Systemic therapies in atopic dermatitis: The pipeline

Dupilumab for atopic dermatitis: a real-world portuguese multicenter retrospective study

Introduction: Atopic dermatitis (AD) is a difficult-to-treat inflammatory skin disease with a high impact on patients' quality of life. Dupilumab, an IL-4 and IL-13 inhibitor, was the first monoclonal antibody approved for the treatment of moderate-to-severe AD and is currently approved in patients aged 6 or older.Methods: This is a nationwide, multicenter, retrospective, 48-week study designed by the Portuguese Group of AD to assess real-world efficacy and safety of dupilumab for the treatment of AD.Results: A total of 169 patients were enrolled, with a mean disease duration of 22.75 (±11.98) years. The percentage of patients achieving an improvement of at least 75% in Eczema Area and Severity Index (EASI) compared to baseline (EASI75 response) at weeks 12 and 48 was 67.6% and 74.1%, respectively. In the same timepoints, 25.0% and 44.1% achieved an EASI90 response. Patient-reported outcome measures also improved throughout the study period. Regarding safety, 32.0% of the patients developed adverse events, with conjunctivitis (26.6%), persistent facial erythema (4.7%), and arthritis/arthralgia (3.6%) as the more frequently reported.Conclusion: Data from real-world populations are crucial to guide clinicians in their daily decisions. This study provides data demonstrating that dupilumab is an effective and safe therapeutic option for AD.

Concurrent autoimmune orofacial lesions: A rare occurrence!

Autoimmune disorders occur either as a solitary lesion or in pairs, but it is unusual to find two autoimmune disease lesions in the oral cavity in a single patient, who has been previously treated for psoriasis. We present the case of a 30-year-old male who presented with complaints of severe burning in the oral cavity. Examination revealed the presence of co-occurrence of vitiligo with oral lichen planus with a history of psoriasis and was managed conservatively with good response to treatment.

Atopic dermatitis in psychodermatology: a concise review for dermatologists

Atopic Dermatitis (AD) is a chronic disease of the skin with significant pruritus and phases of exacerbation and remission. The hallmarks of AD are changes in the epithelial barrier and chronic inflammation. This condition is associated with an increased risk of developing mental disorders such as depression, anxiety, and suicidal ideation. It has been proposed that psychological stress may impact on immunological factors with an up-regulation of mediating neuropeptides at the level of central nervous system and secondary involvement of endocrine glands, peripheral nervous system, and immune resident skin cells. This article provides a concise review for dermatologists on the psychodermatology of AD, in order to highlight the putative common pathways between the dermatologic and mental health issues in this illness.

The IL-4, IL-13 and IL-31 pathways in atopic dermatitis

Introduction: Atopic dermatitis (AD) is the most common inflammatory skin disease. It has a complex pathophysiology, with a combination of immune dysregulation and intrinsic barrier defects driving cutaneous inflammation and allergic symptomatology. The IL-4, IL-13 and IL-31 inflammatory pathways have been identified as hallmark features in the pathogenesis of the disease, contributing uniquely and synergistically to immune and barrier abnormalities as well as the key symptoms, such as pruritis. Novel therapeutics that target these pathways have been under development to find treatments for AD.Areas covered: This review discusses the IL-4, IL-13 and IL-31 pathways in AD. We will also detail novel targeted therapeutics that have recently been or are currently in clinical trials for AD. A literature search was conducted by querying Scopus, Google Scholar, PubMed, and Clinicaltrials.gov up to January 2021 using combinations of the search terms 'IL-4' 'IL-13' 'IL-31' 'atopic dermatitis' 'immune pathway' 'biologics' 'novel therapeutics' 'JAK/STAT inhibitors.'Expert opinion: The complex pathophysiology of AD advocates for innovation. Novel minimally invasive sampling modalities such as tape stripping will allow for a broader characterization of the immunomechanisms behind AD pathophysiology. This will allow for the continued development of a personalized medicine approach to treat AD.

Use of Tape Strips to Detect Immune and Barrier Abnormalities in the Skin of Children With Early-Onset Atopic Dermatitis

Importance

Molecular profiling of skin biopsies is the criterion standard for evaluating the cutaneous atopic dermatitis (AD) phenotype. However, skin biopsies are not always feasible in children. A reproducible minimally invasive approach that can track cutaneous disease in pediatric longitudinal studies or clinical trials is lacking.

Objective

To assess a minimally invasive approach using tape strips to identify skin biomarkers that may serve as a surrogate to biomarkers identified using whole-tissue biopsies.

Design, Setting, and Participants

This cross-sectional study of 51 children younger than 5 years recruited children with moderate to severe AD and children without AD from the dermatology outpatient clinics at a children's hospital. Sixteen tape strips were serially collected from the nonlesional and lesional skin of 21 children who had AD and were less than 6 months from disease initiation and from the normal skin of 30 children who did not have AD between January 22, 2016, and April 20, 2018.

Main Outcomes and Measures

Gene and protein expression were evaluated using quantitative real-time polymerase chain reaction and immunohistochemistry.

Results

A total of 51 children younger than 5 years were included in the study; 21 children had moderate to severe AD with less than 6 months of disease duration, and 30 children did not have AD. Of the 21 children with AD, the mean (SD) age was 1.7 (1.7) years, and most were male (15 [71.4%] and white (15 [71.4%]). Of the 30 children without AD, the mean (SD) age was 1.8 (2.0) years, and most were female (20 [66.7%]) and white (22 [73.3%]). Seventy-seven of 79 evaluated immune and barrier gene products were detected (gene detection rate, 97%) in 70 of 71 tape strips (sample detection rate, 99%), with 53 of 79 markers differentiating between children with lesional and/or nonlesional AD from children without AD. Many cellular markers of T cells (CD3), AD-related dendritic cells (Fc ε RI and OX40 ligand receptors), and key inflammatory (matrix metallopeptidase 12), innate (interleukin 8 [IL-8] and IL-6), helper T cell 2 (TH2; IL-4, IL-13, and chemokines CCL17 and CCL26), and TH17/TH22 (IL-19, IL-36G, and S100A proteins) genes were significantly increased in lesional and nonlesional AD compared with tape strips from normal skin. For example, IL-4 mean (SE) for lesional was -15.2 (0.91) and normal was -19.5 (0.48); P < .001. Parallel decreases occurred in epidermal barrier gene products (FLG, CLDN23, and FA2H) and negative immune regulators (IL-34 and IL-37). For example, the decrease for FLG lesional was mean (SE) -2.9 (0.42) and for normal was 2.2 (0.45); P < .001. Associations were found between disease severity or transepidermal water loss and TH2 (IL-33 and IL-4R) and TH17/TH22 (IL-36G and S100As) products in lesional and nonlesional AD skin (evaluated using the SCORing Atopic Dermatitis, Eczema Area and Severity Index, and Pruritus Atopic Dermatitis Quickscore tools).

Conclusions and Relevance

In this study, tape strips provide a minimally invasive alternative for serially evaluating AD-associated cutaneous biomarkers and may prove useful for tracking pediatric AD therapeutic response and predicting future course and comorbidities.

Correlation of Blood FoxP3+ Regulatory T Cells and Disease Activity of Atopic Dermatitis

Objectives

To investigate CD4+CD25+FoxP3+ T regulatory cells (Tregs) in the peripheral blood of patients with atopic dermatitis (AD) and its correlation with disease severity.

Methods

Blood samples from 79 AD patients before and after four-week conventional treatment were collected. Cell counts of CD4+CD25+FoxP3+Tregs, CD4+CD25+FoxP3-T effector cells (Teffs), and CD4+IL-10+Tregs were analyzed by flow cytometry. Serum levels of IL-4, IL-10, IL-12, IL-13, IFN-γ, and TGF-β were measured by ELISA.

Results

The pretreatment cell count of CD4+CD25+FoxP3+Tregs positively correlated with disease severity in all patients (P < 0.0001). However, when that correlation was rechecked based on the treatment response, a much stronger correlation of that was found in those patients with remission after treatment, while no correlation of that was found in patients without remission. Both the cell count and proportions of peripheral CD4+CD25+FoxP3+Tregs and CD4+CD25+FoxP3-Teffs reduced significantly after treatment in patients with remission, but remained unchanged in patients without remission. The cell count and proportion of CD4+IL-10+Tregs did not change after treatment in both groups. In patients with remission, serum levels of IL-4 and IL-13 significantly reduced (all P < 0.05); IL-12 and IFN-γ levels increased significantly (all P < 0.05); IL-10 and TGF-β levels remained unchanged after treatment. None of those cytokine levels changed in patients without remission.

Conclusions

CD4+CD25+FoxP3+Tregs is associated with AD development and severity in some patients but not in others. AD maybe divided into CD4+CD25+FoxP3+Treg-associated subtype, which CD4+CD25+FoxP3+Treg is parallel to the activity of AD, and nonassociated subtype, which CD4+CD25+FoxP3+Treg is not related. This subgroup difference may contribute partly to the nonidentical markers that have been found in AD and should be studied further.

New treatments for atopic dermatitis targeting beyond IL-4/IL-13 cytokines

OBJECTIVE

Atopic dermatitis (AD) is an increasingly common inflammatory skin disease undergoing significant revolution in recent years. New data on disease pathogenesis advanced the developments of novel therapeutics, mainly for patients with moderate to severe conditions, for whom treatment options have been largely insufficient for many years.

DATA SOURCES

Review of recent studies investigating systemic treatments for AD.

STUDY SELECTIONS

Relevant literature concerning novel therapeutics for AD beyond targeted monoclonal antibodies antagonizing selectively interleukin (IL)-4 or IL-13 was obtained from a PubMed and clinicaltrials.gov search and summarized.

RESULTS

Multiple clinical trials of both nonspecific as well as specific agents revealed favorable outcomes in AD, including JAK inhibitors, a dual JAK/SYK inhibitor, a histamine H4R antagonist, antagonists of the TSLP/OX40L axis, an IL-22 inhibitor, and IL-33 and IL-17C antagonists. Importantly, negative trials were published as well (eg, phosphodiesterase 4 inhibitor, apremilast).

CONCLUSION

In this rapidly evolving field of AD treatments, a completely new treatment paradigm will be available in the near future.

The oral Janus kinase/spleen tyrosine kinase inhibitor ASN002 demonstrates efficacy and improves associated systemic inflammation in patients with moderate-to-severe atopic dermatitis: results from a randomized double-blind placebo-controlled study

BACKGROUND

ASN002 is an oral dual inhibitor of Janus kinase and spleen tyrosine kinase, which are involved in the pathogenesis of atopic dermatitis (AD) through their regulatory role on T helper (Th)1, Th2 and Th17/Th22 pathways.

OBJECTIVES

The objectives of this study were to evaluate the efficacy, safety, pharmacokinetics and effects on systemic biomarkers of ASN002 in patients with moderate-to-severe AD. Methods A total of 36 patients with moderate-to-severe AD were randomized (3 : 1) to ASN002 or placebo in the phase Ib study. Three dosage cohorts were studied over a 28-day period (20 mg, 40 mg and 80 mg once daily).

RESULTS

ASN002 was superior to placebo for the proportion of patients achieving Eczema Area and Severity Index (EASI) 50 (20 mg 20%, P = 0·93; 40 mg 100%, P = 0·003; 80 mg 83%, P = 0·03; placebo 22%), EASI 75 (20 mg 0%, P = 0·27; 40 mg 71%, P = 0·06; 80 mg 33%, P = 0·65; placebo 22%) and in change from baseline in pruritus (20 mg -1·3 ± 2·1, P = 0·81; 40 mg -3·1 ± 2·7, P = 0·27; 80 mg -4·7 ± 2·1, P = 0·01; placebo -1·6 ± 1·8). Adverse events were generally mild and similar across all groups. ASN002 showed dose-dependent plasma exposure with low interpatient variability, significantly downregulated several serum biomarkers involved in Th1, Th2 and Th17/Th22 immunity, and decreased the atherosclerosis-associated biomarker E selectin/SELE.

CONCLUSIONS

In patients with moderate-to-severe AD, ASN002 showed strong efficacy with rapid onset of action and associated improvements in systemic inflammation.

JAK Inhibitors for Atopic Dermatitis: An Update

Atopic dermatitis (AD) is one of the most common inflammatory skin diseases. AD is driven by barrier dysfunction and abnormal immune activation of T helper (Th) 2, Th22, and varying degrees of Th1 and Th17 among various subtypes. The Janus kinase (JAK)-signal transducer and activator of transcription (STAT) and spleen tyrosine kinase (SYK) pathways are involved in signaling of several AD-related cytokines, such as IFN-γ, IL-4, IL-13, IL-31, IL-33, IL-23, IL-22, and IL-17, mediating downstream inflammation and barrier alterations. While AD is primarily Th2-driven, the clinical and molecular heterogeneity of AD endotypes highlights the unmet need for effective therapeutic options that target more than one immune axis and are safe for long-term use. The JAK inhibitors, which target different combinations of kinases, have overlapping but distinct mechanisms of action and safety profiles. Several topical and oral JAK inhibitors have been shown to decrease AD severity and symptoms. A review of the JAK and SYK inhibitors that are currently undergoing evaluation for efficacy and safety in the treatment of AD summarizes available data on a promising area of therapeutics and further elucidates the complex molecular interactions that drive AD.

GBR 830, an anti-OX40, improves skin gene signatures and clinical scores in patients with atopic dermatitis

BACKGROUND

GBR 830 is a humanized mAb against OX40, a costimulatory receptor on activated T cells. OX40 inhibition might have a therapeutic role in T cell-mediated diseases, including atopic dermatitis (AD).

OBJECTIVE

This exploratory phase 2a study investigated the safety, efficacy, and tissue effects of GBR 830 in patients with AD.

METHODS

Patients with moderate-to-severe AD (affected body surface area, ≥10%; Eczema Area and Severity Index score, ≥12; and inadequate response to topical treatments) were randomized 3:1 to 10 mg/kg intravenous GBR 830 or placebo on day 1 (baseline) and day 29. Biopsy specimens were collected (n = 40) at days 1, 29, and 71. Primary end points included treatment-emergent adverse events (TEAEs) and changes from baseline in biomarkers (epidermal hyperplasia/cytokines) at days 29 and 71.

RESULTS

GBR 830 was well tolerated, with equal TEAE distribution (GBR 830, 63.0% [29/46]; placebo, 63.0% [10/16]). One serious TEAE in the GBR 830 group was deemed unrelated to study drug. At day 71, the proportion of intent-to-treat subjects achieving 50% or greater improvement in Eczema Area and Severity Index score was greater with GBR 830 (76.9% [20/26]) versus placebo (37.5% [3/8]). GBR 830 induced significant progressive reductions in T_H1 (IFN-γ/CXCL10), T_H2 (IL-31/CCL11/CCL17), and T_H17/T_H22 (IL-23p19/IL-8/S100A12) mRNA expression in lesional skin. Significant progressive reductions until day 71 in the drug group were seen in OX40⁺ T cells and OX40L⁺ dendritic cells (P < .001). Hyperplasia measures (thickness/keratin 16/Ki67) showed greater reductions with GBR 830 (P < .001).

CONCLUSIONS

Two doses of GBR 830 administered 4 weeks apart were well tolerated and induced significant progressive tissue and clinical changes until day 71 (42 days after the last dose), highlighting the potential of OX40 targeting in patients with AD.

Testing biologics and intracellular signaling inhibitors on pediatric atopic dermatitis: a stairway to modern therapeutic approaches

INTRODUCTION

Atopic dermatitis (AD) is the most common cutaneous inflammatory disease in adults and children. In the last few years, the pathogenesis of AD has been profoundly revised, and this has led to the identification of novel druggable targets and the development of new agents targeting specific molecular pathways. Despite the high prevalence of AD in the pediatric population, the clinical development of new treatments, either topical or systemic, has been focused on the adult population in recent years; only a limited number of these new agents have been tested in pediatric cohorts.

AREAS COVERED

In this review, we describe the pathogenic model of pediatric AD which shows similarities and substantial differences when compared to adult AD. The identification of therapeutic targets is highlighted, and novel targeted therapies, both topical and systemic, are discussed.

EXPERT OPINION

The current therapeutic armamentarium for pediatric AD is very limited, and this represents a critical unmet need. The enhancement of clinical research on pediatric patients is necessary to facilitate an increase in the number of new targeted therapeutic options being available on the market.

Are Biologics Efficacious in Atopic Dermatitis? A Systematic Review and Meta-Analysis

BACKGROUND

Current systemic treatments for atopic dermatitis (AD) offer limited efficacy and are often restricted by safety concerns. Biologics may address the unmet need for improved AD therapeutics.

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of biologic agents in AD.

METHODS

A systematic review and meta-analysis of studies evaluating AD patients treated with biologics was performed. The primary outcome was the Eczema Area and Severity Index (EASI)-75 response, while secondary outcomes were SCOring Atopic Dermatitis (SCORAD)-75, EASI-50, SCORAD-50, Investigator Global Assessment 0/1 responses, change in responses from baseline, and adverse events.

RESULTS

We included 13 randomized controlled trials (RCTs) and 10 observational studies evaluating nine biologics. High-quality evidence was available for dupilumab, nemolizumab and ustekinumab. Pooling five studies, at weeks 12-16 dupilumab 300 mg every week to every 2 weeks achieved EASI-75 responses of 55%, superior to placebo [relative risk (RR) 3.3, 95% confidence interval (CI) 2.9-3.6]. Nemolizumab had similar EASI-75 responses as placebo, but significantly improved pruritus. In online reports, lebrikizumab demonstrated superior EASI-50 responses versus placebo (RR 1.3, 95% CI 1.04-1.7), while tralokinumab had superior SCORAD-50 responses versus placebo, with borderline significance (RR 1.7, 95% CI 0.97-3.1). In two RCTs each, omalizumab and ustekinumab were comparable with placebo, while antithymic stromal lymphopoietin receptor, infliximab, and rituximab lacked adequate evidence of efficacy. All medications had a comparable safety profile to placebo.

LIMITATIONS

Lack of RCTs and the use of variable outcome measures limited conclusions.

CONCLUSION

Dupilumab is currently the only biologic with robust evidence of efficacy in AD. Nemolizumab, lebrikizumab, and tralokinumab show promise but further data are needed. Longer follow-up and larger studies will establish their safety profile.

Dupilumab for the Treatment of Atopic Dermatitis

Atopic dermatitis (AD) is a common, chronic, inflammatory skin disorder with high physical and emotional burden. AD usually starts in early childhood and has a heterogeneous course. Emerging evidence suggests that IL-4 and IL-13 are key cytokines in the immunopathogenesis of AD. Dupilumab is a monoclonal antibody directed against IL-4 receptor α subunit, that blocks both IL-4 and IL-13 signaling. Data from Phase I-III studies revealed that dupilumab, administered as monotherapy or with topical corticosteroids, is effective and well tolerated in the treatment of adult patients with moderate-to-severe AD. A large proportion of patients receiving dupilumab had significant improvements in multiple efficacy indexes, including Eczema Area and Severity Index, Investigator's Global Assessment and SCORing Atopic Dermatitis scores. These results introduce a new era of targeted therapies in the management of AD.