What's new in atopic eczema? An analysis of systematic reviews published in 2017. Part 1: treatment and prevention

Design, optimization, and characterization of Althaea officinalis-loaded transliposomes for the treatment of atopic dermatitis: a Box Behnken Design, in vitro, and ex vivo study

A chronic skin disorder called atopic dermatitis (AD) is brought on by the deterioration of the skin's barrier function marked by inflammation, dryness, and bacterial infection along with immunological changes. Althaea officinalis (AO), known for its anti-inflammatory and immunomodulatory properties, has been explored as a potential treatment for AD. This study aimed to develop and evaluate a novel transliposomes (TL) formulation containing AO for AD treatment. Using rotary evaporation, AO-TL formulations were created and optimized employing Box Behnken Design. The optimized AO-TL formulation showed consistent characteristics: vesicle size of 145.8 nm, polydispersity index of 0.201, zeta potential of -28.22 mV, and entrapment efficiency of 86.21%. TEM imaging shows the spherical shapes of the vesicle. These findings demonstrate the formulation's stability and ability to encapsulate AO effectively. In vitro drug release studies revealed that the AO-TL formulation released 81.28% of the drug, outperforming conventional AO dispersion (56.80%). Additionally, when applied to rat skin, the TL gel demonstrated deeper penetration (30 μm) in comparison to the standard solution (5.0 μm) based on confocal laser scanning microscopy (CLSM). Ex vivo and dermatokinetics studies showed improved penetration of drug-loaded transliposomes gel in rat skin than the conventional AO gel. Overall, the optimized AO-TL formulation offers promising characteristics and performance for the topical treatment of AD. Its drug release, antioxidant activity, and deeper penetration suggest enhanced therapeutic effects. Further research and clinical trials are needed to validate its efficacy and safety in AD patients.

Topical non-pharmacological treatment of eczema: an Italian consensus

Eczematous diseases (contact dermatitis, atopic dermatitis, hand eczema) are among the most frequent findings in dermatological clinical practice. A large body of evidence exists on structural and functional skin barrier damage in eczematous diseases, and on the importance of interventions aimed to repair such damage. While there is substantial agreement on pharmacological treatment, more sparse data are available on role, indications and usefulness of topical non-pharmacological treatments, despite significant research and progress in the composition and technology of emollients, cleansers and barrier creams significantly changed and expanded the functional activities of these products. This often leads to inadequate prescription and/or use, which increase individual and social costs of the disease and make the products useless or, in some cases, even counterproductive. This consensus document, discussed and compiled in a series of meetings by a group of Italian dermatologists experienced in the field of eczematous diseases, summarizes epidemiology and clinical features of the nosological entities of the "eczema family", illustrates the chemical/biochemical structure of emollients, cleansers and barrier creams, and aims to help physicians to exploit the full potential of available products, by providing a detailed but practical guide on characteristics, indications and correct use of non-pharmacological treatments currently available for eczematous diseases.

Impact of Althaea Officinalis extract in patients with atopic eczema: a double-blind randomized controlled trial

Background

Althaea Officinalis introduced as an emerging anti-inflammatory agent with immunomodulatory effects that may suppress the symptoms of atopic eczema. In this study, we aimed to investigate the impact of liposomal formulation of Althaea Officinalis flower extract compared with steroids for atopic eczema treatment.

Methods

In this randomized, double-blind controlled trial phase II, forty patients with moderate to severe allergic atopic eczema confirmed by skin prick test were enrolled in the study from October 2018 to January 2019. Steroids on the lesions of the left side of the body and topical Althaea Officinalis extract (intervention) or eucerin as a topical placebo on the lesions of the right side of the body were tested. SCORAD (SCORing Atopic Dermatitis) was assessed at the baseline, and two, and four weeks after completing the trial. Data were analyzed by SPSS version 22.

Results

In the active treatment group, after two weeks, the SCORAD was significantly lower in the left side (recovery with steroid treatment) (p < 0.001), and after 4 weeks the SCORAD was lower on both sides, and there were no significant differences between two sides (similarity between Althaea Officinalis and steroid effects). In the control group, the SCORAD score was significantly lower on the left side (steroid) after two and four weeks (p < 0.001). There was no side effect and reaction to drugs.

Conclusions

Considering the potential side effects of steroids, and the similar efficacy of Althaea Officinalis flower extract, using this component may be accompanied by higher benefits in patients with atopic eczema.

Trial registration

IRCT2016102323235N5.

Patient Journey in Atopic Dermatitis: The Real-World Scenario

Introduction

The diagnosis and management of atopic dermatitis (AD) is extensively addressed in detailed clinical guidelines. However, the high heterogeneity regarding presentation and progression and the increasingly broad therapeutic landscape suggest a complex real-world scenario, leading to multiple trajectories of AD patients.

Methods

Using a Delphi methodology for assessing the degree of consensus, we explored the views of a panel of dermatologists regarding the patients’ trajectory through the diagnosis (block 1), treatment (block 2), and long-term management (block 3) of AD. Based on a systematic search of the literature, a scientific committee prepared a questionnaire of relevant items that were rated on a 10-point scale (from “totally agree” to “totally disagree”) by a panel of dermatologists attending patients with AD in the hospital setting. Consensus was established based on predefined rules.

Results

The final questionnaire included 58 items and was answered by 17 dermatologists. Overall, consensus was reached on 22 items (37.9%), each of which was a consensus for agreement. The consensus rates in blocks 1, 2, and 3 were 22.7%, 19.0%, and 86%, respectively.

Conclusions

Our analysis revealed a remarkable lack of consensus on various aspects of the routine diagnosis and treatment of AD. These findings suggest the presence of unmet needs or limited implementation of guidelines for the management of AD and encourage further research to explore the causes of this low consensus on the management of AD in the real-world setting.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-021-00592-y.

Immunosuppressive and Immunomodulating Therapy for Atopic Dermatitis in Pregnancy: An Appraisal of the Literature

The aim of this appraisal of the literature is to elucidate the effects of immunosuppressive and immunomodulating agents used to treat atopic dermatitis (AD) on risk factors for fertility, pregnancy, and breastfeeding. Negative side effects of the psychological and physical stresses associated to AD flairs and uncontrolled AD are discussed, in order to evaluate the consequences of abstaining from treatment. Research on pregnancies in Danish women suggests a tendency towards an increased use of topical steroids and ultraviolet light therapy during pregnancy, compared to before conception, confirming the need for these patients to receive treatment, as well as decreased use of systemic treatments, suggesting a tendency towards undertreatment in this patient population. It is important that effective treatment be provided to pregnant women with AD. Here we present an appraisal of current knowledge on treatments for AD and the risks of exposure for the fetus and breastfed infant. Since little is known about the association between AD, pregnancy, and systemic treatment, we generalize conclusions based on studies on treatments of pregnant women who have undergone organ transplantation and who have inflammatory bowel disease, rheumatic disease, and autoimmune disease. The majority of recommendations are therefore based on a low or very low quality of evidence according to the GRADE system. The selected studies reflect the authors’ assessment regarding originality and importance in the context of this appraisal. It is always the treating doctor’s responsibility to stay updated on current literature when treating patients, especially pregnant patients.

Long-term effectiveness and safety of treatment with dupilumab in patients with atopic dermatitis: Results of the TREAT NL (TREatment of ATopic eczema, the Netherlands) registry

BACKGROUND

Evidence on long-term dupilumab treatment for atopic dermatitis in daily practice is lacking.

OBJECTIVE

To investigate patient characteristics, treatment aspects, effectiveness, and safety of up to 84 weeks of dupilumab treatment.

METHODS

An observational prospective cohort study was conducted of patients with atopic dermatitis starting dupilumab in routine clinical care.

RESULTS

Of the 221 included patients, 103 used systemic therapy at baseline. At 84 weeks, we found a change of -15.2 (SE, 1.7) for the Eczema Area and Severity Index, -16.9 (SE, 1.4) for the Patient-Oriented Eczema Measure, and -17.2 (SE, 1.6) for the Dermatology Life Quality Index. We found a trend for improvement over time for the Investigator Global Assessment and Numerical Rating Scale for pruritus. Severe (n = 79) including serious (n = 11) adverse events were observed in 69 patients. Eye complaints were most frequently reported (n = 46). Twenty-one patients adjusted the regular dosing schedule, and 14 patients discontinued treatment, mainly due to ineffectiveness (n = 7).

LIMITATIONS

Only adverse events of severe and serious nature were registered for feasibility reasons.

CONCLUSION

Daily practice dupilumab treatment of up to 84 weeks is generally well-tolerated, apart from the reporting of eye complaints. It can be considered a long-term effective treatment for atopic dermatitis in combination with topical and initial concomitant systemic treatment, showing a sustained improvement of signs, symptoms, and quality of life.

The Regulatory Effects of Interleukin-4 Receptor Signaling on Neutrophils in Type 2 Immune Responses

Interleukin-4 (IL-4) receptor (IL-4R) signaling plays a pivotal role in type 2 immune responses. Type 2 immunity ensures several host-protective processes such as defense against helminth parasites and wound repair, however, type 2 immune responses also drive the pathogenesis of allergic diseases. Neutrophil granulocytes (neutrophils) have not traditionally been considered a part of type 2 immunity. While neutrophils might be beneficial in initiating a type 2 immune response, their involvement and activation is rather unwanted at later stages. This is evidenced by examples of type 2 immune responses where increased neutrophil responses are able to enhance immunity, however, at the cost of increased tissue damage. Recent studies have linked the type 2 cytokines IL-4 and IL-13 and their signaling via type I and type II IL-4Rs on neutrophils to inhibition of several neutrophil effector functions. This mechanism directly curtails neutrophil chemotaxis toward potent intermediary chemoattractants, inhibits the formation of neutrophil extracellular traps, and antagonizes the effects of granulocyte colony-stimulating factor on neutrophils. These effects are observed in both mouse and human neutrophils. Thus, we propose for type 2 immune responses that neutrophils are, as in other immune responses, the first non-resident cells to arrive at a site of inflammation or infection, thereby guiding and attracting other innate and adaptive immune cells; however, as soon as the type 2 cytokines IL-4 and IL-13 predominate, neutrophil recruitment, chemotaxis, and effector functions are rapidly shut off by IL-4/IL-13-mediated IL-4R signaling in neutrophils to prevent them from damaging healthy tissues. Insight into this neutrophil checkpoint pathway will help understand regulation of neutrophilic type 2 inflammation and guide the design of targeted therapeutic approaches for modulating neutrophils during inflammation and neutropenia.