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Caron AGM, Bloem M, El Khattabi H, de Waal AC, van Huizen AM, Denswil NP, Gerbens LAA, Spuls PI. The wide variety of methotrexate dosing regimens for the treatment of atopic dermatitis: a systematic review. J DERMATOL TREAT 2024; 35:2292962. [PMID: 38124505 DOI: 10.1080/09546634.2023.2292962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023]
Abstract
Background:Methotrexate is an off-label therapy for atopic dermatitis. A lack of consensus on dosing regimens poses a risk of underdosing and ineffective treatment or overdosing and increased risk of side effects. This systematic review summarizes the available evidence on dosing regimens.Materials and methods:A literature search was conducted, screening all randomized controlled trials (RCTs) and guidelines published up to 6 July 2023, in the MEDLINE, Embase, and Cochrane Library databases.Results:Five RCTs and 21 guidelines were included. RCTs compared methotrexate with other treatments rather than different methotrexate dosing regimens. The start and maintenance doses in RCTs varied between 7.5-15 mg/week and 14.5-25 mg/week, respectively. Despite varied dosing, all RCTs demonstrated efficacy in improving atopic dermatitis signs and symptoms. Guidelines exhibited substantial heterogeneity but predominantly proposed starting doses of 5-15 mg/week for adults and 10-15 mg/m2/week for children. Maintenance doses suggested were 7.5-25 mg/week for adults and 0.2-0.7 mg/kg/week for children. One guideline suggested a test dose and nearly half advised folic acid supplementation.Conclusion:This systematic review highlights the lack of methotrexate dosing guidelines for atopic dermatitis. It identifies commonly recommended and utilized dosing regimens, serving as a valuable resource for clinicians prescribing methotrexate off-label and providing input for an upcoming consensus study.
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Affiliation(s)
- Anouk G M Caron
- Dermatology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Infection and Immunity, University of Amsterdam, Amsterdam, the Netherlands
| | - Manja Bloem
- Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Hajar El Khattabi
- Dermatology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Ayla C de Waal
- Dermatology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Astrid M van Huizen
- Dermatology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Infection and Immunity, University of Amsterdam, Amsterdam, the Netherlands
| | - Nerissa P Denswil
- Medical Library, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Louise A A Gerbens
- Dermatology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Infection and Immunity, University of Amsterdam, Amsterdam, the Netherlands
| | - Phyllis I Spuls
- Dermatology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Infection and Immunity, University of Amsterdam, Amsterdam, the Netherlands
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2
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Fomina DS, Mukhina OA, Mikhailova VI, Lebedkina MS, Sedova EL, Bobrikova EN, Elisyutina OG, Fedenko ES, Nurpeisov TT, Karaulov AV, Lysenko MA, Ensina LFC. Treatment of atopic dermatitis with upadacitinib: adcare single center experience. Front Med (Lausanne) 2024; 11:1385720. [PMID: 38695023 PMCID: PMC11061355 DOI: 10.3389/fmed.2024.1385720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 03/12/2024] [Indexed: 05/04/2024] Open
Abstract
Introduction The role of upadacitinib in the management of moderate to severe atopic dermatitis seems promising, but more data on its efficacy and safety are needed. This study endeavors to assess the practical impact and safety of upadacitinib in patients with moderate to severe atopic dermatitis. The study aims to evaluate the efficacy and safety of upadacitinib in the treatment of moderate to severe atopic dermatitis, focusing on analyzing patient responses to the treatment. Methods In this study, adult patients diagnosed with moderate to severe atopic dermatitis received upadacitinib at daily doses of 15 mg or 30 mg, as prescribed by their attending physicians. The therapeutic efficacy of upadacitinib was meticulously assessed using established clinical metrics. Simultaneously, a comprehensive safety assessment was conducted through monthly monitoring, including the evaluation of potential effects of upadacitinib intake on hepatic function, lipid profile, and hematopoiesis using the pertinent laboratory tests. Results Sixteen participants were enrolled in the study. At 1month follow-up, there was a significant reduction in the mean Eczema Area and Severity Index (EASI) score to 18.8 points, which further increased to 24 points at the 4-month mark. Additionally, 9 participants (56%) demonstrated an EASI-50 response after 1 month of treatment, with this response increasing to 9 participants (90%) after 4 months. Furthermore, enhanced therapeutic responses were observed at 4 months, with 6 patients (38%) achieving an EASI-75 response at 1month and 8 patients (80%) achieving this milestone at the 4-month follow-up. This study highlights the potential of upadacitinib as an effective treatment option for moderate to severe atopic dermatitis. While it demonstrates improved symptom management, close monitoring for potential adverse events, particularly infections and the known risks of Janus kinase inhibitors, is essential. Further research is essential to determine the long-term safety and efficacy of upadacitinib.
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Affiliation(s)
- Daria S. Fomina
- City Clinical Hospital No. 52 of the Moscow Healthcare Department, State Budgetary Healthcare Institution, Moscow, Russia
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Olga A. Mukhina
- City Clinical Hospital No. 52 of the Moscow Healthcare Department, State Budgetary Healthcare Institution, Moscow, Russia
| | - Valeria I. Mikhailova
- City Clinical Hospital No. 52 of the Moscow Healthcare Department, State Budgetary Healthcare Institution, Moscow, Russia
| | - Marina S. Lebedkina
- City Clinical Hospital No. 52 of the Moscow Healthcare Department, State Budgetary Healthcare Institution, Moscow, Russia
| | - Elizaveta L. Sedova
- City Clinical Hospital No. 52 of the Moscow Healthcare Department, State Budgetary Healthcare Institution, Moscow, Russia
| | - Elena N. Bobrikova
- City Clinical Hospital No. 52 of the Moscow Healthcare Department, State Budgetary Healthcare Institution, Moscow, Russia
| | - Olga G. Elisyutina
- NRC Institute of Immunology FMBA of Russia, Moscow, Russia
- Peoples’ Friendship University of Russia (RUDN University), Moscow, Russia
| | | | - Tair T. Nurpeisov
- Department of General Immunology, Asfendiyarov Kazakh National Medical University (KazNMU), Almaty, Kazakhstan
- Republican Allergy Center, Research Institute of Cardiology and Internal Medicine, Almaty, Kazakhstan
| | - Alexander V. Karaulov
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Mar’yana A. Lysenko
- City Clinical Hospital No. 52 of the Moscow Healthcare Department, State Budgetary Healthcare Institution, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Luis Felipe C. Ensina
- Division of Allergy, Immunology, Rheumatology, Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil
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Clowry J, Dempsey DJ, Claxton TJ, Towell AM, Turley MB, Sutton M, Geoghegan JA, Kezic S, Jakasa I, White A, Irvine AD, McLoughlin RM. Distinct T cell signatures are associated with Staphylococcus aureus skin infection in pediatric atopic dermatitis. JCI Insight 2024; 9:e178789. [PMID: 38716729 PMCID: PMC11141913 DOI: 10.1172/jci.insight.178789] [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: 12/26/2023] [Accepted: 04/03/2024] [Indexed: 06/02/2024] Open
Abstract
Atopic dermatitis (AD) is an inflammatory skin condition with a childhood prevalence of up to 25%. Microbial dysbiosis is characteristic of AD, with Staphylococcus aureus the most frequent pathogen associated with disease flares and increasingly implicated in disease pathogenesis. Therapeutics to mitigate the effects of S. aureus have had limited efficacy and S. aureus-associated temporal disease flares are synonymous with AD. An alternative approach is an anti-S. aureus vaccine, tailored to AD. Experimental vaccines have highlighted the importance of T cells in conferring protective anti-S. aureus responses; however, correlates of T cell immunity against S. aureus in AD have not been identified. We identify a systemic and cutaneous immunological signature associated with S. aureus skin infection (ADS.aureus) in a pediatric AD cohort, using a combined Bayesian multinomial analysis. ADS.aureus was most highly associated with elevated cutaneous chemokines IP10 and TARC, which preferentially direct Th1 and Th2 cells to skin. Systemic CD4+ and CD8+ T cells, except for Th2 cells, were suppressed in ADS.aureus, particularly circulating Th1, memory IL-10+ T cells, and skin-homing memory Th17 cells. Systemic γδ T cell expansion in ADS.aureus was also observed. This study suggests that augmentation of protective T cell subsets is a potential therapeutic strategy in the management of S. aureus in AD.
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Affiliation(s)
- Julianne Clowry
- Department of Dermatology, National Children’s Research Centre, Children’s Health Ireland at Crumlin, Dublin, Ireland
- Clinical Medicine, Trinity College Dublin, Dublin, Ireland
- Host-Pathogen Interactions Group, School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Daniel J. Dempsey
- Host-Pathogen Interactions Group, School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Tracey J. Claxton
- Host-Pathogen Interactions Group, School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Aisling M. Towell
- Department of Microbiology, Moyne Institute of Preventive Medicine, School of Genetics and Microbiology, Trinity College Dublin, Dublin, Ireland
| | - Mary B. Turley
- Department of Microbiology, Moyne Institute of Preventive Medicine, School of Genetics and Microbiology, Trinity College Dublin, Dublin, Ireland
- Institute of Microbiology and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Martin Sutton
- Department of Microbiology, Moyne Institute of Preventive Medicine, School of Genetics and Microbiology, Trinity College Dublin, Dublin, Ireland
| | - Joan A. Geoghegan
- Department of Microbiology, Moyne Institute of Preventive Medicine, School of Genetics and Microbiology, Trinity College Dublin, Dublin, Ireland
- Institute of Microbiology and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Sanja Kezic
- Amsterdam UMC, University of Amsterdam, Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Ivone Jakasa
- Laboratory for Analytical Chemistry, Department of Chemistry and Biochemistry, Faculty of Food Technology and Biotechnology, University of Zagreb, Zagreb, Croatia
| | - Arthur White
- School of Computer Science and Statistics, Trinity College Dublin, Dublin, Ireland
| | - Alan D. Irvine
- Department of Dermatology, National Children’s Research Centre, Children’s Health Ireland at Crumlin, Dublin, Ireland
- Clinical Medicine, Trinity College Dublin, Dublin, Ireland
| | - Rachel M. McLoughlin
- Host-Pathogen Interactions Group, School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
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4
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Wang Q, Chen L. Methotrexate therapy for adult and paediatric moderate-to-severe atopic dermatitis: A PRISMA-compliant meta-analysis of data from daily practice. Australas J Dermatol 2024; 65:114-127. [PMID: 37941136 DOI: 10.1111/ajd.14183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 09/20/2023] [Accepted: 10/15/2023] [Indexed: 11/10/2023]
Abstract
Of the 15 eligible studies identified via electronic searches in MEDLINE, EMBASE and CENTRAL in November 2022 for methotrexate therapy of moderate-to-severe atopic dermatitis, 12 were non-randomized controlled trial (non-RCT) studies with data from 437 patients (235 adults and 202 children). The response rates for short-term therapy were 77% [95% CI 55-99] (four studies; adults) - comparable to 81% [54-100] of RCTs (two studies; adults) (p = 0.63) - and 61% [43-79] (two studies; children), and for medium/long-term therapy were 88.9% [74.3-100.0] (four studies; adults) and 77.7% [61.5-94.0] (three studies; children). Children had a markedly lower rate of treatment discontinuation due to side effects [2.0% (five studies; children) vs. 14.9% (six studies; adults)], but were more likely to experience gastrointestinal disorders {relative risk (RR) 2.0 [1.44-2.71]}, fatigue (RR 2.3 [1.35-3.72]), headache (RR 2.8 [1.23-5.61]), and infections (RR 2.9 [2.18-3.58]). Other adverse events (children vs. adults) included hepatic disorders (32/176 vs. 35/305) and blood and lymphatic system/bone marrow disorders (25/148 vs. 19/184). Four serious adverse events were reported (children). Evidence from daily practice was limited by bias in the selection of participants in the study.
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Affiliation(s)
- Qiaohong Wang
- Department of Rheumatology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Liheng Chen
- Department of Endocrinology, Fourth Affiliated Hospital, College of Medicine, Zhejiang University, Yiwu, China
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5
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Orfali RL, Lorenzini D, Bressan A, Tanaka AA, Cerqueira AMMD, Hirayama ADS, Ramos AMC, Proença CC, Silva CMDR, Laczynski CMM, Carneiro FR, Duarte G, Hans Filho G, Gonçalves HDS, Melo LPD, Azulay-Abulafia L, Weber MB, Rivitti-Machado MC, Zaniboni MC, Ogawa M, Pires MC, Ianhez M, Felix PAO, Bonamigo R, Takaoka R, Lazzarini R, Cestari S, Mayor SAS, Cestari T, Oliveira ZNPD, Spuls PI, Gerbens LAA, Aoki V. Consensus on the therapeutic management of atopic dermatitis ‒ Brazilian Society of Dermatology: an update on phototherapy and systemic therapy using e-Delphi technique. An Bras Dermatol 2023; 98:814-836. [PMID: 37302894 PMCID: PMC10589461 DOI: 10.1016/j.abd.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/04/2023] [Accepted: 04/09/2023] [Indexed: 06/13/2023] Open
Abstract
This publication is an update of the "Consensus on the therapeutic management of atopic dermatitis - Brazilian Society of Dermatology" published in 2019, considering the novel, targeted-oriented systemic therapies for atopic dermatitis. The initial recommendations of the current consensus for systemic treatment of patients with atopic dermatitis were based on a recent review of scientific published data and a consensus was reached after voting. The Brazilian Society of Dermatology invited 31 experts from all regions of Brazil and 2 international experts on atopic dermatitis who fully contributed to the process. The methods included an e-Delphi study to avoid bias, a literature search and a final consensus meeting. The authors added novel approved drugs in Brazil and the indication for phototherapy and systemic therapy for AD. The therapeutical response to systemic treatment is hereby reported in a suitable form for clinical practice and is also part of this updated manuscript.
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Affiliation(s)
- Raquel Leao Orfali
- Department of Dermatology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Daniel Lorenzini
- Department of Dermatology, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | - Aline Bressan
- Department of Dermatology, Hospital Universitário Pedro Ernesto, Universidade Estadual do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Anber Ancel Tanaka
- Department of Dermatology, Hospital Universitário Evangélico Mackenzie, Curitiba, PR, Brazil
| | | | - André da Silva Hirayama
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Andréa Machado Coelho Ramos
- Department of Dermatology, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Carolina Contin Proença
- Dermatology Clinic, Irmandade Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | | | | | | | - Gleison Duarte
- Department of Dermatology, Instituto Bahiano de Imunoterapia, Salvador, BH, Brazil
| | - Gunter Hans Filho
- Department of Dermatology, Hospital Universitário Maria Aparecida Pedrossian, Universidade Federal de Mato Grosso do Sul, Campo Grande, MS, Brazil
| | - Heitor de Sá Gonçalves
- Department of Health, National Reference Center in Sanitary Dermatology Dona Libânia, Fortaleza, CE, Brazil
| | - Ligia Pessoa de Melo
- Department of Dermatology, Instituto de Medicina Integral Professor Fernando Figueira, Recife, PE, Brazil; Health Department, Hospital Otávio de Freitas, Recife, PE, Brazil
| | - Luna Azulay-Abulafia
- Department of Dermatology, Hospital Universitário Pedro Ernesto, Universidade Estadual do Rio de Janeiro, Rio de Janeiro, RJ, Brazil; Professor Rubem David Azulay Institute of Dermatology, Santa Casa de Misericórdia do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Maria Cecília Rivitti-Machado
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil; Department of Dermatology, Universidade Metropolitana de Santos, Santos, SP, Brazil
| | - Mariana Colombini Zaniboni
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marília Ogawa
- Department of Dermatology, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Mario Cezar Pires
- Department of Dermatology, Complexo Hospitalar Padre Bento, Guarulhos, SP, Brazil; Department of Dermatology, State Public Servant Hospital, São Paulo, SP, Brazil
| | - Mayra Ianhez
- Department of Dermatology, Hospital for Tropical Diseases, Goiânia, GO, Brazil; Department of Dermatology, Universidade Federal de Goiás, Goiânia, GO, Brazil
| | | | - Renan Bonamigo
- Department of Dermatology, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Roberto Takaoka
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Rosana Lazzarini
- Dermatology Clinic, Irmandade Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Silmara Cestari
- Department of Dermatology, Teaching and Research Institute of Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | | | - Tania Cestari
- Department of Dermatology, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - Phyllis I Spuls
- Department of Dermatology, Amsterdam UMC, Academic Medical Center, University of Amsterdam, Amsterdam Public Health, Infection and Immunity, The Netherlands
| | - Louise A A Gerbens
- Department of Dermatology, Amsterdam UMC, Academic Medical Center, University of Amsterdam, Amsterdam Public Health, Infection and Immunity, The Netherlands
| | - Valeria Aoki
- Department of Dermatology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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6
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Kim K, Kim M, Rhee E, Lee MH, Yang HJ, Park S, Kim HS. Efficacy and Safety of Low-Dose Cyclosporine Relative to Immunomodulatory Drugs Used in Atopic Dermatitis: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12041390. [PMID: 36835928 PMCID: PMC9959975 DOI: 10.3390/jcm12041390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/03/2023] [Accepted: 02/03/2023] [Indexed: 02/12/2023] Open
Abstract
Cyclosporine A (CsA) is effective in treating moderate-to-severe atopic dermatitis (AD). This systematic review and meta-analysis aimed to summarize the effectiveness and safety of low-dose (<4 mg/kg) versus high-dose (≥4 mg/kg) CsA and other systemic immunomodulatory agents in patients with AD. Five randomized controlled trials met the inclusion criteria. The meta-analysis included 159 patients with moderate-to-severe AD who were randomized to receive low-dose CsA, and 165 patients randomized to receive high-dose CsA and other systemic immunomodulatory agents. We found that low-dose CsA was not inferior to high-dose CsA and other systemic immunomodulatory agents in reducing AD symptoms [standard mean difference (SMD) -1.62, 95% confidence interval (CI) -6.47; 3.23]. High-dose CsA and other systemic immunomodulatory agents showed a significantly lower incidence of adverse events [incidence rate ratio (IRR) 0.72, 95% CI 0.56; 0.93], however, after sensitivity analysis, there was no difference between the two groups except for one study (IRR 0.76, 95% CI 0.54; 1.07). Regarding serious adverse events requiring discontinuation of treatment, we observed no significant differences between low-dose CsA and other systemic immunomodulatory agents (IRR 1.83, 95% CI 0.62; 5.41). Our study may justify the use of low-dose CsA rather than high-dose CsA and other systemic immunomodulatory agents in moderate-to-severe AD.
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Affiliation(s)
- Kyunghoon Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Mina Kim
- Department of Applied Statistics, Chung-Ang University, Seoul 06974, Republic of Korea
| | - EunHee Rhee
- SCH Biomedical Informatics Research Unit, Soonchunhyang University Seoul Hospital, Seoul 04401, Republic of Korea
- Department of Pediatrics, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul 04401, Republic of Korea
| | - Mi-Hee Lee
- Department of Pediatrics, Incheon Medical Center, Incheon 22532, Republic of Korea
| | - Hyeon-Jong Yang
- SCH Biomedical Informatics Research Unit, Soonchunhyang University Seoul Hospital, Seoul 04401, Republic of Korea
- Department of Pediatrics, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul 04401, Republic of Korea
| | - Suyeon Park
- Department of Applied Statistics, Chung-Ang University, Seoul 06974, Republic of Korea
- Department of Biostatistics, Soonchunhyang University Seoul Hospital, Seoul 04401, Republic of Korea
- Correspondence: (S.P.); (H.S.K.)
| | - Hwan Soo Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Correspondence: (S.P.); (H.S.K.)
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7
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Cannabinoid Compounds as a Pharmacotherapeutic Option for the Treatment of Non-Cancer Skin Diseases. Cells 2022; 11:cells11244102. [PMID: 36552866 PMCID: PMC9777118 DOI: 10.3390/cells11244102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/19/2022] [Accepted: 10/25/2022] [Indexed: 12/23/2022] Open
Abstract
The endocannabinoid system has been shown to be involved in various skin functions, such as melanogenesis and the maintenance of redox balance in skin cells exposed to UV radiation, as well as barrier functions, sebaceous gland activity, wound healing and the skin's immune response. In addition to the potential use of cannabinoids in the treatment and prevention of skin cancer, cannabinoid compounds and derivatives are of interest as potential systemic and topical applications for the treatment of various inflammatory, fibrotic and pruritic skin conditions. In this context, cannabinoid compounds have been successfully tested as a therapeutic option for the treatment of androgenetic alopecia, atopic and seborrhoeic dermatitis, dermatomyositis, asteatotic and atopic eczema, uraemic pruritis, scalp psoriasis, systemic sclerosis and venous leg ulcers. This review provides an insight into the current literature on cannabinoid compounds as potential medicines for the treatment of skin diseases.
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8
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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: 105] [Impact Index Per Article: 52.5] [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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9
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Ming SWY, Zhou Y, Smith M, Were J. A Retrospective Database Cohort Study Evaluating the Association Between Immune Suppressive Therapy and the Development of Cancer in Patients with Atopic Dermatitis Within UK Primary Care. EUROPEAN MEDICAL JOURNAL 2022. [DOI: 10.33590/emj/22-00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Introduction: First-line regular systemic treatment for atopic dermatitis (AD) in the UK consists of methotrexate, azathioprine, ciclosporin, or mycophenolate (immune-suppressive therapies [IST]). ISTs have been associated with malignancy, hence the need for evaluation for the relationship to the risk of developing cancer.
Method: This retrospective cohort study utilising the Clinical Practice Research Datalink (CPRD) followed two cohorts with moderate or severe AD: one prescribed ISTs and one without. A total of 222,978 patients were included. The index date was the date of first IST prescription within primary care for the IST cohort, and the date of first potent topical steroid prescription from January 2001 to May 2021. Cohorts were propensity matched 1:1, resulting in 17,556 patients per cohort. Cox proportional hazard models were used to model the hazard of a cancer diagnosis. A secondary analysis was carried out on a restricted population, excluding patients with other comorbidities where ISTs were commonly prescribed. A further analysis explored the relation between the dose and the association with the risk of cancer.
Results: Both the primary (hazard ratio: 1.01; 95% confidence interval: 0.94–1.08) and secondary (hazard ratio: 1.03; 95% confidence interval: 0.93–1.14) analyses did not show a significant difference in the hazard of a cancer code in the IST and non-IST cohorts. The exploratory dose–response analysis showed a higher risk of cancer associated with more prescriptions of IST per year.
Conclusion: This study shows that amongst patients with moderate or severe AD, overall IST prescription in primary care is not associated with the onset of a cancer code. However, there is a trend with a higher risk of cancer coding with more prescriptions of IST.
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10
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Dupilumab Provides Acceptable Safety and Sustained Efficacy for up to 4 Years in an Open-Label Study of Adults with Moderate-to-Severe Atopic Dermatitis. Am J Clin Dermatol 2022; 23:393-408. [PMID: 35503163 PMCID: PMC9063621 DOI: 10.1007/s40257-022-00685-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 11/10/2022]
Abstract
Background Moderate‐to‐severe atopic dermatitis (AD) often requires long-term management with systemic therapies. Objective Our objective was to report the safety and efficacy of dupilumab treatment up to 4 years in adults with moderate-to-severe AD and efficacy in a subgroup of patients who transitioned from dupilumab once-weekly (qw) to administration every other week (q2w). Methods This interim analysis of the open-label extension study (NCT01949311) evaluated dupilumab 300 mg qw or q2w in adults previously enrolled in dupilumab trials for moderate-to-severe AD. Patients switched from qw to q2w following protocol amendment. The primary outcome was safety; efficacy was also assessed. Results Of 2677 patients enrolled and treated, 352 (13.1%) completed week 204 (end of efficacy assessments) and 202 (7.5%) completed safety follow-up through week 244. Self-reported compliance was 98.1%. Dupilumab’s safety profile was consistent with previous reports. Common treatment-emergent adverse events (≥5%) included nasopharyngitis, AD, upper respiratory tract infection, oral herpes, conjunctivitis, injection-site reaction, and headache. At week 204, mean ± standard deviation (SD) Eczema Area and Severity Index was 2.46 ± 3.98, and mean percent change from parent study baseline (PSBL) was −91.07%; mean ± SD Pruritus Numerical Rating Scale score was 2.10 ± 1.83, and mean percent change from PSBL was −68.74%. Efficacy was maintained in patients (n = 226) who transitioned from qw to q2w dosing. Limitations of this study included its open-label design, the lack of control arm, and smaller subsets of patients at later timepoints and receiving the approved q2w regimen. Conclusion These results support dupilumab as continuous long-term treatment for adults with moderate-to-severe AD; efficacy was sustained following transition from qw to q2w dosing. Trial Registration ClinicalTrials.gov NCT01949311. Supplementary Information The online version contains supplementary material available at 10.1007/s40257-022-00685-0. Atopic dermatitis is a chronic skin disease associated with inflamed skin and intense itching. People with moderate-to-severe atopic dermatitis often need long-term treatment, but many available treatments do not have demonstrated long-term safety data. In multiple clinical trials, dupilumab treatment resulted in significant improvements in signs and symptoms of atopic dermatitis. This study examined the safety and efficacy of up to 4 years of dupilumab treatment in adults with moderate-to-severe atopic dermatitis, and whether dupilumab continued to be effective in patients who switched from receiving treatment each week to treatment every other week. To address these questions, we collected data from adults who received 300 milligrams of dupilumab every week or every other week. In this study, safety findings were consistent with the known dupilumab safety profile. Patients' signs and symptoms were evaluated before and during treatment with evaluation tools including the Eczema Area and Severity Index (EASI), which indicates the extent and severity of disease, and the Pruritus Numerical Rating Scale (NRS), which indicates the intensity of itching. Reductions of 91% in EASI scores and 69% in Pruritus NRS scores showed that the improvement in signs and symptoms persisted for 204 weeks (almost 4 years) of treatment, and these effects were sustained following the switch from weekly treatment to the approved every other week treatment with dupilumab. The safety and efficacy data presented here support the use of dupilumab as a continuous, long-term treatment for up to 4 years for adults with moderate-to-severe atopic dermatitis.
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11
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Elsgaard S, Danielsen AK, Thyssen JP, Deleuran M, Vestergaard C. Drug survival of systemic immunosuppressive treatments for atopic dermatitis in a long-term pediatric cohort. Int J Womens Dermatol 2022; 7:708-715. [PMID: 35028369 PMCID: PMC8714597 DOI: 10.1016/j.ijwd.2021.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 07/08/2021] [Accepted: 07/10/2021] [Indexed: 01/06/2023] Open
Abstract
Background : Systemic immunosuppressive treatments are central in the treatment of severe atopic dermatitis (AD). Yet, comparative data are sparse on the performance of such immunosuppressive treatments in pediatric cohorts with severe AD. Objective : This study aimed to examine the drug survival of systemic immunosuppressive treatments in a cohort of children with severe AD. Methods : A retrospective pediatric cohort was identified using diagnosis and treatment codes registered in medical charts. In total, 135 cases were identified; of these, 36 were excluded. All information was obtained through examination of clinical records. Drug survival was analyzed with Kaplan–Meier plots, and a log-rank test was used to test for differences in drug survival. Results : First-line treatment was primarily methotrexate (MTX; n = 63) and azathioprine (AZA; n = 32). For MTX, the drug survival rates were 69%, 50%, and 18% after 1, 2, and 4 years, respectively, with a median drug survival time of 1.58 years. For AZA, these rates were 63%, 53%, and 21%, respectively, with a median drug survival time of 1.14 years. There was no significant difference in drug survival between the treatments. The main reason for discontinuation was adverse effects (MTX: 25%; AZA: 41%). Despite this, a majority of patients experienced a good effect at the moment of discontinuation or data-lock (MTX: 60%; AZA: 53%), and treatment effect assessed as improvement in sleep quality was highly significant (p = .001). Second-line treatments included MTX (n = 12), AZA (n = 7), and cyclosporine (n = 5). These showed a median drug survival time of 1.8, 0.2, and 0.885 years, respectively. Conclusion : MTX and AZA were the dominant first-line treatments prescribed and were safe and equally valuable treatment options for severe childhood AD with similar drug survival outcomes. MTX was the most used second-line treatment.
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Affiliation(s)
- Stine Elsgaard
- Department of Dermatology, Aarhus University Hospital, Aarhus Denmark
| | | | - Jacob P Thyssen
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Denmark
| | - Mette Deleuran
- Department of Dermatology, Aarhus University Hospital, Aarhus Denmark
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12
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Lee JH, Kim JE, Park GH, Bae JM, Byun JY, Shin MK, Han TY, Hong SP, Jang YH, Kim HO, Na CH, Lew BL, Ahn J, Park CO, Seo YJ, Lee YW, Son SW, Choi EH, Park YL, Roh JY. Consensus Update for Systemic Treatment of Atopic Dermatitis. Ann Dermatol 2021; 33:497-514. [PMID: 34858001 PMCID: PMC8577915 DOI: 10.5021/ad.2021.33.6.497] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 02/04/2021] [Accepted: 03/02/2021] [Indexed: 11/21/2022] Open
Abstract
Background In 2015, the Korean Atopic Dermatitis Association (KADA) working group published consensus guidelines for treating atopic dermatitis (AD). Objective We aimed to provide updated consensus recommendations for systemic treatment of AD in South Korea based on recent evidence and experience. Methods We compiled a database of references from relevant systematic reviews and guidelines on the systemic management of AD. Evidence for each statement was graded and classified based on thestrength of the recommendation. Forty-two council members from the KADA participated in three rounds of voting to establish a consensus on expert recommendations. Results We do not recommend long-term treatment with systemic steroids forpatients with moderate-to-severe AD due to the risk of adverse effects. We recommend treatment with cyclosporine or dupilumab and selective treatment with methotrexate or azathioprine for patients with moderate-to-severe AD. We suggest treatment with antihistamines as an option for alleviating clinical symptoms of AD. We recommend selective treatment with narrowband ultraviolet B for patients with chronic moderate-to-severe AD. We do not recommend treatment with oral antibiotics for patients with moderate-to-severe AD but who have no signs of infection. We did not reach a consensus on recommendations for treatment with allergen-specific immunotherapy, probiotics, evening primrose oil, orvitamin D for patients with moderate-to-severe AD. We also recommend educational interventions and counselling for patients with AD and caregivers to improve the treatment success rate. Conclusion We look forward to implementing a new and updated consensus of systemic therapy in controlling patients with moderate-to-severe AD.
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Affiliation(s)
- Ji Hyun Lee
- Department of Dermatology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Eun Kim
- Department of Dermatology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Gyeong-Hun Park
- Department of Dermatology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Jung Min Bae
- Department of Dermatology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji Yeon Byun
- Department of Dermatology, Ewha Womans University College of Medicine, Seoul, Korea
| | - Min Kyung Shin
- Department of Dermatology, Kyung Hee University College of Medicine, Seoul, Korea
| | - Tae Young Han
- Department of Dermatology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Seung Phil Hong
- Department of Dermatology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yong Hyun Jang
- Department of Dermatology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Hye One Kim
- Department of Dermatology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Chan Ho Na
- Department of Dermatology, College of Medicine, Chosun University, Gwangju, Korea
| | - Bark-Lynn Lew
- Department of Dermatology, Kyung Hee University College of Medicine, Seoul, Korea
| | - JiYoung Ahn
- Department of Dermatology, National Medical Center, Seoul, Korea
| | - Chang Ook Park
- Department of Dermatology, Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Joon Seo
- Department of Dermatology, Chungnam National University College of Medicine, Daejeon, Korea
| | - Yang Won Lee
- Department of Dermatology, Konkuk University School of Medicine, Seoul, Korea
| | - Sang Wook Son
- Department of Dermatology, Korea University College of Medicine, Seoul, Korea
| | - Eung Ho Choi
- Department of Dermatology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young Lip Park
- Department of Dermatology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Joo Young Roh
- Department of Dermatology, Gil Medical Center, Gachon University School of Medicine, Incheon, Korea
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13
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van Huizen AM, Vermeulen FM, Bik CMJM, Borgonjen R, Karsch SAT, Kuin RA, Gerbens LAA, Spuls PI. On which evidence can we rely when prescribing off-label methotrexate in dermatological practice? - a systematic review with GRADE approach. J DERMATOL TREAT 2021; 33:1947-1966. [PMID: 34425719 DOI: 10.1080/09546634.2021.1961999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
If an authorized drug is prescribed for a use that is not described in the Summary of Product Characteristics, this is defined as 'off-label use.' Methotrexate is often used off-label for dermatological indications. Off-label use is permitted if physicians can justify the treatment based on scientific evidence available to them. Our objective here was therefore to summarize the evidence for the effectiveness, efficacy, and safety of the dermatological off-label use of methotrexate in a systematic review. We searched MEDLINE, EMBASE, and CENTRAL for studies for evidence on the effectiveness, efficacy, and safety of the off-label use of methotrexate in dermatological indications up to November 2019. We used the GRADE system to rate the quality of the evidence. The search retrieved 34,583 hits of which 3566 were selected after the title and abstract screening. After the full-text screening, 143 studies were included, which involved 3688 patients in total. We found low-quality evidence for the effectiveness, efficacy, and safety of the off-label use of methotrexate in 31 dermatological diseases. To optimize the quality of evidence to support off-label use, we need high-quality studies in which well-characterized patients are treated with standardized treatments regimens using well-validated outcomes relevant to patients and physicians.
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Affiliation(s)
- Astrid M van Huizen
- Department of Dermatology, Amsterdam Public Health, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Francisca M Vermeulen
- Department of Dermatology, Amsterdam Public Health, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Rinke Borgonjen
- Department of Dermatology, Gelderland Valley Hospital, Ede, The Netherlands
| | - Saskia A T Karsch
- Department of Family Medicine, UMC Utrecht, Utrecht, The Netherlands
| | - Rosanna A Kuin
- Department of Dermatology, Amsterdam Public Health, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Louise A A Gerbens
- Department of Dermatology, Amsterdam Public Health, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Phyllis I Spuls
- Department of Dermatology, Amsterdam Public Health, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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14
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Update on the Pathogenesis and Therapy of Atopic Dermatitis. Clin Rev Allergy Immunol 2021; 61:324-338. [PMID: 34338977 DOI: 10.1007/s12016-021-08880-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2021] [Indexed: 12/22/2022]
Abstract
Atopic dermatitis (AD) is a common inflammatory skin disorder characterized by recurrent eczematous lesions and intense itch. Although it most often starts in infancy and affects children, it is also highly prevalent in adults. In this article, the main aspects of AD have been updated, with a focus on the pathogenetic and therapeutic aspects. The pathogenesis of AD is complex, and it is evident that a strong genetic predisposition, epidermal dysfunction, skin microbiome abnormalities, immune dysregulation, and the neuroimmune system are critical in AD development. Mutations in the genes associated with disrupted epidermal barrier, exaggerated pathological inflammation and inadequate antimicrobial peptides can promote enhanced Th2 inflammation and mediate pruritus. Current understanding of etiology highlights gut microbial diversity, NK cell deficiency, and different immunological phenotype with age and race. For topical anti-inflammatory treatment for mild-to-severe AD, phosphodiesterase 4 inhibitors (PDE-4), JAK inhibitors, and microbiome transplantation with Roseomonas mucosa provided more management selections. The treatment of moderate-to-severe AD has been limited to merely symptomatic and relatively nonspecific immunosuppressive approaches. In-depth understanding of the pathogenesis of AD has led to the development of innovative and targeted therapies, such as biologic agents targeting interleukin (IL)-4, IL-13 and JAK/STAT inhibitors. Other potential therapeutic agents for AD include agents targeting the T helper (Th) 22 and Th17/IL23 pathway. Antipruritic therapy and complementary probiotics therapy have also been reviewed.
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15
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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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16
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Mohr N, Naatz M, Zeervi L, Langenbruch A, Bieber T, Werfel T, Wollenberg A, Augustin M. Cost‐of‐illness of atopic dermatitis in Germany: data from dermatology routine care. J Eur Acad Dermatol Venereol 2021; 35:1346-1356. [DOI: 10.1111/jdv.17203] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 02/11/2021] [Indexed: 12/27/2022]
Affiliation(s)
- N. Mohr
- Institute for Health Services Research in Dermatology and Nursing (IVDP) University Medical Center Hamburg‐Eppendorf (UKE) Hamburg Germany
| | - M. Naatz
- Institute for Health Services Research in Dermatology and Nursing (IVDP) University Medical Center Hamburg‐Eppendorf (UKE) Hamburg Germany
| | - L. Zeervi
- Institute for Health Services Research in Dermatology and Nursing (IVDP) University Medical Center Hamburg‐Eppendorf (UKE) Hamburg Germany
| | - A. Langenbruch
- Institute for Health Services Research in Dermatology and Nursing (IVDP) University Medical Center Hamburg‐Eppendorf (UKE) Hamburg Germany
| | - T. Bieber
- Department of Dermatology and Allergy University Hospital Bonn Bonn Germany
| | - T. Werfel
- Department Dermatology and Allergy Hannover Medical School Hannover Germany
| | - A. Wollenberg
- Department Dermatology and Allergy Ludwig‐Maximilian University Munich Germany
| | - M. Augustin
- Institute for Health Services Research in Dermatology and Nursing (IVDP) University Medical Center Hamburg‐Eppendorf (UKE) Hamburg Germany
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17
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Marko M, Pawliczak R. Can we safely use systemic treatment in atopic dermatitis during the COVID-19 pandemic? Overview of selected conventional and biologic systemic therapies. Expert Rev Clin Immunol 2021; 17:619-627. [PMID: 33866905 DOI: 10.1080/1744666x.2021.1919511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, the medical community has faced major challenges that affect disease management in all areas. Dermatologists and immunologists have to choose appropriate treatment strategy taking into consideration the risk of infection and possible exacerbation of the course of the disease in patients with confirmed infection. Management of atopic dermatitis (AD) in moderate to severe cases is based on systemic therapy such as cyclosporine, azathioprine, methotrexate and dupilumab.Areas covered: A literature search in PubMed database was performed until 6 March 2021. In this review, the authors discuss non-biologic and biologic systemic medications for AD and provide an overview of therapeutic recommendations during COVID-19 pandemic.Expert opinion: In case of an active COVID-19 infection, conventional systemic treatment and biological treatment needs to be stopped until clinical recovery. Noninfected patients with systemic treatment of AD should continue their therapy via self-application. The authors can conclude that understanding of dupilumab therapy is better recognized in context AD treatment during COVID-19 pandemic in comparison to cyclosporine, azathioprine and methotrexate. However, this systemic immunosuppressants still require further investigation and literature complementation.
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Affiliation(s)
- Monika Marko
- Department of Immunopathology, Faculty of Medicine, Division of Biomedical Science, Medical University of Lodz, Lodz, Poland
| | - Rafał Pawliczak
- Department of Immunopathology, Faculty of Medicine, Division of Biomedical Science, Medical University of Lodz, Lodz, Poland
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18
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Wohlrab J, Mrowietz U, Weidinger S, Werfel T, Wollenberg A. [Recommendations when switching therapy from immunosuppressive drugs to dupilumab in patients with atopic dermatitis]. Hautarzt 2021; 72:321-327. [PMID: 33175219 PMCID: PMC8016796 DOI: 10.1007/s00105-020-04720-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Basierend auf neuen Erkenntnissen zur molekularen Pathogenese der atopischen Dermatitis, wurde neben Glukokortikoiden und Ciclosporin mit Dupilumab nun auch eine zielgerichtete antientzündliche Systemtherapie zugelassen. Wegen ihrer Pharmakologie sind weder Glukokortikoide und Ciclosporin noch die außerhalb der Zulassung angewendeten Substanzen Methotrexat, Azathioprin und Mycophenolsäurederivate für eine Langzeittherapie geeignet. Bei der Umstellung der Therapie von den genannten niedermolekularen Substanzen auf Dupilumab sollten verschiedene Faktoren berücksichtigt werden. Hierbei sind sowohl der konkrete Anlass der Umstellung (Unwirksamkeit, unerwünschte Wirkungen oder sich einstellende Kontraindikationen) als auch die pharmakologischen Gegebenheiten zu berücksichtigen. Da es hierzu bisher keine konkreten klinischen Untersuchungen gibt, haben die Autoren auf der Grundlage einer Literaturrecherche Handlungsempfehlungen für den praktischen Alltag erarbeitet.
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Affiliation(s)
- Johannes Wohlrab
- Universitätsklinik und Poliklinik für Dermatologie und Venerologie, Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Str. 40, 06097, Halle (Saale), Deutschland. .,An-Institut für angewandte Dermatopharmazie, Martin-Luther-Universität Halle-Wittenberg, Halle-Wittenberg, Deutschland.
| | - Ulrich Mrowietz
- Klinik für Dermatologie, Venerologie und Allergologie, Christian-Albrechts-Universität Kiel, Kiel, Deutschland
| | - Stephan Weidinger
- Klinik für Dermatologie, Venerologie und Allergologie, Christian-Albrechts-Universität Kiel, Kiel, Deutschland
| | - Thomas Werfel
- Klinik für Dermatologie und Allergologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Andreas Wollenberg
- Klinik für Dermatologie und Allergologie, Ludwig-Maximilian-Universität München, München, Deutschland
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Siegels D, Heratizadeh A, Abraham S, Binnmyr J, Brockow K, Irvine AD, Halken S, Mortz CG, Flohr C, Schmid‐Grendelmeier P, Poel L, Muraro A, Weidinger S, Werfel T, Schmitt J. Systemic treatments in the management of atopic dermatitis: A systematic review and meta-analysis. Allergy 2021; 76:1053-1076. [PMID: 33074565 DOI: 10.1111/all.14631] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/14/2020] [Accepted: 09/30/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND As an evidence resource for the currently planned European Academy of Allergy and Clinical Immunology (EAACI) clinical practice guideline "systemic treatment of atopic dermatitis (AD)," we critically appraised evidence on systemic treatments for moderate-to-severe AD. METHODS We systematically identified randomized controlled trials (RCTs) investigating the safety and efficacy of systemic treatments for AD up to February 2020. Primary efficacy outcomes were clinical signs, AD symptoms and health-related quality of life. Primary safety outcomes included cumulative incidence rates for (serious) adverse events. Trial quality was assessed applying the Cochrane Risk of Bias Tool 2.0. Meta-analyses were conducted where appropriate. RESULTS 50 RCTs totalling 6681 patients were included. Trial evidence was identified for apremilast, azathioprine (AZA), baricitinib, ciclosporin A (CSA), corticosteroids, dupilumab, interferon-gamma, intravenous immunoglobulins (IVIG), mepolizumab, methotrexate (MTX), omalizumab, upadacitinib and ustekinumab. Meta-analyses were indicated for the efficacy of baricitinib [EASI75 RD 0.16, 95% CI (0.10;0.23)] and dupilumab [EASI75, RD 0.37, 95% CI (0.32;0.42)] indicating short-term (ie 16-week treatment) superiority over placebo. Furthermore, efficacy analyses of AZA and CSA indicated short-term superiority over placebo; however, nonvalidated scores were used and can therefore not be compared to EASI. CONCLUSION The most robust, replicated high-quality trial evidence is present for the efficacy and safety of dupilumab for up to 1 year in adults. Robust trial evidence was further revealed for AZA, baricitinib and CSA. Methodological restrictions led to limited evidence-based conclusions for all other systemic treatments. Head-to-head trials with novel systemic treatments are required to clarify the future role of conventional therapies.
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Affiliation(s)
- Doreen Siegels
- Center for Evidence‐Based Healthcare University Hospital Dresden Dresden Germany
| | - Annice Heratizadeh
- Division of Immunodermatology and Allergy Research Department of Dermatology and Allergy Hannover Medical School Hannover Germany
| | - Susanne Abraham
- Center for Evidence‐Based Healthcare University Hospital Dresden Dresden Germany
- Department of Dermatology Medical Faculty Carl Gustav Carus University Allergy Center TU DresdenDresden Germany
| | - Jonas Binnmyr
- The Swedish Asthma‐ and Allergy Association Stockholm Sweden
- The Swedish Asthma‐ and Allergy Research Foundation Stockholm Sweden
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein School of Medicine Technical University of Munich Munich Germany
| | - Alan D. Irvine
- Department of Clinical Medicine Trinity College Dublin Ireland
- Dermatology, Children’s Health Ireland National Children’s Research Centre Dublin Ireland
| | - Susanne Halken
- Hans Christian Andersen Children’s Hospital Odense University Hospital Odense Denmark
| | - Charlotte G Mortz
- Department of Dermatology and Allergy Center Odense Research Center for Anaphylaxis (ORCA) Odense University Hospital Odense Denmark
| | - Carsten Flohr
- Unit for Population‐Based Dermatology Research St John's Institute of Dermatology Guy’s & St Thomas' NHS Foundation Trust and King’s College London London UK
| | - Peter Schmid‐Grendelmeier
- Allergy Unit Department of Dermatology University Hospital of Zurich Zurich
- Christine‐Kuehne Center for Allergy Research and Education CK_CARE Davos Switzerland
| | - Lauri‐Ann Poel
- Department of Paediatric Allergy Guy's and St Thomas' NHS Foundation Trust UK
| | - Antonella Muraro
- Department of Woman and Child Health Food Allergy Referral Centre Padua University Hospital Padua Italy
| | - Stephan Weidinger
- Department of Dermatology and Allergy University Hospital Schleswig‐Holstein Kiel Germany
| | - Thomas Werfel
- Division of Immunodermatology and Allergy Research Department of Dermatology and Allergy Hannover Medical School Hannover Germany
| | - Jochen Schmitt
- Center for Evidence‐Based Healthcare University Hospital Dresden Dresden Germany
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20
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Werfel T, Heratizadeh A, Aberer W, Ahrens F, Augustin M, Biedermann T, Diepgen T, Fölster-Holst R, Kahle J, Kapp A, Nemat K, Peters E, Schlaeger M, Schmid-Grendelmeier P, Schmitt J, Schwennesen T, Staab D, Traidl-Hoffmann C, Werner R, Wollenberg A, Worm M, Ott H. Aktualisierung„ Systemtherapie bei Neurodermitis“ zur S2k‐Leitlinie Neurodermitis. J Dtsch Dermatol Ges 2021; 19:151-169. [PMID: 33491881 DOI: 10.1111/ddg.14371_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Thomas Werfel
- Abteilung für Immundermatologie und experimentelle Allergologie, Klinik für Dermatologie, Allergologie und Venerologie, Medizinische Hochschule Hannover
| | - Annice Heratizadeh
- Abteilung für Immundermatologie und experimentelle Allergologie, Klinik für Dermatologie, Allergologie und Venerologie, Medizinische Hochschule Hannover
| | - Werner Aberer
- Universitätsklinik für Dermatologie und Venerologie, Medizinische Universität Graz, Austria
| | | | - Matthias Augustin
- Kompetenzzentrum Versorgungsforschung in der Dermatologie (CVderm), Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Eppendorf, Hamburg
| | - Tilo Biedermann
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein, Technische Universität München
| | - Thomas Diepgen
- Institut für Klinische Sozialmedizin, Hautklinik, Universitätsklinikum Heidelberg
| | - Regina Fölster-Holst
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel
| | - Julia Kahle
- Deutscher Allergie- und Asthmabund (DAAB) e.V., Mönchengladbach
| | - Alexander Kapp
- Abteilung für Immundermatologie und experimentelle Allergologie, Klinik für Dermatologie, Allergologie und Venerologie, Medizinische Hochschule Hannover
| | - Katja Nemat
- Praxis für Kinderpneumologie und Allergologie, Kinderzentrum Dresden-Friedrichstadt (Kid), Dresden
| | - Eva Peters
- Klinik für Psychosomatik und Psychotherapie, Universitätsklinikum Gießen (UKGM), Gießen
| | | | | | - Jochen Schmitt
- Zentrum für Evidenzbasierte Gesundheitsversorgung (ZEGV), Medizinische Fakultät Gustav Carus, Technische Universität Dresden
| | | | - Doris Staab
- Klinik für Pädiatrie m. S. Pneumologie und Immunologie, Charité Campus Virchow-Klinikum, Berlin
| | | | - Ricardo Werner
- Klinik für Dermatologie, Venerologie und Allergologie, Division of Evidence-Based Medicine (dEBM), Charité - Universitätsmedizin Berlin
| | - Andreas Wollenberg
- Klinik und Poliklinik für Dermatologie und Allergologie, Ludwigs-Maximilians-Universität, München
| | - Margitta Worm
- Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin
| | - Hagen Ott
- Fachbereich Pädiatrische Dermatologie und Allergologie, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover
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21
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Werfel T, Heratizadeh A, Aberer W, Ahrens F, Augustin M, Biedermann T, Diepgen T, Fölster-Holst R, Kahle J, Kapp A, Nemat K, Peters E, Schlaeger M, Schmid-Grendelmeier P, Schmitt J, Schwennesen T, Staab D, Traidl-Hoffmann C, Werner R, Wollenberg A, Worm M, Ott H. Update "Systemic treatment of atopic dermatitis" of the S2k-guideline on atopic dermatitis. J Dtsch Dermatol Ges 2021; 19:151-168. [PMID: 33491884 DOI: 10.1111/ddg.14371] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This guideline is an update from August 2020 the S2k-guideline "Atopic dermatitis" published in 2015. The reason for updating this chapter of the guideline were the current developments in the field of systemic therapy of atopic dermatitis. The agreed recommendations for systemic treatment in atopic dermatitis of the present guideline are based on current scientific data. Due to the approval of dupilumab for the treatment of moderate to severe atopic dermatitis, which cannot be treated sufficiently with topical drugs alone, this part of the guideline has now been adapted and newly consented. The indication for systemic therapy and the therapeutic response to topical and systemic treatment should be recorded and documented in a suitable form in clinic and practice. A standardized documentation of the indication for system therapy in atopic dermatitis can be recommended and is also part of the updated chapter of this guideline.
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Affiliation(s)
- Thomas Werfel
- Abteilung für Immundermatologie und experimentelle Allergologie, Klinik für Dermatologie, Allergologie und Venerologie, Medizinische Hochschule Hannover
| | - Annice Heratizadeh
- Abteilung für Immundermatologie und experimentelle Allergologie, Klinik für Dermatologie, Allergologie und Venerologie, Medizinische Hochschule Hannover
| | - Werner Aberer
- Universitätsklinik für Dermatologie und Venerologie, Medizinische Universität Graz, Austria
| | | | - Matthias Augustin
- Kompetenzzentrum Versorgungsforschung in der Dermatologie (CVderm), Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Eppendorf, Hamburg
| | - Tilo Biedermann
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein, Technische Universität München
| | - Thomas Diepgen
- Institut für Klinische Sozialmedizin, Hautklinik, Universitätsklinikum Heidelberg
| | - Regina Fölster-Holst
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel
| | - Julia Kahle
- Deutscher Allergie- und Asthmabund (DAAB) e.V., Mönchengladbach
| | - Alexander Kapp
- Abteilung für Immundermatologie und experimentelle Allergologie, Klinik für Dermatologie, Allergologie und Venerologie, Medizinische Hochschule Hannover
| | - Katja Nemat
- Praxis für Kinderpneumologie und Allergologie, Kinderzentrum Dresden-Friedrichstadt (Kid), Dresden
| | - Eva Peters
- Klinik für Psychosomatik und Psychotherapie, Universitätsklinikum Gießen (UKGM), Gießen
| | | | | | - Jochen Schmitt
- Zentrum für Evidenzbasierte Gesundheitsforschung, Technische Universität Dresden
| | | | - Doris Staab
- Klinik für Pädiatrie m. S. Pneumologie und Immunologie, Charité Campus Virchow-Klinikum, Berlin
| | | | - Ricardo Werner
- Klinik für Dermatologie, Venerologie und Allergologie, Division of Evidence-Based Medicine (dEBM), Charité - Universitätsmedizin Berlin
| | - Andreas Wollenberg
- Klinik und Poliklinik für Dermatologie und Allergologie, Ludwigs-Maximilians-Universität, München
| | - Margitta Worm
- Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin
| | - Hagen Ott
- Fachbereich Pädiatrische Dermatologie und Allergologie, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover
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22
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Wollenberg A, Christen‐Zäch S, Taieb A, Paul C, Thyssen J, Bruin‐Weller M, Vestergaard C, Seneschal J, Werfel T, Cork M, Kunz B, Fölster‐Holst R, Trzeciak M, Darsow U, Szalai Z, Deleuran M, Kobyletzki L, Barbarot S, Heratizadeh A, Gieler U, Hijnen D, Weidinger S, De Raeve L, Svensson Å, Simon D, Stalder J, Ring J. ETFAD/EADV Eczema task force 2020 position paper on diagnosis and treatment of atopic dermatitis in adults and children. J Eur Acad Dermatol Venereol 2020; 34:2717-2744. [DOI: 10.1111/jdv.16892] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/10/2020] [Accepted: 07/23/2020] [Indexed: 02/06/2023]
Affiliation(s)
- A. Wollenberg
- Department of Dermatology and Allergy Ludwig‐Maximilian‐University Munich Germany
| | - S. Christen‐Zäch
- Pediatric Dermatology Unit Departments of Dermatology and Pediatrics Centre Hospitalier Universitaire Vaudois Lausanne Switzerland
| | - A. Taieb
- University of Bordeaux Bordeaux France
| | - C. Paul
- Department of Dermatology and Allergy Toulouse University and CHU Toulouse France
| | - J.P. Thyssen
- Department of Dermatology and Allergy Herlev‐Gentofte HospitalUniversity of Copenhagen Hellerup Denmark
| | - M. Bruin‐Weller
- National Expertise Center for Atopic Dermatitis Department of Dermatology and Allergology University Medical Center Utrecht The Netherlands
| | - C. Vestergaard
- Department of Dermatology Aarhus University Hospital Aarhus Denmark
| | - J. Seneschal
- Department of Dermatology National Reference Center for Rare Skin Diseases Bordeaux University Hospitals Bordeaux France
| | - T. Werfel
- Division of Immunodermatology and Allergy Research Department of Dermatology and Allergy Hannover Medical School Hannover Germany
| | - M.J. Cork
- Sheffield Dermatology Research IICDUniversity of Sheffield UK
| | - B. Kunz
- Dermatologikum Hamburg Hamburg Germany
| | - R. Fölster‐Holst
- Department of Dermatology and Allergy University Hospital Schleswig‐Holstein Kiel Germany
| | - M. Trzeciak
- Department of Dermatology, Venereology and Allergology Medical University of Gdansk Gdansk Poland
| | - U. Darsow
- Department of Dermatology and Allergy Biederstein Technische Universität München Munich Germany
- ZAUM – Center of Allergy & Environment Munich Germany
| | - Z. Szalai
- Department of Dermatology Heim Pál National Children’s Institute Budapest Hungary
| | - M. Deleuran
- Department of Dermatology Aarhus University Hospital Aarhus Denmark
| | - L. Kobyletzki
- School of Medical Sciences Lund University Malmö Sweden
- School of Medical Sciences Örebro University Örebro Sweden
| | - S. Barbarot
- Department of Dermatology CHU Nantes UMR 1280 PhAN INRA, F‐44000 Nantes Université Nantes France
| | - A. Heratizadeh
- Division of Immunodermatology and Allergy Research Department of Dermatology and Allergy Hannover Medical School Hannover Germany
| | - U. Gieler
- Department of Dermatology University of Gießen and Marburg GmbH Gießen Germany
| | - D.J. Hijnen
- Department of Dermatology Erasmus MC University Medical Center Rotterdam The Netherlands
| | - S. Weidinger
- Department of Dermatology and Allergy University Hospital Schleswig‐Holstein Kiel Germany
| | - L. De Raeve
- Department of Dermatology Universitair Ziekenhuis Brussel (UZB)Free University of Brussels (VUB) Brussels Belgium
| | - Å. Svensson
- Department of Dermatology Skane University Hospital Malmö Sweden
| | - D. Simon
- Department of Dermatology, Inselspital Bern University Hospital University of Bern Bern Switzerland
| | - J.F. Stalder
- Department of Dermatology CHU Nantes UMR 1280 PhAN INRAE, F‐44000 Nantes Université Nantes France
| | - J. Ring
- Department of Dermatology and Allergy Biederstein Technische Universität München Munich Germany
- Christiane‐Kühne Center for Allergy Research and Education (CK‐Care) Davos Switzerland
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23
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Thyssen JP, Andersen YMF, Vittrup I, Pierce E, DeLozier A, Egeberg A. Treatment of adult atopic dermatitis patients according to disease characteristics and demographics. Dermatol Ther 2020; 33:e14439. [PMID: 33084105 DOI: 10.1111/dth.14439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 10/14/2020] [Accepted: 10/18/2020] [Indexed: 12/12/2022]
Abstract
Little is currently known about possible associations between disease specific characteristics of atopic dermatitis (AD) and use of medical treatments. We explored the use of AD treatments within the past 12 months in Danish adults according to distinct patient characteristics. Patients who had received a diagnosis of AD in a hospital in- or outpatient setting as adults were surveyed and data cross-linked to a national prescription registry. AD severity was measured by the Patient-Oriented SCORing Atopic Dermatitis (PO-SCORAD). A total of 3834 patients participated. Use of topical medication in the past 12 months increased with increasing AD severity, whereas no difference was observed for systemic medication use. Positive associations between AD in the face and neck, and use of mild and moderately potent topical corticosteroids were observed, while involvement of palms and chest was associated with use of more potent topical corticosteroids. The mean DLQI, skin pain, and itch severity scores were lower in patients managed only with topical corticosteroids (5.5, 3.2, and 4.3, respectively) compared to patients treated with both oral and topical medication (7.1, 3.8, and 5.0, respectively). Patients with frequent topical corticosteroid use tended to be older (50.7 vs 48.6 years), males (50.0% vs 33.6%), current daily smokers (17.3% vs 13.7%), and having asthma (59.1% vs 43.8%) compared with infrequent users of topical corticosteroids. We found a disconnect between the severity of AD signs and symptoms, and use of AD therapies. In particular, a very modest use of systemic immunosuppressants was seen even among patients with severe AD symptoms. However, the underlying clinical decisions and reasons behind this disconnect is not clear based on the current data.
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Affiliation(s)
- Jacob P Thyssen
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Yuki M F Andersen
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Ida Vittrup
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | | | - Amy DeLozier
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Alexander Egeberg
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
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24
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Lam M, Zhu JW, Maqbool T, Adam G, Tadrous M, Rochon P, Drucker AM. Inclusion of Older Adults in Randomized Clinical Trials for Systemic Medications for Atopic Dermatitis. JAMA Dermatol 2020; 156:1240. [DOI: 10.1001/jamadermatol.2020.2940] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- Megan Lam
- Michael G. DeGroote School of Medicine, Faculty of Medicine, Hamilton, Ontario, Canada
| | - Jie Wei Zhu
- Michael G. DeGroote School of Medicine, Faculty of Medicine, Hamilton, Ontario, Canada
| | - Talha Maqbool
- Department of Family and Community Medicine, University of Toronto, Ontario, Canada
| | - Gaelen Adam
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Mina Tadrous
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
| | - Paula Rochon
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
| | - Aaron M. Drucker
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- Division of Dermatology, University of Toronto, Ontario, Canada
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25
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Sawangjit R, Dilokthornsakul P, Lloyd-Lavery A, Lai NM, Dellavalle R, Chaiyakunapruk N. Systemic treatments for eczema: a network meta-analysis. Cochrane Database Syst Rev 2020; 9:CD013206. [PMID: 32927498 PMCID: PMC8128359 DOI: 10.1002/14651858.cd013206.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Eczema is a common and chronic, relapsing, inflammatory skin disorder. It seriously impacts quality of life and economic outcomes, especially for those with moderate to severe eczema. Various treatments allow sustained control of the disease; however, their relative benefit remains unclear due to the limited number of trials directly comparing treatments. OBJECTIVES To assess the comparative efficacy and safety of different types of systemic immunosuppressive treatments for moderate to severe eczema using NMA and to generate rankings of available systemic immunosuppressive treatments for eczema according to their efficacy and safety. SEARCH METHODS We searched the following databases up to August 2019: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase. SELECTION CRITERIA All randomised controlled trials (RCTs) of systemic immunosuppressive agents for moderate to severe atopic eczema when compared against placebo or any other eligible eczema treatment. DATA COLLECTION AND ANALYSIS We synthesised data using pair-wise analysis and NMA to compare treatments and rank them according to their effectiveness. Effectiveness was assessed primarily by determining the proportion of participants who achieved at least 75% improvement in the Eczema Area and Severity Index (EASI75) and improvement in the Patient-Oriented Eczema Measure (POEM). Safety was evaluated primarily by considering the proportion of participants with serious adverse events (SAEs) and infection. We deemed short-term follow-up as ≤ 16 weeks and long-term follow-up as > 16 weeks. We assessed the certainty of the body of evidence from the NMA for these primary outcomes using six domains of CiNEMA grading. MAIN RESULTS We included a total of 74 studies, with 8177 randomised participants. Approximately 55% of participants were male, with average age of 32 years (range 2 to 84 years), although age and gender were unreported for 419 and 902 participants, respectively. Most of the included trials were placebo controlled (65%), 34% were head-to-head studies (15% assessed the effects of different doses of the same drug), and 1% were multi-armed studies with both an active comparator and a placebo. All trials included participants with moderate to severe eczema, but 62% of studies did not separate data by severity; 38% of studies assessed only severe eczema. The total duration of included trials ranged from 2 weeks to 60 months, whereas treatment duration varied from a single dose (CIM331, KPL-716) to 60 months (methotrexate (MTX)). Seventy studies were available for quantitative synthesis; this review assessed 29 immunosuppressive agents from three classes of interventions. These included (1) conventional treatments, with ciclosporin assessed most commonly; (2) small molecule treatments, including phosphodiesterase (PDE)-4 inhibitors, tyrosine kinase inhibitors, and Janus kinase (JAK) inhibitors; and (3) biological treatments, including anti-CD31 receptors, anti-interleukin (IL)-22, anti-IL-31, anti-IL-13, anti-IL-12/23p40, anti-OX40, anti-TSLP, anti-CRTH2, and anti-immunoglobulin E (IgE) monoclonal antibodies, but most commonly dupilumab. Most trials (73) assessed outcomes at a short-term duration ranging from 2 to 16 weeks, whereas 33 trials assessed long-term outcomes, with duration ranging from 5 to 60 months. All participants were from a hospital setting. Fifty-two studies declared a source of funding, and of these, pharmaceutical companies funded 88%. We rated 37 studies as high risk; 21, unclear risk, and 16, low risk of bias, with studies most commonly at high risk of attrition bias. Network meta-analysis suggests that dupilumab ranks first for effectiveness when compared with other biological treatments. Dupilumab is more effective than placebo in achieving EASI75 (risk ratio (RR) 3.04, 95% confidence interval (CI) 2.51 to 3.69) and improvement in POEM score (mean difference 7.30, 95% CI 6.61 to 8.00) at short-term follow-up (high-certainty evidence). Very low-certainty evidence means we are uncertain of the effects of dupilumab when compared with placebo, in terms of the proportion of participants who achieve EASI75 (RR 2.59, 95% CI 1.87 to 3.60) at longer-term follow-up. Low-certainty evidence indicates that tralokinumab may be more effective than placebo in achieving short-term EASI75 (RR 2.54, 95% CI 1.21 to 5.34), but there was no evidence for tralokinumab to allow us to assess short-term follow-up of POEM or long-term follow-up of EASI75. We are uncertain of the effect of ustekinumab compared with placebo in achieving EASI75 (long-term follow-up: RR 1.17, 95% CI 0.40 to 3.45; short-term follow-up: RR 0.91, 95% CI 0.28 to 2.97; both very low certainty). We found no evidence on ustekinumab for the POEM outcome. We are uncertain whether other immunosuppressive agents that targeted our key outcomes influence the achievement of short-term EASI75 compared with placebo due to low- or very low-certainty evidence. Dupilumab and ustekinumab were the only immunosuppressive agents evaluated for longer-term EASI75. Dupilumab was the only agent evaluated for improvement in POEM during short-term follow-up. Low- to moderate-certainty evidence indicates a lower proportion of participants with SAEs after treatment with QAW039 and dupilumab compared to placebo during short-term follow-up, but low- to very low-certainty evidence suggests no difference in SAEs during short-term follow-up of other immunosuppressive agents compared to placebo. Evidence for effects of immunosuppressive agents on risk of any infection during short-term follow-up and SAEs during long-term follow-up compared with placebo was of low or very low certainty but did not indicate a difference. We did not identify differences in other adverse events (AEs), but dupilumab is associated with specific AEs, including eye inflammation and eosinophilia. AUTHORS' CONCLUSIONS Our findings indicate that dupilumab is the most effective biological treatment for eczema. Compared to placebo, dupilumab reduces eczema signs and symptoms in the short term for people with moderate to severe atopic eczema. Short-term safety outcomes from clinical trials did not reveal new safety concerns with dupilumab. Overall, evidence for the efficacy of most other immunosuppressive treatments for moderate to severe atopic eczema is of low or very low certainty. Given the lack of data comparing conventional with newer biological treatments for the primary outcomes, there remains high uncertainty for ranking the efficacy and safety of conventional treatments such as ciclosporin and biological treatments such as dupilumab. Most studies were placebo-controlled and assessed only short-term efficacy of immunosuppressive agents. Further adequately powered head-to-head RCTs should evaluate comparative long-term efficacy and safety of available treatments for moderate to severe eczema.
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Affiliation(s)
- Ratree Sawangjit
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mahasarakham University, Mahasarakham, Thailand
| | - Piyameth Dilokthornsakul
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Antonia Lloyd-Lavery
- Department of Dermatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nai Ming Lai
- School of Medicine, Taylor's University, Subang Jaya, Malaysia
| | | | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
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26
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Pereyra-Rodriguez JJ, Domínguez-Cruz J, Ruiz-Villaverde R, Silvestre JF, Galán M, Curto L, Figueras I, Serra-Baldrich E, Armario-Hita JC. Drug survival of systemic and biological treatments for moderate-to-severe atopic dermatitis in adults: a multicentre retrospective observational study. Br J Dermatol 2020; 184:175-176. [PMID: 32730674 DOI: 10.1111/bjd.19428] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 07/26/2020] [Accepted: 07/27/2020] [Indexed: 11/28/2022]
Affiliation(s)
| | - J Domínguez-Cruz
- Department of Dermatology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - R Ruiz-Villaverde
- Department of Dermatology, Hospital Universitario Parque Tecnológico de la Salud, Granada, Spain
| | - J F Silvestre
- Department of Dermatology, Hospital General de Alicante, Alicante, Spain
| | - M Galán
- Department of Dermatology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - L Curto
- Department of Dermatology, Hospital del Mar-Parc de Salut Mar, Barcelona, Spain
| | - I Figueras
- Department of Dermatology, Hospital de Bellvitge, Barcelona, Spain
| | - E Serra-Baldrich
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - J C Armario-Hita
- Department of Dermatology, Hospital Universitario Puerto Real, Cádiz, Spain
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Vermeulen FM, Gerbens LAA, Schmitt J, Deleuran M, Irvine AD, Logan K, Ouwerkerk W, Vestergaard C, Flohr C, Spuls PI. The European TREatment of ATopic eczema (TREAT) Registry Taskforce survey: prescribing practices in Europe for phototherapy and systemic therapy in adult patients with moderate-to-severe atopic eczema. Br J Dermatol 2020; 183:1073-1082. [PMID: 32068893 PMCID: PMC7754420 DOI: 10.1111/bjd.18959] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2020] [Indexed: 01/01/2023]
Abstract
Background For many years dermatologists have had access to few therapies for patients with moderate‐to‐severe atopic eczema (AE). New promising therapies are entering the market but conventional phototherapies and systemic therapies have more well‐known safety profiles, lower costs and wider availability. Objectives To provide insight into current prescribing practices of conventional phototherapy and systemic immunomodulatory therapies for adults with chronic AE, and the factors influencing these prescribing practices, before biologics and other novel therapeutics become routine clinical practice. Methods In this exploratory study dermatologists were invited to participate in an online survey via a mailing list of the European Academy of Dermatology and Venereology and national societies. Data were collected on participant characteristics (including clinical practice data), the use of phototherapies and systemic therapies, and factors influencing their use. Results From 30 European countries, 238 out of 361 dermatologists willing to participate (65·9%) completed the survey, with 229 meeting the inclusion criteria. For phototherapy (prescribed by 84·7%), most preferred narrowband ultraviolet B as first line (80·9%) and psoralen plus ultraviolet A as second (21·6%). For systemic therapy (prescribed by 95·2%) ciclosporin (54·1%), oral corticosteroids (32·6%) and methotrexate (30·7%) were used first line. Dermatologists relied mostly on personal experience for prescribing phototherapy and systemic therapy. Azathioprine and mycophenolic acid were prescribed by only 135 (59·0%) and 85 (37·1%) participants in total, mostly due to a lack of personal experience. Conclusions This study provides insight into prescribing practices for conventional phototherapy and systemic therapy in Europe and shows that off‐label therapies are also preferred as first‐line choice of systemic therapy. What is already known about this topic? Varying prescribing practices were found for adult (in the UK) and paediatric (in Northern America and Europe) patients with moderate‐to-severe atopic eczema (AE). Not much is known about the prescription of phototherapy and (off‐label) systemic therapy for adult patients in Europe. Although therapies like dupilumab are promising new treatment modalities, better‐known safety profiles, lower costs and better availability are reasons to improve the evidence profile of conventional systemic therapies like ciclosporin.
What does this study add? Prescribing practices of European dermatologists treating adult patients with moderate‐to-severe AE show diversity. Most dermatologists prefer narrowband ultraviolet B as first‐line phototherapy, followed by psoralen plus ultraviolet A as second line. Next to ciclosporin, which is most commonly prescribed, (off‐label) methotrexate and oral corticosteroids are also frequently used as first‐line systemic agents in chronic AE. Lack of personal experience with azathioprine and mycophenolic acid was the most important reason against their prescription.
What are the clinical implications of the work? The results from this study might help to improve the experience with, and prescribing of, all available conventional phototherapies and (off‐label) systemic therapies. Guidelines developers might use these results to develop and implement treatment algorithms.
Linked Comment:Bruin‐Weller. Br J Dermatol 2020; 183:987–988. Plain language summary available online
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Affiliation(s)
- F M Vermeulen
- Department of Dermatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Public Health, Infection and Immunity, Meibergdreef 9, Amsterdam, the Netherlands
| | - L A A Gerbens
- Department of Dermatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Public Health, Infection and Immunity, Meibergdreef 9, Amsterdam, the Netherlands
| | - J Schmitt
- Centre for Evidence-Based Healthcare, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany.,University Allergy Centre, University Hospital Carl Gustav Carus, Dresden, Germany
| | - M Deleuran
- Department of Dermatology and Venereology, Aarhus University Hospital, Aarhus, Denmark
| | - A D Irvine
- Department of Paediatric Dermatology, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland.,Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland.,National Children's Research Centre, Dublin, Ireland
| | - K Logan
- The Paediatric Allergy Research Group, the Department of Women and Children's Health, King's College London, London, UK
| | - W Ouwerkerk
- Department of Dermatology and Netherlands Institute for Pigment Disorders, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Infection & Immunity Institute, Cancer Center Amsterdam, Amsterdam, the Netherlands.,National Heart Centre Singapore, Singapore
| | - C Vestergaard
- Department of Dermatology and Venereology, Aarhus University Hospital, Aarhus, Denmark
| | - C Flohr
- National Heart Centre Singapore, Singapore
| | - P I Spuls
- Department of Dermatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Public Health, Infection and Immunity, Meibergdreef 9, Amsterdam, the Netherlands
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Weidinger S, Apfelbacher C. A critical appraisal and implications of the new National Institute for Health and Care Excellence guideline on dupilumab for treating moderate-to-severe atopic eczema. Br J Dermatol 2020; 180:435-437. [PMID: 30821391 DOI: 10.1111/bjd.17329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- S Weidinger
- Department of Dermatology and Allergy, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - C Apfelbacher
- Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
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Chambrelan E, Barbarot S, Bekel L, Poizeau F, Mahé E, Puzenat E, Delaunay J, Mallet S, Bessis D, Maruani A, Miquel J, Raison-Peyron N, Abasq C, Phan A, Du Thanh A, Kupfer I, Bonniaud B, Bouzille G, Dupuy A, Droitcourt C. Drug survival and postdrug survival of systemic treatments in a national French cohort of children with atopic dermatitis. Br J Dermatol 2020; 183:376-378. [PMID: 32037515 DOI: 10.1111/bjd.18941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- E Chambrelan
- Department of Dermatology, CHU Rennes, F35000, Rennes, France.,University of Rennes 1, F35000, Rennes, France
| | - S Barbarot
- Department of Dermatology, CHU Nantes, F44093, Nantes, France
| | - L Bekel
- Department of Dermatology and Pediatric Dermatology, Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris (APHP), F75015, Paris, France
| | - F Poizeau
- Department of Dermatology, CHU Rennes, F35000, Rennes, France.,University of Rennes 1, F35000, Rennes, France.,EA 7449 REPERES Pharmacoepidemiology and Health Services Research, F35000, Rennes, France
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - A Dupuy
- Department of Dermatology, CHU Rennes, F35000, Rennes, France.,University of Rennes 1, F35000, Rennes, France.,EA 7449 REPERES Pharmacoepidemiology and Health Services Research, F35000, Rennes, France
| | - C Droitcourt
- Department of Dermatology, CHU Rennes, F35000, Rennes, France.,University of Rennes 1, F35000, Rennes, France.,EA 7449 REPERES Pharmacoepidemiology and Health Services Research, F35000, Rennes, France
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Purvis D, Lee M, Agnew K, Birchall N, Dalziel SR. Long-term effect of methotrexate for childhood atopic dermatitis. J Paediatr Child Health 2019; 55:1487-1491. [PMID: 31016803 DOI: 10.1111/jpc.14478] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/28/2019] [Accepted: 04/01/2019] [Indexed: 11/27/2022]
Abstract
AIM To evaluate methotrexate (MTX) for paediatric atopic dermatitis (AD) while on and post-treatment. METHODS Medical records of children prescribed MTX for AD between 2011 and 2016 at Starship Children's Hospital, Auckland, New Zealand, were reviewed for demographics, dose and duration of MTX and hospitalisations for AD. In the follow-up by telephone in 2017, parents of the patients reported response on MTX, AD relapses and use of additional systemic treatment and completed a patient-oriented eczema measure (POEM). RESULTS Forty-three patients aged 2-16 years were included. Four (9%) had previous systemic treatment, and 14 (33%) were hospitalised (28 admissions). MTX was given at median dose of 0.33 mg/kg (interquartile range (IQR) 0.26-0.40) for a median of 17 months (IQR 7.5-20). After initiating MTX, only six (14%) were hospitalised (nine admissions). Thirty (70%) parents of patients were followed up for a median of 29 months (IQR 14-45) after discontinuing MTX. Five (17%) reported 'no change', 2 (7%) 'slightly better' and 23 (77%) 'a lot better' AD on MTX. Of the 25 who responded to MTX, AD relapsed in 10 (40%) at a median of 24 months post-MTX; only four (16%) restarted MTX. Median POEM at follow-up was 6 (IQR 1-17). Eleven (37%) were clear (POEM 0-2), 11 (37%) had mild to moderate AD (POEM 3-16), and 8 (27%) had severe AD (POEM ≥17). CONCLUSIONS Although a natural resolution cannot be excluded, MTX for severe AD was effective and well tolerated. Improvement was reported by 83%, and AD hospitalisation reduced by half. At a median of 2 years after discontinuing MTX, one third were clear, and one third had mild to moderate AD, suggesting persistence of benefit post-MTX.
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Affiliation(s)
- Diana Purvis
- Department of Paediatric Dermatology, Starship Children's Health, Auckland City Hospital, Auckland, New Zealand
| | - Martin Lee
- Department of Paediatric Dermatology, Starship Children's Health, Auckland City Hospital, Auckland, New Zealand
| | - Karen Agnew
- Department of Paediatric Dermatology, Starship Children's Health, Auckland City Hospital, Auckland, New Zealand
| | - Nick Birchall
- Department of Paediatric Dermatology, Starship Children's Health, Auckland City Hospital, Auckland, New Zealand
| | - Stuart R Dalziel
- Department of Paediatric Dermatology, Starship Children's Health, Auckland City Hospital, Auckland, New Zealand.,Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
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31
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Abstract
In severe cases of atopic dermatitis (AD) systemic treatment is indicated. So far, cyclosporine and systemic glucocorticosteroids represented the only systemic treatment options approved for the indications of AD in Germany; however, from clinical practice there is increasing evidence for beneficial therapeutic effects in AD by other immunosuppressive or immunomodulatory substances, such as mycophenolate, methotrexate, alitretinoin and ustekinumab. Beyond this, ongoing research activities focus on a better understanding of genetic and immunological aspects of this chronic inflammatory skin disease. Regarding treatment with mycophenolate, genetic polymorphisms in AD patients could be identified that might predict responsiveness to this medication. Moreover, several new substances specifically targeting inflammation in AD are currently being studied and the first promising treatment effects on skin condition and pruritic symptoms of AD could be observed. As an exceptional result of this development in September 2017 in Europe and therefore in Germany the first biologic as first-line treatment was approved for the indication of moderate to severe AD in adults. Dupilumab is a human monoclonal IgG4 antibody that blocks a subunit of the interleukin (IL)-4 and IL-13 receptors, thus inhibiting the proinflammatory effects of these cytokines. Furthermore, the cytokine IL-13 itself, the IL-31 receptor, which is of particular relevance for pruritus in AD, the histamine-4-receptor and Janus kinases represent further promising targets currently being investigated in clinical trials for the treatment of AD.
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32
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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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33
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Strategies for Successful Management of Severe Atopic Dermatitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:1-16. [DOI: 10.1016/j.jaip.2018.10.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/18/2018] [Accepted: 10/22/2018] [Indexed: 12/21/2022]
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34
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Dhadwal G, Albrecht L, Gniadecki R, Poulin Y, Yeung J, Hong CH, Gooderham MJ. Approach to the Assessment and Management of Adult Patients With Atopic Dermatitis: A Consensus Document. Section IV: Treatment Options for the Management of Atopic Dermatitis. J Cutan Med Surg 2018; 22:21S-29S. [DOI: 10.1177/1203475418805721] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The objectives of therapy for atopic dermatitis (AD) are to reduce skin inflammation and pruritus, restore skin barrier function, and improve quality of life (QoL). Treatments can be classified as moisturizing and basic care, topical therapy, phototherapy, and systemic therapy. In this review, we summarize the treatments for AD and recommendations for their use.
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35
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Irvine AD, Jones AP, Beattie P, Baron S, Browne F, Ashoor F, O'Neill L, Rosala-Hallas A, Sach T, Spowart C, Taams L, Walker C, Wan M, Webb N, Williamson P, Flohr C. A randomized controlled trial protocol assessing the effectiveness, safety and cost-effectiveness of methotrexate vs. ciclosporin in the treatment of severe atopic eczema in children: the TREatment of severe Atopic eczema Trial (TREAT). Br J Dermatol 2018; 179:1297-1306. [PMID: 29727479 DOI: 10.1111/bjd.16717] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Oral systemic immunomodulatory medication is regularly used off-licence in children with severe atopic eczema. However, there is no firm evidence regarding the effectiveness, safety, cost-effectiveness and impact on quality of life from an adequately powered randomized controlled trial (RCT) using systemic medication in children. OBJECTIVES To assess whether there is a difference in the speed of onset, effectiveness, side-effect profile and reduction in flares post-treatment between ciclosporin (CyA) and methotrexate (MTX), and also the cost-effectiveness of the drugs. Treatment impact on quality of life will also be examined in addition to whether FLG genotype influences treatment response. In addition, the trial studies the immune-metabolic effects of CyA and MTX. METHODS Multicentre, parallel group, assessor-blind, pragmatic RCT of 36 weeks' duration with a 24-week follow-up period. In total, 102 children aged 2-16 years with moderate-to-severe atopic eczema, unresponsive to topical treatment will be randomized (1 : 1) to receive MTX (0·4 mg kg-1 per week) or CyA (4 mg kg-1 per day). RESULTS The trial has two primary outcomes: change from baseline to 12 weeks in Objective Severity Scoring of Atopic Dermatitis (o-SCORAD) and time to first significant flare following treatment cessation. CONCLUSIONS This trial addresses important therapeutic questions, highlighted in systematic reviews and treatment guidelines for atopic eczema. The trial design is pragmatic to reflect current clinical practice.
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Affiliation(s)
- A D Irvine
- Clinical Medicine, Trinity College Dublin, Dublin, Ireland.,Paediatric Dermatology, Our Lady's Children Hospital Crumlin, Dublin, Ireland.,National Children's Research Centre, Crumlin, Dublin, Ireland
| | - A P Jones
- Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, U.K
| | - P Beattie
- Royal Hospital for Children NHS Trust, Glasgow, U.K
| | - S Baron
- 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, U.K
| | - F Browne
- Paediatric Dermatology, Our Lady's Children Hospital Crumlin, Dublin, Ireland
| | - F Ashoor
- Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, U.K
| | - L O'Neill
- Biochemistry, Trinity College Dublin, Dublin, Ireland
| | - A Rosala-Hallas
- Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, U.K
| | - T Sach
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, U.K
| | - C Spowart
- Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, U.K
| | - L Taams
- Centre for Molecular and Cellular Biology of Inflammation, King's College London, London, U.K
| | - C Walker
- 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, U.K
| | - M Wan
- 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, U.K
| | - N Webb
- Renal Research Laboratories, Manchester Royal Infirmary, Manchester, U.K
| | - P Williamson
- Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, U.K
| | - C 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, U.K
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- 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, U.K
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36
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Seger EW, Wechter T, Strowd L, Feldman SR. Relative efficacy of systemic treatments for atopic dermatitis. J Am Acad Dermatol 2018; 80:411-416.e4. [PMID: 30296535 DOI: 10.1016/j.jaad.2018.09.053] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/25/2018] [Accepted: 09/27/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Systemic medications are often required for severe atopic dermatitis (AD) refractory to topical therapies. Biologic medications are a recent advancement in the field and a comparison with standard systemic approaches would be beneficial. OBJECTIVE To compare efficacies of systemic therapies for the treatment of AD. METHODS A systematic literature review was performed using Medline, Ovid, and Embase. Randomized controlled trials looking at the efficacy of systemic treatments for AD in adults and children were included. RESULTS A total of 41 studies met criteria and were included in our final analysis. Consistent improvements in Eczema Area and Severity Index and Scoring Atopic Dermatitis were reported with dupilumab and cyclosporine. Phase 2 clinical trials for lebrikizumab and tralokinumab were effective and would benefit from phase 3 trials. No study reported efficacy of biologic medications in pediatric patients; however, cyclosporine improved clinical severity by the greatest amount in this group. LIMITATIONS A lack of well controlled comparison studies make direct comparisons between the treatments difficult. CONCLUSION For treatment of severe AD, the strongest evidence currently exists for dupilumab and cyclosporine at improving clinical disease severity. Further research is required to determine long-term safety and efficacy of biologic medications.
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Affiliation(s)
- Edward W Seger
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Todd Wechter
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Lindsay Strowd
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Steven R Feldman
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina.
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37
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von Kobyletzki L, Svensson Å. Building the evidence base for current systemic treatments for severe, chronic atopic dermatitis: methotrexate vs. azathioprine. Br J Dermatol 2018; 178:1236-1237. [DOI: 10.1111/bjd.16594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | - Å. Svensson
- Department of Dermatology; Malmo University Hospital; Malmo University Hospital UMAS; SE-205 02 Malmo Sweden
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