Atopic dermatitis

Incidence of Cardiovascular Disease and Venous Thromboembolism in Patients With Atopic Dermatitis

BACKGROUND

Atopic dermatitis (AD) may increase risk for atherothrombotic and cardiovascular (CV) disease.

OBJECTIVE

Determine CV disease and venous thromboembolism risk among patients with AD.

METHODS

Cohort study using electronic health data from U.K. general practices in 1994 to 2015. Children (<18 y) and adults (≥18 y) with AD were matched to patients without AD on age, same practice, and encounter date. Treatments and specialist referrals served as proxies of AD severity. Outcomes were incident myocardial infarction, cerebrovascular accident (CVA), diabetes, hypertension, dyslipidemia, deep vein thrombosis (DVT), and pulmonary embolism. Cox regression analysis was used to compare outcomes in AD versus non-AD patients.

RESULTS

Comparing 409,341 children with AD (93.2% mild, 5.5% moderate, and 1.3% severe) to 1,809,029 unaffected children, AD was associated with higher risk of DVT (hazard ratio [HR] 1.23; 95% confidence interval [95% CI] 1.02-1.48) and severe AD was associated with higher risk of CVA (HR 2.43; 95% CI 1.13-5.22) and diabetes (HR 1.46; 95% CI 1.06-2.01). Comparing 625,083 adults with AD (65.7% mild, 31.4% moderate, and 2.9% severe) to 2,678,888 unaffected adults, AD, especially when severe, was associated with higher risk of DVT (HR 1.14; 95% CI 1.11-1.18; and HR 1.64; 95% CI 1.49-1.82, respectively) and small but increased risks of CVA, diabetes, and dyslipidemia. Adults with severe AD had higher risk of myocardial infarction (HR 1.27; 95% CI 1.15-1.39), CVA (HR 1.21; 95% CI 1.13-1.30), diabetes (HR 1.15; 95% CI 1.09-1.22), dyslipidemia (HR 1.11; 95% CI 1.06-1.17), and pulmonary embolism (HR 1.39; 95% CI 1.21-1.60) compared with adults without AD.

CONCLUSIONS

Atopic dermatitis, particularly when severe, is associated with small but increased risks of CV risk factors and events and significantly increased risk of venous thromboembolism.

Isosorbide Fatty Acid Diesters Have Synergistic Anti-Inflammatory Effects in Cytokine-Induced Tissue Culture Models of Atopic Dermatitis

Atopic dermatitis (AD) is a chronic disease in which epidermal barrier disruption triggers Th2-mediated eruption of eczematous lesions. Topical emollients are a cornerstone of chronic management. This study evaluated efficacy of two plant-derived oil derivatives, isosorbide di-(linoleate/oleate) (IDL) and isosorbide dicaprylate (IDC), using AD-like tissue culture models. Treatment of reconstituted human epidermis with cytokine cocktail (IL-4 + IL-13 + TNF-α + IL-31) compromised the epidermal barrier, but this was prevented by co-treatment with IDL and IDC. Cytokine stimulation also dysregulated expression of keratinocyte (KC) differentiation genes whereas treatment with IDC or IDL + IDC up-regulated genes associated with early (but not late) KC differentiation. Although neither IDL nor IDC inhibited Th2 cytokine responses, both compounds repressed TNF-α-induced genes and IDL + IDC led to synergistic down-regulation of inflammatory (IL1B, ITGA5) and neurogenic pruritus (TRPA1) mediators. Treatment of cytokine-stimulated skin explants with IDC decreased lactate dehydrogenase (LDH) secretion by more than 50% (more than observed with cyclosporine) and in vitro LDH activity was inhibited by IDL and IDC. These results demonstrate anti-inflammatory mechanisms of isosorbide fatty acid diesters in AD-like skin models. Our findings highlight the multifunctional potential of plant oil derivatives as topical ingredients and support studies of IDL and IDC as therapeutic candidates.

The Combination of Dupilumab with Other Monoclonal Antibodies

INTRODUCTION

Dupilumab is an interleukin-4 (IL-4) receptor alpha antagonist indicated for the treatment of moderate-to-severe atopic dermatitis (AD), which could be associated with atopic and non-atopic comorbidities for which concomitant administration of targeted pharmacotherapy including monoclonal antibodies could be required. However, the safety of combining dupilumab with other monoclonal antibodies for different therapeutic indication may be debated.

METHODS

We conducted an extensive search in MEDLINE via PubMed for original articles published from January 1, 2017 to October 22, 2022, reporting clinical cases in which dupilumab has been associated with other monoclonal antibodies.

RESULTS

Four small case series were identified reporting data on a total of 16 patients. To them, we have added other patients (n = 8) derived from our clinical practice, achieving a total of 24 cases followed for a period of 2-22 months. Patients were receiving dupilumab mainly because of AD (except one patient for bullous pemphigoid and one for asthma) and other monoclonal antibodies for psoriasis treated with guselkumab (n = 7) and secukinumab (n = 1), asthma with omalizumab or benralizumab (n = 3), Crohn's disease with adalimumab (n = 3), chronic spontaneous urticaria with omalizumab (n = 3), primary familial hypercholesterolemia with evolocumab (n = 2), hidradenitis suppurativa with adalimumab (n = 1), psoriatic arthritis with secukinumab (n = 1), rheumatoid arthritis with abatacept (n = 1), ankylosing spondylitis with secukinumab (n = 1) and colorectal carcinoma with cetuximab (n = 1). No adverse events related to the combination of the two monoclonal antibodies were reported except for a mild injection site reaction (n = 1) and arthralgia, which resolved spontaneously within a few weeks (n = 1).

CONCLUSIONS

Because the evidence is modest, the question remains open as to whether dupilumab can be safely combined with other monoclonal antibodies. Dupilumab does not exert immunosuppressive effects and does not impair the activity of cytochrome P450 isozymes.

Dermatologic Disease-Directed Targeted Therapy (D3T2): The Application of Biomarker-Based Precision Medicine for the Personalized Treatment of Skin Conditions-Precision Dermatology

Precision dermatology uses individualized dermatologic disease-directed targeted therapy (D³T²) for the management of dermatoses and for the evaluation and therapy of cutaneous malignancies. Personalized/precision strategies are based on biomarkers that are most frequently derived from tissue transcriptomic expression or genomic sequencing or from circulating cytokines. For instance, the pathologic diagnosis of a pigmented lesion and determining the prognosis of a malignant melanocytic neoplasm can be enhanced by genomic/transcriptomic analysis. In addition to biopsy, innovative techniques have been developed for obtaining transcriptomes in skin conditions; as an example, patches can be applied to a psoriasis plaque for a few minutes to capture the epidermis/upper dermis transcriptome. Atopic dermatitis and prurigo nodularis may also be candidate conditions for precision dermatology. Precision dermatology has a role in managing melanoma and nonmelanoma skin cancers and rare cutaneous tumors-such as perivascular epithelioid cell tumor (PEComa)-that can originate in or metastasize to the skin. For instance, advanced/metastatic basal cell carcinomas can be treated with Hedgehog inhibitors (vismodegib and sonidegib) targeting the smoothened (SMO) or patched 1 (PTCH1) gene alterations that are a hallmark of these cancers and activate the Hedgehog pathway. Advanced/metastatic basal and cutaneous squamous cell cancers often have a high tumor mutational burden (which predicts immunotherapy response); immune checkpoint blockade with cemiplimab, a programmed cell death protein 1 (PD1) inhibitor, is now approved for these malignancies. Gene expression profiling of primary cutaneous squamous cell carcinoma can identify those individuals at high risk for subsequent metastases. In the realm of rare neoplasms, PEComas-which can originate in the skin, albeit uncommonly-have tuberous sclerosis complex 1 (TSC1)/tuberous sclerosis complex 2 (TSC2) gene alterations, which activate mammalian target of rapamycin (mTOR) signaling, and can be suppressed by nab-sirolimus, now approved for this condition. In summary, precision dermatologic techniques/strategies are an important emerging approach for evaluation and management of skin disorders and cutaneous neoplasms, and may serve as a paradigm for the application of precision medicine beyond dermatology.