Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations

Relationship between patients with atopic dermatitis and the incidence of stroke: A systematic review with meta-analysis

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin condition associated with a variety of comorbidities, including cardiovascular and mental health issues. Recent studies have suggested a potential link between AD and an increased risk of stroke, particularly ischemic stroke. However, the association remains unclear, warranting further investigation.

METHODS

This study conducted a systematic review and meta-analysis to explore the relationship between AD and stroke risk. PRISMA guidelines were followed, and a comprehensive search was carried out in multiple databases, including PubMed/MEDLINE, Biblioteca Virtual em Saúde (BVS), Embase, Cochrane, Web of Science, and Scopus. Observational studies reporting on the incidence of stroke in patients with AD were included. A meta-analysis was performed to assess the odds ratio (OR), hazard ratio (HR), and relative risk (RR) for stroke incidence. Heterogeneity and publication bias were evaluated using Cochran's Q test, I² statistic, and funnel plots.

RESULTS

A total of 11 studies were included, with the majority being cohort studies. The meta-analysis revealed a significant association between AD and an increased risk of ischemic stroke, with an HR of 1.19 (95 % CI 1.13-1.26, p < 0.00001) and moderate heterogeneity (I² = 57 %). However, no statistically significant increase in hemorrhagic stroke risk was observed (HR = 1.13, 95 % CI 1-1.29, p = 0.06). Patients with severe AD exhibited a higher stroke risk compared to those with mild AD, with ORs of 1.29 (95 % CI 1.07-1.56) and 1.06 (95 % CI 0.88-1.27), respectively.

CONCLUSIONS

This meta-analysis confirms a significant association between AD and ischemic stroke, particularly in patients with severe AD. Further research is needed to understand this relationship better and explore potential preventative strategies, including the role of AD treatment in reducing stroke risk.

Patient-reported outcome assessment of adults and adolescents with atopic dermatitis: a cross-sectional qualitative interview study

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease that impacts patient health and quality of life. Understanding patient experience of relevant symptoms and impacts of AD is crucial for improving outcomes. This study aimed to characterise adult (≥ 18 years) and adolescent (12-17 years) patients' experiences of AD and assess the content validity of selected patient-reported outcomes (PROs).

METHODOLOGY

This non-interventional, cross-sectional, qualitative study recruited US-based, English-speaking adults and adolescents with moderate-to-severe AD, either naïve or experienced with biologics. A 90-minute interview was conducted via teleconferencing software, consisting of concept elicitation (CE) of AD experiences and cognitive debriefing (CD), where participants provided feedback on PROs assessing skin pain, sleep disturbance, and fatigue. Interview data were coded and analysed using qualitative data software to determine the AD experience and content validity of selected PROs. A conceptual disease model was developed from the CE portion of the interview. Results from the CD portion were mapped to this model to evaluate the conceptual coverage of the PROs.

RESULTS

In total, 16 adults (mean age 48 years, 56% White, 63% female, 50% biologic naïve) and 20 adolescents (mean age 16 years, 60% White, 75% female, 50% biologic naïve) were included in the analysis. During CE, 13 symptoms and impacts in 7 domains were identified. The most reported symptom was itchiness (adults, 100%; adolescents, 100%) and the most reported impact was emotional functioning (adults, 94%; adolescents 95%). Participants also commonly reported experiencing pain/discomfort (adults, 69%; adolescents, 80%) and sleep disturbance (adults, 88%; adolescents, 75%). Fatigue was reported by 94% of adults across CE and CD segments. When probed during CE, 65% of adolescents identified fatigue as an impact of AD. During CD, 70-100% of participants confirmed the selected PROs were comprehensible and relevant.

CONCLUSIONS

This study provides evidence that the experience of AD is similar between adults and adolescents as well as biologic-naïve and biologic-experienced participants. Relevant disease concepts in patients with AD were identified, and content validity was established for the selected PROs, supporting their use in future clinical studies.

Medication-related perceptions of children and adolescents with severe asthma and moderate-to-severe atopic dermatitis: a non-interventional exploratory study

BACKGROUND

Severe asthma and moderate-to-severe atopic dermatitis can significantly impact the lives of children and adolescents. However, real-world data on pediatric patients' perceptions of their medication are limited.

METHODS

This non-interventional cross-sectional study at a university hospital explored patients' perceptions. We included patients aged between 6 and 17 with severe asthma and/or moderate-to-severe atopic dermatitis. For patients treated with dupilumab, a minimum dupilumab treatment duration of 16 weeks was required. We conducted one structured interview per patient, based on a questionnaire consisting of open questions and ratings on 6-point Likert scales (response scale range: "0: not at all" to "5: very strongly").

RESULTS

The study included 57 participants (severe asthma: n = 31; moderate-to-severe atopic dermatitis: n = 21; both: n = 5) who reported a "rather moderate" burden of asthma (median: 2; Q25/Q75: 0.3/2.8) or atopic dermatitis (3; 1.5/3.5). They experienced their current medications as "rather helpful" (asthma: 4; 3/5; atopic dermatitis: 4; 3/5). Twelve of the participants (21%) reported refusing to take their medication because of reluctance, but all resumed treatment. All participants receiving dupilumab therapy (n = 16) reported an improvement in their disease within a maximum of 2.5 months after starting treatment. The median fear of injection decreased from 3 (0/5) before the first injection to 0.5 (0/1) at the time of the survey.

CONCLUSIONS

In this real-world, interview-based study, we found that pediatric patients perceived treatment as highly beneficial for asthma and atopic dermatitis. Furthermore, pediatric patients seemed to respond well to dupilumab therapy in terms of both disease improvement and less fear of injection.

TRIAL REGISTRATION

DRKSID DRKS00028092.

Cure for the itch: current clinical standards and therapies in allergic eczema

Allergic Eczema (AE) is a chronic, relapsing skin condition that significantly affects the quality of life of the AE patients and their caretakers. Decades of scientific and clinical research has helped understand the highly complex underpinnings of AE presentation wherein a multitude of variables, including the conspicuous variables such as environmental allergens, immunological triggers, genetic predisposition of individuals, to more nuanced socio-economic status, play an important part. Given the complexity of the disease, it is imperative to develop biomarkers enabling early and reliable clinical identifications and help in the active management of the disease, thereby minimizing the impact and burden of the disease on the patients. In this mini review, we provide a brief overview of AE, affected demographics, variables that trigger its onset, and summarize the discovery of various clinical biomarkers such as total and specific serum IgE levels, Th2 cytokine levels, filaggrin (FLG) mutations, periostin levels in skin, etc. that have been developed over the years to further improve the state of clinical monitoring of AE presentation and progression. Lastly, we also provide an overview of the clinical interventions and therapies, such as topical agents, phototherapy, and biologics, that are available to the patients to manage AE-related complications. While we have vastly improved the standard of care and diagnosis for the AE patients, there are still many unmet needs such as developing non-invasive, effective, and reliable clinical predictors and biomarkers which can usher better personalized treatments and provide a better quality of life to affected demographics.

Risk of Developing Pediatric Uveitis Among Patients With Early-Onset Atopic Dermatitis

Importance

The relationship between atopic dermatitis (AD) and pediatric uveitis may be underexplored, warranting large-scale, multicenter studies.

Objective

To evaluate the risk of pediatric uveitis among children with early-onset AD compared with a matched control population.

Design, Setting, and Participants

This cohort study used aggregated electronic health records of US patients with early-onset AD and matched controls from January 1, 2004, through December 14, 2024, sourced from health care organizations in the collaborative research network TriNetX. Patients with early-onset AD and matched controls without AD were included in the analysis; those with uveitis prior to AD diagnosis were excluded. Propensity score matching was applied to balance baseline characteristics. The analyses were conducted on December 14, 2024.

Exposure

International Classification of Diseases, 10th Revision (ICD-10) diagnosis code for AD.

Main Outcomes and Measures

The primary outcome was the hazard ratio (HR) for developing pediatric uveitis in the AD cohort compared with the matched controls. Cox proportional hazards models were applied to assess the risk.

Results

A total of 114 889 patients were identified in the AD cohort (mean [SD] follow-up, 6.0 [3.3] years; mean [SD] age, 0.5 [0.7] years; 64 817 male [56.4%]) and the control cohort (mean [SD] follow-up, 6.6 [3.7] years; mean [SD] age, 0.6 [0.8] years; 65 377 male [56.9%]) after matching. The AD cohort demonstrated a higher risk of developing pediatric uveitis compared with controls (94 [0.08%] vs 58 [0.05%]; HR, 1.92 [95% CI, 1.38-2.66]). Sensitivity analyses among patients without dupilumab use (89 of 113 284 [0.08%] vs 59 of 113 284 [0.05%]; HR, 1.77 [95% CI, 1.27-2.46]) and those without autoimmune conditions (80 of 114 425 [0.07%] vs 61 of 114 425 [0.05%]; HR, 1.52 [95% CI, 1.09-2.12]) similarly indicated an increased risk in the AD cohort. Additionally, patients with severe AD had a higher risk of developing pediatric uveitis compared with those with nonsevere AD (12 of 3004 [0.40%] vs 97 of 126 482 [0.08%]; HR, 3.64 [95% CI, 2.00-6.66]).

Conclusions and Relevance

This cohort study of children with early-onset AD found an elevated risk of pediatric uveitis compared with matched controls, independent of autoimmune conditions or dupilumab use. These findings support the potential need to consider ophthalmologic monitoring in children with early-onset AD to try to detect and subsequently manage uveitis if it develops.

Update on atopic dermatitis

Atopic dermatitis is the most common chronic inflammatory skin condition. This review highlights most recent advances in understanding and treating this debilitating disease. We summarize new insights regarding molecular endotypes and clinical phenotypes that characterize atopic dermatitis, the role of the skin microbiome, and improvements in diagnostic tools. We also emphasize recent scientific advancements in understanding the mechanisms driving atopic dermatitis pathogenesis and discuss the identification and implementation of new targeted treatment approaches that have revolutionized therapeutic options for affected patients.

Topical treatments in special populations of atopic dermatitis - Chinese perspective

INTRODUCTION

Atopic Dermatitis (AD) is a common chronic, recurrent inflammatory skin disease, characterized mainly by polymorphic skin lesions and severe itching, significantly affecting patients' physical and mental health. The pathogenesis of AD is complex, involving multiple factors such as genetics, environment, immunity, and microbiota. In terms of treatment, traditional systemic therapies are gradually being replaced by more targeted molecular immunotherapies, and the range of topical medications has become more diverse. However, research on AD treatment in special populations, such as children, pregnant women, lactating women, and the elderly, remains relatively limited.

AREAS COVERED

This review aims to discuss the research progress on topical treatments for AD in special populations both domestically and internationally, with a focus on personalized treatment approaches. It covers many aspects such as hormones, antimicrobial drugs, small molecule drugs, nanotechnology and microecological therapies, and proposes personalized treatments for each group and problems that need to be solved by current research.

EXPERT OPINION

Special populations have unique physiological characteristics, which may lead to different responses to topical medications. Therefore, personalized treatment strategies are especially important in this context. As insights into pathogenesis evolves, the novel therapies are on the rise, holding promise for more targeted treatment approaches.

Efficacy and safety of BSZY cream for mild-to-moderate atopic facial dermatitis: protocol of a randomised, double-blind, controlled trial

INTRODUCTION

Limited by the specific location of atopic facial dermatitis, treatment options for atopic dermatitis are limited. Our previous research confirms that BiShengZhiYan cream (BSZY cream) can reconstruct the damaged skin barrier and strengthen the repair ability of skin. However, little evidence of its efficacy and safety for the treatment of atopic facial dermatitis is available.

METHODS AND ANALYSIS

A protocol for a randomised, double-blind, controlled trial of BSZY cream is designed for patients with mild-to-moderate atopic facial dermatitis. We will recruit 130 patients with mild-to-moderate atopic facial dermatitis from the Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine. The participants will be assigned to the BSZY cream group (treatment group) or the emulsion matrix group (control group) randomly. The intervention period will be 4 weeks, once daily in the morning and once in the evening. The primary outcome is the Scoring Atopic Dermatitis Scale. The Clinical Dermatologist Evaluation Form, Patient Self-Assessment Questionnaire and Safety Indicators will be evaluated as secondary outcomes. The follow-up will be conducted at week 8±3 days. The skin condition is assessed by a clinical dermatologist at week 0±3 days, week 2±3 days and week 4±3 days.

ETHICS AND DISSEMINATION

The protocol has been approved by Shanghai University of Traditional Chinese Medicine's Yueyang Hospital ethics committee (No. 2023-024). All participants will be asked to sign an informed consent in compliance with the Declaration of Helsinki. On completion of the trial, we plan to disseminate the results through peer-reviewed publications and present the findings at relevant scientific conferences. Data will be provided on reasonable request under participant confidentiality and data privacy regulations.

TRIAL REGISTRATION NUMBER

NCT05792826.

Long-Term Disease Control and Minimal Disease Activity of Head and Neck Atopic Dermatitis in Patients Treated with Tralokinumab up to 4 Years

BACKGROUND AND OBJECTIVE

There is a need for long-term atopic dermatitis (AD) treatments that can effectively improve AD involvement of the head and neck (H&N) region (referred to as H&N AD). Tralokinumab, a high-affinity monoclonal antibody that neutralizes interleukin-13, is approved for the treatment of moderate-to-severe AD. Recent real-world studies have observed the effectiveness of tralokinumab for H&N AD. Here, data from phase III parent trials, ECZTRA 1 and ECZTRA 2, and the long-term extension trial, ECZTEND, were used to assess impacts of long-term tralokinumab treatment on H&N AD and the association between improvements in H&N AD and patient quality of life, and to evaluate whether a proportion of patients developed paradoxical H&N erythema.

METHODS

These post hoc analyses included data from all patients initiated on tralokinumab in ECZTRA 1 or ECZTRA 2. Patients were treated up to 4 years (i.e., up to 52 weeks in ECZTRA 1 or ECZTRA 2 plus up to 152 weeks in ECZTEND). Outcomes included body region subscores of the Eczema Area and Severity Index (EASI; H&N, upper limbs, trunk, lower limbs) and the Dermatology Life Quality Index (DLQI). Correlations between H&N EASI and DLQI were assessed with Spearman's correlation coefficient (ρ). The incidence of paradoxical H&N erythema (defined as H&N EASI erythema increasing from baseline to a score of 3, while all other regional EASI subscores are 0 or 1, during two or more consecutive visits) was also assessed.

RESULTS

Overall, 1192 patients who were initiated on tralokinumab in ECZTRA 1 and ECZTRA 2, of whom 523 patients opted to continue in ECZTEND, were analyzed. Percentages of patients who had H&N EASI ≤ 1 increased from 12.2% at parent trial baseline to 87.2% by week 152 of ECZTEND. Improvements in EASI subscore outcomes from parent trial baseline were comparable across body regions throughout all timepoints of the study. At parent trial week 16, H&N EASI was moderately correlated with total DLQI (ρ = 0.47), with the strongest numerical correlations observed for DLQI questions regarding skin discomfort (ρ = 0.43) and embarrassment due to skin (ρ = 0.40). During up to 4 years of treatment, seven tralokinumab-treated patients exhibited paradoxical H&N erythema, five of whom improved to absent or mild H&N EASI erythema with continued tralokinumab treatment.

CONCLUSIONS

Tralokinumab provided progressive and sustained improvements in H&N AD, with H&N EASI 0/1 observed in nearly 90% of patients treated up to 4 years. Improvements in H&N EASI were similar to improvements observed for other body regions and were associated with improvements in patient quality of life, particularly for skin discomfort and self-consciousness/embarrassment due to skin.

CLINICAL TRIAL REGISTRATION

NCT03131648 (ECZTRA 1); study start date: 30 May, 2017; primary completion date: 7 August, 2018; study completion date: 10 October, 2019. NCT03160885 (ECZTRA 2); study start date: 12 June, 2017; primary completion date: 4 September, 2019; study completion date: 14 August, 2019. NCT03587805 (ECZTEND); study start date: 18 March, 2018; data cut-off date: 30 April, 2022; primary completion date: 3 July, 2024; study completion date: 3 July, 2024.

Atopic Dermatitis in Adults: Focus on Topical Therapy

Objective To review the topical therapies for adults, including older adults, with atopic dermatitis. A background on atopic dermatitis in adults, overview of treatment recommendations, and the pharmacists' role for care is included. Data Sources Articles indexed in PubMed, Cochrane Reviews, and Google Scholar in the past 10 years using the search terms atopic dermatitis, atopic dermatitis and treatment, and atopic dermatitis and adults were reviewed. Current guidelines and manufacturers' prescribing information were reviewed. Primary sources were used to locate additional resources. Study Selection/Data Extraction Forty-five publications were reviewed and criteria supporting the objectives identified useful resources. Data Synthesis Selected literature included practice guidelines, review articles, research articles, product prescribing information, and drug information databases. Conclusion Atopic dermatitis is a common chronic inflammatory cutaneous disease that may present at any age. Atopic dermatitis has a relapsing course with active disease followed by periods of remission. Atopic dermatitis is not curable, but available and recommended regimens can control patient symptoms. Topical therapies are the preferred treatment and are able to control atopic dermatitis in most adults. Topical moisturizers are the mainstay of therapy. Despite regular use of a moisturizer, most patients will need a topical anti-inflammatory agent to control disease flares. The Food and Drug Administration-approved topical anti-inflammatory agents include the corticosteroids, calcineurin inhibitors, a phosphodiesterase-4 enzyme inhibitor, and a Janus Kinase inhibitor. Pharmacists are in a unique position to counsel patients about the appropriate use and benefits and risks of atopic dermatitis therapies.

Advancements in pharmacological interventions for atopic dermatitis current strategies and future directions

Atopic dermatitis (AD) is a complex chronic inflammatory skin disorder, with its incidence significantly increasing in recent years. The pathogenesis of AD is complex, involving multiple factors such as genetic susceptibility, dysbiosis of the skin microbiome, autoimmune abnormalities, impaired epidermal barrier function, and environmental factors. These factors collectively contribute to the high incidence of the disease and its significant socio-economic burden. This article reviews the pathogenesis of AD and analyzes the current traditional treatment approaches, including topical and systemic therapies, highlighting the issues they face. It focuses on the current status and treatment strategies. Specifically, as the significant heterogeneity of AD, treatment paradigms are gradually shifting from a "one-size-fits-all" approach to personalized treatments. The aim is to achieve more effective management of AD and address the issues arising from individual differences. Through these discussions, this article aims to provide new perspectives and strategies for the clinical treatment of AD, in order to reduce the disease burden on patients.

An evaluation of the recently approved drugs for treating atopic dermatitis in the context of their safety and efficacy: a systematic review and meta-analysis

INTRODUCTION

The present paper aimed to conduct an updated systematic review and meta-analysis to evaluate the safety and efficacy of crisaborole, delgocitinib, and ruxolitinib in treating mild-to-moderate atopic dermatitis (AD).

METHODS

MEDLINE and Google Scholar databases were utilized to search articles published during the years 2015-2024. The review was limited to randomized controlled studies that measured specific outcomes for safety and efficacy aspects, including adverse events (AEs) or treatment-emergent adverse events (TEAEs) to evaluate safety and Investigator's static global assessment (ISGA) or improvement of at least 75% of Eczema Area and Severity Index (EASI-75) to evaluate efficacy.

RESULTS

The review included 17 articles in the analysis. The safety odds ratios (ORs) among participants using crisaborole, delgocitinib, and ruxolitinib were 1.14, 95% CI [0.97-1.36], 1.18, 95% CI [0.84-1.67], and 0.72, 95% CI [0.55-0.94], respectively, when compared to control groups. The three studied topical AD treatments were found to be significantly more effective compared to control groups (crisaborole, OR = 1.78, 95% CI [1.51-2.10], delgocitinib, OR = 6.34, 95% CI [3.57-11.27], and ruxolitinib, OR = 7.30, 95% CI [5.10-10.44]).

CONCLUSION

Delgocitinib and ruxolitinib demonstrated favorable safety and effectiveness profiles across various age cohorts, whereas crisaborole raised concerns over its safety and efficacy, particularly in children.

Type 2 inflammation: a Portuguese consensus using Web-Delphi and decision conferencing (INFLAT2-PT)

OBJECTIVES

Atopic/allergic diseases impose a growing burden on public health, affecting millions of patients worldwide. The main objective of this study was to develop a national expert consensus on relevant clinical questions related to type 2 inflammation.

METHODS

We conducted: a comprehensive literature review with a qualitative analysis to identify the most repeated themes on the overlap of conditions; a modified 3-round Web-Delphi (or e-Delphi); and a final online decision conference.

RESULTS

We included 51 studies. Following three Web-Delphi rounds, we ended up with 30 statements with a 76% overall full agreement rate, 16% agreement, 2% disagreement, and 0% full disagreement. The decision conference enabled adjustments, and the expert panel agreed unanimously on the final set of statements. The consensus used evidence synthesis, Web-Delphi, and decision conference to produce 30 statements on type 2 inflammation as a driver for multimorbidity in asthma, certain rhinitis phenotypes, atopic dermatitis, chronic rhinosinusitis with nasal polyps, and eosinophilic esophagitis grouped under five domains in underlying pathophysiology, multimorbidity, diagnosis and management, multidisciplinary management, and impact on mental health.

CONCLUSION

We expect the first Portuguese expert consensus INFLAT2-PT to promote understanding of type 2 inflammation diseases, multidisciplinary care, integrated care pathways, future research, and inform health authorities.

Cardiovascular and metabolic outcomes associated with moderate-to-severe atopic dermatitis: A systematic review and meta-analysis

Background

Chronic systemic inflammation in individuals with moderate-to-severe atopic dermatitis (AD) potentially predisposes them to metabolic and cardiovascular diseases. Nevertheless, evidence with regard to such association is limited.

Objective

To assess the association between metabolic and cardiovascular outcomes and moderate-to-severe AD.

Methods

A systematic search was performed through PubMed, Scopus, EMBASE, and Cochrane for population-based studies that addressed the effects of moderate-to-severe AD on metabolic and cardiovascular outcomes compared with the general population from inception to August 31, 2023. Meta-analysis was performed using the random effects model. The pooled odds ratio (OR) and certainty of evidence for each outcome were reported.

Results

We included 11 studies, 4 retrospective cohorts, 1 prospective cohort, 4 cross-sectional, and 2 case-control studies involving 405,170 moderate-to-severe AD patients compared to 4,591,478 unaffected controls. Moderate-to-severe AD was associated with a higher risk of myocardial infarction with an OR (95% CI) of 1.33 (1.07, 1.65), angina 1.33 (1.06, 1.66), heart failure 1.56 (1.28, 1.90), stroke 1.45 (1.21, 1.74), hypertension 1.38 (1.18, 1.63), dyslipidemia 1.27 (1.15, 1.41), and metabolic syndrome 1.24 (1.05, 1.42) with very low certainty of evidence. No significantly increased risk of cardiovascular death with an odds ratio (95% CI) of 1.81 (0.96, 3.44) and diabetes of 1.24 (0.91, 1.68) was observed. High heterogeneity was observed in most studies for all of the outcomes.

Conclusion

Our meta-analysis demonstrated a modest but significant association between moderate-to-severe AD and increased susceptibility to metabolic and cardiovascular diseases. Initial assessment of cardiovascular and metabolic risk for patients with moderate-to-severe AD should be considered to enable early management strategies.

The future of topical JAK inhibitors in the treatment of atopic dermatitis

INTRODUCTION

Atopic dermatitis (AD) is a chronic inflammatory skin condition, rising in prevalence and significantly impacting quality of life. Janus kinase (JAK) inhibitors are small molecules targeting the JAK-STAT signaling pathway, responsible for immune response and cell proliferation. Therapy with topical JAK inhibitors (JAKinibs) improves AD itch and skin lesions and is well tolerated with no major side effects, making it an interesting novel therapy for AD.

AREAS COVERED

This review provides a comprehensive look at the available research on topical JAK inhibitors, primarily for atopic dermatitis, based on clinical trial outcomes.

EXPERT OPINION

In this review, we summarize research on topical JAKinibs, including ruxolitinib, tofacitinib, delgocitinib, cerdulatinib, and bredocitinib, which target multiple cytokine pathways and have been shown to reduce the itch and inflammation. Their low bioavailability contributes to infrequent and mild side effects. The main limitation of predominantly short-term studies is that the long-term effects of JAK inhibitor therapy are not yet fully known. The body of research is growing, and more information about their effectiveness and safety is being added each year.

Allergen immunotherapy and dupilumab in atopic dermatitis: Clinical efficacy and disparities in immunological indicators

Objective

Allergen immunotherapy (AIT) and dupilumab have been confirmed to improve symptoms of atopic dermatitis (AD); however, the precise immune mechanisms underlying their efficacy and whether they can elicit synergistic immune effects remain not fully elucidated. We aimed to investigate the clinical efficacy and immunological changes in AD patients undergoing AIT, dupilumab, and a combination of AIT and dupilumab treatment.

Methods

Clinical data, serum samples, and peripheral blood mononuclear cells (PBMC) were collected from house dust mite (HDM)-sensitized AD patients receiving AIT and/or dupilumab at baseline and 6 months. Changes in clinical efficacy, HDM-specific IgE and IgG4, serum cytokines, and lymphocyte subgroups were compared among the treatment groups.

Results

A total of 77 AD patients were included, with 39 in the AIT group, 19 in the dupilumab group, and 19 in the AIT combined dupilumab group. The SCORAD scores significantly improved in all groups after 6 months. Levels of HDM-specific IgE and total IgE remained stable in the AIT group but decreased in the dupilumab and combination groups. Levels of IgG4 against major mite components Der p1 and Der p23 increased in the AIT group and combined treatment group. Serum cytokine levels showed no significant changes, except for a decrease in CCL17 in the dupilumab group. Th1/Th2 and Th17/Th2 ratios increased after dupilumab treatment. There were notable differences in T cell subpopulations when PBMCs were stimulated with HDM extracts after 6-month treatment, tSNE analysis showed the proportion of IL-4+IL-13+CRTH2+T cells increased in the dupilumab group but had no changes in the AIT and combination group.

Conclusions

AIT, dupilumab, and their combination improved clinical symptoms and quality of life in AD patients. AIT promoted allergen-specific IgG4 production, while dupilumab modulated T cell responses and reduced allergen-specific IgE synthesis. The combination of AIT and dupilumab exhibited the immunological parameter changes characteristic of both treatments but did not result in a significantly greater improvement in AD symptoms.

Infections in Patients with Atopic Dermatitis and the Influence of Treatment

Atopic dermatitis (AD) is a T helper 2-mediated chronic inflammatory skin disease that affects children and adults. Patients with AD are prone to recurrent infections of the skin and other organs, which can severely worsen the disease course. This review summarises the current evidence on the aetiology, pathogenesis, treatment and prevention of infections in patients with AD. PubMed was searched for English-language research articles, systematic reviews, meta-analyses and guidelines published until February 2023 using the key term "atopic dermatitis" and terms relevant to infections. Patients with AD have an increased risk of bacterial, viral and fungal infections of the skin, mainly due to impaired barrier function, altered immune response and frequent scratching. The most common pathogens are Staphylococcus aureus and herpes simplex virus, which can cause impetigo, folliculitis, abscesses, eczema herpeticum and other complications. They also appear to increase susceptibility to systemic infections, including respiratory and urinary tract infections and sepsis. Certain systemic treatments for AD, such as mycophenolate mofetil and Janus kinase inhibitors, increase the risk of viral infections. Prevention and treatment of recurrent infections in patients with AD require a multifaceted approach that includes topical and systemic antimicrobials, skin care and effective control of AD symptoms (to break the itch-scratch cycle). Preventing and limiting the development of infections are important considerations in choosing an AD treatment.

Atopic dermatitis

Atopic dermatitis is the most common chronic inflammatory skin disease globally. Key features include an eczematous eruption accompanied by intense itch, which can have an enormous negative effect on patients' quality of life, especially in those with moderate-to-severe disease. Atopic dermatitis is part of a spectrum of atopic conditions that can also include several non-cutaneous organs such as respiratory (eg, allergic rhinitis and asthma) and gastrointestinal (eg, food allergy) systems. For decades, long-term disease control and maintenance were particularly challenging given that treatment options were limited to broad topical and systemic immunosuppressive agents. However, better insights into the pathophysiology of this condition over the past decade have led to the development and approval of safe and efficacious novel targeted treatment approaches. The updated pathophysiological understanding and the evolving therapeutic landscape of atopic dermatitis are discussed in this Seminar.

Comparative Real-World Analysis of Baseline Demographic Characteristics and Comorbidities in Atopic Dermatitis Patients Initiating Biologics Versus JAK Inhibitors

Background: Systemic advanced therapies, including biologic drugs and Janus kinase (JAK) inhibitors, have revolutionized atopic dermatitis management. The increasing number of available options for such complex diseases demands careful treatment selection for each patient, considering numerous variables. Comparative analyses of these treatment modalities in the real world are still limited. Only a faithful basal characterization would enable posterior meaningful and accurate comparisons of the efficacy and safety profiles of these groups of drugs. This communication focuses on describing and comparing the baseline demographics and comorbidities of patients with atopic dermatitis currently treated with biologic therapies versus JAK inhibitors in our setting. Methods: We conducted an observational, descriptive, and ambispective study across three hospitals covering a population of over 500,000 inhabitants from January 2019 to December 2024. Baseline demographic data, anthropometric measures, lifestyle factors, cardiovascular risk factors, and comorbidities were analyzed using descriptive and inferential statistics. Additionally, basal severity and effectivity over time have also been compared. Results: A total of 150 patients were analyzed. A total of 102 had received biological therapies (dupilumab or tralokinumab), whereas 48 patients had received JAK inhibitors (upadacitinib, baricitinib, or abrocitinib). Ages ranged from 11 to 76 years. The overall cohort had a mean age of 35.87 ± 14.37 years and a male predominance (male-to-female ratio 1.63:1). Hypertension was more prevalent in the JAK inhibitors group (p = 0.0175), yet other cardiovascular risk factors, body measurements, atopic and non-atopic comorbidities, and disease severity were comparable across both groups. Conclusions: This study helped to characterize the baseline characteristics of patients treated with advanced systemic therapies in a real-world clinical setting. It pointed to just slight differences between the profiles of patients treated with biologics versus JAK inhibitors. This homogeneity in baseline characteristics sets the ground for further future comparisons of treatment outcomes in this cohort as potential confounding factors related to group imbalances are minimized.

Clinical and Pathophysiological Tangles Between Allergy and Autoimmunity: Deconstructing an Old Dichotomic Paradigm

Allergic and autoimmune disorders are characterised by dysregulation of the immune responses to otherwise inert environmental substances and autoantigens, leading to inflammation and tissue damage. Their incidence has constantly increased in the last decades, and their co-occurrence defies current standards in patient care. For years, allergy and autoimmunity have been considered opposite conditions, with IgE and Th2 lymphocytes cascade driving canonical allergic manifestations and Th1/Th17-related pathways accounting for autoimmunity. Conversely, growing evidence suggests that these conditions not only share some common inciting triggers but also are subtended by overlapping pathogenic pathways. Permissive genetic backgrounds, along with epithelial barrier damage and changes in the microbiome, are now appreciated as common risk factors for both allergy and autoimmunity. Eosinophils and mast cells, along with autoreactive IgE, are emerging players in triggering and sustaining autoimmunity, while pharmacological modulation of B cells and Th17 responses has provided novel clues to the pathophysiology of allergy. By combining clinical and therapeutic evidence with data from mechanistic studies, this review provides a state-of-the-art update on the complex interplay between allergy and autoimmunity, deconstructing old dichotomic paradigms and offering potential clues for future research.

Allergens in Atopic Dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin disease with a complex relationship to allergens. While AD itself is not an allergic reaction and does not necessarily involve allergen sensitization, AD patients show higher rates of sensitization to food and inhalant allergens compared to the general population. Recent evidence refining the "dual allergen exposure hypothesis" demonstrates that early oral exposure to allergens through an intact gastrointestinal barrier typically promotes tolerance, while exposure through compromised skin or respiratory barriers often leads to sensitization. Therefore, the impaired skin barrier function in AD patients increases the risk of transcutaneous sensitization and may interfere with oral tolerance development. Interestingly, AD patients' sensitivity to contact allergens (such as metals and fragrances) is not necessarily higher than that of the general population, which may be related to the inherent properties of these allergens. Personalized allergen testing can help guide appropriate allergen avoidance and reintroduction strategies in AD management. The insights into optimal allergen exposure conditions have also expanded the potential applications of allergen-specific immunotherapy in preventing AD onset in high-risk populations and halting the atopic march.

Topical Steroid Withdrawal Is a Targetable Excess of Mitochondrial NAD

Topical steroid withdrawal (TSW) is a controversial diagnosis advocated by patients but often confused for atopic dermatitis. We conducted a multimodal pilot study of 16 patients fitting the TSW diagnostic profile, contrasting them against patients with atopic dermatitis (n = 10) and healthy controls (n = 11). Our clinical evaluations established objective diagnostic criteria that distinguish TSW from atopic dermatitis, metabolomics and transcriptomics of skin biopsies suggested that neuroinflammatory pathways are associated with complex I-mediated oxidation of NAD+, cellular and mouse models demonstrated that NAD+ metabolism was proinflammatory and glucocorticoid responsive, whereas functional assays demonstrated that the metabolic effects of glucocorticoids on the only cell type that aligns with the distribution and duration of TSW pathology could be mitigated by complex I blockade. These results informed a successful open-label trial using complex I-inhibiting interventions: metformin and berberine. Although this work represents a pilot study, to our knowledge, this work offers previously unreported mechanistic insights into TSW.

Pearls for practice from the 2023 joint task force anaphylaxis practice parameter

PURPOSE OF REVIEW

To share important highlights on the management of anaphylaxis from the latest 2023 practice parameter.

RECENT FINDINGS

The 2023 Allergy Immunology Joint Task Force on Practice Parameters (JTFPP) anaphylaxis practice parameter provides updated anaphylaxis guidance. Criteria for the diagnosis of anaphylaxis are reviewed. The parameter highlights that while anaphylaxis is not more severe in younger children, age-specific symptoms can vary. Activation of emergency medical services may not be required in patients who experience prompt resolution of symptoms following epinephrine use and caregivers are comfortable with observation. For children weighing <15 kg, the anaphylaxis parameter suggests the clinician may prescribe either the 0.1 mg or the 0.15 mg epinephrine autoinjector, with the 0.3 mg autoinjector prescribed for those weighing 25 kg or greater. In patients with heart disease, discontinuing or changing beta blockers and/or angiotensin converting enzyme inhibitors may pose a larger risk for worsened cardiovascular disease compared with risk for severe anaphylaxis with medication continuation. Furthermore, in patients with a history of perioperative anaphylaxis, shared decision-making based on diagnostic testing and clinical history is recommended prior to repeat anesthesia use. Beyond the recent parameter update, novel contemporary therapies can decrease risk of community anaphylaxis.

SUMMARY

The 2023 JTFPP Anaphylaxis Guidelines offer up-to-date guidance for the diagnosis and management of anaphylaxis in infants, children, and adults.

ROCKET: a phase 3 program evaluating the efficacy and safety of rocatinlimab in moderate-to-severe atopic dermatitis

Atopic dermatitis (AD) is a chronic inflammatory disease affecting ~ 10% of adults and ~ 20% of children globally. Many patients with moderate-to-severe AD receiving systemic therapies, including biologics and Janus kinase (JAK) inhibitors, fail to reach or maintain treatment goals due to lack of durable response or safety/tolerability issues. Rocatinlimab is a T-cell rebalancing therapy that inhibits and reduces pathogenic T cells by targeting the OX40 receptor. ROCKET, a large, global phase 3 program of eight clinical trials (NCT05398445; NCT05651711; NCT05724199; NCT05899816; NCT05704738; NCT05633355; NCT05882877; NCT06224192), will evaluate the efficacy, durability of response, and long-term safety of rocatinlimab as monotherapy and combination therapy in adult and adolescent patients with moderate-to-severe AD with or without prior exposure to biologics or systemic JAK inhibitors.

Preventing NLRP3 inflammasome activation: Therapeutic atrategy and challenges in atopic dermatitis

Atopic dermatitis (AD) is a prevalent inflammatory skin disorder characterized by its chronic, persistent, and recurrent nature. The pathophysiology of this condition is complex, involving various factors including cell-mediated immune responses, compromised skin barrier function, and alterations in hypersensitivity reactions. These components synergistically contribute to the perpetuation of the bothersome "itch-scratch-itch" cycle. Recent research has highlighted the significant role of the NLRP3 inflammasome in the development of AD and other inflammatory conditions. Current research indicates that the NLRP3 inflammasome plays a pivotal role in both the acute and chronic phases of AD by modulating the Th2/Th1 immune deviation. Moreover, the pharmacological suppression of NLRP3 has shown promising results in mitigating the pathological aspects of AD. This review outlines potential drug development strategies that target the NLRP3 inflammasome as a therapeutic approach for AD and the challenges faced in this endeavor.

Anti-Inflammatory Effects of Cannabigerol In Vitro and In Vivo Are Mediated Through the JAK/STAT/NFκB Signaling Pathway

Cannabinoid compounds have potential as treatments for a variety of conditions, with cannabigerol (CBG) being known for its anti-inflammatory properties. In this study, we investigated the effects of CBG in a cellular model of 1-chloro-2,4-dinitrobenzene (DNCB)-induced atopic dermatitis (AD). In the cellular model, we confirmed the cytotoxicity of CBG and downregulated the expression of inflammatory markers CCL26, IL1B, IL6, and TNF (p < 0.001). In the mouse model, clinical, histological, and immunological changes were analyzed. The results showed that CBG improved dermatitis severity score, epidermal thickness, and mast cell count and reduced inflammatory cytokines (Tslp, Il1b, Il4, Il6, Il13, Il17, Il18, Il22, and Il33) by qRT-PCR (p < 0.001). Western blot results showed modulated changes in JAK1, JAK2, TYK2, STAT1, STAT2, STAT3, p-STAT3, STAT6, and p-STAT6 (p < 0.05). Subsequently, p-IκBα, NF-κB, and p-NF-κB signaling factors were also reduced (p < 0.05), with corresponding changes in skin barrier factors. The results of this study indicate that CBG effectively alleviates AD-like symptoms and suggest the potential of CBG as a therapeutic agent.

Identification of Drug-Targetable Genes for Eczema and Dermatitis Using Integrated Genomic and Proteomic Approaches

Background: Eczema and dermatitis are common inflammatory skin conditions with significant morbidity. Identifying drug-targetable genes can facilitate the development of effective treatments. Methods: This study analyzed data obtained by meta-analysis of 2 genome-wide association studies on eczema/dermatitis (57,311 cases and 896,779 controls, European ancestry). We identified drug-targetable genes from the Drug-Gene Interaction Database and Finan et al's findings. Cis-expression quantitative trait loci (eQTL) data from human blood and skin tissues were used for Mendelian randomization (MR) analysis. Bayesian colocalization, proteomic MR, and meta-analysis validated the causal relationships. Finally, protein-protein interactions (PPIs) and correlation analysis of potential drug targets and cytokines were performed. Results: We identified 2532 drug-targetable genes; 3378 Single Nucleotide Polymorphism (SNPs) were associated with 1531 genes in blood cis-eQTLs, 664 SNPs with 667 genes in sun-exposed skin eQTLs, and 572 SNPs with 574 genes in nonsun-exposed skin eQTLs. Five genes (SLC22A5, NOTCH4, AGER, HLA-DRB5, and EHMT2) showed causal relationships with eczema/dermatitis across multiple datasets. Single-variable and multi-variable Mendelian randomization (SMR) and multi-SNP SMR analysis identified 8 genes (PIK3R4, DHODH, CXCR2, Interleukin (IL)18, LGALS9, RPS6KB2, SLC22A5, and AGER) across all tissues. Functional Summary Information for Variants in the Online Network (FUSION) analysis confirmed associations for SLC22A5 and AGER. Bayesian colocalization indicated AGER (PPH4: 0.95) as a shared causal variant. Proteomic MR and meta-analysis showed that increased AGER protein levels were associated with a lower risk of eczema or dermatitis (odds ratio: 0.995, 95% confidence interval: 0.997-0.993, P = 0.0002). A PPI network revealed interactions of AGER with NOTCH4 and multiple cytokines, whereas SLC22A5 showed no cytokine interactions. Conclusions: This study identified potential drug-targetable genes, with AGER showing strong potential as a target for reducing eczema/dermatitis risk. These findings provide a basis for developing targeted therapies.

Atopic dermatitis: Best of guidelines and yardstick

Background: Atopic dermatitis (AD), a common chronic inflammatory skin disorder is characterized by a complex pathology with skin-barrier abnormalities, immune dysregulation, and microbial dysbiosis. Patients' quality of life is often negatively impacted by persistent pruritus, sleep disturbance, and recurrent skin infections. In addition, patients may have comorbid atopic as well as nonatopic diseases. Objective: The objective was to help clinicians better manage AD by using new therapies and new indications, including a topical (Janus kinase [JAK]) inhibitor as well as monoclonal antibodies and oral JAK inhibitors, have been approved for AD. Methods: This review presents highlights from the American College of Allergy, Asthma and Immunology AD Yardstick Update, which incorporates Expert Commentary, and from the Joint Task Force (JTF) AD 2023 Guidelines that use Grading of Recommendations, Assessment, Development, and Evaluation methodology. Results: Practical pearls from the AD Yardstick Update Expert Commentary are presented, along with results from systematic reviews and meta-analyses that addressed specific recommendations on the role of (1) dilute bleach baths, (2) dietary avoidance and/or elimination diets, (3) allergen immunotherapy, (4) topical treatments, and (5) systemic treatments, informing the JTF 2023 AD Guidelines. These guidelines are noteworthy for addressing patient values and preferences. Conclusion: The AD Yardstick Update Expert Commentary and JTF 2023 AD Guidelines provide timely, practical, and trustworthy information to help clinicians manage patients with AD.

[Consensus for the treatment of atopic dermatitis in primary care: resolving myths and legends based on evidence]

Atopic dermatitis (AD) is a disease that significantly impacts the quality of life of patients. Although there are multiple evidence-based guidelines, they are usually aimed at providing recommendations to AD specialists rather than primary care physicians (PCPs). The aim of this study was to construct a consensus document for PCPs, with the aim of presenting evidence-based recommendations that allow general practitioners, family physicians, pediatricians, internists and emergency physicians to provide appropriate care to AD patients, facilitating their diagnosis, management, and avoiding delays that can deteriorate patients' f quality of life. As a central source of information, we used the recommendations of different international AD guidelines. Delegates from distinct medical societies identify barriers to care and possible solutions for the application of recommendations in primary care. Subsequently, a second evaluation for physicians from different Latin American countries was carried out. The main doubts and barriers that PCPs face in applying the recommendations proposed by the guidelines were identified across different areas, diagnostic criteria, non-pharmacological therapies, pharmacological therapies, management in special conditions and guidelines for referral to a specialist. Consensus solutions were proposed for each identified issue. In conclusion, this consensus contains recommendations regarding the management and treatment of AD in children and adults, which clarify doubts and provide tools to primary care physicians to offer effective treatment for patients and their families.

Highly Biocompatible Lamellar Liquid Crystals Based on Hempseed or Flaxseed Oil with Incorporated Betamethasone Dipropionate: A Bioinspired Multi-Target Dermal Drug Delivery System for Atopic Dermatitis Treatment

Purpose

Atopic dermatitis (AD) is the most common chronic inflammatory skin disease that severely impairs patient's life quality and represents significant therapeutic challenge due to its pathophysiology arising from skin barrier dysfunction. Topical corticosteroids, the mainstay treatment for mild to moderate AD, are usually formulated into conventional dosage forms that are impeded by low drug permeation, resulting in high doses with consequent adverse effects, and also lack properties that would strengthen the skin barrier. Herein, we aimed to develop biomimetic lamellar lyotropic liquid crystals (LLCs), offering a novel alternative to conventional AD treatment.

Methods

In screening studies, pseudoternary phase diagrams alongside polarized light microscopy (PLM) and viscosity measurements were utilized. Next, the selected LCCs underwent comprehensive characterization via PLM, small-angle X-ray scattering, differential scanning calorimetry, and rheological analysis. Lastly, their performance was evaluated and compared with the commercially available reference medicine in chemical stability study, in vitro permeation testing, in vitro safety assessment using cell proliferation assay, inverted light microscopy, and Raman mapping of keratinocytes, besides gap closure assay performed by live-cell imaging.

Results

Formulation (L/T)Ho30, containing the highest amount of lecithin/Tween 80 mixture (21%) and hempseed oil (28%), demonstrated lamellar microstructure with high skin hydration potential and favourable rheological features for skin administration. Moreover, in comparison with the reference medicine, it stood out by providing suitable chemical BD (betamethasone dipropionate) stability, improved 3-fold BD permeation, and excellent biocompatibility with over 85% cell proliferation at all tested concentrations, ensuring keratinocytes' integrity, as well as promoting skin healing with gap closure observed after 36 hours.

Conclusion

Unique multi-target drug delivery strategy depicted in newly developed bioinspired lamellar LCCs structurally resembling stratum corneum intercellular lipids, with incorporated BD drug, and composed of multifunctional components that synergistically strengthen skin barrier, was presented here and shows a promising approach for improved AD treatment.

Comparative efficacy of targeted systemic therapies for pruritus in moderate-to-severe atopic dermatitis without topical treatment: a network meta-analysis

BACKGROUND

Chronic pruritus is the most prevalent and severe symptom of atopic dermatitis (AD).

OBJECTIVE

This network meta-analysis aims to assess the comparative efficacy of systemic targeted monotherapies in alleviating pruritus among adults and adolescents with moderate-to-severe AD.

METHODS

Data were collected from phase 3/4 randomized controlled trials (RCTs) published until 24 August 2024, focusing on targeted therapies for moderate-to-severe AD. The outcome measure was the proportion of patients achieving a ≥ 4-point improvement from baseline on the Pruritus Numerical Rating Scale (NRS). This analysis included both primary endpoints (week 12 or week 16) and secondary endpoints (weeks 2, 4, and 8).

RESULTS

Eleven reports comprising 16 studies with 8,462 participants were included. At all time points examined, targeted therapies demonstrated statistically significant efficacy over placebo, with upadacitinib 30 mg showing the highest response rate. The next most effective treatments at the primary endpoint were abrocitinib 200 mg, upadacitinib 15 mg, dupilumab 300 mg, and lebrikizumab 250 mg. Cumulative ranking probabilities at secondary endpoints varied based on time points.

CONCLUSION

Targeted therapies, particularly upadacitinib 30 mg, showed significant advantages in managing moderate-to-severe AD pruritus. Further direct comparative trials are needed for conclusive evidence.

Atopic dermatitis: pathogenesis and therapeutic intervention

The skin serves as the first protective barrier for nonspecific immunity and encompasses a vast network of skin-associated immune cells. Atopic dermatitis (AD) is a prevalent inflammatory skin disease that affects individuals of all ages and races, with a complex pathogenesis intricately linked to genetic, environmental factors, skin barrier dysfunction as well as immune dysfunction. Individuals diagnosed with AD frequently exhibit genetic predispositions, characterized by mutations that impact the structural integrity of the skin barrier. This barrier dysfunction leads to the release of alarmins, activating the type 2 immune pathway and recruiting various immune cells to the skin, where they coordinate cutaneous immune responses. In this review, we summarize experimental models of AD and provide an overview of its pathogenesis and the therapeutic interventions. We focus on elucidating the intricate interplay between the immune system of the skin and the complex regulatory mechanisms, as well as commonly used treatments for AD, aiming to systematically understand the cellular and molecular crosstalk in AD-affected skin. Our overarching objective is to provide novel insights and inform potential clinical interventions to reduce the incidence and impact of AD.

A Narrative Review of the OX40-OX40L Pathway as a Potential Therapeutic Target in Atopic Dermatitis: Focus on Rocatinlimab and Amlitelimab

Atopic dermatitis (AD) is a common chronic inflammatory skin disease involving complex immune dysregulation, including the OX40-OX40L pathway. Rocatinlimab and amlitelimab, monoclonal antibodies targeting OX40 and OX40L, respectively, have shown promise in treating moderate-to-severe AD. Both therapies have demonstrated significant efficacy in reducing disease severity, with favorable safety profiles and no serious treatment-related adverse events. Both treatments outperformed placebo across key clinical endpoints, including skin clearance and symptom reduction, highlighting their potential as effective AD therapies. Although initial results are promising, further research is needed to evaluate the long-term effects, durability of response, and safety of these treatments. These findings support the therapeutic potential of targeting the OX40-OX40L pathway in AD, providing new options for patients with moderate-to-severe disease, with ongoing trials necessary to confirm their sustained benefits.

Environmental and behavioral mitigation strategies for patients with atopic dermatitis

Objective

Herein, we aimed to summarize the evidence-base for these interventions with a focus on the role of specific chemicals in driving AD.

Methods

A narrative review of nonprescription mitigation strategies in AD was conducted.

Results

We identified avoidance strategies for the various routes of exposure such as air pollution, water contamination, or inclusion in home goods, skin care products, and cleansers. Evidence for and against dietary modification and emollient use as primary prevention were also elucidated. To remember these interventions we propose a mnemonic, HELPSS AD: Home decor, Emollients, Laundering, Probiotics, Soaks, Social support, Air quality, and Diet.

Limitations

Each of these categories presents nuanced molecular differences that must be considered. For example, probiotic responses vary by the specific species while home products and pollution must be analyzed by the specific toxins.

Conclusion

Although the interventions discussed lack the level of evidence required for inclusion into formal guidelines, awareness of these approaches may offer aid to, and build trust with, patients and caregivers.

Atopic Dermatitis: A Review of Diagnosis and Treatment

Atopic dermatitis, more commonly known as atopic eczema, is a chronic, relapsing inflammatory skin disorder characterized by dry skin, localized erythematous rash, and intense pruritus. The clinical manifestations are variable and age dependent. As one of the most common skin disorders globally, atopic dermatitis poses a significant clinical and economic burden on affected patients. Individual treatment strategies are imperative in improving patient outcomes and reducing these burdens. Recent advances in understanding the genetic, immunologic, and environmental factors influencing atopic dermatitis have opened avenues for novel treatment modalities. This article highlights the clinical presentation, pathophysiology, diagnosis criteria, as well as current recommendations on treatment of atopic dermatitis.

Sodium Propionate Alleviates Atopic Dermatitis by Inhibiting Ferroptosis via Activation of LTBP2/FABP4 Signaling Pathway

Background

Atopic dermatitis (AD) is a common pediatric skin disease, with recent studies suggesting a role for ferroptosis in its pathogenesis. Sodium propionate (SP) has shown therapeutic potential in AD, yet its mechanism, particularly regarding ferroptosis modulation, remains unclear. This study aims to explore whether SP alleviates AD by modulating ferroptosis-related pathways through bioinformatic and in vitro analyses.

Methods

We analyzed the GEO AD cohort (GSE107361). Ferroptosis-related genes was compiled from the GeneCards Database and SP-associated therapeutic target genes were obtained from Swiss Target Prediction. To explore potential biological mechanisms, we employed Gene Set Variation Analysis (GSVA), Gene Ontology (GO), and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses. Weighted Gene Co-expression Network Analysis (WGCNA) and differential expression analysis identified key gene modules. We also established TNF-α/IFN-γ induced AD cell models using HaCat cells and collected cell samples for further experiments.

Results

The GSVA analysis demonstrated that ferroptosis-related genes could differentiate between healthy children and those with AD. The identified module includes genes with correlated expression patterns specifically linked to AD. Analysis using three algorithms identified potential therapeutic targets of SP. We screened 51 key genes related to AD and ferroptosis, selecting cyclin-dependent kinase 1 (CDK1) and latent transforming growth factor beta binding protein 2 (LTBP2) as co-expressed genes. Machine learning identified fatty acid binding protein 4 (FABP4) as a significant gene intersection of the 51 key genes. The bioinformatics analysis results were validated through cell experiments, showing that SP treatment increased the expression of the damaged skin genes loricrin (LOR) and filaggrin (FLG).

Conclusion

Our study indicates that SP may alleviate AD symptoms by modulating ferroptosis through the LTBP2/FABP4 pathway.

Evolving therapies for atopic dermatitis: Bridging guidelines and practice

Atopic dermatitis (AD) is a chronic, relapsing inflammatory skin condition characterised by dysregulated type 2 immune responses, skin barrier dysfunction and intense pruritus (itching). The disease burden of AD is substantial, affecting at least 171 million individuals worldwide in 2019, representing 2.23% of the global population.1 Among skin diseases, AD ranks highest in disease burden, as measured by disability-adjusted life-years (DALYs).2 Its profound impact on patients’ quality of life, along with significant economic burdens, underscores its status as a major healthcare challenge.

The screening and management of skin diseases in remote African regions: a narrative review

INTRODUCTION

Skin diseases in remote African regions are often exacerbated due to a lack of resources and expertise with little current research addressing the challenges that patients and healthcare systems experience. Although skin diseases in remote African regions are prevalent and pose a substantial health burden, they remain neglected and understudied. This review aims to explore current challenges in the diagnosis and management of skin diseases in African regions and focus on the need for enhanced understanding and improved healthcare strategies.

METHODS

We reviewed papers that were retrieved from PubMed, Google Scholar, and other relevant academic search sites to analyze the prevalence, screening techniques, as well as management strategies and obstacles associated with dermatological diseases in remote African regions.

RESULTS

Current literature suggests there is indeed a high prevalence of skin diseases where other infections are predominant. Further, different factors, such as socioeconomic status and environmental conditions, make it challenging for optimal screening and treatment of skin diseases in remote African regions. Common screening methods for skin diseases involve clinical examination and laboratory tests, while management includes pharmacotherapy, surgery, and counseling approaches. Overall, access to medications and adequate healthcare services remains limited.

CONCLUSION

Early diagnosis and management of skin diseases in remote African regions have significant challenges, including a lack of funding for dermatology, education, and research. Future promising strategies such as teledermatology, point-of-care diagnostic technologies, and task shifting show promise in improving access to care. However, there is a need for sustained efforts to address the underlying socioeconomic factors and improve healthcare delivery in remote African regions.

Combining treat-to-target principles and shared decision-making: International expert consensus-based recommendations with a novel concept for minimal disease activity criteria in atopic dermatitis

BACKGROUND

Current treat-to-target recommendations for atopic dermatitis (AD) may not include high enough treatment targets and do not fully consider patient needs.

OBJECTIVE

To develop recommendations for optimized AD management, including disease severity assessments, treatment goals and targets, and guidance for treatment escalation/modification.

METHODS

An international group of expert dermatologists drafted a series of recommendations for AD management using insights from a global patient study and 87 expert dermatologists from 44 countries. Experts voted on recommendations using a modified eDelphi voting process.

RESULTS

The Aiming High in Eczema/Atopic Dermatitis (AHEAD) recommendations establish a novel approach to AD management, incorporating shared decision-making and a concept for minimal disease activity (MDA). Consensus (≥70% agreement) was reached for all recommendations in 1 round of voting; strong consensus (≥90% agreement) was reached for 30/34 recommendations. In the AHEAD approach, patients select their most troublesome AD feature(s); the clinician chooses a corresponding patient-reported severity measure and objective severity measure. Treatment targets are chosen from a list of 'moderate' and 'optimal' targets, with achievement of 'optimal' targets defined as MDA.

CONCLUSIONS

Patient and expert insights led to the development of AHEAD recommendations, which establish a novel approach to AD management. Patients were not involved in the eDelphi voting process used to generate consensus on each recommendation. However, patient perspectives were captured in a global, qualitative patient research study that was considered by the experts in their initial drafting of the recommendations.

Current and Emerging Biologics for Atopic Dermatitis

Atopic dermatitis (AD) is a common chronic pruritic inflammatory skin disease that affects all ages and is recognized as a global health problem. Pathophysiology is complex with skin barrier abnormalities, immune dysregulation, and microbial dysbiosis all implicated. Markers of immune and inflammatory activation in the circulation provide a rationale for systemic therapy. Type 2 immune polarization is central, though other cytokine pathways including Th22 and Th17/IL-23 have been described, suggesting additional therapeutic targets in a subset of patients. Dupilumab and tralokinumab are monoclonal antibodies currently approved for moderate-to-severe AD with lebrikizumab and nemolizumab in late stages of development.

Factors Associated With Dupilumab Response in Atopic Dermatitis: A Systematic Review and Meta-Analysis

BACKGROUND

Dupilumab was approved for treating moderate to severe atopic dermatitis (AD). However, a notable subset of patients remains unresponsive and factors associated with dupilumab response remain limited.

OBJECTIVE

To review and establish factors related to dupilumab response systematically in AD.

METHODS

We searched electronic databases, including PubMed and MEDLINE, Embase, Ovid, and the Cochrane Center of Controlled Trials from inception to March 2023. The primary outcome was factors linked to dupilumab response in AD. The odds ratios and 95% CIs related to a 75% reduction at 12 to 16 weeks in the Eczema Area and Severity Index (EASI) score were synthesized using a random-effects meta-analysis.

RESULTS

Of 21 studies involving 5,575 patients with AD, three were post hoc analyses of phase 3 dupilumab studies, 12 were retrospective, and six were prospective studies. Factors associated with favorable responses to dupilumab, defined by the percentage of patients achieving EASI75 at 12 to 16 weeks, included female sex (OR [95% CI] = 2.16 [1.38-3.38]), young age (2.81 [1.64-4.81]), absence of allergic rhinitis (2.64 [1.07-6.50]), low body mass index (1.97 [1.18-3.30]), and low blood eosinophil count (6.47 [3.36-12.48]), with very low certainty of evidence. Age at onset, baseline EASI score, total IgE level, and serum lactate dehydrogenase level were unrelated to dupilumab response.

CONCLUSIONS

Female sex, young age, absence of allergic rhinitis, low body mass index, and low blood eosinophil count were associated with a favorable response to dupilumab in patients with AD. These factors should be taken into account when considering dupilumab therapy in clinical practice.

Atopic Dermatitis (Eczema) Guidelines 2023: Highlights

Atopic dermatitis is a common chronic inflammatory skin disorder, with a complex pathogenesis. It is characterized by eczematous skin lesions, pruritus, and recurrent skin infections and has a negative impact on patients' and caregivers' quality of life. The American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma and Immunology Joint Task Force Atopic Dermatitis Guideline Panel recently released updated AD guidelines. This guideline focuses on addressing clinical questions using trustworthy guideline development standards, including mitigating the potential influence of financial and nonfinancial conflicts of interest, and Grading of Recommendations Assessment, Development, and Evaluation methodology. A multidisciplinary panel used systematic reviews and meta-analyses to inform specific recommendations addressing optimal use of topical treatments, dilute bleach bath, dietary avoidance/elimination, allergen immunotherapy, and systemic treatments. The comprehensive recommendations, emphasizing the third principle of evidence-based medicine-that evidence alone is never enough, and that patient values and preferences must be carefully considered when determining optimal treatments for patients and populations-provide a framework to support clinicians in selecting an optimal treatment plan for each patient. This review provides an overview of the guideline and discusses how those recommendations relate to current practice.

Participation in Daily Activities of Children with Atopic Diseases and Its Relation to Their Sensory Modulation Difficulties

(1) Background: Participation in daily activities is critical for a child's health, development and wellbeing and is considered a main outcome measure of intervention efficiency. Atopic diseases affect children's daily life and routines but the knowledge about impacts on participation is limited. (2) Objectives: a. to profile the preference to participate in daily activities of children with atopic diseases as compared to healthy controls; b. to profile sensory modulation difficulties (SMD) in each atopic group; c. to examine whether SMD correlate with activity preference. (3) Methods: This cross-section and correlative study included 253 children aged 4-11: 37 with Asthma, 37 with atopic dermatitis (AD), and 31 with Rhinitis. The controls were 148 healthy children. All children completed the Preference for Activities of Children (PAC) while their parents completed a socio-demographic questionnaire and the Short Sensory Profile (SSP). (4) Results: Children with atopic diseases showed significantly lower preference to participate in activities than healthy controls and preferred quiet activities that can be performed alone. Within the atopic groups, children with AD, and specifically girls, had the highest activity preference while boys with Asthma had the lowest preference. SMD was significantly more prevalent in children with atopic diseases and correlated with their reduced preference to participate in activities. (5) Conclusions: Atopic diseases may restrict children's participation. Clinicians should evaluate participation of children with atopic diseases and examine whether comorbidities as SMD affect participation. Understanding the implications on children's daily life may improve intervention efficiency and elevate development and wellbeing.

Efficacy and Potential Mechanisms of Naringin in Atopic Dermatitis

Atopic dermatitis (AD) is one of the most prevalent chronic inflammatory skin diseases. Topical treatments are recommended for all patients regardless of severity, making it essential to develop an effective topical AD treatment with minimal side effects; We investigated the efficacy of topical application of naringin in AD and explored the possible mechanisms using an AD mouse model induced by 1-chloro-2,4-dinitrobenzene (DNCB). Clinical, histological, and immunological changes related to AD and Janus kinase (JAK)-signal transducer and activator of transcription (STAT) signaling proteins in the skin tissues were measured as outcomes; Naringin treatment resulted in a significant improvement in dermatitis severity score and reduced epidermal thickness and mast cell count in the skin (p < 0.05). Naringin also demonstrated the ability to inhibit DNCB-induced changes in interleukin (IL) 4, chemokine (C-C motif) ligand (CCL) 17, CCL22, IL1β, interferon-gamma (IFN-γ), and tumor necrosis factor-alpha (TNF-α) levels by quantitative real-time polymerase chain reaction (qRT-PCR) and IL13 by enzyme-linked immunosorbent assay (ELISA) (p < 0.05). Western blot results exhibited the decreased JAK1, JAK2, STAT1, STAT3, phospho-STAT3, and STAT6 expression in the naringin-treated groups (p < 0.05); The findings of this study suggest that topical naringin may effectively improve the symptoms of AD and could be used as a therapeutic agent for AD.

Efficacy and safety of dupilumab with concomitant topical corticosteroids in Japanese pediatric patients with moderate-to-severe atopic dermatitis: A randomized, double-blind, placebo-controlled phase 3 study

BACKGROUND

We investigated the efficacy and safety of dupilumab in Japanese patients aged ≥6 months to <18 years old with moderate-to-severe atopic dermatitis not adequately controlled with existing therapies.

METHODS

In this randomized, double-blind, phase 3 study, patients received dupilumab (n = 30) or placebo (n = 32) with concomitant topical corticosteroids for 16 weeks, then all patients received dupilumab from 16 to 52 weeks. The primary endpoint was the proportion of patients with ≥75% improvement in Eczema Area and Severity Index (EASI) score from baseline (EASI-75) to Week 16. Key secondary endpoints included changes in EASI score, proportion of patients with investigator global assessment (IGA) scores of 0/1, and changes in worst daily itch numerical rating scale (NRS) scores (evaluated in patients aged ≥6 to <12 years [n = 35]).

RESULTS

At Week 16, more patients achieved EASI-75 with dupilumab than placebo (43.3% vs 18.8%; P = 0.0304), and the least squares mean (LSM) difference in percent change in EASI scores at Week 16 of dupilumab vs placebo was -39.4% (P = 0.0003). However, no significant difference in the proportion of patients achieving IGA scores of 0/1 at Week 16 with dupilumab versus placebo were seen (10.0% vs 9.4%; P = 0.8476). The percent change in worst daily itch NRS scores at Week 16 was higher with dupilumab (LSM difference: -33.3%; nominal P = 0.0117). Dupilumab was well tolerated; no new safety signals were identified.

CONCLUSIONS

Dupilumab showed consistent efficacy and was well tolerated in Japanese patients aged ≥6 months to <18 years with moderate-to-severe atopic dermatitis previously insufficiently controlled with existing therapies.

Patient-Centered Practice Guidelines: GRADEing Evidence to Incorporate Certainty, Balance Between Benefits and Harms, Equity, Feasibility, and Cost-Effectiveness

The practice of medicine in recent years has emphasized the use of evidence-based clinical guidelines to help inform treatment decisions. Since its development in 2004, the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach has offered a systematic process for reviewing and summarizing the certainty of evidence found in the medical literature regarding various treatment options. To develop truly patient-centered care guidelines, this appraisal of the certainty of evidence must be combined with an understanding of the balance between benefits and harms, patient preferences, equity, feasibility, cost-effectiveness, and policy implications. This review examines each of these domains in detail, exploring the process and benefits of developing relevant, patient-focused guidelines directly applicable to the practice of modern medicine.

Updated Guidelines for Atopic Dermatitis-AAAAI/ACAAI Joint Task Force

This Viewpoint discusses the updated guidelines from the American Academy of Allergy, Asthma, and Immunology (AAAAI)/American College of Allergy, Asthma and Immunology (ACAAI) Joint Task Force on atopic dermatitis (eczema) management.