The impact of dupilumab on patch testing and the prevalence of comorbid allergic contact dermatitis in recalcitrant atopic dermatitis: A retrospective chart review

Beyond Avoidance: Advanced Therapies for Contact Dermatitis

Contact dermatitis (CD) is a common and burdensome condition divided into irritant contact dermatitis and allergic contact dermatitis. Treatment relies on accurate diagnosis and identification of the trigger, because definitive treatment is irritant or allergen avoidance. However, avoidance is not always possible, such as when the patient is reacting to a necessary medical device, when the trigger is integral to the patient's occupation, and when avoidance is practically untenable. In these cases, treatment is particularly challenging, especially because the literature on treatments in this clinical scenario is limited. In addition, CD has a complex pathophysiology that varies according to the trigger type, leading to variable treatment efficacy. This article reviews the current literature on treatments for CD with a focus on treatments when trigger avoidance is not feasible.

Patch testing while immunosuppressed: potential risks and benefits

INTRODUCTION

Allergic contact dermatitis (ACD) is a common cutaneous inflammatory skin disorder that is diagnosed via epicutaneous patch testing (PT). ACD may also coexist with other systemic inflammatory conditions such as atopic dermatitis and psoriasis. Many of the treatments used to manage severe ACD, along with other systemic conditions, interact with and suppress the immune system, thereby potentially interfering with the mechanism of PT. There is uncertainty in the literature regarding the effects of immunosuppression on the results of PT.

METHODS

A comprehensive literature review was conducted using PubMed and Google Scholar to identify articles relevant to the topic of this review. Only articles available in English were included.

AREAS COVERED

This review discusses the impact of immunomodulating therapies on the results of PT. We summarize the available evidence and provide updated recommendations for several immunomodulating drugs commonly used in patients undergoing PT.

EXPERT OPINION

In general, the results of PT are most reliable when performed without immunosuppression. If this is not feasible, it is best to have patients on as low a dose of immunosuppression as possible, but it may not be necessary to stop or change an immunomodulating drug prior to PT.

Dupilumab-associated head and neck dermatitis shows a pronounced type 22 immune signature mediated by oligoclonally expanded T cells

Dupilumab, an IL4R-blocking antibody, has shown clinical efficacy for atopic dermatitis (AD) treatment. In addition to conjunctivitis/blepharitis, the de novo appearance of head/neck dermatitis is now recognized as a distinct side effect, occurring in up to 10% of patients. Histopathological features distinct from AD suggest a drug effect, but exact underlying mechanisms remain unknown. We profiled punch biopsies from dupilumab-associated head and neck dermatitis (DAHND) by using single-cell RNA sequencing and compared data with untreated AD and healthy control skin. We show that dupilumab treatment was accompanied by normalization of IL-4/IL-13 downstream activity markers such as CCL13, CCL17, CCL18 and CCL26. By contrast, we found strong increases in type 22-associated markers (IL22, AHR) especially in oligoclonally expanded T cells, accompanied by enhanced keratinocyte activation and IL-22 receptor upregulation. Taken together, we demonstrate that dupilumab effectively dampens conventional type 2 inflammation in DAHND lesions, with concomitant hyperactivation of IL22-associated responses.

Impact of dupilumab on patch test results and allergic contact dermatitis: A prospective multicenter study

BACKGROUND

Limited and conflicting data have been reported on the impact of dupilumab (DUPI) on patch test (PT) results and its efficacy against allergic contact dermatitis (ACD).

OBJECTIVE

This study was undertaken to analyze PT reactivities and relevance during treatment with DUPI to determine whether they could detect ACD in patients with uncontrolled or worsened atopic dermatitis (AD) who were receiving this agent.

METHODS

This prospective, multicenter study examined 76 DUPI-treated patients who had undergone PTs. The relevant information was collected during 3 visits.

RESULTS

Overall, 36 patients (47%) had ≥1 positive PT reaction, and 142 PT results were positive. Twenty-three patients (30%) had ≥1 positive and clinically relevant PT result. Five of them had clinical eczema improvement after allergen avoidance. We compared the PT results of 36 patients before and during DUPI therapy, representing 1230 paired PT allergens, of which 1022 were the same, 34 were positive, 44 were lost, and 130 were uninterpretable.

LIMITATIONS

Because the number of patients included remains limited, our findings should be confirmed with a larger sample.

CONCLUSION

Our results confirmed the usefulness of PTs for patients receiving DUPI, with good PT reproducibility. We suggest that all DUPI-treated patients with AD developing partial responses or experiencing symptom worsening should undergo PTs to look for contact sensitization.

Prevalence and burden of atopic dermatitis involving the head, neck, face, and hand: A cross sectional study from the TARGET-DERM AD cohort

BACKGROUND

Atopic dermatitis (AD) is severely burdensome, and there has been poor characterization of any differences in impact based on the area affected.

OBJECTIVE

To estimate the prevalence and HRQoL impact of head/face/neck/hand (HFNH) involvement among patients with moderate-to-severe atopic dermatitis.

METHODS

All TARGET-DERM AD registry patients with moderate/severe Investigator Global Assessment (vIGA-AD) were assessed using the Patient Oriented SCORing Atopic Dermatitis, Patient Oriented Eczema Measure (POEM) and the (Children's) Dermatology Life Quality Index ((C)DLQI).

RESULTS

541 participants met the criteria (75.0% adults) and 84% (N = 453) reported HFNH involvement. HFNH and non-HFNH involved participants had similar characteristics; 55.2% female and 46.9% White. Compared to the non-HFNH involved, the involved had severe vIGA-AD (28.5% vs 16.3%, P = .02) and higher median body surface area affected (15% vs 10%, P ≤ .01) and were twice as likely to have higher (C)DLQI and POEM scores.

LIMITATIONS

This was an analysis of real-world and patient reported outcome data.

CONCLUSION

Real-world HFNH involved AD patients were associated with significantly worse quality of life, POEM/(C)DLQI, and more severe disease. Detailed assessments of specific areas affected by AD are needed to personalize treatment.

Patch Testing in Patients With Severe Atopic Dermatitis Treated With Dupilumab: A Multicentric Approach in Spain

Background: Persistent localized dermatitis (PLD) or eczema flare-ups (EF) may occur in atopic dermatitis (AD) patients treated with dupilumab. They may reflect concomitant allergic contact dermatitis (ACD) exposed by the inhibition of the Th2 pathway by dupilumab in some cases. Objective: To evaluate the prevalence and etiology of these events and the impact of dupilumab on patch test outcome. Methods: We performed patch tests on 54 AD patients treated with dupilumab and evaluated the prevalence and final diagnosis of EF and PLD as well as the patch test results. Results: The patch test results were positive in 20/54 (37.0%). 21/54 patients (38.9%) had PLD and 12/54 (22.2%) had EF. Ten of 54 (18.5%) had both conditions and 11/54 (20.4%) had neither PLD nor EF. 64.5% of PLD involved the face. 83.9% patients with PLD and 90.9% patients with EF were diagnosed with inadequately controlled AD. 9.7% patients with PLD and 4.5% patients with EF were finally diagnosed with ACD. Nine of 21 (42.9%) patients patch tested twice were positive either before and/or during dupilumab. Patch tests results changed over time in all of them. Conclusions: Patch testing assisted us to exclude ACD as the cause of PLD/EF in AD patients treated with dupilumab. Most PLD and EF were, however, diagnosed as poorly controlled AD. Dupilumab appeared to impact the patch test outcomes.

Case report: Dupilumab leads to an increased chance of head and neck Staphylococcus aureus infection in atopic dermatitis patients

Dupilumab was the first biological medication licensed to treat atopic dermatitis (AD), and it has shown remarkable effectiveness and safety in the treatment of moderate-to-severe atopic dermatitis. There are limited drug-related adverse events associated with dupilumab in atopic dermatitis (AD) treatment. Here, we present two cases of local Staphylococcus aureus infection during the treatment of atopic dermatitis with dupilumab.

[Translated article] Haptens, Proteins, and Atopic Dermatitis

Atopic dermatitis is a chronic inflammatory disease that is multifactorial in nature. Allergic contact dermatitis and protein contact dermatitis are allergic conditions that may occur in the context of atopic dermatitis and be the cause of exacerbations. Although the prevalence of allergic contact dermatitis is similar in atopic patients and the general population, these 2 conditions are frequently associated because atopic inflammation disrupts the skin barrier. Skin tests are therefore recommended in atopic individuals. Dupilumab could be useful for treating allergic contact dermatitis if it is mediated by type 2 helper T cells but could exacerbate inflammation if mediated by T_H1 cells: further study is needed before conclusions can be drawn. Although the mechanism by which exposure to environmental proteins exacerbates atopic dermatitis remains under discussion, such exacerbations are routinely seen in clinical practice. Prick testing is recommended in symptomatic atopic dermatitis. When prick-test findings are positive, patients should be advised to avoid the culprit substances.

Dupilumab for Atopic Dermatitis-From Clinical Trials to Molecular and Cellular Mechanisms

Dupilumab is a monoclonal antibody that represents the first approved targeted biological therapy for adults, adolescents, and children older than 6 years with moderate-to-severe atopic dermatitis (AD). Dupilumab binds the shared chain of the interleukin-4 and interleukin-13 receptor blocking the downstream signaling of these cytokines. The clinical improvements induced by dupilumab were associated with remission of the dysregulated immune mechanisms linked with AD. Dupilumab reversed the epidermal barrier defects and improved the global molecular signature of AD. This review seeks to provide an overview on the development of dupilumab as the first target-specific biological treatment for AD, with a description of the clinical trials that have been performed in different age groups, their outcomes, and reported adverse effects. Novel aspects of dupilumab treatment, as well as the current knowledge on the molecular and cellular mechanisms underlying the treatment of AD with dupilumab, are summarized and discussed.

Haptens, Proteins, and Atopic Dermatitis

Atopic dermatitis is a chronic inflammatory disease that is multifactorial in nature. Allergic contact dermatitis and protein contact dermatitis are allergic conditions that may occur in the context of atopic dermatitis and be the cause of exacerbations. Although the prevalence of allergic contact dermatitis is similar in atopic patients and the general population, these 2 conditions are frequently associated because atopic inflammation disrupts the skin barrier. Skin tests are therefore recommended in atopic individuals. Dupilumab could be useful for treating allergic contact dermatitis if it is mediated by type 2 helper T cells but could exacerbate inflammation if mediated by T_H1 cells: further study is needed before conclusions can be drawn. Although the mechanism by which exposure to environmental proteins exacerbates atopic dermatitis remains under discussion, such exacerbations are routinely seen in clinical practice. Prick testing is recommended in symptomatic atopic dermatitis. When prick-test findings are positive, patients should be advised to avoid the culprit substances.

Metal Allergy: State-of-the-Art Mechanisms, Biomarkers, Hypersensitivity to Implants

Metal allergy is mainly an environmental disorder which can cause allergic contact dermatitis. Environmental metal exposures include jewelry, everyday metal items, mobile phones, leather, metal-rich food and implants, including stents or anchors. While consumer exposure is liable for the majority of metal hypersensitivity cases, the significance of occupational exposure to metals remains relevant. Although the most common metal allergens are nickel, chromium, and cobalt; however, lately, gold, palladium, titanium, and some others have also attracted attention. This review highlights advances in metal allergy mechanisms, biomarkers for potential patients' stratification as well as biological treatments. The most recent evidence of human exposure to metal for risk assessment is discussed, as well as the relationship between the occurrence of metal hypersensitivity and implanted devices, including non-characteristic symptoms. The latest data on the diagnosis of metal hypersensitivity are also reported.

Systematic Review of Systemic Corticosteroid Effects on Patch Testing

ABSTRACT

Systemic corticosteroids are commonly used as a short-term management option for inflammatory skin conditions, such as contact dermatitis. The purpose of our systematic review was to compare presence and degree of patch test reactions with or without different doses of systemic corticosteroid therapy. The relationship between 20, 30, and 40 mg daily doses of prednisone and retained, diminished, and negated reactions was not linear, whereas the reaction ratings for all patches placed with or without corticosteroid therapy revealed trends toward lower intensity reactions while receiving prednisone (P < 0.0001, χ2, for all doses of prednisone). Our review provides insight into directions for future studies that examine the effect of corticosteroids on patch testing.

Facial Erythema in Patients with Atopic Dermatitis Treated with Dupilumab- A Descriptive Study of Morphology and Etiology

BACKGROUND

The development of dermatitis on face and neck, which was not described in phase 3 clinical trials, has been reported in the literature in patients treated with dupilumab. Little is known regarding the causes or defining features of the facial dermatitis.

OBJECTIVES

We conducted surveys of consecutive patients with AD on dupilumab to describe its clinical features, morphology, and etiology.

METHODS

A multicenter prospective cohort study was conducted from January 1, 2020, to December 31, 2020. A total of 162 patients under dupilumab treatment were asked to complete a questionnaire and patients were evaluated by dermatologists.

RESULTS

Out of all 162 patients, 137 (84.6%) patients reported pre-existing facial dermatitis prior to dupilumab therapy. 121 (88.3%) patients with pre-existing facial dermatitis reported improvement of their facial dermatitis with dupilumab therapy, 9 (6.6%) patients reported no change after the treatment, and 7 (4.3%) patients of them got worse after the treatment (exacerbation group). Out of 25 patients who reported no pre-existing active facial dermatitis, 6 (24%) patients reported new-onset facial erythema after the starting dupilumab therapy (new-onset group). A large proportion of the patients in both the exacerbation (86%) and new-onset groups (67%) had a history of facial TCS use. Both groups showed similar clinical manifestations and distribution with few differences.

CONCLUSIONS

The vast majority of patients treated with dupilumab in academic institutions from Korea and U.S. experienced improvement in their facial dermatitis with dupilumab therapy. A small proportion of patients had new onset and exacerbation. Although the mechanisms of this adverse event remains unclear, steroid withdrawal should be considered as a diagnosis of the erythema in some patients.

Dupilumab for Atopic Dermatitis-From Clinical Trials to Molecular and Cellular Mechanisms

Dupilumab is a monoclonal antibody that represents the first approved targeted biological therapy for adults, adolescents, and children older than 6 years with moderate-to-severe atopic dermatitis (AD). Dupilumab binds the shared chain of the interleukin-4 and interleukin-13 receptor blocking the downstream signaling of these cytokines. The clinical improvements induced by dupilumab were associated with remission of the dysregulated immune mechanisms linked with AD. Dupilumab reversed the epidermal barrier defects and improved the global molecular signature of AD. This review seeks to provide an overview on the development of dupilumab as the first target-specific biological treatment for AD, with a description of the clinical trials that have been performed in different age groups, their outcomes, and reported adverse effects. Novel aspects of dupilumab treatment, as well as the current knowledge on the molecular and cellular mechanisms underlying the treatment of AD with dupilumab, are summarized and discussed.

The benefit of late readings in patch testing depends both on allergen and patient characteristics

BACKGROUND

Patch test (PT) readings are recommended after 48 h and 72 h (D3). An additional day 7 (D7) reading has been suggested by some, although data on efficient patient selection are scarce. We investigated positive D7 reactions regarding (i) allergens in the baseline series and additional PT series of the German Contact Dermatitis Research Group (DKG) and (ii) characteristics of the patients tested.

METHODS

Retrospective, multicentre analysis of 190 allergens derived from 17 DKG test series in 4687 patients with an additional D7 reading. Patients were patch tested with the baseline series and additional series, if required. Occurrence of novel D7 reactions as well as increasing skin reactions from D3 to D7 was analysed separately.

RESULTS

Depending on the allergen tested, waiving D7 readings would have missed 4.4-26.8% of positive PT results. Patch test series with the highest number of novel D7 reactions were baseline series, metal series, and leather/shoe series. New positive reactions on D7 were associated with age over 50 years and with a negative irritant control containing sodium lauryl sulphate. Of note, application of the PT allergens for 48 h instead of 24 h was positively associated with late PT reactions.

CONCLUSION

Within the most frequently tested allergens, without late readings, on average 11.7% of sensitizations would have been missed. Novel late reacting allergens were identified. This study comprehensively dissects patient-, allergen- and test-dependent parameters in support for D7 readings. We propose to always consider late readings individually based on effort-benefit considerations.

Comorbidity Identification and Referral in Atopic Dermatitis: a Consensus Document

BACKGROUND

Atopic dermatitis (AD) is associated with different comorbidities.

OBJECTIVE

To develop evidence-based and practical recommendations for comorbidity detection in patients with AD in daily practice.

METHODS

We employed a modified RAND/UCLA methodology, including a systematic literature review (SLR). A group of six experts on AD was established. We conducted a comprehensive search strategy on Medline, Embase, and Cochrane Library up to June 2020. The selection criteria included studies with AD patients with any comorbidity reporting data on comorbidity prevalence, burden, and management. The included studies quality was assessed. The SLR results were discussed in a nominal group meeting, and several recommendations were generated. The recommendation agreement grade was tested on additional experts through a Delphi process.

RESULTS

The recommendations cover the following issues: 1) Which comorbidities should be investigated at the first and subsequent visits; 2) How and when should comorbidities be investigated (screening); 3) How should patients with specific comorbidities be referred to confirm their diagnosis and initiate management; 4) Specific recommendations to ensure an integral care approach for AD patients with any comorbidity.

CONCLUSIONS

These recommendations seek to guide dermatologists, patients, and other stakeholders in regard to early comorbidity identification and AD patient referral to improve decision-making.

What We Have Learned–Milestones in Pediatric Contact Dermatitis

Purpose of Review

This review highlights recent developments in the field of pediatric allergic contact dermatitis (ACD) and patch testing. We will review updates on the pathophysiology of contact dermatitis, discuss new contact allergens, explore the impact of dupilumab on patch testing, and provide pearls for the diagnosis and management of ACD in children.

Recent Findings

ACD is not a single immunologic phenomenon but rather has contributions from multiple inflammatory pathways. Emerging contact allergens include ingredients found in “slime” toys, glucose monitors and insulin pumps, and electronic equipment. Data thus far suggests that patch testing results are generally reliable in the face of concurrent dupilumab use.

Summary

ACD is likely underrecognized and underdiagnosed in pediatric patients, including infants and young children. Providers should keep patient-specific factors and emerging trends in mind when addressing suspected ACD, consider contact dermatitis when they encounter challenging cases of atypical, refractory, or chronic dermatitis, and feel comfortable performing patch testing in children.

Management of inadequate response and adverse effects to dupilumab in atopic dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin disease characterized by pruritus, skin pain, and sleep disturbances. Currently, dupilumab is the only systemic therapy and biologic medication approved by the United States Food and Drug Administration for moderate-to-severe AD in adults and children. There is a sparsity of literature available on determining treatment failure with dupilumab and the next steps health care providers can take to treat AD. Individual goals and quality of life and not just body surface area should be considered when defining treatment failure. Possible confounding dermatoses also should be ruled out. Early identification of dupilumab-induced adverse events is important. For most patients, dupilumab can be continued while treatment for the adverse event is initiated. Adjusting the frequency of dupilumab dosing also may be considered in some circumstances. Adjuvant therapies, such as methotrexate, azathioprine, mycophenolate mofetil, cyclosporine, or phototherapy can be added but the safety and efficacy of these combination treatments are not known at this time.

Novel insights into contact dermatitis

Contact dermatitis is a common disease, caused by repeated skin contact to contact allergens or irritants, resulting in allergic contact dermatitis (ACD) and/or irritant contact dermatitis. Attempts have been made to identify biomarkers to distinguish irritant and allergic patch test reactions, which could aid diagnosis. Some promising candidates have recently been identified, but verification and validation in clinical cases still need to be done. New causes of ACD are constantly recognized. In this review, 10 new contact allergens from recent years, were identified, several relating to anti-age products. Frequent allergens causing considerable morbidity in the population such as the preservative methylisothiazolinone (MI) have been regulated in EU. A significant drop in cases has been seen, while high rates are still occurring in other areas such as North America. Other frequent causes are fragrance allergens especially widely used terpenes and acrylates used in medical devises for control of diabetes. These represent unsolved problems. Recent advances in immunology have opened for a better understanding of the complexity of contact dermatitis, especially ACD. The disease may be more heterogenous that previous understood with several subtypes. With the rapidly evolving molecular understanding of the disease, the potential for development of new drugs for personalized treatment of contact dermatitis is considerable.

Characterization of Residual Facial Dermatitis during Dupilumab Therapy: A Retrospective Chart Review to Delineate the Potential Role of Expanded Series Patch Testing

OBJECTIVE

We sought to determine the incidence of RFDD in patients receiving dupilumab and the rate of resolution of RFDD after expanded series patch testing (ESPT) and allergen avoidance.

METHODS

This is a retrospective chart review of 80 patients with atopic dermatitis who were evaluated for RFDD after treatment with dupilumab. Expanded series patch testing findings and response to allergen avoidance were assessed in the subset of patients with RFDD who subsequently underwent ESPT while continuing to receive dupilumab.

RESULTS

Forty-nine patients (61.3%) experienced facial dermatitis before initiating dupilumab. Thirty-five patients (43.8%) experienced RFDD after starting dupilumab. Of the 14 patients with RFDD who received ESPT, 92.9% had 1 or more relevant positive patch test results, with 50% of such patients being mostly to completely clear of facial dermatitis after allergen avoidance. Importantly, 50.6% of the positive reactions to allergens were not included on the North American Contact Dermatitis Group Core 80.

CONCLUSIONS

Many patients with RFDD benefit from patch testing and subsequent allergen avoidance. Expanded series patch testing should be offered to patients who experience RFDD after beginning dupilumab therapy to ensure that such patients have eliminated any exogenous component of their dermatitis, such as concomitant allergic contact dermatitis.

Dupilumab Facial Redness/Dupilumab Facial Dermatitis: A Guide for Clinicians

Dupilumab facial redness (DFR), or the development of an eczematous rash of the face and neck with dupilumab use, has been observed in recent case reports. It is estimated to impact between 4 and 43.8% of dupilumab users, including children and adults. Aside from reviewing the pathogenesis and clinical presentation, we present potential diagnostic steps (such as skin scraping, serologies, biopsy, and patch testing) and management options for DFR ranging from allergen avoidance to dupilumab interruption. It is hoped that this article will serve as a means for clinicians to familiarize themselves with DFR regarding the differential diagnosis, diagnostic tools, and treatment options associated with this phenomenon.

Therapeutic Impact and Management of Persistent Head and Neck Atopic Dermatitis in Dupilumab-Treated Patients

BACKGROUND

Localization of atopic dermatitis (AD) in exposed areas such as the hands, head, and neck has been considered as a negative factor impacting on dupilumab response, although a comparison of exposed versus unexposed areas is not currently available.

OBJECTIVES

The aim of this study is to evaluate the clinical response to dupilumab depending on the presence or persistency of AD skin manifestations in specific body areas.

METHODS

The study retrospectively collected clinical and demographic data of adult patients affected by moderate to severe AD. Based on the anatomical sites involved, 5 subcohorts of patients were identified.

RESULTS

A total of 41 patients were included in the study. Disease amelioration was detected during the study period, although baseline head/neck and hand localization was associated with a significantly lower likelihood of achieving an Eczema Area Severity Index (EASI) ≤1. In addition, patients with head/neck persistency showed a significantly lower response when compared to patients without persistency of head/neck AD in terms of both mean EASI and Dermatology Life Quality Index (DLQI) reduction.

CONCLUSION

AD localization in exposed areas at the baseline and AD persistency at the head/neck may have a negative impact on certain treatment response parameters to dupilumab therapy.

Patch Test Clinic Start-up: From Basics to Pearls

Allergic contact dermatitis is a prevalent burdensome condition affecting millions of Americans. Patch testing, the criterion-standard allergic contact dermatitis diagnostic tool, is underused by US dermatologists. Incorporating patch testing into modern dermatology practices is achievable with utilization of accurate resources and sustainable support. This review focuses on the basics of patch testing and provides practical pearls to assist novice providers in establishing a contact dermatitis specialty practice.

Prominent Role of Type 2 Immunity in Skin Diseases-Beyond Atopic Dermatitis

Type 2 immunity, illustrated by T helper 2 lymphocytes (Th2) and downstream cytokines (IL-4, IL-13, IL-31) as well as group 2 innate lymphoid cells (ILC2), is important in host defense and wound healing.¹ The hallmark of type 2 inflammation is eosinophilia and/or high IgE counts and is best recognized in atopic diathesis. Persistent eosinophilia, such as seen in hypereosinophilic syndromes, leads to fibrosis and hence therapeutic Type 2 inhibition in fibrotic diseases is of high interest. Furthermore, as demonstrated in cutaneous T cell lymphoma, advanced disease is characterized by Th1 to Th2 switch allowing cancer progression and immunosuppression. Development of targeted monoclonal antibodies against IL-4Rα (eg, dupilumab) led to a paradigm shift for the treatment of atopic dermatitis (AD) and stimulated research to better understand the role of Type 2 inflammation in other skin conditions. In this review, we summarize up to date knowledge on the role of Type 2 inflammation in skin diseases other than AD and highlight whether the use of Type 2 targeted therapies has been documented or is being investigated in clinical trials. This manuscript reviews the role of Type 2 inflammation in dermatitis, neurodermatitis, IgE-mediated dermatoses (eg, bullous pemphigoid, chronic spontaneous urticaria), sclerodermoid conditions and skin neoplasms.

Advances in the Translational Science of Dermatitis

The cycle of converting mechanistic insight into therapeutic interventions is called translational science. It has been relatively sluggish in atopic dermatitis (AD), but finally pathomechanisms have been identified and therapeutic targets selected and refined. From inflammatory mediators, skin barrier enhancement, itch relief, and alteration of the microbiota, several therapies have been proposed and are actively being studied for AD, suggesting an end to the drought of innovation.

Contact dermatitis

Contact dermatitis (CD) is among the most common inflammatory dermatological conditions and includes allergic CD, photoallergic CD, irritant CD, photoirritant CD (also called phototoxic CD) and protein CD. Occupational CD can be of any type and is the most prevalent occupational skin disease. Each CD type is characterized by different immunological mechanisms and/or requisite exposures. Clinical manifestations of CD vary widely and multiple subtypes may occur simultaneously. The diagnosis relies on clinical presentation, thorough exposure assessment and evaluation with techniques such as patch testing and skin-prick testing. Management is based on patient education, avoidance strategies of specific substances, and topical treatments; in severe or recalcitrant cases, which can negatively affect the quality of life of patients, systemic medications may be needed.

Patch Testing During Immunosuppressive Therapy: A Systematic Review

ABSTRACT

Patch testing, used in the assessment of allergic contact dermatitis, is ideally avoided in patients receiving immunosuppressive therapy because of concerns with reductions in accuracy; however, this is not well characterized in the literature. This systematic review summarizes patch testing results in patients receiving immunosuppressive therapy. We identified 16 studies, comprising 195 patients with dermatitis or psoriasis, who were patch tested while receiving immunosuppressants. Of these, 7 studies, comprising 85 patients with dermatitis, patch tests were performed before and during immunosuppression. Overall, 67.9% (n = 19) of the dermatitis patients receiving dupilumab maintained positive reactions to an allergen that previously graded as a 2+/3+ reaction. Several immunosuppressants were also associated with positive patch test results for various allergens. These include dupilumab, cyclosporine, and low-dose prednisone (≤10 mg/d) for dermatitis, and tumor necrosis factor α inhibitors, ustekinumab, and methotrexate for psoriasis. Ideally, it is preferable to patch test when patients are not receiving oral immunosuppressants or immunomodulators. However, clinicians may choose to assess the risks and benefits of patch testing for each patient given the impact of allergic contact dermatitis on patient quality of life.

Pediatric allergic contact dermatitis. Part 2: Patch testing series, procedure, and unique scenarios

Patch testing is the criterion standard for diagnosing allergic contact dermatitis. Causative allergens differ between children and adults, necessitating the development of pediatric-specific patch test series. The Pediatric Baseline Series was developed in 2018 through expert consensus and includes relevant pediatric allergens that dermatologists can use in practice. Obstacles in patch testing, such as the need for multiple office visits, length of patch application, and avoidance of sweat and water on the testing area, are particularly challenging for the pediatric population, and several strategies are proposed. Aside from formal patch testing, alternatives like the repeat open application test and empiric allergen avoidance can be helpful in children. The key to management of allergic contact dermatitis is allergen avoidance, with emphasis on the need to properly identify causative allergens. Continued data collection through registries allows for a better understanding of the diagnosis and management of pediatric allergic contact dermatitis.

A review of contact dermatitis

OBJECTIVE

To familiarize the reader with the mechanisms and causes of contact dermatitis.

DATA SOURCES

Recent research articles, relevant review articles, and case series/reports in English from PubMed database, mostly from 2010 onwards.

STUDY SELECTIONS

Most data were in the form of retrospective studies. Efforts were made to include clinical trials; however, for newer allergens and data on biologics, case series and case reports were included. Older studies regarding the mechanism were included if they were of particular importance.

RESULTS

An understanding of this review should enable the reader to approach the patient with unknown dermatitis with a better understanding of the cause and management.

CONCLUSION

Clinical suspicion for relevant allergens combined with the interpretation of patch tests are important in the diagnosis and treatment of patients with contact dermatitis.

Real-world evidence of dupilumab efficacy and risk of adverse events: A systematic review and meta-analysis

BACKGROUND

Dupilumab, the first biological drug to be approved for the treatment of moderate to severe atopic dermatitis in adolescents and adults, has shown good efficacy and safety in clinical trials.

OBJECTIVE

To evaluate real-world data on the efficacy and safety of dupilumab in atopic dermatitis.

METHODS

PubMed and EMBASE were searched for observational studies with data on efficacy, drug survival, and safety of dupilumab for the treatment of atopic dermatitis. Primary outcomes were mean percentage change in Eczema Area and Severity Index (EASI) score and proportion of atopic dermatitis patients achieving 50%, 75%, and 90% improvement in EASI score after dupilumab therapy.

RESULTS

Twenty-two unique studies encompassing 3303 atopic dermatitis patients were included. After 16 weeks of dupilumab therapy, the pooled proportion of patients achieving 50%, 75%, and 90% EASI score improvement was 85.1%, 59.8%, and 26.8%, respectively, and the weighted mean reduction in EASI score was 69.6%. Conjunctivitis was the most common adverse event, reported in a pooled proportion of 26.1%.

LIMITATIONS

Limited data in terms of size and follow-up time were available.

CONCLUSION

Real-world data show that dupilumab is a successful and well-tolerated therapy for atopic dermatitis, but ocular adverse events commonly occur. Registries are needed to monitor for adverse events.

Biologics for Allergic Dermatologic Diseases

PURPOSE OF REVIEW

Atopic dermatitis (AD), chronic spontaneous urticaria (CSU), and allergic contact dermatitis (ACD) represent three important allergic dermatoses with many unmet therapeutic needs. The development of biologic agents has opened the door to both new treatment options and improved understanding of the underlying pathophysiology, both shared and unique for these entities. With several FDA-approved medications available and many more in development, the biologic revolution has begun for allergic dermatoses.

RECENT FINDINGS

This is a narrative review on the current state of pathomechanisms and appropriately targeted biologic agents for these three common allergic skin conditions. The importance of Th2 inflammation and the effect of inflammatory cytokines on the skin barrier may help explain the impressive efficacy of biologic agents, while maintaining relative safety. While some of the biologic agents show efficacy across multiple allergic dermatoses, more often it seems these more targeted pathways show accordingly precise efficacy. However, in each disease, multiple agents hold promise, and may be differentiated by safety and adverse effect profile rather than simply by efficacy. New understanding of the pathogenesis of the allergic dermatoses has ushered in a new era of biologic therapies. Competing mechanisms and molecules will continue to be developed and vetted in trials with hopes of continuously refined precision therapies with optimized safety and efficacy profiles.

Pitfalls in Patch Testing: Minimizing the Risk of Avoidable False-Negative Reactions

Patch testing is the gold-standard diagnostic tool for the diagnosis of allergic contact dermatitis; unfortunately, it is a procedure with potential for errors, including false-negative reactions. Some of the factors responsible for this are likely unavoidable; however, others may potentially lie within the control of the user. Knowledge and management of these controllable factors may improve the outcome of patch testing and minimize the incidence of false-negative patch test results.

Investigating the role of allergic contact dermatitis in residual ocular surface disease on dupilumab (ROSDD),

Background

The mechanisms underlying eye-related complications with dupilumab are poorly understood.

Objective

This study aimed to determine the incidence and characteristics of ocular complications with dupilumab and the prevalence of comorbid allergic contact dermatitis in the same subpopulation.

Methods

This is a retrospective chart review of 48 patients with atopic dermatitis who received dupilumab. For patients with eye involvement at first follow-up, we discuss the presence of eyelid dermatitis, blepharitis, or conjunctivitis and analyze available patch test findings in patients with ocular complications while treated with dupilumab.

Results

A total of 14 patients (29.2%) showed eye involvement while on dupilumab, all of whom experienced eye involvement prior to dupilumab. The results of the patch test were most commonly positive for emulsifier/surfactants (42.5%) and fragrances (30.4%). Nine patients experienced improvement with allergen avoidance subsequent to patch testing, and four of nine patients’ conditions cleared almost entirely. This is a non-randomized study in a small cohort of patients. Only 18 patients had their disease confirmed by an ophthalmologist.

Conclusion

All patients with eye involvement while on dupilumab had a history of eye involvement prior to dupilumab, suggest that dupilumab may encourage rather than cause ocular surface inflammation. Significant improvement after patch testing in nearly half of patients suggests that allergic contact dermatitis contributes to some cases of dupilumab-associated eye complications.