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Polesie S, Alsterholm M. A systematic review investigating the proportion of clinical images shared in prospective randomized controlled trials involving patients with atopic dermatitis and systemic pharmacotherapy. J DERMATOL TREAT 2024; 35:2338280. [PMID: 38569598 DOI: 10.1080/09546634.2024.2338280] [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: 02/28/2024] [Accepted: 03/27/2024] [Indexed: 04/05/2024]
Abstract
For individuals with atopic dermatitis (AD), interpreting scientific papers that present clinical outcomes including the Eczema Area and Severity Index (EASI) and Investigators Global Assessment may be difficult. When compared to tabulated data and graphs, images from before and after treatment are often far more meaningful to these patients that ultimately will be candidates for the treatment. This systematic review focused on determining the frequency of clinical image sharing in AD research. Conducted in accordance with PRISMA guidelines, the review concentrated on randomized controlled trials that investigated predefined and available systemic treatments for AD. The search was performed in the MEDLINE database for studies published from the inception until 21 December 2023. The review included 60 studies, encompassing 17,799 randomized patients. Across these studies, 16 images representing 6 patients were shared in the manuscripts, leading to a sharing rate of 0.3‰. The almost missing inclusion of patient images in clinical trial publications hinders patient understanding. Adding images to scientific manuscripts could significantly improve patients' comprehension of potential treatment outcomes. This review highlights the need for authors, the pharmaceutical industry, study sponsors, and publishers to enhance and promote patient information through increased use of visual data.
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Affiliation(s)
- Sam Polesie
- Department of Dermatology and Venereology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Dermatology and Venereology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mikael Alsterholm
- Department of Dermatology and Venereology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Dermatology and Venereology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Dermatology and Venereology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Geng RSQ, Sibbald RG. Atopic Dermatitis: Clinical Aspects and Treatments. Adv Skin Wound Care 2024; 37:346-352. [PMID: 38899816 DOI: 10.1097/asw.0000000000000161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
GENERAL PURPOSE To review issues related to atopic dermatitis, including its classification, clinical presentation, potential triggers, and treatment options. TARGET AUDIENCE This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and registered nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES After participating in this educational activity, the participant will:1. Synthesize a differential diagnosis for atopic dermatitis (AD).2. Explain the classification of AD cases.3. Select triggers or exacerbating factors for AD.4. Explain pharmacologic and nonpharmacologic treatment options for patients with AD.
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Woo YR, Choi A, Song SW, Kim S, Son SW, Cho SH, Kim S, Kim JE. Risk of Developing Hypertension in Atopic Dermatitis Patients Receiving Long-term and Low-dose Cyclosporine: A Nationwide Population-based Cohort Study. Ann Dermatol 2024; 36:112-119. [PMID: 38576249 PMCID: PMC10995617 DOI: 10.5021/ad.23.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/09/2023] [Accepted: 11/14/2023] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Cyclosporine (CS) is a first-line immunosuppressive agent used to manage moderate to severe atopic dermatitis (AD). To date, the risk of developing hypertension associated with the long-term use of low-dose CS in AD patients is understudied. OBJECTIVE To determine the cumulative dose-dependent effect of CS on the risk of developing hypertension in patients with AD. METHODS A nationwide population-based retrospective cohort with 1,844,009 AD patients was built from the Korean National Health Insurance System database from 2005 to 2009. A Cox proportional-hazard regression analysis was performed according to patients' CS treatment history adjusted for potential confounders. RESULTS Current use of CS was associated with an increased risk of developing hypertension (adjusted hazard ratio, 4.442; 95% confidence interval, 3.761-5.247). Among the current CS users, a higher cumulative dose of CS (≥39,725 mg) or longer cumulative use of CS (≥182 days), was significantly associated with an increased risk of developing hypertension. CONCLUSION The incidence of CS-associated hypertension is very low when using low-dose treatment regimens for AD. However, the current use or a high cumulative dose of CS for treating patients with AD increases the risk of developing hypertension. Precaution is needed when prescribing CS for long-term treatment of AD.
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Affiliation(s)
- Yu Ri Woo
- Department of Dermatology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Arum Choi
- Department of Preventive Medicine and Public Health, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seo Won Song
- Department of Dermatology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Suyeun Kim
- Department of Dermatology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Wook Son
- Department of Dermatology, Korea University College of Medicine, Seoul, Korea
| | - Sang Hyun Cho
- Department of Dermatology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sukil Kim
- Department of Preventive Medicine and Public Health, 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.
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Davis DMR, Drucker AM, Alikhan A, Bercovitch L, Cohen DE, Darr JM, Eichenfield LF, Frazer-Green L, Paller AS, Schwarzenberger K, Silverberg JI, Singh AM, Wu PA, Sidbury R. Guidelines of care for the management of atopic dermatitis in adults with phototherapy and systemic therapies. J Am Acad Dermatol 2024; 90:e43-e56. [PMID: 37943240 DOI: 10.1016/j.jaad.2023.08.102] [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: 06/27/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND For people with atopic dermatitis (AD) refractory to topical therapies, treatment with phototherapy and systemic therapies can be considered. Multiple biologic therapies and Janus kinase (JAK)inhibitors have been approved since 2014 to treat AD. These guidelines update the 2014 recommendations for management of AD with phototherapy and systemic therapies. OBJECTIVE To provide evidence-based recommendations on the use of phototherapy and systemic therapies for AD in adults. METHODS A multidisciplinary workgroup conducted a systematic review and applied the GRADE approach for assessing the certainty of evidence and formulating and grading recommendations. RESULTS The workgroup developed 11 recommendations on the management of AD in adults with phototherapy and systemic agents, including biologics, oral JAK inhibitors, and other immunomodulatory medications. LIMITATIONS Most randomized controlled trials of phototherapy and systemic therapies for AD are of short duration with subsequent extension studies, limiting comparative long-term efficacy and safety conclusions. CONCLUSIONS We make strong recommendations for the use of dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib. We make conditional recommendations in favor of using phototherapy, azathioprine, cyclosporine, methotrexate, and mycophenolate, and against the use of systemic corticosteroids.
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Affiliation(s)
- Dawn M R Davis
- Departments of Dermatology and Pediatrics, Mayo Clinic, Rochester, Minnesota
| | - Aaron M Drucker
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Ali Alikhan
- Department of Dermatology, Sutter Medical Foundation, Sacramento, California
| | - Lionel Bercovitch
- Department of Dermatology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - David E Cohen
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York City, New York
| | - Jennifer M Darr
- Department of Pediatrics, Pediatric Behavioral Health, National Jewish Health, Denver, Colorado
| | - Lawrence F Eichenfield
- Departments of Dermatology and Pediatrics, University of California San Diego and Rady Children's Hospital San Diego, San Diego, California
| | | | - Amy S Paller
- Departments of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Jonathan I Silverberg
- Department of Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Anne Marie Singh
- Departments of Pediatrics, Dermatology and Medical Microbiology/Immunology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Peggy A Wu
- Department of Dermatology, University of California, Davis, Sacramento, California
| | - Robert Sidbury
- Division of Dermatology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington
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Chu AWL, Wong MM, Rayner DG, Guyatt GH, Díaz Martinez JP, Ceccacci R, Zhao IX, McMullen E, Srivastava A, Wang J, Wen A, Wang FC, Brignardello-Petersen R, Izcovich A, Oykhman P, Wheeler KE, Wang J, Spergel JM, Singh JA, Silverberg JI, Ong PY, O'Brien M, Martin SA, Lio PA, Lind ML, LeBovidge J, Kim E, Huynh J, Greenhawt M, Gardner DD, Frazier WT, Ellison K, Chen L, Capozza K, De Benedetto A, Boguniewicz M, Smith Begolka W, Asiniwasis RN, Schneider LC, Chu DK. Systemic treatments for atopic dermatitis (eczema): Systematic review and network meta-analysis of randomized trials. J Allergy Clin Immunol 2023; 152:1470-1492. [PMID: 37678577 DOI: 10.1016/j.jaci.2023.08.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/06/2023] [Accepted: 08/15/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Atopic dermatitis (AD) is an inflammatory skin condition with multiple systemic treatments and uncertainty regarding their comparative impact on AD outcomes. OBJECTIVE We sought to systematically synthesize the benefits and harms of AD systemic treatments. METHODS For the 2023 American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma, and Immunology Joint Task Force on Practice Parameters AD guidelines, we searched MEDLINE, EMBASE, CENTRAL, Web of Science, and GREAT databases from inception to November 29, 2022, for randomized trials addressing systemic treatments and phototherapy for AD. Paired reviewers independently screened records, extracted data, and assessed risk of bias. Random-effects network meta-analyses addressed AD severity, itch, sleep, AD-related quality of life, flares, and harms. The Grading of Recommendations Assessment, Development and Evaluation approach informed certainty of evidence ratings. This review is registered in the Open Science Framework (https://osf.io/e5sna). RESULTS The 149 included trials (28,686 patients with moderate-to-severe AD) evaluated 75 interventions. With high-certainty evidence, high-dose upadacitinib was among the most effective for 5 of 6 patient-important outcomes; high-dose abrocitinib and low-dose upadacitinib were among the most effective for 2 outcomes. These Janus kinase inhibitors were among the most harmful in increasing adverse events. With high-certainty evidence, dupilumab, lebrikizumab, and tralokinumab were of intermediate effectiveness and among the safest, modestly increasing conjunctivitis. Low-dose baricitinib was among the least effective. Efficacy and safety of azathioprine, oral corticosteroids, cyclosporine, methotrexate, mycophenolate, phototherapy, and many novel agents are less certain. CONCLUSIONS Among individuals with moderate-to-severe AD, high-certainty evidence demonstrates that high-dose upadacitinib is among the most effective in addressing multiple patient-important outcomes, but also is among the most harmful. High-dose abrocitinib and low-dose upadacitinib are effective, but also among the most harmful. Dupilumab, lebrikizumab, and tralokinumab are of intermediate effectiveness and have favorable safety.
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Key Words
- Atopic dermatitis (eczema)
- Janus kinase (JAK) inhibitors (upadacitinib, abrocitinib, baricitinib), patient-important outcomes and adverse events or adverse reactions, disease severity, itch, sleep, itch and sleep disturbance quality of life
- network meta-analysis (comparative effectiveness, multiple treatment comparison)
- systemic treatments and phototherapy (light therapy, immunosuppressants, immunomodulators, DMARDs, cyclosporine, methotrexate, azathioprine, mycophenolate, cortiosteroids, narrow-band UVB), biologics (dupilumab, lebrikizumab, tralokinumab, nemolizumab)
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Affiliation(s)
- Alexandro W L Chu
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - Melanie M Wong
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - Daniel G Rayner
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Gordon H Guyatt
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Juan Pablo Díaz Martinez
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Renata Ceccacci
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - Irene X Zhao
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - Eric McMullen
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - Archita Srivastava
- Evidence in Allergy Group, McMaster University, Hamilton, Canada; Department of Internal Medicine, Western University, London, Canada
| | - Jason Wang
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - Aaron Wen
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - Fang Chi Wang
- Evidence in Allergy Group, McMaster University, Hamilton, Canada; Schulich School of Medicine & Dentistry, Western University, London, Canada
| | | | - Ariel Izcovich
- Servicio de Clínica Médica, Hospital Aleman, Buenos Aires, Argentina
| | - Paul Oykhman
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | | | - Julie Wang
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jonathan M Spergel
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Jasvinder A Singh
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Ala
| | - Jonathan I Silverberg
- Department of Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Peck Y Ong
- Division of Clinical Immunology and Allergy, Children's Hospital Los Angeles, Los Angeles, Calif; Department of Pediatrics, Keck School of Medicine of USC, Los Angeles, Calif
| | | | | | - Peter A Lio
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Ill; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Mary Laura Lind
- School for Engineering of Matter, Transport and Energy, Arizona State University, Tempe, Ariz
| | - Jennifer LeBovidge
- Division of Immunology, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | | | - Joey Huynh
- Sepulveda VA Medical Center, North Hills, Calif
| | - Matthew Greenhawt
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo; Section of Allergy and Immunology, Children's Hospital Colorado, Aurora, Colo
| | | | | | | | - Lina Chen
- Evidence in Allergy Group, McMaster University, Hamilton, Canada; Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Korey Capozza
- Global Parents for Eczema Research, Santa Barbara, Calif
| | - Anna De Benedetto
- Department of Dermatology, University of Rochester Medical Center, Rochester, NY
| | - Mark Boguniewicz
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo; Division of Pediatric Allergy and Clinical Immunology, National Jewish Health, Denver, Colo
| | | | - Rachel N Asiniwasis
- Department of Dermatology, University of Saskatchewan, Regina, Saskatchewan, Canada
| | | | - Derek K Chu
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; The Research Institute of St. Joe's Hamilton, Hamilton, Canada.
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Kim S, Lee YS, Yeo J, Lee D, Ko DK, Ha IH. Healthcare utilization for atopic dermatitis: An analysis of the 2010-2018 health insurance review and assessment service national patient sample data. PLoS One 2023; 18:e0286449. [PMID: 37363912 DOI: 10.1371/journal.pone.0286449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 05/16/2023] [Indexed: 06/28/2023] Open
Abstract
This cross-sectional, retrospective, observational study aimed to analyze the distribution and healthcare usage patterns of patients with atopic dermatitis using the 2010-2018 Health Insurance Review and Assessment Service data. Patients diagnosed with atopic dermatitis in Korea between January 2010 and December 2018 and registered in the Health Insurance Review and Assessment national database were identified, and 270,008 patients who used healthcare services at least once during this period were evaluated to ascertain the healthcare usage patterns and treatment methods for atopic dermatitis. The number of patients with atopic dermatitis plateaued during the study period, while the number of claims and total expenses increased by a small margin. Atopic dermatitis prevalence was the highest among patients aged <5 years (31.4%), followed by those aged 5-14 years (23.53%) and 15-24 years (15.33%). However, the prevalence in these age groups showed a decreasing trend over time. The most used Western medicine treatments were injections and oral medications involving topical corticosteroids, antihistamine agents, and oral steroids, while it was acupuncture therapy in Korean medicine. The frequency of the most frequently prescribed medication, topical corticosteroid, showed a decreasing trend over time. The findings in this study will inform healthcare policy makers and clinicians across different countries on the usage trends of Western medicine and Korean medicine treatment.
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Affiliation(s)
- Sowon Kim
- Jaseng Hospital of Korean Medicine, Gangnam-daero, Gangnam-gu, Seoul, Republic of Korea
| | - Ye-Seul Lee
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Gangnam-daero, Gangnam-gu, Seoul, Republic of Korea
| | - Jiyoon Yeo
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Gangnam-daero, Gangnam-gu, Seoul, Republic of Korea
| | - Donghyo Lee
- Department of Ophthalmology, Otolaryngology, and Dermatology, College of Korean Medicine, Woo-Suk University, Jeonju, Korea
| | - Dong Kun Ko
- Jayeonsaeng Korean Medicine Clinic, Yongin, Korea
| | - In-Hyuk Ha
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Gangnam-daero, Gangnam-gu, Seoul, Republic of Korea
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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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Rodriguez-Le Roy Y, Ficheux AS, Misery L, Brenaut E. Efficacy of topical and systemic treatments for atopic dermatitis on pruritus: A systematic literature review and meta-analysis. Front Med (Lausanne) 2022; 9:1079323. [PMID: 36619624 PMCID: PMC9814490 DOI: 10.3389/fmed.2022.1079323] [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: 10/25/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Pruritus is a major and burdensome symptom in atopic dermatitis (AD). The number of systemic treatments available for AD has increased recently, enabling improved patient relief. Objective To evaluate the effect of AD treatments on pruritus. Methods A systematic literature review and a meta-analysis were conducted to evaluate and compare the effects of treatment used in AD on pruritus. PubMed and Embase databases were searched to find articles published between January 1990 and December 2021. Topical and systemic treatments were studied in patients aged ≥10 years. Results Among the 448 articles identified, 56 studies were retained in the systematic review. A total of 15 studies evaluated topical treatments: topical corticosteroids (TCS; 2), calcineurin inhibitors (6), PDE4 inhibitors (3), and Jak inhibitors (4). A total of five studies were included in the meta- analysis. All treatments had a positive effect on pruritus, with a mean overall reduction of 3.32/10, 95% IC [2.32-4.33]. The greatest reduction was observed with halometasone (mean: 4.75), followed by tofacitinib 2% (mean: 4.38). A total of 41 studies evaluated systemic therapies: cyclosporine (6), phototherapy (5), azathioprine (2), dupilumab (9), anti-IL 13 (5), nemolizumab (3), Jak inhibitors (9), mepolizumab (1), and apremilast (1). A total of 17 studies were included in 2 meta-analyses according to the concomitant use or not of TCS. In the meta-analysis without TCS, the overall decrease was 3.07/10, 95% IC [2.58-3.56]. The molecules with the highest efficacy on pruritus were upadacitinib 30 mg (mean: 4.90) and nemolizumab (mean: 4.81). Discussion The therapeutic arsenal for AD has increased rapidly, and many molecules are under development. The primary endpoint of clinical trials is most often a score that assesses the severity of AD; however, the assessment of pruritus is also essential. The majority of molecules have a positive effect on pruritus, but the improvement varies between them. Efficacy on pruritus is not always correlated with efficacy on AD lesions; therefore, these two criteria are crucial to evaluate. The limitations of this study were the heterogeneity in the assessment of pruritus, the moment of the assessment, and the concomitant application of TCS or not for studies evaluating systemics. In the future, it would be useful to use standardized criteria for assessing pruritus.
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Affiliation(s)
| | | | - Laurent Misery
- Department of Dermatology, University Hospital of Brest, Brest, France,Université de Bretagne Occidentale, LIEN, Brest, France
| | - Emilie Brenaut
- Department of Dermatology, University Hospital of Brest, Brest, France,Université de Bretagne Occidentale, LIEN, Brest, France,*Correspondence: Emilie Brenaut,
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Patruno C, Potestio L, Napolitano M. Clinical phenotypes of adult atopic dermatitis and related therapies. Curr Opin Allergy Clin Immunol 2022; 22:242-249. [PMID: 35786802 DOI: 10.1097/aci.0000000000000837] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To report current knowledge on the different clinical phenotypes of adult atopic dermatitis. Possible therapeutic intervention in relation to phenotype is also evaluated. RECENT FINDINGS Atopic dermatitis is a chronic inflammatory disease affecting up to 10% of adults. It can manifest with different clinical phenotypes, causing diagnostic difficulties. Long-term is often required and systemic drugs are needed for moderate-to-severe forms. However, few drugs are registered for atopic dermatitis in many countries. Furthermore, limited data exist regarding the treatment in relation to individual clinical phenotypes. SUMMARY Currently, the most relevant data are those for cyclosporine, alitretinoin, and dupilumab. Cyclosporine and dupilumab showed to be effective in the treatment of atopic dermatitis, although in trials and real-life experiences the different phenotypes treated are usually not reported. However, cyclosporine appears to be effective in prurigo nodularis. Alitretinoin is reported to be particularly efficacious for atopic dermatitis of the hands, while it is ineffective for other locations of the disease. Dupilumab demonstrated its efficacy in prurigo nodularis and nummular eczema phenotypes of atopic dermatitis; moreover, especially in elderly patients, its effectiveness seems to be faster if the folds of the limbs are involved.
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Affiliation(s)
- Cataldo Patruno
- Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro
| | - Luca Potestio
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples
| | - Maddalena Napolitano
- Department of Medicine and Health Sciences Vincenzo Tiberio, University of Molise, Campobasso, Italy
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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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11
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Tan XL, Thomas BR, Tan YJ, O'Toole EA. Effects of systemic therapies on pruritus in adults with atopic dermatitis: a systematic review and meta-analysis. Clin Exp Dermatol 2021; 47:658-666. [PMID: 34643956 DOI: 10.1111/ced.14976] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/20/2021] [Accepted: 10/11/2021] [Indexed: 11/29/2022]
Abstract
Pruritus is a hallmark of atopic dermatitis (AD), affecting disease severity and patients' quality of life. In AD uncontrolled with first-line topical therapies or in moderate-to-severe AD, systemic therapies are used, however, there are paucity of head-to-head trials comparing their effectiveness. The aim was to compare the effectiveness between the systemic therapies on relieving pruritus in moderate-to-severe AD in adults through meta-analysis. PubMed, EMBASE, Medline and CINAHL databases were searched from inception up to 31 May 2020 for placebo-controlled randomised controlled trials investigating the effectiveness of systemic therapies on pruritus with moderate-to-severe AD in adults aged ≥ 16. 26 studies were identified (n = 5,190 participants). There was a large reduction in pruritus compared to placebo (standard mean difference [95% confidence interval]) with dupilumab every 2 weeks (q2w) (-0.88 [-1.13, -0.63]), q2w + topical corticosteroids (-0.77 [-0.91, -0.62]); dupilumab once weekly (qw) (-0.99 [-1.29, -0.68]), qw + topical corticosteroids (-0.70 [-0.81, -0.59]); a large reduction with ciclosporin (-1.30 [-2.34, -0.26]); a small reduction with mepolizumab (-0.27 [-0.89, 0.35]), interferon gamma (-0.31 [-0.75, 0.12]); a large reduction with azathioprine (-0.85 [-2.07, 0.35]). Amongst investigational drugs, nemolizumab 2.0mg/kg was the most effective (-8.13 [-9.31, -6.94]). The majority of systemic therapies were superior to placebo in reducing pruritus. In particular, dupilumab studies consistently showed large improvements in pruritus and nemolizumab showed the strongest anti-pruritic effects, however future head-to-head trials are required for conclusive evidence.
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Affiliation(s)
- X L Tan
- Centre for Cell Biology and Cutaneous Research, The Blizard Institute, Barts and the London School of Medicine and Dentistry, 4 Newark Street, London, E1 2AT, UK
| | - B R Thomas
- Centre for Cell Biology and Cutaneous Research, The Blizard Institute, Barts and the London School of Medicine and Dentistry, 4 Newark Street, London, E1 2AT, UK.,Department of Dermatology, Royal London Hospital and ERN Skin, Barts Health NHS Trust, Whitechapel Road, London, E1 1BB, UK
| | - Y J Tan
- Centre for Cell Biology and Cutaneous Research, The Blizard Institute, Barts and the London School of Medicine and Dentistry, 4 Newark Street, London, E1 2AT, UK
| | - E A O'Toole
- Centre for Cell Biology and Cutaneous Research, The Blizard Institute, Barts and the London School of Medicine and Dentistry, 4 Newark Street, London, E1 2AT, UK.,Department of Dermatology, Royal London Hospital and ERN Skin, Barts Health NHS Trust, Whitechapel Road, London, E1 1BB, UK
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12
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Yousaf M, Ayasse M, Ahmed A, Gwillim E, Janmohamed SR, Yousaf A, Patel KR, Thyssen JP, Silverberg JI. Association between Atopic Dermatitis and Hypertension: A Systematic Review and Meta-Analysis. Br J Dermatol 2021; 186:227-235. [PMID: 34319589 DOI: 10.1111/bjd.20661] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Previous studies found conflicting results about the association of atopic dermatitis (AD) with hypertension. OBJECTIVES Determine whether AD and AD severity are associated with hypertension. METHODS A systematic review was performed of published studies in MEDLINE, EMBASE, Scopus, Web of Science, and GREAT databases. At least 2 reviewers conducted title/abstract, full-text review, and data extraction. Quality of evidence was assessed using the Newcastle-Ottawa Scale. RESULTS Fifty-one studies met inclusion criteria; 19 had sufficient data for meta-analysis. AD was associated with higher odds of hypertension compared to healthy controls (increased in 9 of 16 studies; pooled prevalence: 16.4% vs 13.8%; random-effects regression, pooled unadjusted odds ratio [OR][95% confidence interval <CI95>]: 1.16 [1.04-1.30]), but lower odds of hypertension compared to psoriasis (decreased in 5 of 8 studies; 15.4% vs 24.8%; 0.53 [0.37-0.76]). In particular, moderate-severe AD were associated with hypertension compared to healthy controls (increased in 4 of 6 studies; 24.9% vs 14.7%; 2.33 [1.10-4.94]). Hypertension was commonly reported as an adverse-event secondary to AD treatments, particularly systemic cyclosporine A. Limitations include lack of longitudinal studies or individual-level data and potential confounding. CONCLUSIONS AD, particularly moderate-to-severe disease, was associated with increased hypertension compared to healthy controls, but lower odds than psoriasis.
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Affiliation(s)
- M Yousaf
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - M Ayasse
- Department of Dermatology, George Washington University School of Medicine, Washington, DC, USA
| | - A Ahmed
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - E Gwillim
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - S R Janmohamed
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Department of Dermatology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - A Yousaf
- Department of Dermatology, West Virginia University School of Medicine, Morgantown
| | - K R Patel
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - J P Thyssen
- Department of Dermatology and Allergy, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark
| | - J I Silverberg
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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13
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Chun PIF, Lehman H. Current and Future Monoclonal Antibodies in the Treatment of Atopic Dermatitis. Clin Rev Allergy Immunol 2021; 59:208-219. [PMID: 32617839 DOI: 10.1007/s12016-020-08802-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Atopic dermatitis is a common immunologic skin disease. Mild atopic dermatitis can be managed with emollients and topical therapies such as low potency topical steroids, which have a favorable safety profile. Severe atopic dermatitis, in contrast, is a challenging disease to treat. Topical therapies are typically inadequate for control of severe atopic dermatitis. When topical therapies fail, the mainstay of therapy for severe atopic dermatitis has traditionally been phototherapy or off-label use of systemic immunosuppressant treatment, yet systemic immunosuppressants all have significant potential toxicities, drug interactions, and contraindications, requiring close monitoring. Targeted biologics are therefore attractive treatment options for topical therapy-refractory cases of atopic dermatitis, with the potential to offer effective, safer treatment of uncontrolled atopic dermatitis. Dupilumab, as the only biologic therapy currently FDA-approved for atopic dermatitis, is effective for many patients, but there is need for continuing study of additional biologic therapies to address the needs of diverse patients with uncontrolled atopic dermatitis.
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Affiliation(s)
- Peter Ip Fung Chun
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Heather Lehman
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA. .,Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, 1001 Main Street, Buffalo, NY, 14203, USA.
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14
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Davari DR, Nieman EL, McShane DB, Morrell DS. Current Perspectives on the Systemic Management of Atopic Dermatitis. J Asthma Allergy 2021; 14:595-607. [PMID: 34103945 PMCID: PMC8179820 DOI: 10.2147/jaa.s287638] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/13/2021] [Indexed: 01/07/2023] Open
Abstract
Atopic dermatitis (AD) is a common disease of childhood, and some patients experience a prolonged clinical course into adolescence and adulthood. Systemic management is required when AD is not adequately controlled with topical medications. Our aim is to provide a comprehensive review of commonly used systemic immunomodulating agents in childhood and adult AD, including cyclosporine A (CsA), azathioprine (AZA), methotrexate (MTX) and mycophenolate mofetil (MMF), which are prescribed off-label in the United States, as well as dupilumab, an FDA-approved biologic. We will also provide a brief overview of emerging systemic therapies currently under investigation.
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Affiliation(s)
- Danielle R Davari
- Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Elizabeth L Nieman
- Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Diana B McShane
- Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Dean S Morrell
- Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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15
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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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16
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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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17
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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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18
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Phan K, Charlton O, Baker C, Foley P, Smith SD. Dermatologist attitudes toward ciclosporin use in atopic dermatitis. J DERMATOL TREAT 2020; 32:922-924. [PMID: 31996056 DOI: 10.1080/09546634.2020.1724251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Ciclosporin (CsA) is a systemic immunosuppressive agent indicated for use in the treatment of patients with recalcitrant atopic dermatitis (AD). Studies demonstrate reasonable evidence of benefit compared with placebo. However as biologic agents are under development for use in AD, an assessment of the use, attitude to and safety of CsA is essential in understanding unmet needs in severe AD. We present the results of a survey asking questions relating to initial dose, duration of prescription, precautions and monitoring undertaken during treatment, adverse events seen, and hierarchy of use for systemic agents. This survey was distributed at the annual meeting of the Australasian College of Dermatologists. Twenty-two percent of respondents never prescribe CsA, and 50% prescribe it only 1-2 times per month. When prescribed, the most frequently recommended duration was 6-12 months (24%). Of prescribers, 56% start with a low dose of <3.5 mg/kg daily, and when stratified according to years of experience, a higher proportion of more junior dermatologists commenced with lower doses (p=.028). Regarding side effects, 95% of respondents expressed concern about nephrotoxicity, 37% about hypertension, and 17% infection. The results suggest that although most dermatologists consider CsA to be effective, there are concerns regarding the safety profile.
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Affiliation(s)
- Kevin Phan
- Department of Dermatology, Liverpool Hospital, Sydney, Australia
| | | | - Chris Baker
- St Vincent's Hospital, The University of Melbourne, Melbourne, Australia.,Skin & Cancer Foundation Inc, Carlton, Australia
| | - Peter Foley
- St Vincent's Hospital, The University of Melbourne, Melbourne, Australia.,Skin & Cancer Foundation Inc, Carlton, Australia
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20
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Blake SC, Murrell DF. Monitoring trough levels in cyclosporine for atopic dermatitis: A systematic review. Pediatr Dermatol 2019; 36:843-853. [PMID: 31566785 DOI: 10.1111/pde.13999] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Cyclosporine is a useful immunosuppressive agent for achieving disease control in moderate to severe atopic dermatitis in children and adults. However, it carries the potential for nephrotoxicity. Monitoring of drug levels is performed in other patient groups, such as transplant recipients, but is not commonplace in the management of atopic dermatitis. OBJECTIVES To investigate levels of nephrotoxicity associated with cyclosporine use in atopic dermatitis and assess potential correlation with trough levels of cyclosporine. METHODS An electronic search was conducted on MEDLINE, EMBASE, and Cochrane databases for randomized controlled trials and cohort studies assessing the safety profile of cyclosporine compared to placebo or other atopic dermatitis treatments, in adult and pediatric atopic dermatitis patients from 1966 to May 2019. Studies that did not assess renal toxicity were excluded from analysis. RESULTS Thirty-eight trials were included for analysis, excluding 11 that did not assess renal toxicity. Descriptive statistical analysis only was performed, due to the high heterogeneity between study methodologies. Significant renal toxicity was seen in 0%-9% of pediatric participants. Monitoring of trough cyclosporine levels was performed in only 10 of the studies, and their correlation to toxicity or disease activity was not explored. CONCLUSION There is limited evidence in atopic dermatitis regarding trough level monitoring of cyclosporine. Currently, the practice is not commonplace, particularly in pediatrics, and this is reflected in trial methodology. Monitoring may be useful in specific pediatric groups, such as those on multiple concurrent medications, patients with hepatic or renal dysfunction and non-responders to therapy.
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Affiliation(s)
- Stephanie C Blake
- Department of Dermatology, St George Hospital, Sydney, NSW, Australia.,Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Dedee F Murrell
- Department of Dermatology, St George Hospital, Sydney, NSW, Australia.,Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
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Holmes GA, Vassantachart JM, Sung CT, Goldenberg A, Jacob SE. Contact dermatitis and atopic dermatitis: two tales, an interwoven story. GIORN ITAL DERMAT V 2019; 154:425-434. [DOI: 10.23736/s0392-0488.18.06236-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Berth-Jones J, Exton LS, Ladoyanni E, Mohd Mustapa MF, Tebbs VM, Yesudian PD, Levell NJ. British Association of Dermatologists guidelines for the safe and effective prescribing of oral ciclosporin in dermatology 2018. Br J Dermatol 2019; 180:1312-1338. [PMID: 30653672 DOI: 10.1111/bjd.17587] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2018] [Indexed: 02/06/2023]
Affiliation(s)
- J Berth-Jones
- Department of Dermatology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, U.K
| | - L S Exton
- British Association of Dermatologists, Willan House, London, W1T 5HQ, U.K
| | - E Ladoyanni
- Department of Dermatology, Dudley Group NHS Foundation Trust, Dudley, DY1 2HQ, U.K
| | - M F Mohd Mustapa
- British Association of Dermatologists, Willan House, London, W1T 5HQ, U.K
| | - V M Tebbs
- formerly of George Eliot Hospital, College Street, Nuneaton, CV10 7DJ, U.K
| | - P D Yesudian
- Wrexham Maelor Hospital, Croesnewydd Road, Wrexham, LL13 7TD, U.K
| | - N J Levell
- Dermatology Department, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, U.K
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Gelfand EW, Landwehr LP, Esterl B, Mazer B. Intravenous immune globulin: an alternative therapy in steroid-dependent allergic diseases. Clin Exp Immunol 2019. [DOI: 10.1111/cei.1996.104.s1.61] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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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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25
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de Bruin-Weller M, Thaçi D, Smith C, Reich K, Cork M, Radin A, Zhang Q, Akinlade B, Gadkari A, Eckert L, Hultsch T, Chen Z, Pirozzi G, Graham N, Shumel B. Dupilumab with concomitant topical corticosteroid treatment in adults with atopic dermatitis with an inadequate response or intolerance to ciclosporin A or when this treatment is medically inadvisable: a placebo-controlled, randomized phase III clinical t. Br J Dermatol 2018; 178:1083-1101. [DOI: 10.1111/bjd.16156] [Citation(s) in RCA: 279] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2017] [Indexed: 12/14/2022]
Affiliation(s)
| | - D. Thaçi
- University of Lübeck; Lübeck Germany
| | - C.H. Smith
- St. John's Institute of Dermatology; London U.K
| | - K. Reich
- Dermatologikum and TFS Research Institute; Hamburg Germany
| | - M.J. Cork
- Sheffield Dermatology Research; The University of Sheffield; Sheffield U.K
| | - A. Radin
- Regeneron Pharmaceuticals, Inc.; Tarrytown NY U.S.A
| | - Q. Zhang
- Regeneron Pharmaceuticals, Inc.; Basking Ridge NJ U.S.A
| | - B. Akinlade
- Regeneron Pharmaceuticals, Inc.; Tarrytown NY U.S.A
| | - A. Gadkari
- Regeneron Pharmaceuticals, Inc.; Tarrytown NY U.S.A
| | | | | | - Z. Chen
- Regeneron Pharmaceuticals, Inc.; Tarrytown NY U.S.A
| | | | | | - B. Shumel
- Regeneron Pharmaceuticals, Inc.; Tarrytown NY U.S.A
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Thomson J, Wernham A, Williams H. Long‐term management of moderate‐to‐severe atopic dermatitis with dupilumab and concomitant topical corticosteroids (
LIBERTY AD CHRONOS
): a critical appraisal. Br J Dermatol 2018; 178:897-902. [DOI: 10.1111/bjd.16317] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- J. Thomson
- Department of Dermatology The Royal London Hospital Barts Health NHS Trust London U.K
| | - A.G.H. Wernham
- Department of Dermatology University Hospitals Birmingham NHS Trust Birmingham U.K
| | - H.C. Williams
- Centre of Evidence Based Dermatology King's Meadow Campus Nottingham U.K
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Lacour JP. L’actuel et le futur du traitement de la dermatite atopique de l’adulte. Ann Dermatol Venereol 2017; 144 Suppl 5:VS29-VS37. [DOI: 10.1016/s0151-9638(18)30089-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Systemic Therapy of Atopic Dermatitis: When, How, for How Long? CURRENT DERMATOLOGY REPORTS 2017. [DOI: 10.1007/s13671-017-0176-7] [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]
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Nankervis H, Thomas K, Delamere F, Barbarot S, Smith S, Rogers N, Williams H. What is the evidence base for atopic eczema treatments? A summary of published randomized controlled trials. Br J Dermatol 2017; 176:910-927. [DOI: 10.1111/bjd.14999] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2016] [Indexed: 12/23/2022]
Affiliation(s)
- H. Nankervis
- Centre of Evidence Based Dermatology; University of Nottingham; King's Meadow Campus, Lenton Lane Nottingham NG7 2NR U.K
| | - K.S. Thomas
- Centre of Evidence Based Dermatology; University of Nottingham; King's Meadow Campus, Lenton Lane Nottingham NG7 2NR U.K
| | - F.M. Delamere
- Centre of Evidence Based Dermatology; University of Nottingham; King's Meadow Campus, Lenton Lane Nottingham NG7 2NR U.K
| | - S. Barbarot
- Centre of Evidence Based Dermatology; University of Nottingham; King's Meadow Campus, Lenton Lane Nottingham NG7 2NR U.K
| | - S. Smith
- Centre of Evidence Based Dermatology; University of Nottingham; King's Meadow Campus, Lenton Lane Nottingham NG7 2NR U.K
| | - N.K. Rogers
- Centre of Evidence Based Dermatology; University of Nottingham; King's Meadow Campus, Lenton Lane Nottingham NG7 2NR U.K
| | - H.C. Williams
- Centre of Evidence Based Dermatology; University of Nottingham; King's Meadow Campus, Lenton Lane Nottingham NG7 2NR U.K
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Abstract
Atopic dermatitis (AD) is a chronic inflammatory skin condition that requires a manifold approach to therapy. The goal of therapy is to restore the function of the epidermal barrier and to reduce skin inflammation. This can be achieved with skin moisturization and topical anti-inflammatory agents, such as topical corticosteroids and calcineurin inhibitors. Furthermore, proactive therapy with twice weekly use of both topical corticosteroids and calcineurin inhibitors in previously affected areas has been found to reduce the time to the next eczematous flare. Adjunctive treatment options include wet wrap therapy, anti-histamines, and vitamin D supplementation. Bacterial colonization, in particular Staphylococcus aureus, can contribute to eczematous flares and overt infection. Use of systemic antibiotics in infected lesions is warranted; however, empiric antibiotics use in uninfected lesions is controversial. Local antiseptic measures (i.e., bleach baths) and topical antimicrobial therapies can be considered in patients with high bacterial colonization. Difficult-to-treat AD is a complex clinical problem that may require re-evaluation of the initial diagnosis of AD, especially if the onset of disease occurs in adulthood. It may also necessitate evaluation for contact, food, and inhaled allergens that may exacerbate the underlying AD. There are a host of systemic therapies that have been successful in patients with difficult-to-treat AD, however, these agents are limited by their side effect profiles. Lastly, with further insight into the pathophysiology of AD, new biological agents have been investigated with promising results.
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Affiliation(s)
- Melanie Chong
- Rheumatology, Allergy & Immunology, Winthrop University Hospital, 120 Mineola Blvd, Suite 410, Mineola, NY, 11501, USA.
| | - Luz Fonacier
- Rheumatology, Allergy & Immunology, Winthrop University Hospital, 120 Mineola Blvd, Suite 410, Mineola, NY, 11501, USA
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31
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Gooderham M, Lynde CW, Papp K, Bourcier M, Guenther L, Gulliver W, Hong CH, Poulin Y, Sussman G, Vender R. Review of Systemic Treatment Options for Adult Atopic Dermatitis. J Cutan Med Surg 2016; 21:31-39. [DOI: 10.1177/1203475416670364] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Atopic dermatitis (AD) is a chronic, pruritic inflammatory skin disease resulting from defects in skin barrier and aberrant immune responses. AD significantly affects the quality of life. Not all patients respond to topical therapies, and often systemic therapy is required to control the disease. Objective: To review the treatment options for adult AD patients including those options for patients who do not respond adequately or have contraindications to oral systemic therapy. Methods: A working group of clinicians with experience managing AD was convened to review the current literature on treatment options for adult AD patients. This review is based on the best available evidence from a published systematic review and an additional literature search. Results: Current treatments for AD are reviewed, including options for adult AD patients who do not respond or have contraindications to current systemic therapies. A new approach with targeted therapies is reviewed based on best available evidence. Conclusion: Many AD patients respond satisfactorily to topical or systemic treatments, but for those patients who do not respond or have contraindications, new biologic agents appear to be promising therapies.
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Affiliation(s)
- Melinda Gooderham
- Queen’s University, SKiN Centre for Dermatology, and Probity Medical Research, Peterborough, ON, Canada
| | - Charles W. Lynde
- Lynde Dermatology, Probity Medical Research, Markham Ontario, and Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kim Papp
- K Papp Clinical Research and Probity Medical Research, Waterloo, ON, Canada
| | | | - Lyn Guenther
- University of Western Ontario, London ON, Canada
| | - Wayne Gulliver
- Memorial University of Newfoundland St. John’s, NL, Canada
| | - Chih-ho Hong
- Department of Dermatology and Skin Science, University of British Columbia, and Probity Medical Research, Surrey, BC, Canada
| | - Yves Poulin
- Laval University and CDQM and CRDQ, Quebec, QC, Canada
| | - Gordon Sussman
- Division of Clinical Immunology and Allergy, University of Toronto, Toronto, ON, Canada
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Romero GB, Arntjen A, Keck CM, Müller RH. Amorphous cyclosporin A nanoparticles for enhanced dermal bioavailability. Int J Pharm 2015; 498:217-24. [PMID: 26688038 DOI: 10.1016/j.ijpharm.2015.12.019] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/03/2015] [Accepted: 12/09/2015] [Indexed: 10/22/2022]
Abstract
Cylosporin A (CyA) was formulated as amorphous nanoparticle suspension to increase dermal penetration, e.g. applicable in psoriasis. The suspension consisted of 5% CyA in water, stabilized with vitamin E polyethylene glycol succinate (TPGS, Kolliphor TPGS) and was produced by bead milling. The diameter of the bulk population was about 350 nm, laser diffraction diameter 99% was 690 nm. The suspension was physically stable over one year of storage at room temperature, and most important the amorphous state also remained stable. Despite the high dispersitivity and related large surface area in contact with water, the drug content reduced only by 5% over 1 year of storage. i.e. the formulation is feasible as commercial product with expiry date. The CyA nanoparticles and μm-sized CyA particles were incorporated into hydroxypropylcellulose (HPC) gels and the penetration studied into fresh pig ear skin applying the tape stripping method. At tape number 30, the penetrated cumulative amount of CyA from nanoparticles was 6.3 fold higher compared to the μm-sized raw drug powder (450.1 μg/cm(2) vs. 71.3 μg/cm(2)). A theoretical mechanism is presented to explain the observed superiority in penetration. Based on amorphous CyA nanoparticles, dermal formulations for improved dermal CyA delivery seem to be feasible.
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Affiliation(s)
- Gregori B Romero
- Pharmaceutics, Pharmaceutical Nanotechnology & NutriCosmetics, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany.
| | - Anja Arntjen
- Applied Pharmacy, University of Applied Sciences Kaiserslautern, Campus Pirmasens, Carl-Schurz-Str. 10-16, 66953 Pirmasens, Germany
| | - Cornelia M Keck
- Applied Pharmacy, University of Applied Sciences Kaiserslautern, Campus Pirmasens, Carl-Schurz-Str. 10-16, 66953 Pirmasens, Germany
| | - Rainer H Müller
- Pharmaceutics, Pharmaceutical Nanotechnology & NutriCosmetics, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany.
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Küster D, Spuls PI, Flohr C, Smith C, Hooft L, Deckert S, Schwennesen T, Roekevisch E, Schmitt J. Effects of systemic immunosuppressive therapies for moderate-to-severe eczema in children and adults. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011939] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Denise Küster
- Universitätsklinikum Carl Gustav Carus an der Technische Universität Dresden; Center for Evidence-Based Healthcare; Fetscherstrasse 74 Dresden Germany 01307
| | - Phyllis I Spuls
- Academisch Medisch Centrum; Department of Dermatology; A0-227, Meibergdreef 9 Amsterdam Netherlands 1105 AZ
| | - Carsten Flohr
- St Thomas' Hospital; Department of Paediatric Dermatology and Children's Allergies; Lambeth Palace Road London UK SE1 7EH
| | - Catherine Smith
- Guy's and St Thomas' NHS Foundation Trust; St John's Institute of Dermatology; Guys Hospital, London Bridge London UK SE1 9RT
| | - Lotty Hooft
- Julius Center for Health Sciences and Primary Care / University Medical Center Utrecht; Dutch Cochrane Centre; Room Str. 6.127 P.O. Box 85500 Utrecht Netherlands 3508 GA
| | - Stefanie Deckert
- Universitätsklinikum Carl Gustav Carus an der Technische Universität Dresden; Center for Evidence-Based Healthcare; Fetscherstrasse 74 Dresden Germany 01307
| | | | - Evelien Roekevisch
- Academisch Medisch Centrum; Department of Dermatology; A0-227, Meibergdreef 9 Amsterdam Netherlands 1105 AZ
| | - Jochen Schmitt
- Faculty of Medicine Carl Gustav Carus, TU Dresden; Center for Evidence-Based Healthcare; Fetscherstr. 74 Dresden Germany 01307
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Placebo Effects on Itch: A Meta-Analysis of Clinical Trials of Patients with Dermatological Conditions. J Invest Dermatol 2015; 135:1234-1243. [DOI: 10.1038/jid.2014.522] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 10/31/2014] [Accepted: 12/01/2014] [Indexed: 01/21/2023]
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Ohtsuka T. Different effect of oral cyclosporine therapy and oral antihistamine therapy on serum high-sensitivity C-reactive protein level and thymus and activation-regulated chemokine level in atopic dermatitis in older children and adulthood. Int J Dermatol 2014; 54:648-55. [DOI: 10.1111/ijd.12374] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 05/02/2013] [Accepted: 06/19/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Tsutomu Ohtsuka
- Department of Dermatology; International University of Health and Welfare Hospital; Nasushiobara Tochigi Japan
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36
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Koppelhus U, Poulsen J, Grunnet N, Deleuran MS, Obitz E. Cyclosporine and Extracorporeal Photopheresis are Equipotent in Treating Severe Atopic Dermatitis: A Randomized Cross-Over Study Comparing Two Efficient Treatment Modalities. Front Med (Lausanne) 2014; 1:33. [PMID: 25593907 PMCID: PMC4292191 DOI: 10.3389/fmed.2014.00033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Accepted: 09/15/2014] [Indexed: 11/13/2022] Open
Abstract
Background: Severe atopic dermatitis (AD) is a recurrent and debilitating disease often requiring systemic immunosuppressive treatment. The efficacy of cyclosporine A (CsA) is well proven but potential side effects are concerning. Several reports point at extracorporeal photopheresis (ECP) as an alternative treatment modality with few and mild side effects. However, no direct comparison between CsA and ECP in the treatment of AD has been performed so far. Objectives: To compare the efficacy of CsA (3 mg/kg/day) and ECP (administered two consecutive days twice a month) in a cohort of patients with severe AD. Methods: A randomized cross-over study involving twenty patients with severe AD (SCORAD index 41-89) refractory to other treatments. The patients were allocated to a 4-month course of either of the two treatment modalities. Individual relapse periods (2–8 weeks) were interspersed before cross-over to the other treatment modality. Treatment efficacy was evaluated by SCORAD, PRURITUS (VAS-index 0–10), “overall global assessment” and serological biomarkers; sIL-2Rα, sE-selectin, eosinophilocytes, basophilocytes, and sIgE. Results: 15 patients completed treatment. Both treatments lead to a marked and significant decrease in SCORAD and pruritus index. The average reduction of the SCORAD and pruritus index, respectively was a little higher for ECP treatment compared to CsA treatment; however, the differences did not reach statistical significance. The “overall global assessment” was significantly better in patients who underwent ECP therapy as compared to CsA treatment. None of the biomarkers showed significant changes after either treatment when compared to the initial values. Conclusion: ECP administered on two consecutive days twice a month to patients with severe AD has similar potency as CsA administered daily in a moderate dose. ECP is a treatment alternative in patients with severe AD that do not tolerate or are refractory to conventional immunosuppressants.
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Affiliation(s)
- Uffe Koppelhus
- Department of Dermatology, Aarhus University Hospital , Aarhus , Denmark
| | - Johan Poulsen
- Department of Dermatology, Aarhus University Hospital , Aarhus , Denmark
| | - Niels Grunnet
- Department of Clinical Immunology, Aarhus University Hospital , Aarhus , Denmark
| | | | - Erik Obitz
- Department of Dermatology, Aarhus University Hospital , Aarhus , Denmark
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Nygaard U, Vestergaard C, Deleuran M. Systemic Treatment of Severe Atopic Dermatitis in Children and Adults. CURRENT TREATMENT OPTIONS IN ALLERGY 2014. [DOI: 10.1007/s40521-014-0032-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Sidbury R, Davis DM, Cohen DE, Cordoro KM, Berger TG, Bergman JN, Chamlin SL, Cooper KD, Feldman SR, Hanifin JM, Krol A, Margolis DJ, Paller AS, Schwarzenberger K, Silverman RA, Simpson EL, Tom WL, Williams HC, Elmets CA, Block J, Harrod CG, Begolka WS, Eichenfield LF. Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents. J Am Acad Dermatol 2014; 71:327-49. [PMID: 24813298 DOI: 10.1016/j.jaad.2014.03.030] [Citation(s) in RCA: 533] [Impact Index Per Article: 53.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 03/16/2014] [Accepted: 03/17/2014] [Indexed: 11/16/2022]
Abstract
Atopic dermatitis is a chronic, pruritic inflammatory dermatosis that affects up to 25% of children and 2% to 3% of adults. This guideline addresses important clinical questions that arise in atopic dermatitis management and care, providing recommendations based on the available evidence. In this third of 4 sections, treatment of atopic dermatitis with phototherapy and systemic immunomodulators, antimicrobials, and antihistamines is reviewed, including indications for use and the risk-benefit profile of each treatment option.
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Affiliation(s)
- Robert Sidbury
- Department of Dermatology, Seattle Children's Hospital, Seattle, Washington
| | - Dawn M Davis
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - David E Cohen
- Department of Dermatology, New York University School of Medicine, New York, New York
| | - Kelly M Cordoro
- Department of Dermatology, University of California, San Francisco, California
| | - Timothy G Berger
- Department of Dermatology, University of California, San Francisco, California
| | - James N Bergman
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sarah L Chamlin
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kevin D Cooper
- Department of Dermatology, Case Western University, Cleveland, Ohio
| | - Steven R Feldman
- Department of Dermatology, Wake Forest University Health Sciences, Winston-Salem, North Carolina
| | - Jon M Hanifin
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | - Alfons Krol
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | - David J Margolis
- Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Amy S Paller
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kathryn Schwarzenberger
- Kaplan-Amonette Department of Dermatology, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Eric L Simpson
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | - Wynnis L Tom
- University of San Diego, San Diego, California; Division of Pediatric and Adolescent Dermatology, Rady Children's Hospital, San Diego, California
| | - Hywel C Williams
- Center of Evidence-based Dermatology, Nottingham University Hospitals National Health Service Trust, Nottingham, United Kingdom
| | - Craig A Elmets
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Julie Block
- National Eczema Association, San Rafael, California
| | | | | | - Lawrence F Eichenfield
- University of San Diego, San Diego, California; Division of Pediatric and Adolescent Dermatology, Rady Children's Hospital, San Diego, California
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Roekevisch E, Spuls PI, Kuester D, Limpens J, Schmitt J. Efficacy and safety of systemic treatments for moderate-to-severe atopic dermatitis: A systematic review. J Allergy Clin Immunol 2014; 133:429-38. [DOI: 10.1016/j.jaci.2013.07.049] [Citation(s) in RCA: 228] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 07/02/2013] [Accepted: 07/31/2013] [Indexed: 11/30/2022]
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Abstract
Systemic therapy for atopic dermatitis (AD) is indicated in patients with severe disease refractory to adequate topical treatment. Currently available drugs aim to decrease inflammation by suppressing and/or modulating immune responses and thus may indirectly improve skin barrier function, resulting in a decrease in clinical signs and symptoms in particular pruritus. Before considering systemic treatment, patient adherence to topical treatment including skin care has to be ensured. The selection of the drug depends on the disease severity, localization, complications, concomitant diseases, and age of the patient, but also on their availability and costs as well as the doctor's experience. Bearing in mind the potential risk of resistance, systemic therapy with antibiotics should be exclusively considered in clinically manifest infections such as in children. Here, we review recently published clinical trials and case reports on systemic therapy of pediatric and adult patients with AD to draw conclusions for clinical practice. Although AD is a common disease, controlled clinical studies investigating the efficacy of systemic drugs are scarce, except for cyclosporine, which has been approved for the therapy of severe AD.
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Affiliation(s)
- D. Simon
- Department of Dermatology; Inselspital; Bern University Hospital; University of Bern; Bern Switzerland
| | - T. Bieber
- Department of Dermatology and Allergy; University of Bonn; Bonn Germany
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Schneider L, Tilles S, Lio P, Boguniewicz M, Beck L, LeBovidge J, Novak N, Bernstein D, Blessing-Moore J, Khan D, Lang D, Nicklas R, Oppenheimer J, Portnoy J, Randolph C, Schuller D, Spector S, Tilles S, Wallace D. Atopic dermatitis: a practice parameter update 2012. J Allergy Clin Immunol 2013; 131:295-9.e1-27. [PMID: 23374261 DOI: 10.1016/j.jaci.2012.12.672] [Citation(s) in RCA: 269] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 12/18/2012] [Indexed: 10/27/2022]
Abstract
This parameter was developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing "Atopic dermatitis: a practice parameter update 2012." This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma & Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion. Published practice parameters of the Joint Task Force on Practice Parameters for Allergy & Immunology are available online at http://www.jcaai.org.
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Abstract
Difficult to control atopic dermatitis (AD) presents a therapeutic challenge and often requires combinations of topical and systemic treatment. Anti-inflammatory treatment of severe AD most commonly includes topical glucocorticosteroids and topical calcineurin antagonists used for exacerbation management and more recently for proactive therapy in selected cases. Topical corticosteroids remain the mainstay of therapy, the topical calcineurin inhibitors tacrolimus and pimecrolimus are preferred in certain locations. Systemic anti-inflammatory treatment is an option for severe refractory cases. Microbial colonization and superinfection contribute to disease exacerbation and thus justify additional antimicrobial / antiseptic treatment. Systemic antihistamines (H1) may relieve pruritus but do not have sufficient effect on eczema. Adjuvant therapy includes UV irradiation preferably of UVA1 wavelength. “Eczema school” educational programs have been proven to be helpful.
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Frankel H, Frangos J, Qureshi A. Tapering cyclosporine after long-term treatment of atopic dermatitis. J Eur Acad Dermatol Venereol 2012; 26:792-3. [DOI: 10.1111/j.1468-3083.2011.04142.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Beaumont DR, Arkwright PD. Factors determining the effectiveness of oral ciclosporin in the treatment of severe childhood atopic dermatitis. J DERMATOL TREAT 2012; 23:318-22. [DOI: 10.3109/09546634.2012.672709] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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47
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Abstract
Atopic dermatitis, commonly known as eczema, is a common chronic, relapsing skin disease characterized by pruritus, disrupted epidermal barrier function, and immunoglobulin E-mediated sensitization to food and environmental allergens. Atopic dermatitis is a complex disease that arises from interactions between genes and the environment. Loci on several chromosomes have been identified, including a family of epithelium-related genes called the epidermal differentiation complex on chromosome 1q21. Mutations in filaggrin, a key protein in epidermal differentiation, have also been identified in early-onset and severe atopic dermatitis. There are 3 classical stages of eczema: infantile, childhood, and adulthood. The spectrum of eczema presentation varies widely from a variant that only affect the hand to major forms where a patient presents with erythroderma. The acute and subacute lesions of atopic dermatitis are often characterized by intensely pruritic, erythematous papules and vesicles with excoriations and a serous exudate. Chronic atopic dermatitis is exemplified by lichenified plaques and papules with excoriations. Atopic dermatitis patients are also at higher risk for skin infections, including bacterial and viral superinfections. Conventional therapy includes avoidance of irritants and potential allergens, as well as continued hydration of the skin with thick emollients. Topical corticosteroids and topical immunomodulators are often used primarily. Other therapies including phototherapy, antimicrobials, antihistamines, and systemic immunosuppressives are also options in certain situations.
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Affiliation(s)
- Andrew Sohn
- Mount Sinai School of Medicine, New York, NY, USA
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48
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Muellenhoff MW, Koo JY. Cyclosporine and skin cancer: an international dermatologic perspective over 25 years of experience. A comprehensive review and pursuit to define safe use of cyclosporine in dermatology. J DERMATOL TREAT 2011; 23:290-304. [DOI: 10.3109/09546634.2011.590792] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Matthew W. Muellenhoff
- SIERRADERM, Center for Dermatology, Grass Valley, California, USA
- NOVA Southeastern University, Sun Coast Hospital, Largo, Florida, USA
| | - John Y. Koo
- Department of Dermatology,
University of California San Francisco, Psoriasis Treatment Center, San Francisco, California, USA
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49
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Survase SA, Kagliwal LD, Annapure US, Singhal RS. Cyclosporin A--a review on fermentative production, downstream processing and pharmacological applications. Biotechnol Adv 2011; 29:418-35. [PMID: 21447377 DOI: 10.1016/j.biotechadv.2011.03.004] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2010] [Revised: 03/05/2011] [Accepted: 03/15/2011] [Indexed: 10/18/2022]
Abstract
In present times, the immunosuppressants have gained considerable importance in the world market. Cyclosporin A (CyA) is a cyclic undecapeptide with a variety of biological activities including immunosuppressive, anti-inflammatory, antifungal and antiparasitic properties. CyA is produced by various types of fermentation techniques using Tolypocladium inflatum. In the present review, we discuss the biosynthetic pathway, fermentative production, downstream processing and pharmacological activities of CyA.
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Affiliation(s)
- Shrikant A Survase
- Food Engineering and Technology Department, Institute of Chemical Technology, Matunga, Mumbai 400019, India
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50
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Haeck IM, Knol MJ, Ten Berge O, van Velsen SGA, de Bruin-Weller MS, Bruijnzeel-Koomen CAFM. Enteric-coated mycophenolate sodium versus cyclosporin A as long-term treatment in adult patients with severe atopic dermatitis: a randomized controlled trial. J Am Acad Dermatol 2011; 64:1074-84. [PMID: 21458107 DOI: 10.1016/j.jaad.2010.04.027] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Revised: 04/10/2010] [Accepted: 04/12/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Cyclosporin A (CsA) is frequently used in the treatment of severe atopic dermatitis (AD). Enteric-coated mycophenolate sodium (EC-MPS) may be an alternative with equal efficacy and fewer side effects. OBJECTIVE The aim of this observer-blinded randomized controlled trial was to compare EC-MPS with CsA as long-term treatment in adult patients with severe AD. METHODS Fifty five patients with AD were treated with CsA (5 mg/kg) in a 6-week run-in period. Thereafter, patients either received CsA (3 mg/kg; n = 26) or EC-MPS (1440 mg; n = 24) during a maintenance phase of 30 weeks and there was a 12-week follow-up period. Disease activity was measured using the objective SCORAD and serum thymus and activation-regulated chemokine (TARC) levels and side effects were registered. RESULTS During the first 10 weeks the objective SCORAD and serum TARC levels in the EC-MPS study arm were higher in comparison with the CsA study arm. In addition, 7 of the 24 patients treated with EC-MPS required short oral corticosteroid courses. During maintenance phase disease activity was comparable in both study arms. Side effects in both study arms were mild and transient. After study medication withdrawal, disease activity of the patients in the CsA study arm significantly increased compared with the EC-MPS study arm. LIMITATION The nonblinding of patients and prescriber of rescue medication are limitations. CONCLUSIONS This study shows that EC-MPS is as effective as CsA as maintenance therapy in patients with AD. However, clinical improvement with EC-MPS is delayed in comparison with CsA. Clinical remission after stopping EC-MPS lasts longer compared with CsA.
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Affiliation(s)
- Inge M Haeck
- Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht, The Netherlands.
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