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Caron AGM, Bloem M, El Khattabi H, de Waal AC, van Huizen AM, Denswil NP, Gerbens LAA, Spuls PI. The wide variety of methotrexate dosing regimens for the treatment of atopic dermatitis: a systematic review. J DERMATOL TREAT 2024; 35:2292962. [PMID: 38124505 DOI: 10.1080/09546634.2023.2292962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023]
Abstract
Background:Methotrexate is an off-label therapy for atopic dermatitis. A lack of consensus on dosing regimens poses a risk of underdosing and ineffective treatment or overdosing and increased risk of side effects. This systematic review summarizes the available evidence on dosing regimens.Materials and methods:A literature search was conducted, screening all randomized controlled trials (RCTs) and guidelines published up to 6 July 2023, in the MEDLINE, Embase, and Cochrane Library databases.Results:Five RCTs and 21 guidelines were included. RCTs compared methotrexate with other treatments rather than different methotrexate dosing regimens. The start and maintenance doses in RCTs varied between 7.5-15 mg/week and 14.5-25 mg/week, respectively. Despite varied dosing, all RCTs demonstrated efficacy in improving atopic dermatitis signs and symptoms. Guidelines exhibited substantial heterogeneity but predominantly proposed starting doses of 5-15 mg/week for adults and 10-15 mg/m2/week for children. Maintenance doses suggested were 7.5-25 mg/week for adults and 0.2-0.7 mg/kg/week for children. One guideline suggested a test dose and nearly half advised folic acid supplementation.Conclusion:This systematic review highlights the lack of methotrexate dosing guidelines for atopic dermatitis. It identifies commonly recommended and utilized dosing regimens, serving as a valuable resource for clinicians prescribing methotrexate off-label and providing input for an upcoming consensus study.
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Affiliation(s)
- Anouk G M Caron
- Dermatology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Infection and Immunity, University of Amsterdam, Amsterdam, the Netherlands
| | - Manja Bloem
- Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Hajar El Khattabi
- Dermatology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Ayla C de Waal
- Dermatology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Astrid M van Huizen
- Dermatology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Infection and Immunity, University of Amsterdam, Amsterdam, the Netherlands
| | - Nerissa P Denswil
- Medical Library, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Louise A A Gerbens
- Dermatology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Infection and Immunity, University of Amsterdam, Amsterdam, the Netherlands
| | - Phyllis I Spuls
- Dermatology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Infection and Immunity, University of Amsterdam, Amsterdam, the Netherlands
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2
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Jiménez-Andrade Y, Hillette KR, Yoshida T, Kashiwagi M, Choo MK, Liang Y, Georgopoulos K, Park JM. The Developmental Transcription Factor p63 Is Redeployed to Drive Allergic Skin Inflammation through Phosphorylation by p38α. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2022; 208:2613-2621. [PMID: 35623662 PMCID: PMC9308733 DOI: 10.4049/jimmunol.2101160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 04/03/2022] [Indexed: 06/15/2023]
Abstract
Keratinocytes, the epithelial cells of the skin, reprogram their gene expression and produce immune effector molecules when exposed to environmental and endogenous triggers of inflammation. It remains unclear how keratinocytes process physiological signals generated during skin irritation and switch from a homeostatic to an inflammatory state. In this article, we show that the stress-activated protein kinase p38α is crucial for keratinocytes to prompt changes in their transcriptome upon cytokine stimulation and drive inflammation in allergen-exposed skin. p38α serves this function by phosphorylating p63, a transcription factor essential for the lineage identity and stemness of the skin epithelium. Phosphorylation by p38α alters the activity of p63 and redeploys this developmental transcription factor to a gene expression program linked to inflammation. Genetic ablation and pharmacological inhibition of p38α or the p38α-p63 target gene product MMP13 attenuate atopic dermatitis-like disease in mice. Our study reveals an epithelial molecular pathway promoting skin inflammation and actionable through treatment with topical small-molecule therapeutics.
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Affiliation(s)
- Yanek Jiménez-Andrade
- Cutaneous Biology Research Center, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Kathryn R Hillette
- Cutaneous Biology Research Center, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Toshimi Yoshida
- Cutaneous Biology Research Center, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
- International Research Center for Medical Sciences, Kumamoto University, Kumamoto, Japan; and
| | - Mariko Kashiwagi
- Cutaneous Biology Research Center, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Min-Kyung Choo
- Cutaneous Biology Research Center, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Yinming Liang
- School of Laboratory Medicine, Xinxiang Medical University, Xinxiang, China
| | - Katia Georgopoulos
- Cutaneous Biology Research Center, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Jin Mo Park
- Cutaneous Biology Research Center, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA;
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Chovatiya R, Silverberg JI. Evaluating the Longitudinal Course of Atopic Dermatitis: Implications for Clinical Practice. Am J Clin Dermatol 2022; 23:459-468. [PMID: 35639253 PMCID: PMC10166131 DOI: 10.1007/s40257-022-00697-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2022] [Indexed: 11/01/2022]
Abstract
Atopic dermatitis (AD) is characterized by a heterogenous longitudinal course with varying severity, flares, and persistence. However, AD course is not routinely assessed in clinical practice or controlled trials. Our objective was to review the longitudinal course of AD in children and adults and discuss implications for routine practice and clinical trials. We conducted a focused review of the published literature, including retrospective, prospective, and interventional studies, clinical trials, and consensus guidelines. Estimates of AD persistence varied widely across studies but suggested that AD can indeed persist through childhood and into adulthood. Predictors of persistence are broad and include both disease-intrinsic and disease-extrinsic (i.e., environmental) factors. In real-world practice, most individuals with AD experience fluctuations in the signs and symptoms over time and do not experience persistent clearance of skin lesions. Clinical trials use mainly static measurements that do not take into account fluctuations in course, which may confound treatment effects. The heterogenous temporal pattern of AD can be incorporated into routine practice to better set expectations and offer a realistic prognosis. AD course should be routinely incorporated into clinical decision making. Future studies are needed to develop a standardized approach to AD assessment and treatment that includes longitudinal course.
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DESCRIBE-AD: A novel classification framework for atopic dermatitis. J Am Acad Dermatol 2021; 87:541-550. [PMID: 34774658 PMCID: PMC10119387 DOI: 10.1016/j.jaad.2021.10.058] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 09/27/2021] [Accepted: 10/29/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Atopic dermatitis (AD) is a chronic, inflammatory skin disease associated with heterogeneous morphology, distribution, symptoms, severity, extent, longitudinal courses, quality of life burden, comorbidities, and treatment responses. This heterogeneity contributes to challenges in diagnosis, the characterization of disease activity, and therapeutic stratification. OBJECTIVE To develop a framework to standardize AD assessment. METHODS We propose a novel framework to assess AD based on a literature review and clinical experience. RESULTS DESCRIBE-AD is a framework that can effectively capture the clinical domains contributing to AD heterogeneity and includes both patient- and clinician-reported perspectives. DESCRIBE-AD includes assessments of Dermatitis morphology and phenotype, Evolution of disease, Symptom severity, Comorbid health disorders, Response to therapy, Intensity of lesions, Burden of disease, and Extent of lesions. Rather than placing the focus on any single, specific aspect of AD, DESCRIBE-AD allows for a comprehensive approach to the assessment and clinical management of AD. CONCLUSIONS DESCRIBE-AD is a novel framework that can be used to better describe the heterogeneity of AD and guide treatment decisions.
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5
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Chovatiya R, Lei D, Ahmed A, Chavda R, Gabriel S, Silverberg JI. Clinical phenotyping of atopic dermatitis using combined itch and lesional severity: A prospective observational study. Ann Allergy Asthma Immunol 2021; 127:83-90.e2. [PMID: 33819616 DOI: 10.1016/j.anai.2021.03.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/08/2021] [Accepted: 03/18/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Patients with atopic dermatitis (AD) have heterogeneous clinical phenotypes, including different combinations of itch and lesional severity. Little is known about the characteristics and course of these subtypes. OBJECTIVE To determine the characteristics, associations, burden, and course of patients with AD using combined itch and lesional severity. METHODS A prospective practice-based study was performed using questionnaires and physical examination (n=592). AD subsets were defined using verbal rating scale for average itch combined with either eczema area and severity index, objective-scoring atopic dermatitis (SCORAD), or validated investigator's global assessment as follows: mild-moderate itch and lesions (MI-ML), mild-moderate itch and severe lesions (MI-SL), severe itch and mild-moderate lesions (SI-ML), and severe itch and lesions (SI-SL). RESULTS At baseline, there were only weak-moderate correlations of numerical rating scales for worst itch or average itch or SCORAD itch with eczema area and severity index, objective-SCORAD, body surface area, and validated investigator's global assessment (Spearman's rho = 0.32-0.62). Most patients had MI-ML (59.4%-62.3%), followed by SI-ML (21.3%-29.1%), SI-SL (6.0%-12.9%), and MI-SL (3.8%-6.4%). Patients with SI-SL, followed by SI-ML and MI-SL, described their AD as being more severe overall and had worse impairment in sleep, mental health, and quality of life. However, those with MI-SL or SI-SL were far more likely to be classified as severe by a physician (multivariable logistic and linear regression, P < .005 for all). Baseline MI-SL, SI-ML, and SI-SL were associated with similar longitudinal courses over time and more AD flares and itch triggers than MI-ML. CONCLUSION Combined itch and lesional severity seem to describe unique AD phenotypes. Further studies are needed to confirm these findings and understand the optimal treatments for these groups.
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Affiliation(s)
- Raj Chovatiya
- Department of Dermatology, Feinberg School of Medicine at Northwestern University, Chicago, Illinois
| | - Donald Lei
- Department of Dermatology, Feinberg School of Medicine at Northwestern University, Chicago, Illinois
| | - Adnan Ahmed
- Department of Dermatology, Feinberg School of Medicine at Northwestern University, Chicago, Illinois
| | - Rajeev Chavda
- Galderma SA, Rx Strategy & Innovation Group, La Tour-de-Peliz, Switzerland
| | - Sylvie Gabriel
- Galderma SA, Rx Strategy & Innovation Group, La Tour-de-Peliz, Switzerland
| | - Jonathan I Silverberg
- Department of Dermatology, Feinberg School of Medicine at Northwestern University, Chicago, Illinois; Department of Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, DC.
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Misery L. Fardeau de la dermatite atopique chez l’enfant et l’adolescent. Ann Dermatol Venereol 2020; 147:11S31-11S36. [DOI: 10.1016/s0151-9638(20)31086-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Hong MR, Lei D, Yousaf M, Chavda R, Gabriel S, Janmohamed SR, Silverberg JI. A real-world study of the longitudinal course of adult atopic dermatitis severity in clinical practice. Ann Allergy Asthma Immunol 2020; 125:686-692.e3. [PMID: 32682980 DOI: 10.1016/j.anai.2020.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/03/2020] [Accepted: 07/10/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Little is known about the longitudinal course of adult atopic dermatitis (AD) lesional severity and extent in clinical practice. OBJECTIVE To determine the longitudinal course of AD in clinical practice. METHODS A prospective, dermatology practice-based study was performed (n = 400). Patients were assessed at baseline and approximately 6, 12, 18, and 24 months by eczema area and severity index (EASI) and objective-scoring atopic dermatitis (objective-SCORAD). Multivariable repeated measures linear regression models were constructed to evaluate AD severity over time. RESULTS Overall, 36.2% and 18.2% of patients had moderate (6.0-22.9) or severe (23.0-72.0) EASI scores at any visit, respectively. Similarly, 29.0% and 26.4% of patients had moderate (24.0-37.9) or severe (38.0-83.0) objective-SCORAD scores at any visit, respectively. Among patients with baseline moderate (6.0-22.9) or severe (23.0-72.0) EASI scores, 25.0% and 18.6% continued to have moderate or severe scores at 1 or more follow-up visits, respectively. Similarly, among patients with baseline moderate (24.0-37.9) or severe (38.0-83.0) objective-SCORAD scores, 22.6% and 24.5% continued to have moderate or severe scores at 1 or more follow-up visits, respectively. In longitudinal regression models, EASI was significantly associated with body surface area (adjusted β [95% confidence interval]: 0.16 [0.09-0.23]) and edema/papulation (2.31 [0.19-4.43]). In addition, objective-SCORAD was significantly associated with body surface area (0.12 [0.04-0.21]), edema/papulation (4.69 [2.05-7.32]), and scratch (3.34 [0.45-6.24]) over time. CONCLUSION AD lesional severity has a heterogeneous longitudinal course. Many patients had fluctuating lesional severity scores over time. A minority of patients had persistently moderate or severe lesions over time. Most patients with moderate-severe disease at baseline were unable to achieve persistent lesional clearance.
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Affiliation(s)
- Mindy R Hong
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Donald Lei
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Muhammad Yousaf
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rajeev Chavda
- Prescription Strategy and Innovation Group, Galderma SA, La Tour-de-Peilz, Switzerland
| | - Sylvie Gabriel
- Prescription Strategy and Innovation Group, Galderma SA, La Tour-de-Peilz, Switzerland
| | - Sherief R Janmohamed
- Department of Dermatology, Universitair Ziekenhuis Brussel (UZB), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Jette, Belgium
| | - Jonathan I Silverberg
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Dermatology, the George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.
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8
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Howell AN, Ghamrawi RI, Strowd LC, Feldman SR. Pharmacological management of atopic dermatitis in the elderly. Expert Opin Pharmacother 2020; 21:761-771. [PMID: 32100586 DOI: 10.1080/14656566.2020.1729738] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 02/11/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The prevalence of atopic dermatitis (AD) in geriatric populations of industrialized countries is currently estimated at 3-4% and continues to increase. AD is associated with significant morbidity, increased susceptibility to infection, and symptoms of pruritus and pain. Treatments may negatively affect elderly patients; thus, plans should be optimized for this population. AREAS COVERED This review summarizes treatment options for AD in the elderly. A systematic review of the literature was conducted using the key terms atopic dermatitis, elderly, geriatric, systemic therapy, therapy, and topical therapy in PubMed. Searches yielded articles on skincare management and topical and systemic pharmacotherapies. EXPERT OPINION Proper use of moisturizer is crucial in all patients with AD. Topical corticosteroids are commonly prescribed; however, they carry an increased risk of adverse events such as skin atrophy. Systemic corticosteroids should be avoided in elderly patients due to questionable efficacy and increased adverse events. Topical calcineurin inhibitors and crisaborole are similarly efficacious with an excellent safety profile. Cyclosporine, azathioprine, methotrexate, and mycophenolate mofetil are systemic agents available for the treatment of refractory AD; however, insufficient data exist to indicate the superiority of any one agent. Dupilumab is a safe and efficacious injectable therapy in elderly patients.
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Affiliation(s)
- Alexander N Howell
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine , Winston-Salem, NC, USA
| | - Rima I Ghamrawi
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine , Winston-Salem, NC, USA
| | - Lindsay C Strowd
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine , Winston-Salem, NC, USA
| | - Steven R Feldman
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine , Winston-Salem, NC, USA
- Department of Pathology, Wake Forest School of Medicine , Winston-Salem, NC, USA
- Department of Social Sciences & Health Policy, Wake Forest School of Medicine , Winston-Salem, NC, USA
- Department of Dermatology, University of Southern Denmark , Odense, Denmark
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9
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Assem M, Khowessah OM, Ghorab D. Nano-crystallization as a tool for the enhancement of beclomethasone dipropionate dermal deposition: Formulation, in vitro characterization and ex vivo study. J Drug Deliv Sci Technol 2019. [DOI: 10.1016/j.jddst.2019.101318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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10
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McKenzie C, Silverberg JI. The prevalence and persistence of atopic dermatitis in urban United States children. Ann Allergy Asthma Immunol 2019; 123:173-178.e1. [PMID: 31128232 DOI: 10.1016/j.anai.2019.05.014] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 05/10/2019] [Accepted: 05/15/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Previous studies found that childhood atopic dermatitis (AD) and asthma are associated with residence in urban areas. However, little is known about the prevalence and determinants of AD in US urban populations and its impact on quality-of-life (QOL) and asthma. OBJECTIVE To determine AD prevalence and persistence, sociodemographic predictors thereof, and association with QOL and atopic comorbidities in US urban children. METHODS We analyzed data from The Fragile Families and Child Wellbeing Study, a prospective cohort study of 4898 women and their children born in 20 large US cities between 1998 and 2000. AD prevalence was determined at ages 5, 9, and 15 years, and stratified by sex, race/ethnicity, and household poverty income level. RESULTS The prevalences (95% confidence interval [CI]) of childhood AD were 15.0% (11.0%-18.9%), 15.1% (11.5%-18.7%), and 14.5% (10.4%%-18.5%) at ages 5, 9, and 15 years, respectively. Female sex (multivariable repeated measures logistic regression; adjusted odds-ratio [95% CI]: 1.56 [1.02-2.37]) and black race (1.80 [1.07-3.01]) were associated with persistent AD across all 3 ages. Children with AD at ages 5 and 15 (2.63 [1.42-4.86]), 5, 8 and 15 (1.47 [1.02-2.12]) and 9 and 15 years (1.61 [1.00-2.60]) had higher odds of poor/fair/good overall health. Children with AD at ages 5 and 9 years had the highest odds of ever having asthma (adjusted odds ratio [95% confidence interval]: 6.05 [5.88-6.22]), followed by children with AD at ages 5, 9, and 15 years (3.17 [3.07%-3.27]). CONCLUSION Atopic dermatitis prevalence and persistence were highest in US urban children who were female or black. Urban children with persistent AD were more likely to have poor QOL and asthma.
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Affiliation(s)
- Costner McKenzie
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jonathan I Silverberg
- Departments of Dermatology, Preventive Medicine and Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Northwestern Medicine Multidisciplinary Eczema Center, Chicago, Illinois.
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Rajagopalan M, De A, Godse K, Krupa Shankar DS, Zawar V, Sharma N, Mukherjee S, Sarda A, Dhar S. Guidelines on Management of Atopic Dermatitis in India: An Evidence-Based Review and an Expert Consensus. Indian J Dermatol 2019; 64:166-181. [PMID: 31148854 PMCID: PMC6537677 DOI: 10.4103/ijd.ijd_683_18] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Atopic dermatitis (AD) is a common and chronic, pruritic inflammatory skin condition that affects all age groups. There was a dearth of consensus document on AD for Indian practitioners. This article aims to provide an evidence-based consensus statement for the management of AD with a special reference to the Indian context. This guideline includes updated definition, etiological factors, classification, and management of atopic dermatitis. METHODOLOGY The preparation of guidelines was done in multiple phases. Indian Dermatology Expert Board Members (DEBM), recommended by the Skin Allergy Society of India, prepared 26 evidence-based recommendations for AD. An extensive literature search was done in MEDLINE, Google scholar, Cochrane, and other resources. Articles published in the past 10 years were reviewed and recommendations were graded based on the quality of evidence as per GRADE. After forming the initial structure, DEBM met in Mumbai and gave their decisions on an agree and disagree scale with an Indian perspective. Finally, their suggestions were compiled for preparing the article. After DEBM finalized the draft, a treatment algorithm was formulated for the management of AD. RESULTS DEBM suggested a working definition for AD. The panel agreed that moisturizers should be used as mainstay of therapy and should be continued in all lines of therapy and in maintenance phase. Topical corticosteroids and topical calcineurin inhibitors should be considered as the first line of treatment. Among systemic therapies, cyclosporin should be considered first line, followed by azathioprine, methotrexate, and mycophenolate mofetil. Phototherapy can be an effecive alternative. Empirical food restriction was recommended against. CONCLUSION These guidelines should form a reference for the management of patients with AD in an evidence-based manner.
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Affiliation(s)
| | - Abhishek De
- Department of Dermatology, Calcutta National Medical College, Kolkata, West Bengal, India
| | - Kiran Godse
- Department of Dermatology, D Y Patil Hospital, Navi Mumbai, Maharashtra, India
| | - D S Krupa Shankar
- Department of Dermatology, Mallige Hospital, Bengaluru, Karnataka, India
| | - Vijay Zawar
- Department of Dermatology, Skin Diseases Center, Nashik, Maharashtra, India
| | - Nidhi Sharma
- Department of Dermatology, The Medicity, Medanta Hospital, Gurugram, Haryana, India
| | - Samipa Mukherjee
- Department of Dermatology, Cloud Nine Hospitals, Bengaluru, Karnataka, India
| | - Aarti Sarda
- Department of Dermatology, Wizderm Specialty Skin and Hair Clinic, Kolkata, West Bengal, India
| | - Sandipan Dhar
- Department of Dermatology, Institute of Child Health, Kolkata, West Bengal, India
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12
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Pacifico A, Iacovelli P, Damiani G, Ferraro C, Cazzaniga S, Conic RRZ, Leone G, Morrone A. 'High dose' vs. 'medium dose' UVA1 phototherapy in italian patients with severe atopic dermatitis. J Eur Acad Dermatol Venereol 2019; 33:718-724. [PMID: 30468530 PMCID: PMC6440836 DOI: 10.1111/jdv.15362] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 10/12/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The current evidences attest UVA1 phototherapy as effective in the treatment of severe atopic dermatitis (AD). Furthermore, in this indication, 'medium dose' is as effective as 'high dose' regimen. To date, a randomized comparison study evaluating the effectiveness as well as safety of different UVA1 protocols in different skin types in the treatment of adult patients with severe AD is still lacking. OBJECTIVE The aim of the present study was to compare the safety and the efficacy of medium and high dose UVA1 either in fair or in dark skin types. METHODS Twenty-seven adult patients with severe AD were consecutively included in a randomized, controlled, open, two arms trial Severity of AD was determined by means of SCORAD index and clinical improvement was also monitored. A total of 13 out of 27 patients were treated with high dose (130 J/cm2 ) UVA1 protocol while 14 out of 27 patients received medium dose (60 J/cm2 ) UVA1 protocol. Phototherapy was performed five times weekly up to 3 weeks. Before and after UVA1 treatment each patient was evaluated for skin pigmentation through Melanin Index (MI) quantitative evaluation. RESULTS Skin status improved in all patients resulting in a reduction of SCORAD index in all groups. Our results demonstrated that among patients with darker skin types and higher MI, high dose UVA1 was significantly more effective than medium dose (P < 0.0001) while within the groups with skin type II, no significant differences between high and medium dose protocols were observed. CONCLUSION Our study, confirms previous observations that UVA1 phototherapy should be considered among the first approaches in the treatment of patients with severe generalized AD and also demonstrates that in darker skin types, high dose UVA1 phototherapy is more effective than medium dose in the treatment of adult patients with severe AD.
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Affiliation(s)
- A Pacifico
- Clinical Dermatology Department, S. Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - P Iacovelli
- Clinical Dermatology Department, S. Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - G Damiani
- Dipartimento di Fisiopatologia Medico-Chirurgica e Dei Trapianti, Unità Operativa di Dermatologia, IRCCS, Fondazione Cà Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milano, Italy
- Study Center of Young Dermatologists Italian Network (YDIN), GISED, Bergamo, Italy
- Department of Dermatology, Case Western Reserve University, Cleveland, OH, USA
| | - C Ferraro
- Clinical Dermatology Department, S. Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - S Cazzaniga
- Centro Studi GISED, Bergamo, Italy
- Department of Dermatology, Inselspital University Hospital, Bern, Switzerland
| | - R R Z Conic
- Department of Dermatology, Case Western Reserve University, Cleveland, OH, USA
| | - G Leone
- Clinical Dermatology Department, S. Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - A Morrone
- Clinical Dermatology Department, S. Gallicano Dermatological Institute, IRCCS, Rome, Italy
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13
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Remitz A, De Pità O, Mota A, Serra-Baldrich E, Vakirlis E, Kapp A. Position statement: topical calcineurin inhibitors in atopic dermatitis. J Eur Acad Dermatol Venereol 2018; 32:2074-2082. [DOI: 10.1111/jdv.15272] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/20/2018] [Indexed: 12/14/2022]
Affiliation(s)
- A. Remitz
- Department of Skin and Allergic Diseases; Helsinki University Central Hospital; Helsinki Finland
| | - O. De Pità
- Department of Dermatology and Allergy; Cristo Re Hospital; Rome Italy
| | - A. Mota
- Department of Dermatology; Faculty of Medicine; University of Porto; i3S Research Institute; Porto Portugal
| | - E. Serra-Baldrich
- Department of Dermatology; Sant Pau Hospital; Autonomous University; Barcelona Spain
| | - E. Vakirlis
- Department of Dermatology and Venereology; Aristotle University Medical School; Thessaloniki Greece
| | - A. Kapp
- Department of Dermatology and Allergy; Hannover Medical School; Hannover Germany
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Dias-Polak D, Bergman R, Avitan-Hersh E. Mycophenolate mofetil therapy in adult patients with recalcitrant atopic dermatitis. J DERMATOL TREAT 2018; 30:49-51. [PMID: 29683760 DOI: 10.1080/09546634.2018.1468068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Patients with severe atopic dermatitis (AD) may require potent immunosuppressive therapy to control their disease. Mycophenolate mofetil (MMF) has been suggested as a safe and effective drug in these cases. OBJECTIVES To investigate effectiveness and tolerability of oral MMF in adult patients with severe recalcitrant AD. METHODS During the years 2010-2017 oral MMF 2-3 g/day was administered to adult patients with severe recalcitrant AD who failed other major systemic drugs, or where other drugs, including cyclosporine (CSA), methotrexate, and azathioprine, were contraindicated. RESULTS Of 9 consecutive adult patients, 4 (44%) responded completely, 2 (22%) had partial response, and 3 (33%) did not respond at all. The MMF therapy was continued for 5-36 months (average 21 months) without major side effects. CONCLUSIONS Oral MMF may be an effective drug in AD. Due to its good safety profile, it may be recommended as a first-line systemic therapy, or successive to CSA in the long term.
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Affiliation(s)
- David Dias-Polak
- a Department of Dermatology, Rambam Health Care Campus , Technion - Israel Institute of Technology , Haifa , Israel
| | - Reuven Bergman
- a Department of Dermatology, Rambam Health Care Campus , Technion - Israel Institute of Technology , Haifa , Israel.,b The Bruce Rappaport Faculty of Medicine , Technion - Israel Institute of Technology , Haifa , Israel
| | - Emily Avitan-Hersh
- a Department of Dermatology, Rambam Health Care Campus , Technion - Israel Institute of Technology , Haifa , Israel.,b The Bruce Rappaport Faculty of Medicine , Technion - Israel Institute of Technology , Haifa , Israel
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Mok CC. Calcineurin inhibitors in systemic lupus erythematosus. Best Pract Res Clin Rheumatol 2017; 31:429-438. [PMID: 29224682 DOI: 10.1016/j.berh.2017.09.010] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 08/06/2017] [Accepted: 09/02/2017] [Indexed: 01/14/2023]
Abstract
The calcineurin inhibitors (CNIs) belong to a group of immunosuppressive agents that block T-cell activation through the suppression of the calcium/calcimodulin-dependent phosphatase calcineurin. Agents such as cyclosporine A (CSA) and tacrolimus (TAC) have long been used in patients with systemic lupus erythematosus (SLE). TAC is preferred to CSA in SLE because of the lower frequency of cosmetic, hypertensive and dyslipidemic adverse effects. Recent randomised controlled trials have demonstrated noninferiority of TAC to mycophenolate mofetil (MMF) or cyclophosphamide (CYC) for induction therapy of lupus nephritis. Low-dose combination of TAC and MMF has also been shown to outperform CYC pulses in inducing remission of lupus nephritis in Chinese patients. TAC does not affect fertility and is relatively safe in pregnancy. In SLE patients who are intolerant or refractory to conventional immunosuppressives, or where contraindications to other immunosuppressive agents exist, TAC is an alternative option. However, the therapeutic window of TAC is narrow, and drug level monitoring is required to ensure drug exposure and minimise toxicities. Current evidence of TAC in lupus nephritis is limited to 6 months, and its long-term safety as maintenance therapy of SLE is yet to be determined. Newer chemical analogues of CNIs, such as voclosporin, with less variable plasma concentration are being tested in lupus nephritis.
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Affiliation(s)
- Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Tsing Chung Koon Road, New Territories, Hong Kong, China.
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