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Hagino T, Yoshida M, Hamada R, Saeki H, Fujimoto E, Kanda N. Early itch relief with upadacitinib predicts later skin clearance in Atopic dermatitis. J DERMATOL TREAT 2024; 35:2291317. [PMID: 38073560 DOI: 10.1080/09546634.2023.2291317] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND Though Janus kinase inhibitors such as upadacitinib rapidly relieve itch in atopic dermatitis (AD) patients, how early itch relief impacts later skin clearance is not examined. OBJECTIVES This study aims to determine if early itch relief by upadacitinib could predict complete skin clearance in later phases. METHODS This retrospective study involved 105 patients with moderate-to-severe AD treated with upadacitinib 15 mg/day. Eczema area and severity index (EASI), atopic dermatitis control tool, and achievement rate of EASI 100 were evaluated at weeks 4, 12, and 24. The threshold of early peak pruritus-numerical rating scale (PP-NRS) predicting later skin clearance was assessed by area under the receiver-operating characteristic curve, and predictors for EASI 100 achievement were determined by logistic regression analysis. RESULTS The rate of achieving EASI 100 at week 24 was extremely higher in patients who achieved week 2 PP-NRS ≤ 1 (42.9%) than in non-achievers (1.4%). The logistic regression analysis showed that the achievement of week 2 PP-NRS ≤ 1 and low body mass index were associated with achievement of EASI 100 at weeks 12 and 24. CONCLUSIONS The achievement of week 2 PP-NRS ≤ 1 may predict later skin clearance in upadacitinib treatment.
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Affiliation(s)
- Teppei Hagino
- Department of Dermatology, Nippon Medical School Chiba Hokusoh Hospital, Inzai, Japan
| | - Mai Yoshida
- Department of Dermatology, Nippon Medical School, Tokyo, Japan
| | - Risa Hamada
- Department of Dermatology, Nippon Medical School, Tokyo, Japan
| | - Hidehisa Saeki
- Department of Dermatology, Nippon Medical School, Tokyo, Japan
| | - Eita Fujimoto
- Department of Dermatology, Fujimoto Dermatology Clinic, Funabashi, Japan
| | - Naoko Kanda
- Department of Dermatology, Nippon Medical School Chiba Hokusoh Hospital, Inzai, Japan
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Müller S, Maintz L, Bieber T. Treatment of atopic dermatitis: Recently approved drugs and advanced clinical development programs. Allergy 2024; 79:1501-1515. [PMID: 38186219 DOI: 10.1111/all.16009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 11/28/2023] [Accepted: 12/19/2023] [Indexed: 01/09/2024]
Abstract
Atopic dermatitis (AD) represents the most common skin disease characterized by heterogeneous endophenotypes and a high disease burden. In Europe, six new systemic therapies for AD have been approved: the biologics dupilumab (anti-interleukin-4 receptor (IL-4R) α in 2017), tralokinumab (anti-IL-13 in 2021), lebrikizumab (anti-IL-13 in 2023), and the oral janus kinase (JAK) inhibitors (JAKi) targeting JAK1/2 (baricitinib in 2020 in the EU) or JAK1 (upadacitinib in 2021 and abrocitinib in 2022). Herein, we give an update on new approvals, long-term safety, and efficacy. Upadacitinib and abrocitinib have the highest short-term efficacy among the approved systemic therapies. In responders, dupilumab and tralokinumab catch up regarding long-term efficacy and incremental clinical benefit within continuous use. Recently, the European Medicines Agency has released recommendations for the use of JAKi in patients at risk (cardiovascular and thromboembolic diseases, malignancies, (former) smoking, and age ≥65 years). Furthermore, we give an overview on emerging therapies currently in Phase III trials. Among the topical therapies, tapinarof (aryl hydrocarbon receptor), ruxolitinib (JAK1/2i), delgocitinib (pan-JAKi), asivatrep (anti-transient receptor potential vanilloid), and phosphodiesterase-4-inhibitors (roflumilast, difamilast) are discussed. Among systemic therapies, current data on cord-blood-derived mesenchymal stem cells, CM310 (anti IL-4Rα), nemolizumab (anti-IL-31RA), anti-OX40/OX40L-antibodies, neurokinin-receptor-1-antagonists, and difelikefalin (κ-opioid-R) are reported.
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Affiliation(s)
- Svenja Müller
- Department of Dermatology and Allergy, University Hospital Bonn, Bonn, Germany
- Christine Kühne Center for Allergy Research and Education Davos (CK-CARE), Davos, Switzerland
| | - Laura Maintz
- Department of Dermatology and Allergy, University Hospital Bonn, Bonn, Germany
- Christine Kühne Center for Allergy Research and Education Davos (CK-CARE), Davos, Switzerland
| | - Thomas Bieber
- Christine Kühne Center for Allergy Research and Education Davos (CK-CARE), Davos, Switzerland
- Davos BioSciences, Davos, Switzerland
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Butler DC, Berger T, Elmariah S, Kim B, Chisolm S, Kwatra SG, Mollanazar N, Yosipovitch G. Chronic Pruritus: A Review. JAMA 2024:2819296. [PMID: 38809527 DOI: 10.1001/jama.2024.4899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
Importance Chronic pruritus, defined as itch experienced for 6 weeks or longer, affects approximately 22% of people in their lifetime. Approximately 1% of physician visits are for the chief concern of chronic pruritus. Chronic pruritus is associated with adverse outcomes, including impaired sleep and reduced quality of life. Observations Chronic pruritus can be categorized by etiology into inflammatory, neuropathic, or a combination of inflammatory and neuropathic pruritus. Chronic pruritus is due to inflammation in approximately 60% of patients and may be caused by eczema, psoriasis, or seborrheic dermatitis. Chronic pruritus is due to a neuropathic or mixed etiology in approximately 25% of patients. Neuropathic causes of chronic pruritus include postherpetic neuralgia and notalgia paresthetica and are typically due to localized or generalized nerve dysregulation. Approximately 15% of people with chronic pruritus have other causes including systemic diseases with secondary itch, such as uremic pruritus and cholestatic pruritus, medication-induced pruritus such as pruritus due to immunotherapy, and infectious etiologies such as tinea corporis and scabies. When few primary changes are present, a thorough history, review of symptoms, and laboratory evaluation should be performed, particularly for people with chronic pruritus lasting less than 1 year. Clinicians should consider the following tests: complete blood cell count, complete metabolic panel, and thyroid function testing to evaluate for hematologic malignancy, liver disease, kidney disease, or thyroid disease. First-line treatment for inflammatory chronic pruritus includes topical anti-inflammatory therapies such as hydrocortisone (2.5%), triamcinolone (0.1%), or tacrolimus ointment. Approximately 10% of patients do not respond to topical therapies. In these patients, referral to dermatology and systemic oral or injectable treatments such as dupilumab or methotrexate may be considered. When no underlying systemic disease associated with pruritus is identified, patients are likely to have neuropathic chronic pruritus or mixed etiology such as chronic pruritus of unknown origin. In these patients, neuropathic topical treatments such as menthol, pramoxine, or lidocaine can be used either alone or in combination with immunomodulatory agents such as topical steroids. Other effective therapies for neuropathic pruritus include gabapentin, antidepressants such as sertraline or doxepin, or opioid receptor agonist/antagonists such as naltrexone or butorphanol. Conclusions and Relevance Chronic pruritus can adversely affect quality of life and can be categorized into inflammatory, neuropathic, or a combined etiology. First-line therapies are topical steroids for inflammatory causes, such as hydrocortisone (2.5%) or triamcinolone (0.1%); topical neuropathic agents for neuropathic causes, such as menthol or pramoxine; and combinations of these therapies for mixed etiologies of chronic pruritus.
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Affiliation(s)
| | - Timothy Berger
- Department of Dermatology, University of California, San Francisco
| | - Sarina Elmariah
- Department of Dermatology, University of California, San Francisco
| | - Brian Kim
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sarah Chisolm
- Department of Dermatology, Emory University, Grady Memorial Hospital, Atlanta, Georgia
- Regional Telehealth Service, Veterans Affairs Veterans Integrated Service Network 7 Southeast Network, Duluth, Georgia
| | - Shawn G Kwatra
- Department of Dermatology, Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Nicholas Mollanazar
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Gil Yosipovitch
- Miami Itch Center, Phillip Frost Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida
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Hagino T, Hamada R, Yoshida M, Saeki H, Fujimoto E, Kanda N. Sustained Effectiveness of Upadacitinib in Moderate-to-Severe Atopic Dermatitis: A 48-Week Real-World Study. Pharmaceuticals (Basel) 2024; 17:519. [PMID: 38675479 PMCID: PMC11054057 DOI: 10.3390/ph17040519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/12/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Clinical trials and real-world studies have shown the effectiveness of upadacitinib for treating rash and pruritus in patients with atopic dermatitis (AD). This study aimed to determine whether the early reduction in rash or pruritus at week 12 of upadacitinib treatment could be maintained at later treatment stages. This retrospective study involved 227 and 73 patients with moderate-to-severe AD treated with 15 and 30 mg upadacitinib daily, respectively. The eczema area and severity index (EASI) scores, peak pruritus numerical rating scale (PP-NRS), and investigator's global assessment (IGA) were analyzed. At week 12, patients were divided into achievers and non-achievers of EASI 75, 90, 100, absolute EASI ≤ 2, IGA0/1, PP-NRS4, or absolute PP-NRS ≤ 1. Achievement rates for each endpoint were assessed at later time points (weeks 24, 36, and 48) in both groups. Week 12 achievers largely maintained their endpoint achievements until week 48, regardless of dosage (15 mg or 30 mg). Week 12 non-achievers saw an increasing achievement rate of EASI 75 until week 48. The initial reduction in rash and pruritus at week 12 persisted until week 48 with upadacitinib treatment, suggesting potential benefits for patients requiring prolonged treatment despite not achieving EASI 75 at week 12.
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Affiliation(s)
- Teppei Hagino
- Department of Dermatology, Nippon Medical School Chiba Hokusoh Hospital, Inzai 270-1694, Japan
| | - Risa Hamada
- Department of Dermatology, Nippon Medical School, Tokyo 113-8602, Japan; (R.H.); (M.Y.); (H.S.)
| | - Mai Yoshida
- Department of Dermatology, Nippon Medical School, Tokyo 113-8602, Japan; (R.H.); (M.Y.); (H.S.)
| | - Hidehisa Saeki
- Department of Dermatology, Nippon Medical School, Tokyo 113-8602, Japan; (R.H.); (M.Y.); (H.S.)
| | - Eita Fujimoto
- Fujimoto Dermatology Clinic, Funabashi 274-0063, Japan;
| | - Naoko Kanda
- Department of Dermatology, Nippon Medical School Chiba Hokusoh Hospital, Inzai 270-1694, Japan
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Ständer S, Luger T, Kim B, Lerner E, Metz M, Adiri R, Canosa JM, Cha A, Yosipovitch G. Cutaneous Components Leading to Pruritus, Pain, and Neurosensitivity in Atopic Dermatitis: A Narrative Review. Dermatol Ther (Heidelb) 2024; 14:45-57. [PMID: 38182845 PMCID: PMC10828226 DOI: 10.1007/s13555-023-01081-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/05/2023] [Indexed: 01/07/2024] Open
Abstract
Atopic dermatitis (AD) is a chronic, relapsing immunoinflammatory skin condition characterized by sensations such as pruritis, pain, and neuronal hypersensitivity. The mechanisms underlying these sensations are multifactorial and involve complex crosstalk among several cutaneous components. This review explores the role these components play in the pathophysiology of atopic dermatitis. In the skin intercellular spaces, sensory nerves interact with keratinocytes and immune cells via myriad mediators and receptors. These interactions generate action potentials that transmit pruritis and pain signals from the peripheral nervous system to the brain. Keratinocytes, the most abundant cell type in the epidermis, are key effector cells, triggering crosstalk with immune cells and sensory neurons to elicit pruritis, pain, and inflammation. Filaggrin expression by keratinocytes is reduced in atopic dermatitis, causing a weakened skin barrier and elevated skin pH. Fibroblasts are the main cell type in the dermis and, in atopic dermatitis, appear to reduce keratinocyte differentiation, further weakening the skin barrier. Fibroblasts and mast cells promote inflammation while dermal dendritic cells appear to attenuate inflammation. Inflammatory cytokines and chemokines play a major role in AD pathogenesis. Type 2 immune responses typically generate pruritis, and the type 1 and type 3 responses generate pain. Type 2 responses and increased skin pH contribute to barrier dysfunction and promote dysbiosis of the skin microbiome, causing the proliferation of Staphyloccocus aureus. In conclusion, understanding the dynamic interactions between cutaneous components in AD could drive the development of therapies to improve the quality of life for patients with AD.
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Affiliation(s)
- Sonja Ständer
- Center for Chronic Pruritus, Münster University Hospital, Münster, Germany.
| | | | - Brian Kim
- Center for the Study of Itch and Sensory Disorders, Washington University School of Medicine, St. Louis, MO, USA
| | - Ethan Lerner
- Massachusetts General Hospital, Charlestown, MA, USA
| | - Martin Metz
- Institute of Allergology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Roni Adiri
- Pfizer Pharmaceuticals Israel Ltd, Herzliya Pituach, Israel
| | | | - Amy Cha
- Pfizer Inc, New York, NY, USA
| | - Gil Yosipovitch
- Pfizer Inc, New York, NY, USA
- Miami Itch Center, Miller School of Medicine, University of Miami, Miami, FL, USA
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Gatmaitan JG, Lee JH. Challenges and Future Trends in Atopic Dermatitis. Int J Mol Sci 2023; 24:11380. [PMID: 37511138 PMCID: PMC10380015 DOI: 10.3390/ijms241411380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
Atopic dermatitis represents a complex and multidimensional interaction that represents potential fields of preventive and therapeutic management. In addition to the treatment armamentarium available for atopic dermatitis, novel drugs targeting significant molecular pathways in atopic dermatitis biologics and small molecules are also being developed given the condition's complex pathophysiology. While most of the patients are expecting better efficacy and long-term control, the response to these drugs would still depend on numerous factors such as complex genotype, diverse environmental triggers and microbiome-derived signals, and, most importantly, dynamic immune responses. This review article highlights the challenges and the recently developed pharmacological agents in atopic dermatitis based on the molecular pathogenesis of this condition, creating a specific therapeutic approach toward a more personalized medicine.
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Affiliation(s)
- Julius Garcia Gatmaitan
- Department of Dermatology, Seoul St. Mary's Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
- Gatmaitan Medical and Skin Center, Baliuag 3006, Bulacan, Philippines
- Skines Aesthetic and Laser Center, Quezon City 1104, Metro Manila, Philippines
| | - Ji Hyun Lee
- Department of Dermatology, Seoul St. Mary's Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
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