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Werfel T, Heratizadeh A, Aberer W, Augustin M, Biedermann T, Bauer A, Fölster-Holst R, Kahle J, Kinberger M, Nemat K, Neustädter I, Peters E, von Kiedrowski R, Schmid-Grendelmeier P, Schmitt J, Schwennesen T, Simon D, Spindler T, Traidl-Hoffmann C, Werner RN, Wollenberg A, Worm M, Ott H. S3 guideline Atopic dermatitis: Part 2 - Systemic treatment. J Dtsch Dermatol Ges 2024; 22:307-320. [PMID: 38161245 DOI: 10.1111/ddg.15229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/27/2023] [Indexed: 01/03/2024]
Abstract
The present S3 guideline was created based on the European English-language S3 guideline, with special consideration given to the medical conditions in the German-speaking region, and with additions from the previous German-language version, in accordance with the criteria of the AWMF. This second part of the guideline addresses the systemic therapy of atopic dermatitis (AD). It covers topics such as the indication for systemic therapy in children, adolescents, and adult patients with AD. Furthermore, it addresses all medications approved for AD, such as the biologics dupilumab and tralokinumab, the Janus kinase inhibitors abrocitinib, baricitinib, and upadacitinib, as well as conventional immunosuppressive therapies with systemic glucocorticosteroids and ciclosporin. Additionally, it discusses systemic off-label therapies. The first part of the guideline, published separately, includes the definition and diagnostic aspects of AD, describes topical therapy, non-drug therapy approaches, and addresses aspects related to special patient groups.
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Affiliation(s)
- Thomas Werfel
- Department of Dermatology, Allergology and Venereology, Hannover Medical School, Hannover, Germany
| | - Annice Heratizadeh
- Department of Dermatology, Allergology and Venereology, Hannover Medical School, Hannover, Germany
| | - Werner Aberer
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - Matthias Augustin
- Competence Center for Health Services Research in Dermatology (CVderm), Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Biedermann
- Department of Dermatology and Allergology, University Medical Center Munich, Technical University of Munich, Munich, Germany
| | - Andrea Bauer
- Department of Dermatology, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Regina Fölster-Holst
- Department of Dermatology, Venereology and Allergology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Julia Kahle
- German Allergy and Asthma Association (DAAB), Mönchengladbach, Germany
| | - Maria Kinberger
- Department of Dermatology, Venereology and Allergology, Division of Evidence Based Medicine in Dermatology (dEBM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Katja Nemat
- Office for Pediatric Pneumology and Allergology, Pediatric Center Dresden-Friedrichstadt (Kid), Dresden, Germany
| | - Irena Neustädter
- Hospital Hallerwiese, Cnopfsche Kinderklinik, Nuremberg, Germany
| | - Eva Peters
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Gießen, Gießen, Germany
| | | | | | - Jochen Schmitt
- Center for Evidence-Based Healthcare (ZEGV), Medical Faculty Gustav Carus, Technical University Dresden, Dresden, Germany
| | | | - Dagmar Simon
- Department of Dermatology, Inselspital Bern, Bern, Switzerland
| | - Thomas Spindler
- Specialized Clinic for Pediatric Pneumology and Allergology, Wangen, Germany
| | | | - Ricardo Niklas Werner
- Department of Dermatology, Venereology and Allergology, Division of Evidence Based Medicine in Dermatology (dEBM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Andreas Wollenberg
- Department of Dermatology and Allergology, University Hospital Augsburg, Augsburg, Germany
- Department of Dermatology and Allergy, Ludwig Maximilian University Munich, Munich, Germany
| | - Margitta Worm
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Hagen Ott
- Department of Pediatric Dermatology and Allergology, Children's and Adolescents' Hospital Auf der Bult, Hannover, Germany
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Werfel T, Heratizadeh A, Aberer W, Augustin M, Biedermann T, Bauer A, Fölster-Holst R, Kahle J, Kinberger M, Nemat K, Neustädter I, Peters E, von Kiedrowski R, Schmid-Grendelmeier P, Schmitt J, Schwennesen T, Simon D, Spindler T, Traidl-Hoffmann C, Werner RN, Wollenberg A, Worm M, Ott H. S3-Leitlinie Atopische Dermatitis: Teil 2 - Systemische Therapie: S3 guideline Atopic dermatitis: Part 2 - Systemic treatment. J Dtsch Dermatol Ges 2024; 22:307-322. [PMID: 38361206 DOI: 10.1111/ddg.15229_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/27/2023] [Indexed: 02/17/2024]
Abstract
ZusammenfassungDie vorliegende S3‐Leitlinie wurde auf der Basis der europäischen englischsprachigen S3‐Leitlinie unter besonderer Berücksichtigung der medizinischen Gegebenheiten im deutschsprachigen Raum und mit Ergänzungen der deutschsprachigen Vorgängerversion, entsprechend den Kriterien der AWMF, erstellt. Dieser zweite Teil der Leitlinie behandelt die systemische Therapie der atopischen Dermatitis (AD). Eingegangen wird unter anderem auf die Indikationsstellung für eine Systemtherapie bei Kindern, Jugendlichen und erwachsenen Patienten mit AD. Darüber hinaus werden alle für die AD zugelassenen Medikamente wie die Biologika Dupilumab und Tralokinumab, die Januskinase‐Inhibitoren Abrocitinib, Baricitinib und Upadacitinib sowie die konventionellen immunsuppressiven Therapien mit systemischen Glukokortikosteroiden und Ciclosporin adressiert. Systemische Off‐Label‐Therapien werden ebenfalls behandelt. Der separat publizierte erste Teil der Leitlinie umfasst die Definition und diagnostischen Aspekte der AD, beschreibt die topische Therapie sowie nichtmedikamentöse Therapieverfahren und geht auf Aspekte bei besonderen Patientengruppen ein.
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Affiliation(s)
- Thomas Werfel
- Klinik für Dermatologie, Allergologie und Venerologie, Medizinische Hochschule Hannover, Deutschland
| | - Annice Heratizadeh
- Klinik für Dermatologie, Allergologie und Venerologie, Medizinische Hochschule Hannover, Deutschland
| | - Werner Aberer
- Universitätsklinik für Dermatologie und Venerologie, Medizinische Universität Graz, Graz, Österreich
| | - Matthias Augustin
- Kompetenzzentrum Versorgungsforschung in der Dermatologie (CVderm), Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Eppendorf, Hamburg, Deutschland
| | - Tilo Biedermann
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein, Technische Universität München, Deutschland
| | - Andrea Bauer
- Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Deutschland
| | - Regina Fölster-Holst
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Deutschland
| | - Julia Kahle
- Deutscher Allergie- und Asthmabund (DAAB) e. V., Mönchengladbach, Deutschland
| | - Maria Kinberger
- Klinik für Dermatologie, Venerologie und Allergologie, Division of Evidence-Based Medicine (dEBM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Deutschland
| | - Katja Nemat
- Praxis für Kinderpneumologie und Allergologie, Kinderzentrum Dresden-Friedrichstadt (Kid), Dresden, Deutschland
| | - Irena Neustädter
- Klinik Hallerwiese, Cnopfsche Kinderklinik, Nürnberg, Deutschland
| | - Eva Peters
- Klinik für Psychosomatik und Psychotherapie, Universitätsklinikum Gießen (UKGM), Gießen, Deutschland
| | | | | | - Jochen Schmitt
- Zentrum für Evidenzbasierte Gesundheitsversorgung (ZEGV), Medizinische Fakultät Gustav Carus, Technische Universität Dresden, Deutschland
| | | | - Dagmar Simon
- Universitätsklinik für Dermatologie, Inselspital Bern, Bern, Schweiz
| | - Thomas Spindler
- Fachklinik für Pädiatrische Pneumologie und Allergologie, Wangen, Deutschland
| | | | - Ricardo Niklas Werner
- Klinik für Dermatologie, Venerologie und Allergologie, Division of Evidence-Based Medicine (dEBM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Deutschland
| | - Andreas Wollenberg
- Klinik für Dermatologie und Allergologie, Universitätsklinikum Augsburg, Augsburg, Deutschland
- Klinik und Poliklinik für Dermatologie und Allergologie, Ludwigs-Maximilians-Universität, München, Deutschland
| | - Margitta Worm
- Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Deutschland
| | - Hagen Ott
- Fachbereich Pädiatrische Dermatologie und Allergologie, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover, Deutschland
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Barrett R, Barry M, McCullagh L. Health technology management: the experience of a managed access approach to the reimbursement of dupilumab in Ireland. Ir J Med Sci 2023; 192:2829-2837. [PMID: 37156985 PMCID: PMC10692243 DOI: 10.1007/s11845-023-03378-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/12/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Dupilumab was the first biological medicine to receive marketing authorisation, in Ireland, for the treatment of atopic dermatitis (AD). In 2019, Ireland's National Centre for Pharmacoeconomics recommended that dupilumab not be reimbursed at the submitted price; it was not cost effective. Following confidential price negotiations, the Health Service Executive (HSE) reimbursed dupilumab subject to a HSE-Managed Access Protocol (MAP). Patients with refractory, moderate-to-severe AD were deemed eligible to receive treatment under the MAP; the cohort for which dupilumab is expected to be most effective and most cost effective (versus standard of care). Approval, for treatment, is granted on an individual patient basis by the HSE-Medicines Management Programme. AIMS Applications for approval of treatment with dupilumab were analysed to determine the percentage of patients deemed eligible. Key characteristics of this population were investigated. METHODS Data from individual patient applications were analysed. Key characteristics of the approved population were investigated using IBM SPSS Statistics® version 27. Data were derived from the HSE-Primary Care Reimbursement Service pharmacy claims database. The number of patients who received dupilumab over the study period was determined. RESULTS In total, 96% of submitted applications were deemed eligible. Of these, 65% were male and 87% were adults. In the main, the approved patient population had severe refractory AD; the mean Eczema Area Severity Index score was 28.72. CONCLUSION The majority of applications submitted were approved. This work highlights how a MAP can facilitate access to treatment in patients who are deemed eligible whilst containing overall expenditure.
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Affiliation(s)
- Rosealeen Barrett
- Department of Pharmacology and Therapeutics, Trinity College Dublin, Trinity Centre for Health Sciences, St. James's Hospital, Dublin 8, Ireland.
- Medicines Management Programme, Health Service Executive, St. James's Hospital, Dublin 8, Ireland.
| | - Michael Barry
- Department of Pharmacology and Therapeutics, Trinity College Dublin, Trinity Centre for Health Sciences, St. James's Hospital, Dublin 8, Ireland
- Medicines Management Programme, Health Service Executive, St. James's Hospital, Dublin 8, Ireland
- National Centre for Pharmacoeconomics, St. James's Hospital, Dublin 8, Ireland
| | - Laura McCullagh
- Department of Pharmacology and Therapeutics, Trinity College Dublin, Trinity Centre for Health Sciences, St. James's Hospital, Dublin 8, Ireland
- National Centre for Pharmacoeconomics, St. James's Hospital, Dublin 8, Ireland
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Yim HJ, Jean T, Ong PY. Recent advances in immunomodulators for atopic dermatitis. Curr Opin Pediatr 2023; 35:671-679. [PMID: 37522635 DOI: 10.1097/mop.0000000000001279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
PURPOSE OF REVIEW Conventional treatments of atopic dermatitis have been inadequate, especially in patients with moderate-to-severe disease. RECENT FINDINGS In the past 5 years, four immunomodulators have been approved for the treatment of atopic dermatitis in children. These include dupilumab, ruxolitinib, upadacitinib, and abrocitinib. The review summarizes the pivotal phase 3 trials of these medications. SUMMARY The newer immunomodulators have transformed the treatment of atopic dermatitis, particularly in patients with moderate-to-severe disease. Dupilumab targets IL-4 and IL-13, which are the main causes of allergic inflammation, resulting in great efficacy and few side effects. Upadacitinib and abrocitinib are alternative systemic medications for adolescents who have failed or are unable to tolerate dupilumab. Ruxolitinib cream is the latest addition to the current topical therapy. It is indicated for children 12 years and older with mild-to-moderate atopic dermatitis. Further studies are needed to confirm its safety and efficacy for younger children and for patients with more severe disease.
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Affiliation(s)
| | - Tiffany Jean
- Department of Allergy, Asthma, & Clinical Immunology, Kaiser Los Angeles Medical Center, Los Angeles
| | - Peck Y Ong
- Division of Clinical Immunology and Allergy, Children's Hospital Los Angeles
- Department of Pediatrics, University of Southern California, Los Angeles, California, USA
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Mostafa N, Smith SD. Improving Psychological Health Outcomes in Children with Atopic Dermatitis. Clin Cosmet Investig Dermatol 2023; 16:2821-2827. [PMID: 37841063 PMCID: PMC10576503 DOI: 10.2147/ccid.s393254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 10/03/2023] [Indexed: 10/17/2023]
Abstract
Introduction Atopic dermatitis (AD) is a chronic inflammatory skin disease that usually develops in early childhood. AD has a significant impact on quality of life and psychological health outcomes in both adults and children. There are increased reported rates of psychiatric comorbidities including anxiety, depression, ADHD and suicidal ideation compared to the general population. Primary caregivers of children with pediatric eczema and their families may also have derangements in psychological health and quality of life. A number of interventions exist for AD and address wellbeing outcomes as an important aspect of effective treatment. Methods A comprehensive literature search was conducted using PubMed/Medline, Embase, the Cochrane Central Register of Controlled Trials in February 2023. Published studies up to April 2023 were included related to interventions for childhood AD that included psychological health or quality of life outcomes. These interventions were stratified according to type and evidence quality. Results Search strategy revealed a wide variety of interventions with demonstrated improvements in quality of life or wellbeing of patients with pediatric AD or their families. Both pharmacological and non-pharmacological interventions demonstrated effectiveness in improving disease outcomes. Conclusion A variety of both pharmacological and non-pharmacological interventions may be employed to improve psychological health outcomes in children with AD.
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Affiliation(s)
- Niyaz Mostafa
- Faculty of Medicine, The University of Sydney, Sydney, NSW, Australia
| | - Saxon D Smith
- ANU Medical School, ANU College of Health and Medicine, The Australian National University, Canberra, ACT, Australia
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6
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Alenazi SD. Atopic dermatitis: a brief review of recent advances in its management. Dermatol Reports 2023; 15:9678. [PMID: 37860723 PMCID: PMC10582657 DOI: 10.4081/dr.2023.9678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/23/2023] [Indexed: 10/21/2023] Open
Abstract
Atopic dermatitis (AD) is a common inflammatory skin disorder characterized by recurrent eczematous lesions and intense itching. The disorder affects people of all ages and ethnicities, has a substantial psychosocial impact on patients and relatives, and is the leading cause of the global burden of skin diseases. Atopic dermatitis is associated with an increased risk of multiple comorbidities, including food allergies, asthma, allergic rhinitis, and mental health disorders. The pathophysiology is complex and involves a strong genetic predisposition, epidermal dysfunction, and T-cell-driven inflammation. Although type-2 mechanisms are dominant, there is increasing evidence that the disorder involves multiple immune pathways. Until recently, the management of AD rested mainly on the judicious use of emollients, topical steroids, and topical calcineurin inhibitors in the majority of patients, and systemic immunosuppressants were advocated in severely diseased patients. However, in the last few years, new therapeutic strategies have been designed and developed to target the various steps in the chain of molecular events that lead to the AD phenotype. This review highlights the recent advancements in the management of AD.
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Sivesind TE, Oganesyan A, Bosma G, Hochheimer C, Schilling LM, Dellavalle R. Prescribing Patterns of Dupilumab for Atopic Dermatitis in Adults: Retrospective, Observational Cohort Study. JMIR DERMATOLOGY 2023; 6:e41194. [PMID: 37647114 PMCID: PMC10500357 DOI: 10.2196/41194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 06/28/2023] [Accepted: 08/07/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Atopic dermatitis (AD) is a common inflammatory disease caused by a type 2 T helper cell-mediated immune response to environmental antigens. Approximately 1 in 5 patients with AD presents with moderate to severe disease, and treatments approved by the Food and Drug Administration include emollients, topical glucocorticoids, and calcineurin inhibitors. Dupilumab, a fully human monoclonal antibody, improves AD via inhibition of interleukin-4 and interleukin-13. OBJECTIVE Our aim was to characterize the prescribing patterns of dupilumab for AD in adults at a large university-affiliated health system. METHODS A retrospective, observational cohort study was conducted using electronic data from the Observational Health Data Sciences and Informatics database, assessing data from the University of Colorado Medical Campus and its affiliates. The outcome measured was the prevalence of dupilumab prescribed for adults with AD (n=6421), between March 28, 2013, and March 28, 2021. We assessed whether the characteristics of patients who received dupilumab were different from those who did not. Each patient characteristic was assessed using a univariate logistic regression with the binary outcome of receiving or not receiving dupilumab. RESULTS We found a population prevalence of 5.6% (6421/114,476) for AD. In our cohort, Black patients with AD were more than twice as likely to have received dupilumab compared to White patients (odds ratio 2.352, 95% CI 1.58-3.39). Patients with a diagnosis of atopic neurodermatitis were approximately twice as likely to have received dupilumab compared to those with other diagnostic variants of AD (odds ratio 1.87, 95% CI 1.01-3.22). CONCLUSIONS Our results demonstrate that both patient racial characteristics and specific AD diagnoses were associated with variations in dupilumab prescription patterns.
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Affiliation(s)
- Torunn E Sivesind
- Department of Dermatology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Ani Oganesyan
- University of Colorado School of Medicine, Aurora, CO, United States
| | - Grace Bosma
- Center for Innovative Design and Analysis, The Colorado School of Public Health, University of Colorado School of Medicine, Aurora, CO, United States
| | - Camille Hochheimer
- Center for Innovative Design and Analysis, The Colorado School of Public Health, University of Colorado School of Medicine, Aurora, CO, United States
| | - Lisa M Schilling
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Robert Dellavalle
- The Colorado School of Public Health, University of Colorado School of Medicine, Aurora, CO, United States
- Dermatology Service, Eastern Colorado Health Care System, US Department of Veterans Affairs, Denver, CO, United States
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8
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de Graaf M, Janmohamed S, Schuttelaar M, Agner T, Alfonso J, De Schepper S, Deleuran M, Despontin K, Elenius V, Ghislain P, Huilaja L, Johansson E, Kvenshagen B, Mandelin J, Olset H, Svensson A, van Tuyll van Serooskerken A, Thyssen J, Vestergaard C. Systemic treatment of children and adolescents with atopic dermatitis aged ≥2 years: a Delphi consensus project mapping expert opinion in Northern Europe. J Eur Acad Dermatol Venereol 2022; 36:2153-2165. [PMID: 35793471 PMCID: PMC9796032 DOI: 10.1111/jdv.18410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 06/14/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Paediatric atopic dermatitis (AD) can be burdensome, affecting mental health and impairing quality of life for children and caregivers. Comprehensive guidelines exist for managing paediatric AD, but practical guidance on using systemic therapy is limited, particularly for new therapies including biologics and Janus kinase (JAK) inhibitors, recently approved for various ages in this indication. OBJECTIVES This expert consensus aimed to provide practical recommendations within this advancing field to enhance clinical decision-making on the use of these and other systemics for children and adolescents aged ≥2 years with moderate-to-severe AD. METHODS Nineteen physicians from Northern Europe were selected for their expertise in managing childhood AD. Using a two-round Delphi process, they reached full or partial consensus on 37 statements. RESULTS Systemic therapy is recommended for children aged ≥2 years with a clear clinical diagnosis of severe AD and persistent disease uncontrolled after optimizing non-systemic therapy. Systemic therapy should achieve long-term disease control and reduce short-term interventions. Recommended are cyclosporine A for short-term use (all ages) and dupilumab or methotrexate for long-term use (ages ≥6 years). Consensus was not reached on the best long-term systemics for children aged 2-6 years, although new systemic therapies will likely become favourable: New biologics and JAK inhibitors will soon be approved for this age group, and more trial and real-world data will become available. CONCLUSIONS This article makes practical recommendations on the use of systemic AD treatments for children and adolescents, to supplement international and regional guidelines. It considers the systemic medication that was available for children and adolescents with moderate-to-severe AD at the time this consensus project was done: azathioprine, cyclosporine A, dupilumab, methotrexate, mycophenolate mofetil and oral glucocorticosteroids. We focus on the geographically similar Northern European countries, whose healthcare systems, local preferences for AD management and reimbursement structures nonetheless differ significantly.
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Affiliation(s)
- M. de Graaf
- Department of Dermatology and Allergology, National Expertise Center for Atopic Dermatitis, Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - S.R. Janmohamed
- Department of Dermatology, Unit Pediatric Dermatology, SKIN Research Group, Universitair Ziekenhuis Brussel (UZ Brussel)Vrije Universiteit Brussel (VUB)BrusselsBelgium
| | - M.L.A. Schuttelaar
- Department of Dermatology, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - T. Agner
- Department of Dermatology and VenereologyBispebjerg HospitalCopenhagenDenmark
| | - J.H. Alfonso
- Department of DermatologyOslo University Hospital, RikshospitaletOsloNorway
| | - S. De Schepper
- Department of DermatologyGent University HospitalGentBelgium
| | - M. Deleuran
- Department of DermatologyAarhus University HospitalAarhusDenmark
| | - K. Despontin
- Department of Dermatology and VenereologyCHU UCL NamurNamurBelgium
| | - V. Elenius
- Department of PediatricsTurku University HospitalTurkuFinland
| | - P.‐D. Ghislain
- Department of Dermatology, UCL St‐LucLouvain UniversityBrusselsBelgium
| | - L. Huilaja
- PEDEGO Research UnitUniversity of OuluOuluFinland,Department of Dermatology and Medical Research Center OuluOulu University HospitalOuluFinland
| | - E.K. Johansson
- Dermatology and Venereology Unit, Department of Medicine SolnaKarolinska InstitutetStockholmSweden,Department of DermatologyKarolinska University HospitalStockholmSweden
| | | | - J.M. Mandelin
- Department of DermatologyHelsinki University Central HospitalHelsinkiFinland
| | - H. Olset
- Department of DermatologyHaukeland University HospitalBergenNorway
| | - A. Svensson
- Department of Dermatology and VenereologyMalmö University HospitalMalmöSweden
| | | | - J.P. Thyssen
- Department of Dermatology and VenereologyBispebjerg HospitalCopenhagenDenmark
| | - C. Vestergaard
- Department of DermatologyAarhus University HospitalAarhusDenmark
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9
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Wollenberg A, Kinberger M, Arents B, Aszodi N, Avila Valle G, Barbarot S, Bieber T, Brough HA, Calzavara Pinton P, Christen-Zäch S, Deleuran M, Dittmann M, Dressler C, Fink-Wagner AH, Fosse N, Gáspár K, Gerbens L, Gieler U, Girolomoni G, Gregoriou S, Mortz CG, Nast A, Nygaard U, Redding M, Rehbinder EM, Ring J, Rossi M, Serra-Baldrich E, Simon D, Szalai ZZ, Szepietowski JC, Torrelo A, Werfel T, Flohr C. European guideline (EuroGuiDerm) on atopic eczema: part I - systemic therapy. J Eur Acad Dermatol Venereol 2022; 36:1409-1431. [PMID: 35980214 DOI: 10.1111/jdv.18345] [Citation(s) in RCA: 110] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/29/2022] [Indexed: 01/03/2023]
Abstract
The evidence- and consensus-based guideline on atopic eczema was developed in accordance with the EuroGuiDerm Guideline and Consensus Statement Development Manual. Four consensus conferences were held between December 2020 and July 2021. Twenty-nine experts (including clinicians and patient representatives) from 12 European countries participated. This first part of the guideline includes general information on its scope and purpose, the health questions covered, target users and a methods section. It also provides guidance on which patients should be treated with systemic therapies, as well as recommendations and detailed information on each systemic drug. The systemic treatment options discussed in the guideline comprise conventional immunosuppressive drugs (azathioprine, ciclosporin, glucocorticosteroids, methotrexate and mycophenolate mofetil), biologics (dupilumab, lebrikizumab, nemolizumab, omalizumab and tralokinumab) and janus kinase inhibitors (abrocitinib, baricitinib and upadacitinib). Part two of the guideline will address avoidance of provocation factors, dietary interventions, immunotherapy, complementary medicine, educational interventions, occupational and psychodermatological aspects, patient perspective and considerations for paediatric, adolescent, pregnant and breastfeeding patients.
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Affiliation(s)
- A Wollenberg
- Department of Dermatology and Allergy, LMU Munich, Munich, Germany.,Department of Dermatology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - M Kinberger
- Division of Evidence-Based Medicine (dEBM), Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - B Arents
- European Federation of Allergy and Airways Diseases Patients' Associations (EFA), Brussels, Belgium
| | - N Aszodi
- Department of Dermatology and Allergy, LMU Munich, Munich, Germany
| | - G Avila Valle
- Division of Evidence-Based Medicine (dEBM), Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - S Barbarot
- Department of Dermatology, CHU Nantes, UMR 1280 PhAN, INRAE, Nantes Université, Nantes, France
| | - T Bieber
- Department of Dermatology and Allergy, University Hospital of Bonn, Bonn, Germany
| | - H A Brough
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK.,Paediatric Allergy Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | | | | | - M Deleuran
- Aarhus University Hospital, Aarhus, Denmark
| | - M Dittmann
- Division of Evidence-Based Medicine (dEBM), Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - C Dressler
- Division of Evidence-Based Medicine (dEBM), Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - A H Fink-Wagner
- Global Allergy and Airways Diseases Patient Platform GAAPP, Vienna, Austria
| | - N Fosse
- Department of Dermatology, University Hospital Basel, Basel, Switzerland
| | - K Gáspár
- Department of Dermatology of the University of Debrecen, Debrecen, Hungary
| | - L Gerbens
- Department of Dermatology, Amsterdam UMC (University Medical Centers), Amsterdam, The Netherlands
| | - U Gieler
- Department of Dermatology, University of Giessen, Giessen, Germany
| | - G Girolomoni
- Dermatology and Venereology Section, Department of Medicine, University of Verona, Verona, Italy
| | - S Gregoriou
- Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - C G Mortz
- Department of Dermatology and Allergy Centre, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - A Nast
- Division of Evidence-Based Medicine (dEBM), Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - U Nygaard
- Department of Dermato-Venerology, Aarhus University Hospital, Aarhus, Denmark
| | - M Redding
- Eczema Outreach Support (UK), Linlithgow, UK
| | - E M Rehbinder
- Dermatology Department, Oslo University Hospital, Oslo, Norway
| | - J Ring
- Department of Dermatology Allergology Biederstein, Technical University Munich, Munich, Germany
| | - M Rossi
- Dermatology Unit, Spedali Civili Hospital Brescia, Brescia, Italy
| | | | - D Simon
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Z Z Szalai
- Pediatric Dermatology Unit, Heim Pál National Children's Institute Budapest, Budapest, Hungary
| | - J C Szepietowski
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland
| | - A Torrelo
- Hospital Infantil Niño Jesús, Madrid, Spain
| | - T Werfel
- Hannover Medical School, Hannover, Germany
| | - C Flohr
- St John's Institute of Dermatology, King's College London, London, UK.,Guy's & St Thomas' NHS Foundation Trust, London, UK
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10
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Sadeghi S, Kalantari Y, Seirafianpour F, Goodarzi A. The Efficacy and Safety of Topical Cyclosporine-A in Dermatology: A Systematic Review. Dermatol Ther 2022; 35:e15490. [PMID: 35384191 DOI: 10.1111/dth.15490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/24/2022] [Accepted: 03/26/2022] [Indexed: 11/29/2022]
Abstract
Cyclosporine-A (Cyc-A) was initially prescribed as systemic therapy for patients receiving solid organ transplants or in patients with graft versus host disease (GVHD). Topical Cyc-A is an ideal form of Cyclosporine in the treatment of mucocutaneous disorders as it causes fewer systemic side effects and has more stable results than steroids; however, poor absorption through the skin makes the development of new formulations necessary to improve skin permeability. To evaluate the efficacy and safety of topical Cyc-A in different dermatological conditions. A thorough systematic review was performed on PubMed/Medline, Embase, Scopus, and Web of Science databases as well as Google Scholar, and relevant studies from 2000 until January 3rd, 2022, were selected. The study was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA). Topical Cyc-A was observed to be an effective medication in the treatment of oral lichen planus, psoriasis, burning mouth syndrome, Pyoderma Gangrenosum, and Zoon's balanitis. Adverse side effects such as dysphagia, burning sensation, lips swealing, and gastrointestinal upset were reported following Cyc-A mouthwash use, whereas mild erythema, dryness, and fissuring of the skin were observed following the Cyc-A lipogel application. Topical Cyc-A was found to be a good alternative to traditional treatment regimens for immune-mediated mucocutaneous conditions. Cyc-A can be considered as a safe and efficient option in cases of long-term treatment as it does not have the same adverse effects of long-term steroids. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Sara Sadeghi
- Rasool Akram Medical Complex Clinical Research Development Center (RCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Yasamin Kalantari
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Farnoosh Seirafianpour
- Student Research Committee, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Azadeh Goodarzi
- Department of Dermatology, Faculty of Dermatology, Rasool Akram Medical Complex Clinical Research Development Center (RCRDC), School of Medicine, Iran University of Medical Sciences, Tehran, Iran.,Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Iran Jordan Dermatology and Hair Transplantation Center, Tehran, Iran
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11
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Ayasse MT, Ahmed A, Espinosa ML, Walker CJ, Yousaf M, Thyssen JP, Silverberg JI. What are the highest yielding search strategy terms for systematic reviews in atopic dermatitis? A systematic review. Arch Dermatol Res 2021; 313:737-750. [PMID: 33221950 DOI: 10.1007/s00403-020-02165-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/16/2020] [Accepted: 10/30/2020] [Indexed: 12/30/2022]
Abstract
The impact of search strategies on systematic reviews (SR) of atopic dermatitis (AD) is unknown. The purpose of this review was to evaluate search strategies used in SR of AD and their impact on the frequency of manuscripts identified. MEDLINE and EMBASE were searched for SR related to AD. Simulations were performed by running combinations of search terms in MEDLINE and EMBASE. Overall, 250 SR met inclusion criteria, of which 225 specified search strategies. SR using 5-6 terms (20.0% to 12.1%) or ≥ 7 (40.0% to 18.8%) terms decreased, whereas SR using 3-4 terms numerically increased (18.8% to 30.2%) and 1-2 terms remained similar (37.5% to 38.9%) from 1999-2009 to 2015-2019. The most commonly searched terms were "atopic dermatitis" (n = 166), followed by "eczema" (n = 156), "dermatitis atopic'" (n = 81), "atopic eczema" (n = 74), "neurodermatitis" (n = 59), "Besniers prurigo" (n = 29), "infantile eczema" (n = 27), and "childhood eczema" (n = 19). Simulations revealed that "eczema" and "atopic dermatitis" yielded the most hits. The number of search terms that maximized hits in MEDLINE and EMBASE was 5 and 4, respectively. Search strategies for AD were heterogeneous, with high proportions of search strategies providing few search hits. Future studies should use standardized and optimized search terms.
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Affiliation(s)
- Marissa T Ayasse
- Department of Dermatology, The George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Avenue NW, Suite 2B-425, Washington, DC, 20037, USA
| | - Adnan Ahmed
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Maria L Espinosa
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Christina J Walker
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Muhammad Yousaf
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jacob P Thyssen
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Jonathan I Silverberg
- Department of Dermatology, The George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Avenue NW, Suite 2B-425, Washington, DC, 20037, USA.
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12
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Li CY, Dai YX, Chang YT, Bai YM, Tsai SJ, Chen TJ, Chen MH. Prenatal exposure to acetaminophen increases the risk of atopic dermatitis in children: A nationwide nested case-control study in Taiwan. Pediatr Allergy Immunol 2021; 32:1080-1088. [PMID: 33544946 DOI: 10.1111/pai.13465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/31/2020] [Accepted: 02/02/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Acetaminophen (APAP) has been associated with the development of atopic diseases. However, little is known about the relationship between prenatal APAP exposure and atopic dermatitis (AD) in offspring. OBJECTIVE To investigate the association between prenatal APAP exposure and AD risk in offspring. METHODS In this study, 2029 study pairs (AD-affected children and their mothers) and 5,058 control pairs were identified between 1998 and 2008 from the Taiwan Longitudinal Health Insurance Database. Maternal APAP exposure during pregnancy was assessed. RESULTS After adjustment for potential confounders, there was a significant association between risk of offspring AD and exposure to acetaminophen in the first trimester (OR 1.16; 95% CI 1.05-1.28), the second trimester (OR 1.14; 95% CI 1.03-1.27), both first and second trimesters (OR 1.30; 95% CI 1.13-1.51), both first and third trimester (OR 1.20; 95% CI 1.04-1.39), any trimester (OR 1.12; 95% CI 1.00-1.26), and all three trimesters (OR 1.32; 95% CI 1.08-1.62) in a dose-response manner. CONCLUSIONS Prenatal exposure to acetaminophen was associated with an increased incidence of offspring AD.
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Affiliation(s)
- Cheng-Yuan Li
- Department of Dermatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ying-Xiu Dai
- Department of Dermatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yun-Ting Chang
- Department of Dermatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ya-Mei Bai
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Jen Tsai
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tzeng-Ji Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Mu-Hong Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
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13
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Chan CX, Zug KA. Diagnosis and Management of Dermatitis, Including Atopic, Contact, and Hand Eczemas. Med Clin North Am 2021; 105:611-626. [PMID: 34059241 DOI: 10.1016/j.mcna.2021.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This is a comprehensive and current guide for the diagnosis, differential diagnosis, treatment, and management of eczematous dermatitis, with a focus on atopic dermatitis, irritant and allergic contact dermatitis, hand dermatitis including recurrent vesicular and hyperkeratotic types, asteatotic dermatitis, and nummular or discoid dermatitis. Diagnostic options highlighted are clinical history, physical examination, and patch testing. Therapeutic options highlighted are moisturizers, topical corticosteroids, topical calcineurin inhibitors, crisaborole, phototherapy, and systemic medications including biologics.
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MESH Headings
- Administration, Topical
- Adrenal Cortex Hormones/administration & dosage
- Adrenal Cortex Hormones/therapeutic use
- Aged
- Biological Products/therapeutic use
- Boron Compounds/administration & dosage
- Boron Compounds/therapeutic use
- Bridged Bicyclo Compounds, Heterocyclic/administration & dosage
- Bridged Bicyclo Compounds, Heterocyclic/therapeutic use
- Calcineurin Inhibitors/administration & dosage
- Calcineurin Inhibitors/therapeutic use
- Child
- Child, Preschool
- Dermatitis, Allergic Contact/diagnosis
- Dermatitis, Allergic Contact/drug therapy
- Dermatitis, Allergic Contact/pathology
- Dermatitis, Atopic/diagnosis
- Dermatitis, Atopic/drug therapy
- Dermatitis, Atopic/pathology
- Diagnosis, Differential
- Eczema/diagnosis
- Eczema/drug therapy
- Eczema/pathology
- Humans
- Infant
- Middle Aged
- Patch Tests/methods
- Phototherapy/methods
- Quality of Life
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Affiliation(s)
- Cynthia X Chan
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
| | - Kathryn A Zug
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA; Department of Dermatology, Dartmouth-Hitchcock Medical Center, 18 Old Etna Road, Lebanon, NH 03766, USA
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14
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Davari DR, Nieman EL, McShane DB, Morrell DS. Current Perspectives on the Systemic Management of Atopic Dermatitis. J Asthma Allergy 2021; 14:595-607. [PMID: 34103945 PMCID: PMC8179820 DOI: 10.2147/jaa.s287638] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/13/2021] [Indexed: 01/07/2023] Open
Abstract
Atopic dermatitis (AD) is a common disease of childhood, and some patients experience a prolonged clinical course into adolescence and adulthood. Systemic management is required when AD is not adequately controlled with topical medications. Our aim is to provide a comprehensive review of commonly used systemic immunomodulating agents in childhood and adult AD, including cyclosporine A (CsA), azathioprine (AZA), methotrexate (MTX) and mycophenolate mofetil (MMF), which are prescribed off-label in the United States, as well as dupilumab, an FDA-approved biologic. We will also provide a brief overview of emerging systemic therapies currently under investigation.
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Affiliation(s)
- Danielle R Davari
- Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Elizabeth L Nieman
- Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Diana B McShane
- Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Dean S Morrell
- Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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15
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Biologics for Treatment of Atopic Dermatitis: Current Status and Future Prospect. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1053-1065. [PMID: 33685604 DOI: 10.1016/j.jaip.2020.11.034] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/18/2020] [Accepted: 11/24/2020] [Indexed: 12/16/2022]
Abstract
Atopic dermatitis (AD) is a common inflammatory skin disease characterized by intense pruritus and recurrent eczematous lesions that significantly impair quality of life. It is a heterogeneous disease affecting both children and adults. The treatment of moderate-to-severe forms of AD is challenging, as topical corticosteroids are often insufficient to achieve disease control or inappropriate and off-label use of immunosuppressants may have significant undesirable side effects. The development of targeted biologic therapies specifically for AD is thus highly desirable. Dupilumab is the only biologic therapy that is Food and Drug Administration approved for the treatment of moderate-to-severe AD in patients 6 years and older, with consistent long-term efficacy and safety trial data. In this article, we review the mechanisms, safety, and efficacy of dupilumab from recent clinical trials, and we review the current data, mechanism of action, clinical efficacy, and limitations of new biologics currently in phase 2 and 3 clinical trials (lebrikizumab, tralokinumab, nemolizumab, tezepelumab, and ISB 830).
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16
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Agache I, Akdis CA, Akdis M, Brockow K, Chivato T, Giacco S, Eiwegger T, Eyerich K, Giménez‐Arnau A, Gutermuth J, Guttman‐Yassky E, Maurer M, Ogg G, Ong PY, O’Mahony L, Schwarze J, Warner A, Werfel T, Palomares O, Jutel M, Asero R, Puga MF, Nart I, Gadina M, Kabashima K, Sugita K. EAACI Biologicals Guidelines-dupilumab for children and adults with moderate-to-severe atopic dermatitis. Allergy 2021; 76:988-1009. [PMID: 33538044 DOI: 10.1111/all.14690] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/19/2020] [Accepted: 12/02/2020] [Indexed: 12/16/2022]
Abstract
Atopic dermatitis imposes a significant burden on patients, families and healthcare systems. Management is difficult, due to disease heterogeneity, co-morbidities, complexity in care pathways and differences between national or regional healthcare systems. Better understanding of the mechanisms has enabled a stratified approach to the management of atopic dermatitis, supporting the use of targeted treatments with biologicals. However, there are still many issues that require further clarification. These include the definition of response, strategies to enhance the responder rate, the duration of treatment and its regimen (in the clinic or home-based), its cost-effectiveness and long-term safety. The EAACI Guidelines on the use of dupilumab in atopic dermatitis follow the GRADE approach in formulating recommendations for each outcome and age group. In addition, future approaches and research priorities are discussed.
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Affiliation(s)
- Ioana Agache
- Faculty of Medicine Transylvania University Brasov Romania
| | - Cezmi A. Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF) University of Zurich Davos Switzerland
- Christine‐Kühne‐Center for Allergy Research and Education (CK‐CARE Davos Switzerland
| | - Mubeccel Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF) University of Zurich Davos Switzerland
| | - Knut Brockow
- Department of Dermatology and Allergology Biederstein School of Medicine Technical University of Munich Munich Germany
| | - Tomas Chivato
- School of Medicine University CEU San Pablo Madrid Spain
| | - Stefano Giacco
- Department of Medical Sciences and Public Health University of Cagliari Cagliari Italy
| | - Thomas Eiwegger
- Translational Medicine Program, Research Institute Hospital for Sick Children Toronto ON Canada
- Department of Immunology University of Toronto Toronto ON Canada
- Division of Immunology and Allergy, Food Allergy and Anaphylaxis Program Departments of Paediatrics and Immunology The Hospital for Sick Children University of Toronto Toronto Canada
| | - Kilian Eyerich
- Department of Dermatology and Allergy Biederstein Technical University of Munich Munich Germany
| | - Ana Giménez‐Arnau
- Department of Dermatology Hospital del Mar‐ Institut Mar d'InvestigacionsMèdiques UniversitatAutònoma de Barcelona Barcelona Spain
| | - Jan Gutermuth
- Department of Dermatology VrijeUniversiteit Brussel (VUB) UniversitairZiekenhuis Brussel Brussels Belgium
| | - Emma Guttman‐Yassky
- Department of Dermatology Icahn School of Medicine at Mount Sinai New York NY USA
| | - Marcus Maurer
- Dermatological Allergology Department of Dermatology and Allergy Allergie‐Centrum‐Charité Charité ‐ Universitätsmedizin Berlin Berlin Germany
| | - Graham Ogg
- MRC Human Immunology Unit Radcliffe Department of Medicine MRC Weatherall Institute of Molecular Medicine Oxford NIHR Biomedical Research Centre University of Oxford Oxford UK
| | - Peck Y. Ong
- Division of Clinical Immunology & Allergy Children’s Hospital Los Angeles Keck School of Medicine University of Southern California Los Angeles CA USA
| | - Liam O’Mahony
- Departments of Medicine and Microbiology APC Microbiome IrelandUniversity College Cork Cork Ireland
| | - Jürgen Schwarze
- Centre for Inflammation Research Child Life and Health The University of Edinburgh Edinburgh UK
| | | | - Thomas Werfel
- Division of Immunodermatology and Allergy Research Department of Dermatology and Allergy Hannover Medical School Hannover Germany
| | - Oscar Palomares
- Department of Biochemistry and Molecular Biology Chemistry School Complutense University of Madrid Madrid Spain
| | - Marek Jutel
- Department of Clinical Immunology University of Wroclaw Wroclaw Poland
- ALL‐MED” Medical Research Institute Wroclaw Poland
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17
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Gilhar A, Reich K, Keren A, Kabashima K, Steinhoff M, Paus R. Mouse models of atopic dermatitis: a critical reappraisal. Exp Dermatol 2021; 30:319-336. [PMID: 33368555 DOI: 10.1111/exd.14270] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 12/17/2020] [Accepted: 12/17/2020] [Indexed: 12/13/2022]
Abstract
Mouse models for atopic dermatitis (AD) are an indispensable preclinical research tool for testing new candidate AD therapeutics and for interrogating AD pathobiology in vivo. In this Viewpoint, we delineate why, unfortunately, none of the currently available so-called "AD" mouse models satisfactorily reflect the clinical complexity of human AD, but imitate more "allergic" or "irriant" contact dermatitis conditions. This limits the predictive value of AD models for clinical outcomes of new tested candidate AD therapeutics and the instructiveness of mouse models for human AD pathophysiology research. Here, we propose to initiate a rational debate on the minimal criteria that a mouse model should meet in order to be considered relevant for human AD. We suggest that valid AD models should at least meet the following criteria: (a) an AD-like epidermal barrier defect with reduced filaggrin expression along with hyperproliferation, hyperplasia; (b) increased epidermal expression of thymic stromal lymphopoietin (TSLP), periostin and/or chemokines such as TARC (CCL17); (c) a characteristic dermal immune cell infiltrate with overexpression of some key cytokines such as IL-4, IL-13, IL-31 and IL-33; (d) distinctive "neurodermatitis" features (sensory skin hyperinnervation, defective beta-adrenergic signalling, neurogenic skin inflammation and triggering or aggravation of AD-like skin lesions by perceived stress); and (e) response of experimentally induced skin lesions to standard AD therapy. Finally, we delineate why humanized AD mouse models (human skin xenotransplants on SCID mice) offer a particularly promising preclinical research alternative to the currently available "AD" mouse models.
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Affiliation(s)
- Amos Gilhar
- Skin Research Laboratory, Rappaport Faculty of Medicine, Technion -Israel Institute of Technology, Haifa, Israel.,Rambam Health Care Campus, Haifa, Israel
| | - Kristian Reich
- Centre for Translational Research in Inflammatory Skin Diseases, Institute for Health Services Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Skinflammation Center, Hamburg, Germany
| | - Aviad Keren
- Skin Research Laboratory, Rappaport Faculty of Medicine, Technion -Israel Institute of Technology, Haifa, Israel
| | - Kenji Kabashima
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Singapore Immunology Network (SIgN) and Institute of Medical Biology, Agency for Science, Technology and Research (A*STAR), Biopolis, Singapore, Singapore
| | - Martin Steinhoff
- Department of Dermatology and Venereology, Hamad Medical Corporation, Qatar University, Doha, Qatar.,School of Medicine, Weill Cornell University-Qatar and Qatar University, Doha, Qatar
| | - Ralf Paus
- Dr. Phillip Frost, Department of Dermatology & Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.,Dermatology Research Centre, University of Manchester and NIHR Manchester Biomedical Research Centre, Manchester, UK.,Monasterium Laboratory, Münster, Germany
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18
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Azzano P, Dufresne É, Poder T, Bégin P. Economic considerations on the usage of biologics in the allergy clinic. Allergy 2021; 76:191-209. [PMID: 32656802 DOI: 10.1111/all.14494] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 07/04/2020] [Accepted: 07/08/2020] [Indexed: 12/27/2022]
Abstract
The advent of biologic therapies has transformed care for severe atopic disorders but their high cost poses new challenges with regard to long-term sustainability and fair allocation of resources. This article covers the basic concepts of cost-utility analyses and reviews the available literature on cost utility of biologic drugs in atopic disorders. When used within their limits as part of a multi-dimensional assessment, economic analyses can be extremely useful to guide decision-making and prioritization of care. Despite the good quality of most cost-utility analyses conducted for the use of biologics in asthma and other atopic diseases, their conclusions regarding cost-effectiveness are extremely variable. This is mainly due to the use of inconsistent estimates of health utility benefit with therapy. Development of reliable and validated instruments to measure disutility in atopic disorders and measure of indirect costs in atopic disease are identified as a priority for future research.
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Affiliation(s)
- Pauline Azzano
- Department of Pediatrics CHU Sainte‐Justine Montreal QC Canada
| | - Élise Dufresne
- Department of Pediatrics CHU Sainte‐Justine Montreal QC Canada
| | - Thomas Poder
- Department of Management, Evaluation and Health Policy School of Public Health University of Montreal Montreal QC Canada
- Research Center of the Institut Universitaire en Santé Mentale de Montréal Montreal QC Canada
| | - Philippe Bégin
- Department of Pediatrics CHU Sainte‐Justine Montreal QC Canada
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19
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Kido‐Nakahara M, Wang B, Ohno F, Tsuji G, Ulzii D, Takemura M, Furue M, Nakahara T. Inhibition of mite-induced dermatitis, pruritus, and nerve sprouting in mice by the endothelin receptor antagonist bosentan. Allergy 2021; 76:291-301. [PMID: 32535962 DOI: 10.1111/all.14451] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 05/09/2020] [Accepted: 05/19/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Endothelin-1 (EDN1) can evoke histamine-independent pruritus in mammals and is upregulated in the lesional epidermis of atopic dermatitis (AD). EDN1 increases the production of interleukin 25 (IL-25) from keratinocytes to accelerate T helper type 2 immune deviation. Plasma EDN1 levels are positively correlated with the clinical severity and itch intensity of AD. Therefore, we hypothesized that the inhibition of EDN1 might be useful for treating atopic inflammation and itch and investigated the effects of the topical application of the EDN1 receptor antagonist bosentan on the skin inflammation and itch in a murine AD model. METHODS We analyzed the mite-induced AD-like NC/Nga murine model, which was topically applied with bosentan or ethanol control every day for 3 weeks. We also subjected in vitro primary sensory neuron culture systems to nerve elongation and branching assays after EDN1 stimulation. RESULTS Topical application of bosentan significantly attenuated the development of mite-induced AD-like skin inflammation, dermatitis scores, ear thickness, scratching bouts, and serum level of thymus and activation-regulated chemokine in NC/Nga mice. Bosentan application also significantly reduced the gene expression of Il13, Il17, and Ifng in the treated lesions. Histologically, the number of infiltrated dermal cells, the epidermal EDN1 expression, and the number of intraepidermal nerve fibers were significantly inhibited upon bosentan application. While EDN1 significantly elongated the neurites of dorsal root ganglion cells in a dose- and time-dependent manner, bosentan treatment attenuated this. CONCLUSIONS EDN1 plays a significant role in mite-induced inflammation and itch. Topical bosentan is a potential protective candidate for AD.
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Affiliation(s)
- Makiko Kido‐Nakahara
- Department of Dermatology Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Bing Wang
- Department of Dermatology Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Fumitaka Ohno
- Department of Dermatology Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Gaku Tsuji
- Department of Dermatology Graduate School of Medical Sciences Kyushu University Fukuoka Japan
- Research and Clinical Center for Yusho and Dioxin Kyushu University Hospital Fukuoka Japan
| | - Dugarmaa Ulzii
- Department of Dermatology Graduate School of Medical Sciences Kyushu University Fukuoka Japan
- Department of Dermatology National Dermatology Center of Mongolia Ulaanbaatar Mongolia
| | - Masaki Takemura
- Department of Dermatology Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Masutaka Furue
- Department of Dermatology Graduate School of Medical Sciences Kyushu University Fukuoka Japan
- Research and Clinical Center for Yusho and Dioxin Kyushu University Hospital Fukuoka Japan
- Division of Skin Surface Sensing Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Takeshi Nakahara
- Department of Dermatology Graduate School of Medical Sciences Kyushu University Fukuoka Japan
- Division of Skin Surface Sensing Graduate School of Medical Sciences Kyushu University Fukuoka Japan
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20
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Otten M, Augustin M. Documenting Patient Data in Psoriasis Clinical Practice-Patient Focus Groups Supporting Psoriasis Experts' Decision-making. Patient Prefer Adherence 2021; 15:549-557. [PMID: 33727800 PMCID: PMC7953889 DOI: 10.2147/ppa.s297569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 02/13/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVES This article presents patients' attitudes about documenting patient data and outcome measures in psoriasis clinical practice to support a Delphi approach of psoriasis experts to develop a standard data set. PATIENTS AND METHODS We conducted three focus groups with 14 patients in a German outpatient unit for psoriasis. The focus was to explore reasons for and against the documentation of single variables concerning personal, anamnesis, clinical, patient-reported outcomes, and other data. RESULTS The patients mainly discussed if a variable has an impact on the disease or treatment decision, or if there might be a practical value from experiences with treatments when documented. In addition, in their point of view, patient-reported outcome data are important to document as it enables physicians to learn about a patient's subjective burden of disease. Patient education and the involvement of other physicians in the treatment process also emerged as relevant aspects. CONCLUSION The results help to understand patients' preferences on documenting patient data and their idea of an exhaustive doctor-patient consultation to improve doctor-patient communication, disease monitoring, and quality of care.
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Affiliation(s)
- Marina Otten
- German Center for Health Services Research in Dermatology (CVderm), Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
- Correspondence: Marina Otten German Center for Health Services Research in Dermatology (CVderm), Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Martinistraße 52, Hamburg, 20246, GermanyTel +49 40 7410 55428Fax +49 40 7410 55348 Email
| | - Matthias Augustin
- German Center for Health Services Research in Dermatology (CVderm), Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
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21
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Wei Y, Tai Y, Dai Y, Chang Y, Chen T, Chen M. Bidirectional association between alopecia areata and atopic dermatitis: A population‐based cohort study in Taiwan. Clin Exp Allergy 2020; 50:1406-1414. [DOI: 10.1111/cea.13729] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/13/2020] [Accepted: 08/31/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Yu‐Hsun Wei
- Department of Dermatology Taipei Veterans General Hospital Taipei Taiwan
- School of Medicine National Yang‐Ming University Taipei Taiwan
| | - Ying‐Hsuan Tai
- School of Medicine National Yang‐Ming University Taipei Taiwan
- Department of Anesthesiology Shuang Ho Hospital Taipei Medical University New Taipei City Taiwan
- Department of Anesthesiology School of Medicine College of Medicine Taipei Medical University Taipei Taiwan
| | - Ying‐Xiu Dai
- Department of Dermatology Taipei Veterans General Hospital Taipei Taiwan
- School of Medicine National Yang‐Ming University Taipei Taiwan
| | - Yun‐Ting Chang
- Department of Dermatology Taipei Veterans General Hospital Taipei Taiwan
- School of Medicine National Yang‐Ming University Taipei Taiwan
| | - Tzeng‐Ji Chen
- School of Medicine National Yang‐Ming University Taipei Taiwan
- Department of Family Medicine Taipei Veterans General Hospital Taipei Taiwan
| | - Mu‐Hong Chen
- School of Medicine National Yang‐Ming University Taipei Taiwan
- Department of Psychiatry Taipei Veterans General Hospital Taipei Taiwan
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22
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Abstract
Atopic dermatitis is a common inflammatory skin disorder characterised by recurrent eczematous lesions and intense itch. The disorder affects people of all ages and ethnicities, has a substantial psychosocial impact on patients and relatives, and is the leading cause of the global burden from skin disease. Atopic dermatitis is associated with increased risk of multiple comorbidities, including food allergy, asthma, allergic rhinitis, and mental health disorders. The pathophysiology is complex and involves a strong genetic predisposition, epidermal dysfunction, and T-cell driven inflammation. Although type-2 mechanisms are dominant, there is increasing evidence that the disorder involves multiple immune pathways. Currently, there is no cure, but increasing numbers of innovative and targeted therapies hold promise for achieving disease control, including in patients with recalcitrant disease. We summarise and discuss advances in our understanding of the disease and their implications for prevention, management, and future research.
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Affiliation(s)
- Sinéad M Langan
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK; St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK; Health Data Research UK, London, UK.
| | - Alan D Irvine
- Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland; Dermatology, Children's Health Ireland, Crumlin, Ireland; National Children's Research Centre, Dublin, Ireland
| | - Stephan Weidinger
- Department of Dermatology and Allergy, University Hospital Schleswig-Holstein, Kiel, Germany
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23
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Olabi B, Worboys S, Garland T, Grindlay DJC, Rogers NK, Harman KE. What’s new in atopic eczema? An analysis of systematic reviews published in 2018. Part 2: systemic therapies. Clin Exp Dermatol 2020; 45:980-985. [DOI: 10.1111/ced.14304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2020] [Indexed: 12/26/2022]
Affiliation(s)
- B. Olabi
- Department of Dermatology Lauriston Building, Lauriston Place Edinburgh UK
| | - S. Worboys
- James Wigg Practice 2 Bartholomew Road London UK
| | - T. Garland
- Department of Dermatology Alexandra Wing, Broadgreen Hospital Liverpool UK
| | - D. J. C. Grindlay
- Centre of Evidence Based Dermatology University of Nottingham King’s Meadow Campus Nottingham UK
| | - N. K. Rogers
- Centre of Evidence Based Dermatology University of Nottingham King’s Meadow Campus Nottingham UK
| | - K. E. Harman
- Centre of Evidence Based Dermatology University of Nottingham King’s Meadow Campus Nottingham UK
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24
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Andreasen T, Christensen M, Halling A, Egeberg A, Thyssen J. Placebo response in phase 2 and 3 trials of systemic and biological therapies for atopic dermatitis—a systematic review and meta‐analysis. J Eur Acad Dermatol Venereol 2020; 34:1143-1150. [DOI: 10.1111/jdv.16163] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 11/19/2019] [Indexed: 12/30/2022]
Affiliation(s)
- T.H. Andreasen
- Department of Dermatology and Allergy Herlev and Gentofte Hospital University of Copenhagen Hellerup Denmark
| | - M.O. Christensen
- Department of Dermatology and Allergy Herlev and Gentofte Hospital University of Copenhagen Hellerup Denmark
| | - A.‐S. Halling
- Department of Dermatology and Allergy Herlev and Gentofte Hospital University of Copenhagen Hellerup Denmark
| | - A. Egeberg
- Department of Dermatology and Allergy Herlev and Gentofte Hospital University of Copenhagen Hellerup Denmark
- Copenhagen Research Group for Inflammatory Skin CORGIS Hellerup Denmark
| | - J.P. Thyssen
- Department of Dermatology and Allergy Herlev and Gentofte Hospital University of Copenhagen Hellerup Denmark
- Copenhagen Research Group for Inflammatory Skin CORGIS Hellerup Denmark
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25
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Agache I, Cojanu C, Laculiceanu A, Rogozea L. Critical Points on the Use of Biologicals in Allergic Diseases and Asthma. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2020; 12:24-41. [PMID: 31743962 PMCID: PMC6875478 DOI: 10.4168/aair.2020.12.1.24] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 10/17/2019] [Accepted: 10/18/2019] [Indexed: 12/19/2022]
Abstract
Improved understanding of the contribution of immune-inflammatory mechanisms in allergic diseases and asthma has encouraged development of biologicals and small molecules specifically targeting the innate and adaptive immune response. There are several critical points impacting the efficacy of this stratified approach, from the complexity of disease endotypes to the effectiveness in real-world settings. We discuss here how these barriers can be overcome to facilitate the development of implementation science for allergic diseases and asthma.
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Affiliation(s)
- Ioana Agache
- Department of Allergy and Clinical Immunology, Faculty of Medicine, Transylvania University of Brasov, Brasov, Romania.
| | - Catalina Cojanu
- Department of Allergy and Clinical Immunology, Faculty of Medicine, Transylvania University of Brasov, Brasov, Romania
| | - Alexandru Laculiceanu
- Department of Allergy and Clinical Immunology, Faculty of Medicine, Transylvania University of Brasov, Brasov, Romania
| | - Liliana Rogozea
- Department of Allergy and Clinical Immunology, Faculty of Medicine, Transylvania University of Brasov, Brasov, Romania
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26
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Alexander H, Patton T, Jabbar-Lopez ZK, Manca A, Flohr C. Novel systemic therapies in atopic dermatitis: what do we need to fulfil the promise of a treatment revolution? F1000Res 2019; 8. [PMID: 30774935 PMCID: PMC6357995 DOI: 10.12688/f1000research.17039.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2019] [Indexed: 12/26/2022] Open
Abstract
Patients with atopic dermatitis (AD) who do not adequately respond to topical therapy and phototherapy often need systemic immunomodulatory treatment to control their symptoms. Conventional systemic agents, such as ciclosporin, azathioprine, and methotrexate, have been used for decades, but there are concerns about their safety profile. There are now many novel systemic agents emerging through clinical trials, which may have great potential in the treatment of AD. Despite this, there are very few data comparing the performance of these drugs against each other. The purpose of this article is to review the current systemic therapies in AD and present an indirect comparison of systemic AD treatments using effectiveness and safety data from published randomised controlled trials, highlighting important remaining gaps in knowledge. Although the latest developments in systemic AD treatments are exciting and dearly needed, further work is required before the promise of a therapeutic revolution becomes reality.
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Affiliation(s)
- Helen Alexander
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Thomas Patton
- Centre for Health Economics, University of York, York, UK
| | - Zarif K Jabbar-Lopez
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Andrea Manca
- Centre for Health Economics, University of York, York, UK
| | - Carsten Flohr
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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