating multiple imputation for missing values due to COVID-19.

RESULTS

Of 901 patients, 300 were randomized to upadacitinib 15mg+TCS, 297 to upadacitinib 30mg+TCS, and 304 to PBO+TCS. For all endpoints, efficacy for upadacitinib 15mg+TCS and upadacitinib 30mg+TCS at week 16 was maintained through week 52. At week 52, the proportions of patients treated with upadacitinib 15mg+TCS and upadacitinib 30mg+TCS who achieved EASI-75 were 50.8% and 69.0%, respectively; 33.5% and 45.2%, respectively, achieved vIGA-AD 0/1; and 45.3% and 57.5%, respectively, achieved WP-NRS improvement ≥4. upadacitinib+TCS was well tolerated through 52 weeks; no new important safety risks beyond the current label were observed. No deaths were reported; events of MACE and VTE were infrequent (≤0.2/100 PY).

CONCLUSION

Results through 52 weeks demonstrate long-term maintenance of efficacy and a favorable safety profile of upadacitinib+TCS in patients with moderate-to-severe AD.

Patch Testing with Ammonium Persulfate: The North American Contact Dermatitis Group Experience, 2015-2018

BACKGROUND

Ammonium persulfate (APS), an oxidizing agent used in hair products, manufacturing, and pool/spa water, can cause skin reactions including allergic contact dermatitis.

OBJECTIVE

To characterize positive patch test reactions to APS (2.5% pet).

METHODS

Retrospective analysis of patients tested to the North American Contact Dermatitis Group (NACDG) screening series from 2015-2018.

RESULTS

Of 10,526 patients, 193 (1.8%) had positive patch test reactions to APS. Compared to negative patients, APS-positive patients were significantly more likely to be male (43.2% vs. 28.0%, p<0.0001), have primary hand (30.2% vs. 22.0%, p=0.0064), scattered generalized (25.5% vs. 17.9%, p=0.0064), or trunk dermatitis (8.9% vs. 4.9%, p=0.0123), and occupationally-related dermatitis (22.2% vs. 10.9%, p<0.0001). Over half of the APS-positive reactions were currently relevant (57.0%); 19 (9.8%) were related to occupation, especially (68.4%) hairdressers. Swimming pools/spas (23.3%) and hair care products (19.2%) were the most common APS sources.

LIMITATIONS

Immediate reactions and follow-up testing not captured.

CONCLUSIONS

The proportion of patients positive to APS was 1.8%. APS positivity was significantly associated with male sex and hand dermatitis. Swimming pool/spa chemicals are important sources of APS exposure.

Association between Atopic Dermatitis and Hypertension: A Systematic Review and Meta-Analysis

BACKGROUND

Previous studies found conflicting results about the association of atopic dermatitis (AD) with hypertension.

OBJECTIVES

Determine whether AD and AD severity are associated with hypertension.

METHODS

A systematic review was performed of published studies in MEDLINE, EMBASE, Scopus, Web of Science, and GREAT databases. At least 2 reviewers conducted title/abstract, full-text review, and data extraction. Quality of evidence was assessed using the Newcastle-Ottawa Scale.

RESULTS

Fifty-one studies met inclusion criteria; 19 had sufficient data for meta-analysis. AD was associated with higher odds of hypertension compared to healthy controls (increased in 9 of 16 studies; pooled prevalence: 16.4% vs 13.8%; random-effects regression, pooled unadjusted odds ratio [OR][95% confidence interval <CI95>]: 1.16 [1.04-1.30]), but lower odds of hypertension compared to psoriasis (decreased in 5 of 8 studies; 15.4% vs 24.8%; 0.53 [0.37-0.76]). In particular, moderate-severe AD were associated with hypertension compared to healthy controls (increased in 4 of 6 studies; 24.9% vs 14.7%; 2.33 [1.10-4.94]). Hypertension was commonly reported as an adverse-event secondary to AD treatments, particularly systemic cyclosporine A. Limitations include lack of longitudinal studies or individual-level data and potential confounding.

CONCLUSIONS

AD, particularly moderate-to-severe disease, was associated with increased hypertension compared to healthy controls, but lower odds than psoriasis.

Age-related differences in patch testing results among children: Analysis of North American Contact Dermatitis Group Data, 2001-2018

BACKGROUND

An updated understanding of allergic contact dermatitis is needed, particularly in children.

OBJECTIVES

To compare positive and clinically relevant reactions in children versus adults referred for patch testing.

METHODS

Retrospective analysis of 1871 children and 41,699 adults from the North American Contact Dermatitis Group (NACDG) from 2001-2018.

RESULTS

Both final diagnosis of allergic contact dermatitis (55.2% versus 57.3%; chi square, P = .0716) and prevalence of ≥ 1 currently relevant reaction to a NACDG screening allergen (49.2% vs 52.2%; P = .1178) were similar between children and adults. Currently in children, the most common relevant allergens were nickel sulfate (17.3%), hydroperoxides of linalool (7.8%), methylisothiazolinone (7.7%), cobalt chloride (7.0%), and fragrance mix I (4.9%). Approximately a fifth of children had a positive reaction to a non-NACDG allergen.

CONCLUSION

Over half of children referred for patch testing were diagnosed with allergic contact dermatitis. The most common relevant allergens in children were nickel sulfate, cobalt chloride, and hydroperoxides of linalool. Twenty percent of children had at least 1 positive reaction to allergens/substances not on the NACDG screening series, underscoring the need for comprehensive testing.

Factors impacting vaccine hesitancy toward Coronavirus disease-19 (COVID-19) vaccination in Brooklyn, New York

The Coronavirus disease-2019 (COVID-19) pandemic led to the development of several candidate vaccines. However, current research suggests that the potential of successful vaccines is tempered by vaccine skepticism or hesitancy. If vaccine efficacy is 80%, then the herd immunity required from vaccination is about 75-90%. The aim of the current study was to study factors impacting COVID-19 vaccine hesitancy in a representative sample of adults (age≥18 years) in a COVID-19 hotspotAbbreviations: COVID-19: coronavirus disease-19.

Association between atopic dermatitis and headaches throughout childhood and adolescence-A longitudinal birth cohort study

BACKGROUND/OBJECTIVES

Atopic dermatitis (AD) is associated with sleep disturbance, psychosocial distress, anxiety, depression, and atopic comorbidities, which may be associated with increased headaches. Our objective was to understand the association of AD and comorbid asthma, sleep and mental health disturbances with headaches throughout childhood and adolescence.

METHODS

Data were analyzed from The Fragile Families and Child Wellbeing Study, a longitudinal birth cohort study of 4898 urban children born in 1998-2000.

RESULTS

AD was associated with headaches at age 5 (adjusted odds ratio [95% confidence interval]: 2.14 [1.27-3.59]), 9 (1.69 [1.27-2.27]) and 15 years (1.71 [1.37-2.14]). AD at age 9 was associated with higher odds of subsequent headaches at age 15 (1.36 [1.05-1.76]). Children with AD at two (1.60 [1.12-2.29]) or all three (1.79 [1.16-2.75]) study-waves had higher odds of headaches at age 15 years. In multivariable repeated measures logistic regression models, significant two-way interactions were found for AD with sleep disturbance (4.59 [3.15-6.69]), attention deficit (hyperactivity) disorder (2.85 [1.87-4.35]), asthma (2.87 [2.18-3.76]), anxiety (2.47 [1.76-3.48]) or depression (2.86 [1.89-4.34]) as predictors of headaches.

CONCLUSION

Children and adolescents with AD, particularly those with sleep disturbances, atopic and mental health comorbidities, had increased headaches. Persistent childhood AD was associated with headaches in adolescence.

Comparative efficacy and safety of systemic therapies used in moderate-to-severe atopic dermatitis: a systematic literature review and network meta-analysis

Given the lack of head-to-head studies of systemic therapies in moderate-to-severe atopic dermatitis (AD), network meta-analyses (NMAs) can provide comparative efficacy and safety data to inform clinical decision-making. In this NMA, eligible randomized controlled trials (RCTs) published before 24 October 2019 were identified by a systematic literature review. Short-term (12-16 weeks) efficacy (Investigator's Global Assessment [IGA] and Eczema Area and Severity Index [EASI] responses), patient-reported outcomes (PROs) and safety data from each trial were abstracted and analysed separately for monotherapy and combination therapy (systemic plus topical anti-inflammatory therapy). RCTs were analysed in fixed-effects and random-effects Bayesian NMA models. Overall, 19 phase 2 and phase 3 RCTs of abrocitinib, baricitinib, dupilumab, lebrikizumab, nemolizumab, tralokinumab and upadacitinib were included. In monotherapy RCTs, upadacitinib 30 mg once daily (QD) had the numerically highest efficacy (83.6% achieved ≥50% improvement in EASI [EASI-50 response]), followed by abrocitinib 200 mg QD (74.6%), upadacitinib 15 mg QD (70.5%), dupilumab 300 mg every 2 weeks (Q2W) (63.4%) and abrocitinib 100 mg QD (56.7%). Similar trends in EASI-75 and EASI-90 response were observed. In combination therapy RCTs, abrocitinib 200 mg QD had the highest EASI-50 (86.6%), followed by dupilumab 300 mg Q2W (82.4%) and abrocitinib 100 mg QD (79.7%). Similar findings were observed for IGA response and PROs. In monotherapy and combination therapy RCTs, the probability of treatment-emergent adverse events (TEAEs) was higher among all active treatments than with placebo (except for dupilumab 300 mg Q2W [odds ratio (OR), 0.96; 95% credible interval (CrI), 0.45-2.18] and abrocitinib 100 mg QD [OR, 0.95; 95% CrI, 0.35-2.66] in combination therapy RCTs), although active treatments did not significantly differ from one another. Abrocitinib, dupilumab and upadacitinib were consistently the most effective systemic therapies in adult and adolescent patients with AD, with no significant TEAE differences in short-term RCTs.

Clinical Relevance of Skin Pain in Atopic Dermatitis

Skin pain is increasingly recognized as an impactful symptom in atopic dermatitis (AD) because of its association with patient discomfort, disease burden, and reduced quality of life. Although the nature of skin pain in AD has not been systematically studied and is therefore not well understood, patients report soreness, discomfort, and tenderness that may reflect peripheral and central pain sensitization. The high prevalence of skin pain suggests that it is not adequately addressed by current therapies for AD and may be undertreated compared with other symptoms. This review discusses the clinical relevance of skin pain with respect to its experience, pathophysiology, relationship with itch, and treatment implications. Recent studies suggest that skin pain presents as a neuropathic symptom independent from itch and the &ldquo;itch-scratch cycle&rdquo;, and poses a unique burden to patients. Recognition of the significant consequences of skin pain and discomfort should reinforce the need to assess and treat this symptom in patients with moderate-to-severe AD. J Drugs Dermatol. 2020;19(10)921-926. doi:10.36849/JDD.2020.5498.

Impact of Atopic Dermatitis Lesion Location on Quality of Life in Adult Patients in a Real-world Study

BACKGROUND

Atopic dermatitis (AD) has a negative impact on patients&rsquo; quality of life (QoL).

OBJECTIVE

To report the impact of specific AD lesion locations on QoL in adult patients with AD using real-world data.

METHODS

The Adelphi US Disease Specific Programme was conducted between January&ndash;April 2018. Physicians documented patient demographics/characteristics, AD lesion locations, and body surface area; patients completed questionnaires reporting the impact of lesion locations on QoL.

RESULTS

AD severity was moderate in 51.6% of patients and severe in 6.0%. Lesions were commonly identified in more than one location. All AD lesion locations impacted QoL. Visible areas were most bothersome, including head/neck (68%), hands/fingers (58%), front (30%), upper extremities (22%), and lower extremities (16%), with statistically significant associations for a number of Dermatology Life Quality Index (DLQI) items. Itch, soreness, pain, and stinging are also associated with a number of body areas but in particular with those that are most visible/accessible. Lesions on the head/neck and hands/fingers (58%) demonstrated an increased impact on the anxiety and depression dimension of the EuroQol 5-Dimension tool.

CONCLUSIONS

In patients with AD, quality of life was most affected in patients with lesions in visible areas, including head/neck, hands/fingers, and upper extremities, with statistically significant associations for a number of DLQI domains. Physicians should be aware of the burden of AD lesions on QoL and consider having conversations with patients to better understand the impact of these lesions. Prior presentation: 28th Annual European Academy of Dermatology and Venereology Congress; 9&ndash;13 October 2019, Madrid, Spain. Poster number P0233.J Drugs Dermatol. 2020;19(10): 943-948. doi:10.36849/JDD.2020.5422.

Safety and efficacy of upadacitinib in combination with topical corticosteroids in adolescents and adults with moderate-to-severe atopic dermatitis (AD Up): results from a randomised, double-blind, placebo-controlled, phase 3 trial

BACKGROUND

Systemic therapies are typically combined with topical corticosteroids for the management of moderate-to-severe atopic dermatitis. Upadacitinib is an oral Janus kinase (JAK) inhibitor with greater inhibitory potency for JAK1 than JAK2, JAK3, or tyrosine kinase 2 that is being tested for atopic dermatitis. We aimed to assess the efficacy and safety of upadacitinib plus topical corticosteroids compared with placebo for the treatment of moderate-to-severe atopic dermatitis.

METHODS

In this randomised, double-blind, placebo-controlled, phase 3 trial (AD Up) adults (aged 18-75 years) and adolescents (aged 12-17 years) with chronic atopic dermatitis that was moderate to severe (≥10% of body surface area affected, Eczema Area and Severity Index [EASI] score of ≥16, validated Investigator's Global Assessment for atopic dermatitis [vIGA-AD] score of ≥3, and weekly average Worst Pruritus Numerical Rating Scale score of ≥4 at baseline) were enrolled at 171 clinical centres across 22 countries in the Asia-Pacific region, Europe, the Middle East, North America, and Oceania. Patients were randomly assigned (1:1:1) to receive upadacitinib 15 mg, upadacitinib 30 mg, or placebo once daily, all in combination with topical corticosteroids for 16 weeks. Randomisation was done using an interactive response technology system, stratified by baseline disease severity, geographical region, and age. Study investigators, study site personnel, and patients were masked to study treatment. The coprimary endpoints were the proportion of patients who had achieved at least a 75% reduction in EASI score from baseline (EASI-75) and the proportion of patients who had achieved a vIGA-AD response (defined as a vIGA-AD score of 0 [clear] or 1 [almost clear] with ≥2 grades of improvement from baseline) at week 16. Efficacy was analysed in the intention-to-treat population and safety was analysed in all patients who received at least one dose of study drug. This study is registered with ClinicalTrials.gov, NCT03568318, and is active, but not recruiting.

FINDINGS

Between Aug 9, 2018, and Dec 20, 2019, 901 patients were randomly assigned to receive upadacitinib 15 mg plus topical corticosteroids (n=300), upadacitinib 30 mg plus topical corticosteroids (n=297), or placebo plus topical corticosteroids (n=304). At week 16, the proportion of patients who had achieved EASI-75 was significantly higher in the upadacitinib 15 mg plus topical corticosteroid group (194 [65%] of 300 patients) and the upadacitinib 30 mg plus topical corticosteroids group (229 [77%] of 297 patients) than the placebo group (80 [26%] of 304 patients; adjusted difference in EASI-75 response rate vs placebo, 38·1% [95% CI 30·8-45·4] for the upadacitinib 15 mg group and 50·6% [43·8-57·4] for the upadacitinib 30 mg group; p<0·0001 for both doses). The proportion of patients who had achieved a vIGA-AD response at week 16 was significantly higher in the upadacitinib 15 mg plus topical corticosteroid group (119 [40%] patients) and upadacitinib 30 mg plus topical corticosteroid group (174 [59%] patients) than the placebo group (33 [11%] patients; adjusted difference in vIGA-AD response vs placebo, 28·5% [22·1-34·9] for the upadacitinib 15 mg group and 47·6% [41·1-54·0] for the upadacitinib 30 mg group; p<0·0001 for both doses). During the double-blind period, upadacitinib 15 and 30 mg were well tolerated in combination with topical corticosteroids. The most frequently reported treatment-emergent adverse events (≥5% in any treatment group) were acne, nasopharyngitis, upper respiratory tract infection, oral herpes, elevation of blood creatine phosphokinase levels, headache, and atopic dermatitis. The incidence of acne was higher in the upadacitinib 15 mg (30 [10%] of 300 patients) and upadacitinib 30 mg (41 [14%] of 297 patients) groups than the placebo group (six [2%] of 304 patients). The incidence of adverse events leading to discontinuation of study drug (four [1%] patients in the upadacitinib 15 mg plus topical corticosteroids group, four [1%] patients in the upadacitinib 30 mg plus topical corticosteroids group, and seven [2%] patients in the placebo plus topical corticosteroids group) and serious adverse events (seven [2%] patients, four [1%] patients, and nine [3%] patients) were similar among treatment groups. No deaths were reported in any treatment group.

INTERPRETATION

Upadacitinib plus topical corticosteroids was well tolerated and superior to placebo plus topical corticosteroids. Upadacitinib as combination therapy had a positive benefit-risk profile in adults and adolescents with moderate-to-severe atopic dermatitis.

FUNDING

AbbVie.

Impact of baricitinib in combination with topical steroids on atopic dermatitis symptoms, quality of life and functioning in adult patients with moderate-to-severe atopic dermatitis from the BREEZE-AD7 Phase 3 randomized trial

Background

Baricitinib is an oral, selective, reversible Janus kinase 1/2 inhibitor approved in the European Union and Japan and under investigation in the United States for treatment of atopic dermatitis (AD).

Objectives

To evaluate the impact of baricitinib plus background topical corticosteroids (TCS) on health‐related quality of life (HRQoL), how AD symptoms impact work productivity and life functioning, and treatment benefit using patient‐reported outcome (PRO) assessments in patients with moderate‐to‐severe AD previously experiencing inadequate response to TCS.

Methods

Adult patients with AD in BREEZE‐AD7, a Phase 3, multicentre, double‐blind trial, were randomised 1 : 1 : 1 to daily oral placebo (control) or baricitinib 4‐ or 2‐mg plus TCS. PROs reported Week 1 through Week 16: Dermatology Life Quality Index (DLQI), Work Productivity and Activity Impairment‐AD (WPAI‐AD); Patient‐Reported Outcomes Measurement Information System (PROMIS) Itch and Sleep measures, and Patient Benefit Index (PBI). Data were analysed using logistic regression (categorical) and mixed model repeated measures (continuous). PBI scores were analysed using analysis of variance.

Results

A total of 329 patients were randomised. Treatment with baricitinib 4‐mg (N = 111) or 2 mg (N = 109) plus TCS led to rapid, statistically significant improvements [vs. TCS plus placebo (N = 109)] in DLQI ≥4‐point improvement starting at Week 2 (4‐mg plus TCS, P ≤ 0.001; 2‐mg plus TCS P ≤ 0.05), change from baseline in WPAI‐AD presenteeism at Week 1 (4‐mg plus TCS, P ≤ 0.01; 2‐mg plus TCS P ≤ 0.05) and PROMIS itch interference at Week 2 (4‐mg plus TCS P ≤ 0.01). Improvements were sustained through Week 16 for baricitinib 4‐mg. Statistically significant improvements were observed at Week 16 for PBI global score (4‐mg plus TCS, P ≤ 0.001; 2‐mg plus TCS P ≤ 0.05).

Conclusions

Baricitinib plus TCS vs. placebo plus TCS showed significant improvements in treatment benefit at Week 16 and rapid significant improvements in HRQoL and impact of AD symptoms on work productivity and functioning through 16 weeks.

Long-term Efficacy of Baricitinib in Adults With Moderate to Severe Atopic Dermatitis Who Were Treatment Responders or Partial Responders: An Extension Study of 2 Randomized Clinical Trials

Question

What is the long-term (68-week) efficacy of baricitinib, 4 and 2 mg, in patients with moderate to severe atopic dermatitis who were treatment responders or partial responders?

Findings

In this long-term extension study of 2 randomized clinical trials, the proportions of 70 responders/partial responders to baricitinib, 4 mg, in the original studies who achieved a validated Investigator Global Assessment for Atopic Dermatitis score of 0 or 1 during continuous treatment were 45.7% at week 16 and 47.1% at week 68. Corresponding proportions for 54 patients receiving baricitinib, 2 mg, were 46.3% at week 16 and 59.3% at week 68.

Meaning

In this study, baricitinib demonstrated sustained long-term efficacy, suggesting that baricitinib may be a longer-term treatment option for moderate to severe atopic dermatitis.

Importance

Baricitinib, an oral selective Janus kinase inhibitor, improved the clinical signs and symptoms of moderate to severe atopic dermatitis in the 16-week, phase 3 monotherapy studies, BREEZE-AD1 and BREEZE-AD2. Long-term efficacy has not yet been examined.

Objective

To evaluate the long-term (68-week) efficacy of baricitinib in adults with moderate to severe atopic dermatitis who were treatment responders or partial responders in BREEZE-AD1 and BREEZE-AD2.

Design, Setting, and Participants

Patients completing BREEZE-AD1/BREEZE-AD2 entered the ongoing, multicenter, double-blind, long-term extension study BREEZE-AD3. The study was initiated on March 28, 2018. Data were analyzed on December 13, 2019.

Interventions

Responders and partial responders (patients achieving validated Investigator Global Assessment for Atopic Dermatitis [vIGA-AD] score of 0 or 1 [0,1], or 2) at BREEZE-AD1/BREEZE-AD2 completion remained on originally assigned treatment for 52 weeks (68 total weeks of continuous therapy).

Main Outcomes and Measures

The primary end point was the proportion of patients achieving a vIGA-AD score of 0,1 at weeks 16, 36, and 52 of BREEZE-AD3. Secondary end points included the proportion of patients achieving 75% or more improvement in the Eczema Area and Severity Index [EASI75] score and 4-point or more improvement in the itch numeric rating scale (NRS), using originating study baseline data. Itch data were collected during the first 16 weeks in BREEZE-AD3. The last originating study visit was the first BREEZE-AD3 visit; therefore, data are presented for continuous weeks of therapy, including the 16-week originating study period. Missing data were imputed by last observation carried forward. Modified intention-to-treat analysis was used.

Results

Of the responder/partial responder population, the proportion of patients treated with baricitinib, 4 mg (n = 70) (mean [SD] age, 36.7 [15.5] years; 42 [60%] were men), achieving vIGA-AD (0,1) at week 16 was 45.7% (BREEZE-AD3 baseline) and, at week 68, 47.1%. Improvement of 75% or more in the EASI score was 70.0% at week 16 and 55.7% at week 68. The proportion of patients achieving an itch NRS improvement greater than or equal to 4 points at week 16 was 52.5% and, at week 32, 45.9%. Of the responder/partial responder population, the proportion of patients treated with baricitinib, 2 mg (n = 54) (mean [SD] age, 32.8 [12.7] years; 28 [51.9%] were men), achieving vIGA-AD (0,1) at week 16 was 46.3% and, at week 68, 59.3%. Improvement in the EASI75 score was 74.1% at week 16 and 81.5% at week 68. The proportion of patients achieving an itch NRS improvement greater than or equal to 4 points at week 16 was 44.2% and, at week 32, 39.5%.

Conclusions and Relevance

In this long-term double-blind extension study of 2 randomized clinical trials, baricitinib, 4 and 2 mg, demonstrated sustained long-term efficacy in patients with moderate to severe atopic dermatitis.

Trial Registration

ClinicalTrials.gov Identifier: NCT03334435

Incidence of Venous Thromboembolism in Patients With Dermatologist-Diagnosed Chronic Inflammatory Skin Diseases

Importance

Several studies have linked chronic inflammatory skin diseases (CISDs) with venous thromboembolism (VTE) in a range of data sources with mixed conclusions.

Objective

To examine the incidence of VTE in patients with vs without CISD.

Design, Setting, and Participants

A cohort study using commercial insurance claims data from a nationwide US health care database from January 1, 2004, through 2019 was conducted. A total of 158 123 patients with dermatologist-recorded psoriasis, atopic dermatitis, alopecia areata, vitiligo, or hidradenitis suppurativa were included. Risk-set sampling identified patients without a CISD. Patient follow-up lasted until the first of the following occurred: VTE, death, disenrollment, or end of data stream.

Exposures

Patients with vs without CISD.

Main Outcomes and Measures

Venous thromboembolism events were identified with validated algorithms. Incidence rates were computed before and after 1:1 propensity-score matching to account for VTE risk factors. Hazard ratios were estimated to compare the incidence of VTE in the CISD vs non-CISD cohorts.

Results

A total of 158 123 patients were identified with CISD: with psoriasis (n = 96 138), atopic dermatitis (n = 30 418), alopecia areata (n = 17 889), vitiligo (n = 7735), or HS (n = 5934); 9 patients had 2 of these conditions. A total of 1 570 387 patients were without a CISD. The median follow-up time was 1.9 years (interquartile range, 0.8-4.0 years) in patients with CISD. The incidence rate (per 1000 person-years) of outpatient or inpatient VTE was 1.57 in psoriasis, 1.83 in atopic dermatitis, 0.94 in alopecia areata, 0.93 in vitiligo, 1.65 in HS and 1.53 in CISD overall, compared with 1.76 in patients without a CISD. Incidence rates increased in patients aged 50 years or older (2.3 per 1000 person-years) and decreased in those aged 18 to 49 years (0.8 per 1000 person-years). After propensity-score matching to patients without a CISD, the hazard ratio (HR) of VTE was 0.86 (95% CI, 0.75-0.99) in psoriasis, 1.19 (95% CI, 0.95-1.48) in atopic dermatitis, 0.97 (95% CI, 0.65-1.46) in alopecia areata, 0.90 (95% CI, 0.49-1.65) in vitiligo, 1.64 (95% CI, 0.82-3.27) in hidradenitis suppurativa, and 0.94 (95% CI, 0.84-1.05) in CISD overall.

Conclusions and Relevance

In this large-scale cohort study, CISDs were not associated with an increased incidence of VTE after controlling for relevant VTE risk factors in a representative dermatology patient population.

Insights into adult atopic dermatitis heterogeneity derived from circulating biomarker profiling in patients with moderate-to-severe disease

Atopic dermatitis (AD) is a heterogeneous systemic inflammatory skin disease associated with dysregulated immune responses, barrier dysfunction and activated sensory nerves. To characterize circulating inflammatory profiles and underlying systemic disease heterogeneity within AD patients, blood samples from adult patients (N = 123) with moderate‐to‐severe AD in a phase 2 study of baricitinib (JAHG) were analysed. Baseline levels of 131 markers were evaluated using high‐throughput and ultrasensitive proteomic platforms, patient clusters were generated based on these peripheral markers. We implemented a novel cluster reproducibility method to validate cluster outcomes within our study and used publicly available AD biomarker data set (73 markers, N = 58 patients) to validate our findings. Cluster reproducibility analysis demonstrated best consistency for 2 clusters by k‐means, reproducibility of this clustering outcome was validated in an independent patient cohort. These unique JAHG patient subgroups either possessed elevated pro‐inflammatory mediators, notably TNFβ, MCP‐3 and IL‐13, among a variety of immune responses (high inflammatory) or lower levels of inflammatory biomarkers (low inflammatory). The high inflammatory subgroup was associated with greater baseline disease severity, demonstrated by greater EASI, SCORAD Index, Itch NRS and DLQI scores, compared with low inflammatory subgroup. African‐American patients were predominantly associated with the high inflammatory subgroup and increased baseline disease severity. In patients with moderate‐to‐severe AD, heterogeneity was identified by the detection of 2 disease subgroups, differential clustering amongst ethnic groups and elevated pro‐inflammatory mediators extending beyond traditional polarized immune responses. Therapeutic strategies targeting multiple pro‐inflammatory cytokines may be needed to address this heterogeneity.

Invasive and in situ squamous cell carcinoma of the skin: a nationwide study in Iceland

BACKGROUND

The worldwide incidence of cutaneous squamous cell carcinoma (cSCC) is increasing.

OBJECTIVES

To evaluate the tumour burden of in situ and invasive cSCC in Iceland, where the population is exposed to limited ultraviolet radiation.

METHODS

This whole-population study used the Icelandic Cancer Registry, which contains records of all in situ and invasive cSCC cases from 1981 to 2017. Incidence of cSCC was evaluated according to age, anatomical location, residence and multiplicity, and trends were assessed using joinpoint analysis. Age-standardized rates (WSR) and age-specific incidence rates per 100 000 person-years were calculated, along with cumulative and lifetime risks.

RESULTS

Between 1981 and 2017, in situ cSCC WSR increased from 1·2 to 19·1 for men and from 2·0 to 22·3 for women. Invasive cSCC WSR rose from 4·6 to 14 for men and from 0·3 to 13·2 for women. The average number of in situ cSCC lesions was 1·71 per woman and 1·39 per man. Women developed more in situ cSCCs than invasive cSCCs in almost all anatomical locations, whereas men developed more invasive cSCCs, mostly on the head and neck. The rates of in situ cSCC were higher in Reykjavik compared with rural areas. Furthermore, women more commonly developed multiple in situ lesions. For lip cSCCs, invasive lesions occurred more frequently than in situ lesions among both sexes. Joinpoint analysis showed that in situ cSCC in women exhibited the most rapid incidence increase.

CONCLUSIONS

cSCC has become an increasingly significant public health problem in Iceland. Tanning bed use and travelling abroad may contribute to skin cancer development. Public health efforts are needed to stem the behaviours leading to this rapid rise in cSCC.

Prevalence and trend of allergen sensitization in patients referred for patch testing with a final diagnosis of psoriasis: North American Contact Dermatitis Group data, 2001-2016

BACKGROUND

Little is known about the relationship between psoriasis and allergic contact dermatitis (ACD).

OBJECTIVE

To examine the associations with ACD, related clinical characteristics, and common positive and clinically relevant allergens of patients with a final diagnosis of psoriasis who were referred for patch testing.

METHODS

Retrospective analysis of 38 723 patients from the North American Contact Dermatitis Group.

RESULTS

Patients with a final diagnosis of psoriasis had lower proportions of ACD than those without psoriasis (32.7% vs 57.8%). In multivariable logistic regression models, psoriasis was inversely associated with female sex, Black or Asian race, and history of atopic dermatitis and hay fever. Patients with a final diagnosis of psoriasis were less likely to have one or more positive allergic patch-test reactions or to have a current clinically relevant patch-test reaction to the majority of the most commonly positive and/or relevant allergens. The most clinically relevant allergens included nickel sulfate, methylisothiazolinone, and fragrance mix I.

CONCLUSION

Approximately one-third of patients who were referred for patch testing with a final diagnosis of psoriasis were also diagnosed with ACD. In select patients with suspected psoriasis who also have a clinical presentation suggestive of ACD, patch testing may be helpful.

Predictors and age-dependent pattern of psychologic problems in childhood atopic dermatitis

BACKGROUND/OBJECTIVES

Little is known about the predictors and trends of psychological comorbidities in childhood atopic dermatitis (AD), or whether they occur in an age-dependent pattern. We hypothesized racial/ethnic and socioeconomic disparities lead to increased psychological problems among children with AD and psychological comorbidities occur in an age-dependent manner.

METHODS

We analyzed cross-sectional data on 228 898 children aged 2-17 years from the 1997-2018 National Health Interview Survey.

RESULTS

Children with AD had higher proportions of depression/sadness (17.2% vs 12.6%; odds ratio [95% confidence interval]: 1.44 [1.37-1.51]), attention deficit (hyperactivity) disorder (ADD/ADHD) (10.0% vs 7.1%; 1.46 [1.38-1.55]), emotional/behavioral difficulties (29.9% vs 23.5%; 1.77 [1.69-1.84]), feelings of frequent worry (38.8% vs 23.5%; 1.66 [1.58-1.74]), and autism (1.9% vs 0.9%; 2.00 [1.75-2.29]). Among children with AD, psychologic comorbidity was associated with atopic comorbidities and multimorbidity and white race, households with lower income and education, and no insurance coverage. In children with or without AD, the prevalence of autism peaked during pre-adolescence; ADD/ADHD and emotional/behavioral difficulties peaked in adolescence; and depression/sadness and feelings of frequent worry increased steadily throughout childhood without plateau.

CONCLUSION

Atopic dermatitis was associated with multiple psychologic disorders, particularly among those with atopic comorbidities, white race, and low household income. Psychologic comorbidities increased in an age-dependent pattern, though similar to children without AD.

Patch testing with sodium disulfite: North American Contact Dermatitis Group experience, 2017 to 2018

BACKGROUND

Sodium disulfite (SD), also known as sodium metabisulfite, is an increasingly recognized cause of allergic contact dermatitis.

OBJECTIVES

The objective of this work was to characterize individuals with positive patch test reactions to SD as well as analyse reaction strength, clinical relevance, and sources.

METHODS

This is a retrospective analysis of patients patch tested with SD (1% petrolatum) by the North American Contact Dermatitis Group (NACDG), 2017 to 2018.

RESULTS

Of 4885 patients patch tested with SD, 132 (2.7%) had a positive reaction. Common primary anatomic sites of dermatitis were face (28.8%), hands (20.5%), and a scattered/generalized distribution (13.6%). Compared with SD-negative patients, SD-positive patients were more likely male (odds ratio 2.81, 95% confidence interval 1.98-4.00) and/or over 40 years (odds ratio 1.95, 95% confidence interval 1.30-2.94). Reactions were most commonly + (50.4%) or ++ (34.1%); 65.2% were considered currently relevant. About 15.2% were definitively confirmed in sources, commonly personal care products (18.9%, especially hair dye), and drugs/medications/alcoholic beverages (9.1%). Only 2.3% of positive reactions were linked to occupation.

CONCLUSIONS

Positive reactions to SD occurred in 2.7% of tested patients. Reactions were often clinically relevant and linked to personal care products and drugs/medications/alcoholic beverages.

The Effect of Isotretinoin on Vitiligo and Autoimmune Comorbidity

Several case reports have noted development of vitiligo as a potential side-effect of isotretinoin. In an IRB approved on-line survey of vitiligo patients we queried 1,301 vitiligo patients, 1115 with generalized vitiligo responding as to whether they had taken isotretinoin to address whether this issue was a common phenomenon amongst vitiligo patients. 3.6% of respondents had taken isotretinoin, 1.4% (n=16) before onset of vitiligo, and 2.2% (n=24) after onset of vitiligo. When compared with age-matched vitiligo peers who had not taken isotretinoin before onset of vitiligo (n=64) , isotretinoin use prior to onset of vitiligo was associated with: decreased disease body surface area (conditional logistic regression: OR of BSA&ge;50% (95% CI)=0.12 (0.03&ndash;0.57), P=0.007); decreased odds of body and face involvement when compared with either body or face alone (OR (95% CI)=0.20 (0.06&ndash;0.73), P=0.02); and decreased co-morbid autoimmunity (OR (95% CI)=0.17 (0.04&ndash;0.58), P=0.01). The volume of isotretinoin usage in vitiligo patients is additionally suggestive of a link between cystic acne and vitiligo. J Drugs Dermatol. 2020;19(6): doi:10.36849/JDD.2020.4938.

Secular trends of atopic dermatitis and its comorbidities in United States children between 1997 and 2018

Previous studies found increased prevalence of childhood atopic dermatitis (AD) in the United States over the past few decades. It is unknown whether the prevalence of AD has plateaued or whether AD comorbidities changed over time. The main objective of this study is to assess the prevalence and secular trends of AD and its comorbidities. We analyzed data on 259,818 children, ages 0 to 17 years, from the National Health Interview Survey, 1997-2018, using logistic regression models. The prevalence (95% confidence interval) of childhood AD steadily increased from 2000 [7.3% (6.8-7.9%)] to 2011 [12.8% (12.1-13.5%)] and remained consistent until 2018 [12.6% (11.6-13.5%)]. In logistic regression models, the odds of AD were significantly increased in all years from 2003 to 2018 compared to 1997. However, the increased odds of AD over time were attenuated when adjusting for socio-demographic factors. AD prevalence increased in most socio-demographic groups, but changed variably by age group, race/ethnicity, and region. There were significant trends of AD comorbidities over time, with increasing prevalence of attention deficit (hyperactivity) disorder, and decreasing prevalence of hay fever and depression/sadness. AD prevalence in US children increased between 1997 and 2011, remaining consistent until 2018 with an overall increase of 59%. Prevalence of comorbid hay fever and sadness/depression decreased, while ADD/ADHD increased. Given divergent trends of AD prevalence by socio-demographic characteristics, future studies are better equipped to identify contributing factors of prevalence change.

Clinical phenotyping of atopic dermatitis using combined itch and lesional severity: A prospective observational study

BACKGROUND

Patients with atopic dermatitis (AD) have heterogeneous clinical phenotypes, including different combinations of itch and lesional severity. Little is known about the characteristics and course of these subtypes.

OBJECTIVE

To determine the characteristics, associations, burden, and course of patients with AD using combined itch and lesional severity.

METHODS

A prospective practice-based study was performed using questionnaires and physical examination (n=592). AD subsets were defined using verbal rating scale for average itch combined with either eczema area and severity index, objective-scoring atopic dermatitis (SCORAD), or validated investigator's global assessment as follows: mild-moderate itch and lesions (MI-ML), mild-moderate itch and severe lesions (MI-SL), severe itch and mild-moderate lesions (SI-ML), and severe itch and lesions (SI-SL).

RESULTS

At baseline, there were only weak-moderate correlations of numerical rating scales for worst itch or average itch or SCORAD itch with eczema area and severity index, objective-SCORAD, body surface area, and validated investigator's global assessment (Spearman's rho = 0.32-0.62). Most patients had MI-ML (59.4%-62.3%), followed by SI-ML (21.3%-29.1%), SI-SL (6.0%-12.9%), and MI-SL (3.8%-6.4%). Patients with SI-SL, followed by SI-ML and MI-SL, described their AD as being more severe overall and had worse impairment in sleep, mental health, and quality of life. However, those with MI-SL or SI-SL were far more likely to be classified as severe by a physician (multivariable logistic and linear regression, P < .005 for all). Baseline MI-SL, SI-ML, and SI-SL were associated with similar longitudinal courses over time and more AD flares and itch triggers than MI-ML.

CONCLUSION

Combined itch and lesional severity seem to describe unique AD phenotypes. Further studies are needed to confirm these findings and understand the optimal treatments for these groups.

Contact dermatitis associated with preservatives: Retrospective analysis of North American Contact Dermatitis Group data, 1994 through 2016

BACKGROUND

Preservatives are often necessary components of commercial products. Large-scale North American studies on preservative allergy are limited.

OBJECTIVE

To evaluate demographics, positive patch test reactions (PPTRs), clinical relevance, and trends for preservatives tested by the North American Contact Dermatitis Group.

METHODS

We conducted a retrospective cross-sectional analysis of North American Contact Dermatitis Group patch testing results of preservatives from 1994 through 2016.

RESULTS

A total of 50,799 patients were tested; 11,338 (22.3%) had a PPTR to at least 1 preservative. The most frequent reactions were to methylisothiazolinone 0.2% aqueous (aq) (12.2%), formaldehyde 2% aq (7.8%), formaldehyde 1% aq (7.8%), quaternium-15 2% petrolatum (pet) (7.7%), and methyldibromo glutaronitrile/phenoxyethanol 2% pet (5.1%). Paraben mix 12% pet (1%), iodopropynyl butylcarbamate 0.1% pet (0.4%), benzyl alcohol 1% pet (0.3%), and phenoxyethanol 1% pet (0.2%) had the lowest PPTRs. Linear regression analysis of preservatives tested showed that only methylchloroisothiazolinone/methylisothiazolinone 0.01% aq (parameter estimate, 0.42; 95% CI, 0.17-0.66; P < .005) had a significant increase in PPTRs over time.

LIMITATIONS

Collected variables are dependent on clinical judgment. Results may be prone to referral selection bias.

CONCLUSIONS

This large North American study provides insight on preservative PPTRs and trends from 1994 through 2016.

Prevalence and Trend of Allergen Sensitization in Adults and Children with Atopic Dermatitis Referred for Patch Testing, North American Contact Dermatitis Group Data, 2001-2016

BACKGROUND

The association between atopic dermatitis (AD) and allergic contact dermatitis (ACD) is controversial.

OBJECTIVE

To analyze the prevalence, reaction strength, and trends of the most commonly positive and relevant allergens in patients with AD referred for patch testing.

METHODS

This was a retrospective analysis of 38,482 patients from the North American Contact Dermatitis Group, 2001 to 2016.

RESULTS

Most adults (56.0%) and children (52.8%) with a history of AD had a final diagnosis of ACD. Adults (66.5% vs 65.6%; χ², P = .1459) and children (61.4% vs 62.3%, P = .7074) with or without a history of AD had similar proportions of one or more allergic patch test reactions. Adults with a history of AD had a greater number of allergic patch test positive reactions than those without it (2.0 ± 2.4 vs 1.9 ± 2.3; t test, P < .0001), whereas children did not (1.5 ± 1.8 vs 1.4 ± 1.6; P = .3839). Nickel sulfate, methylisothiazolinone, formaldehyde, fragrance mix I, sodium gold thiosulfate, and thimerosal were the most common allergens in adults and children with a history of AD. In multivariable logistic regression models, adults with versus without a history of AD had increased odds of reacting to 10 of the top 25 North American Contact Dermatitis Group screening allergens. Most allergens had similar strengths of reaction in adults or children with and without a history of AD or a current AD diagnosis; cobalt, fragrance mix I, and propylene glycol had weaker reactions. In multivariable logistic regression, adults with versus without an AD history had increased odds of relevance for 10 of the 25 most currently relevant allergens, whereas children with an AD history did not have increased relevance for any specific allergens.

CONCLUSIONS

Most patients referred for patch testing with AD history had a final diagnosis of ACD. Patients with AD history had a similar likelihood of having a positive patch test reaction as those without an AD history. Adults with an AD history had a higher number of positive patch test reactions.

Abrocitinib versus Placebo or Dupilumab for Atopic Dermatitis

BACKGROUND

The oral Janus kinase 1 (JAK1) inhibitor abrocitinib, which reduces interleukin-4 and interleukin-13 signaling, is being investigated for the treatment of atopic dermatitis. Data from trials comparing JAK1 inhibitors with monoclonal antibodies, such as dupilumab, that block interleukin-4 receptors are limited.

METHODS

In a phase 3, double-blind trial, we randomly assigned patients with atopic dermatitis that was unresponsive to topical agents or that warranted systemic therapy (in a 2:2:2:1 ratio) to receive 200 mg or 100 mg of abrocitinib orally once daily, 300 mg of dupilumab subcutaneously every other week (after a loading dose of 600 mg), or placebo; all the patients received topical therapy. The primary end points were an Investigator's Global Assessment (IGA) response (defined as a score of 0 [clear] or 1 [almost clear] on the IGA [scores range from 0 to 4], with an improvement of ≥2 points from baseline) and an Eczema Area and Severity Index-75 (EASI-75) response (defined as ≥75% improvement from baseline in the score on the EASI [scores range from 0 to 72]) at week 12. The key secondary end points were itch response (defined as an improvement of ≥4 points in the score on the Peak Pruritus Numerical Rating Scale [scores range from 0 to 10]) at week 2 and IGA and EASI-75 responses at week 16.

RESULTS

A total of 838 patients underwent randomization; 226 patients were assigned to the 200-mg abrocitinib group, 238 to the 100-mg abrocitinib group, 243 to the dupilumab group, and 131 to the placebo group. An IGA response at week 12 was observed in 48.4% of patients in the 200-mg abrocitinib group, 36.6% in the 100-mg abrocitinib group, 36.5% in the dupilumab group, and 14.0% in the placebo group (P<0.001 for both abrocitinib doses vs. placebo); an EASI-75 response at week 12 was observed in 70.3%, 58.7%, 58.1%, and 27.1%, respectively (P<0.001 for both abrocitinib doses vs. placebo). The 200-mg dose, but not the 100-mg dose, of abrocitinib was superior to dupilumab with respect to itch response at week 2. Neither abrocitinib dose differed significantly from dupilumab with respect to most other key secondary end-point comparisons at week 16. Nausea occurred in 11.1% of the patients in the 200-mg abrocitinib group and 4.2% of those in the 100-mg abrocitinib group, and acne occurred in 6.6% and 2.9%, respectively.

CONCLUSIONS

In this trial, abrocitinib at a dose of either 200 mg or 100 mg once daily resulted in significantly greater reductions in signs and symptoms of moderate-to-severe atopic dermatitis than placebo at weeks 12 and 16. The 200-mg dose, but not the 100-mg dose, of abrocitinib was superior to dupilumab with respect to itch response at week 2. Neither abrocitinib dose differed significantly from dupilumab with respect to most other key secondary end-point comparisons at week 16. (Funded by Pfizer; JADE COMPARE ClinicalTrials.gov number, NCT03720470.).

Occupational contact dermatitis: Retrospective analysis of North American Contact Dermatitis Group Data, 2001 to 2016

BACKGROUND

Patch testing is an important diagnostic tool for suspected allergic contact dermatitis (ACD) in occupational settings.

OBJECTIVE

Provide an overview of occupational skin disease (OSD) and an analysis of occupational ACD in North American patients undergoing patch testing between 2001and 2016.

METHODS

Patients with OSD were analyzed for frequency of allergic reactions to a screening series of allergens, occupational relevance, location of skin disease, and exposure sources. Demographic, occupation, and industry information were recorded.

RESULTS

Of 38,614 patients evaluated, 4471 (11.6%) had OSD, of whom 3150 (70.5%) had ACD. The most common occupationally related allergens included rubber accelerators, preservatives, and bisphenol A epoxy resin. Hands (75.8%), arms (30.0%), and face (15.9%) were common sites of dermatitis. The occupations most affected were service workers and machine operators.

LIMITATIONS

Our cohort may not reflect the general working population.

CONCLUSION

This study identified common occupational allergens, exposure sources, and occupations/industries at risk. This information may help the clinician evaluate and manage patients with occupational contact dermatitis.

Efficacy and Safety of Baricitinib Combined With Topical Corticosteroids for Treatment of Moderate to Severe Atopic Dermatitis: A Randomized Clinical Trial

Question

What is the efficacy and safety of 4 mg and 2 mg of baricitinib in combination with background topical corticosteroid (TCS) therapy in adults with moderate to severe atopic dermatitis (AD)?

Findings

In this randomized clinical trial of 329 adults with moderate to severe AD, at week 16, a validated Investigator Global Assessment for Atopic Dermatitis score of 0 (clear) or 1 (almost clear) was achieved by 31% of patients receiving 4 mg of baricitinib with TCS therapy and 24% of patients receiving 2 mg of baricitinib with TCS therapy compared with 15% receiving placebo with TCS therapy.

Meaning

This study found a clinical benefit of Janus kinase inhibition in combination with TCS therapy, the mainstay treatment for AD.

Importance

Baricitinib, an oral selective Janus kinase 1 and 2 inhibitor, effectively reduced disease severity in moderate to severe atopic dermatitis (AD) in 2 phase 3 monotherapy studies.

Objective

To assess the efficacy and safety of 4 mg and 2 mg of baricitinib in combination with background topical corticosteroid (TCS) therapy in adults with moderate to severe AD who previously had an inadequate response to TCS therapy.

Design, Setting, and Participants

This double-blind, placebo-controlled, phase 3 randomized clinical trial, BREEZE-AD7 (Study of Baricitinib [LY3009104] in Combination With Topical Corticosteroids in Adults With Moderate to Severe Atopic Dermatitis) was conducted from November 16, 2018, to August 22, 2019, at 68 centers across 10 countries in Asia, Australia, Europe, and South America. Patients 18 years or older with moderate to severe AD and an inadequate response to TCSs were included. After completing the study, patients were followed up for up to 4 weeks or enrolled in a long-term extension study.

Interventions

Patients were randomly assigned (1:1:1) to receive 2 mg of baricitinib once daily (n = 109), 4 mg of baricitinib once daily (n = 111), or placebo (n = 109) for 16 weeks. The use of low-to-moderate potency TCSs was allowed.

Main Outcomes and Measures

The primary end point was the proportion of patients achieving a validated Investigator Global Assessment for Atopic Dermatitis (vIGA-AD) score of 0 (clear) or 1 (almost clear), with a 2-point or greater improvement from baseline at week 16.

Results

Among 329 patients (mean [SD] age, 33.8 [12.4] years; 216 [66%] male), at week 16, a vIGA-AD score of 0 (clear) or 1 (almost clear) was achieved by 34 patients (31%) receiving 4 mg of baricitinib and 26 (24%) receiving 2 mg of baricitinib compared with 16 (15%) receiving placebo (odds ratio vs placebo, 2.8 [95% CI, 1.4-5.6]; P = .004 for the 4-mg group; 1.9 [95% CI, 0.9-3.9]; P = .08 for the 2-mg group). Treatment-emergent adverse events were reported in 64 of 111 patients (58%) in the 4-mg group, 61 of 109 patients (56%) in the 2-mg group, and 41 of 108 patients (38%) in the placebo group. Serious adverse events were reported in 4 patients (4%) in the 4-mg group, 2 (2%) in the 2-mg group, and 4 (4%) in the placebo group. The most common adverse events were nasopharyngitis, upper respiratory tract infections, and folliculitis.

Conclusions and Relevance

A dose of 4 mg of baricitinib in combination with background TCS therapy significantly improved the signs and symptoms of moderate to severe AD, with a safety profile consistent with previous studies of baricitinib in AD.

Trial Registration

ClinicalTrials.gov Identifier: NCT03733301

Prevalence and trend of allergen sensitization in patients with nummular (discoid) eczema referred for patch testing: North American Contact Dermatitis Group data, 2001-2016

BACKGROUND

Few studies have examined the relationship between nummular (discoid) eczema (NE) and allergic contact dermatitis (ACD).

OBJECTIVE

To examine trends, associations, and clinical relevance of ACD in patients with NE who were referred for patch testing.

METHODS

Retrospective analysis of 38 723 patients from the North American Contact Dermatitis Group.

RESULTS

Overall, 748 patients (1.9%) were diagnosed with NE; 23.9% had a concomitant diagnosis of ACD. The prevalence of NE fluctuated over time between 2001 and 2016, with no overall change in prevalence in diagnosed NE. In multivariable logistic regression models, NE increased steadily with age and was associated with male sex and Asian and other race/ethnicity, and inversely associated with a history of atopic dermatitis (AD) and hay fever. Patients with NE had lower proportions of one or more positive allergic reactions and lower odds of a positive reaction in multiple individual allergens. The most commonly relevant allergens in patients with NE were formaldehyde 2.0% aq., methylisothiazolinone, quaternium 15, fragrance mix I, and propylene glycol.

CONCLUSION

NE is a heterogeneous disorder with distinct subsets of lesional distributions and a profile of relevant allergens, especially formaldehyde and formaldehyde releasers. Nearly one in four patients with NE had ACD, supporting the role of patch testing in patients with NE.

A real-world study of the longitudinal course of itch severity and frequency in adults with atopic dermatitis

Itch is a complex symptom that is both common and burdensome in atopic dermatitis (AD). Yet, little is known about the longitudinal course of itch in AD. A prospective, dermatology practice-based study was performed of adults with AD (n = 463). Patients were assessed at baseline and approximately 6, 12, 18 and 24 months. Itch was assessed using Numeric Rating Scale (NRS) average and worst-itch scores, and frequency of itch in the past week. Repeated-measures regression models were constructed to examine itch over time. Overall, 31.5% and 22.5% had moderate (4-6) or severe (7-10) NRS average-itch scores; 27.4% and 36.4% had moderate (4-6) or severe (7-10) NRS worst-itch scores; 12.7% and 62.0% had itch from eczema 3-4 and ≥ 5 days in the past week; 27.4% and 45.1% reported sometimes and often/almost always having itch, respectively. Among patients with baseline moderate (4-6) or severe (7-10) NRS average-itch scores, 21.2% and 16.3% continued to have moderate or severe scores at ≥ 1 follow-up visits. In repeated-measures regression models, persistent NRS average-itch scores were associated with baseline NRS average-itch [adjusted β (95% CI): 0.75 (0.68, 0.82)] and food allergy [- 0.45 (- 0.84, - 0.07)]. Persistent NRS worst-itch was associated with baseline worst-itch NRS [0.73 (0.66, 0.80)] and Medicaid insurance [1.06 (0.17, 1.94)]. AD patients had a heterogeneous longitudinal course with fluctuating and complex overlapping patterns of average- and worst-itch intensity, and frequency.

Rhinitis prevalence and association with atopic dermatitis: A systematic review and meta-analysis

BACKGROUND

Atopic dermatitis (AD) and rhinitis are common atopic diseases that may co-occur owing to an overlap in pathophysiology. Although most cases of both diseases are mild and managed with topical anti-inflammatory medicaments, the advent of new systemic and biologic treatments targeting type 2 inflammation in both diseases warrants further insight in the exact overlap of AD and rhinitis.

OBJECTIVE

To determine the association between AD and rhinitis.

METHODS

A systematic review and meta-analysis of the databases PubMed, Embase, and CNKI were performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled prevalence and pooled odds ratios (ORs) with 95% confidence intervals (95% CIs) were calculated.

RESULTS

The search resulted in 10,422 citations, and 341 and 302 articles were included in the qualitative and quantitative analyses, respectively. The pooled prevalence of rhinitis was 40.5% (95% CI 39.0-42.0) in patients with AD and 18.0% (95% CI 16.7-19.2) in the reference individuals without AD. The pooled prevalence of having both rhinitis and asthma was 14.2% (95% CI 13.0-15.5) in patients with AD. There was an association between AD and rhinitis (OR 3.00, 95% CI 2.83-3.18), allergic rhinitis (OR 3.25, 95% CI 2.26-4.66), and nonallergic rhinitis (OR 1.99, 95% CI 1.39-2.86), respectively.

CONCLUSION

Rhinitis, both allergic and nonallergic forms, is very common in patients with AD. Future investigations should clarify how medications targeting both diseases should be indicated in these patients.

Neutralizing IFNL3 Autoantibodies in Severe COVID-19 Identified Using Molecular Indexing of Proteins by Self-Assembly

Unbiased antibody profiling can identify the targets of an immune reaction. A number of likely pathogenic autoreactive antibodies have been associated with life-threatening SARS-CoV-2 infection; yet, many additional autoantibodies likely remain unknown. Here we present Molecular Indexing of Proteins by Self Assembly (MIPSA), a technique that produces ORFeome-scale libraries of proteins covalently coupled to uniquely identifying DNA barcodes for analysis by sequencing. We used MIPSA to profile circulating autoantibodies from 55 patients with severe COVID-19 against 11,076 DNA-barcoded proteins of the human ORFeome library. MIPSA identified previously known autoreactivities, and also detected undescribed neutralizing interferon lambda 3 (IFN-λ3) autoantibodies. At-risk individuals with anti- IFN-λ3 antibodies may benefit from interferon supplementation therapies, such as those currently undergoing clinical evaluation.