Tacrolimus ointment 0.03% is safe and effective for the treatment of mild to moderate atopic dermatitis in pediatric patients: results from a randomized, double-blind, vehicle-controlled study

Topical Treatments in Atopic Dermatitis: An Expansive Review

Atopic dermatitis (AD) is a common inflammatory skin condition found worldwide. It impacts patient quality of life (QoL) and is thought to arise as an inflammatory response to epidermal barrier dysfunction and hypersensitivity. AD can lead to large out-of-pocket costs and increased healthcare expenses over a lifetime. An analysis of all randomized control trials conducted since 1990 on topical therapies for AD were reviewed, including 207 trials in the final analysis. It was found that an average of 226 patients were enrolled over 2.43 arms. Common topical treatments included corticosteroids, calcineurin inhibitors, JAK inhibitors, and phosphodiesterase inhibitors. The most utilized tools to identify treatment efficacy were the EASI, IGA, SCORAD, and PGA. There was a paucity of data on trials that evaluated efficacy, QoL, and cost of treatment simultaneously. This review highlights the need for comprehensive trials that evaluate multiple aspects of treatment, including financial cost and QoL impact, to ensure each patient has the best treatment modality for the management of their AD.

Applications of topical immunomodulators enhance clinical signs of vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC): a meta-analysis

PURPOSE

This meta-analysis aimed to review the safety and efficacy of topical cyclosporine A (CsA) and topical tacrolimus in allergic eye disease.

METHODS

A systematic search identified thirteen studies and a total of 445 patients for inclusion, making this the largest meta-analysis published on the subject. The current review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

Thirteen randomized control trials were included in the meta-analysis. Eleven studies used CsA as the treatment, and two used Tacrolimus. In total, 445 participants were included, of whom 76.6% were male. The mean age of participants across the included studies was 14 years. All studies reported clinical signs as evaluated by an examining clinician. Signs were usually assessed by anatomical region, with the most common regions being the conjunctiva and the cornea, and the most common signs assessed were hyperemia and papillae. Three studies accounted for more than 50% of the meta-analysis's weight. Effect size (d) ranged from - 2.37 to - 0.03, negative values favoring immunomodulators. Fixed Effect Meta-Analysis returned an SMD of - 0.81 (95% CI [- 0.98, - 0.65]). However, there was significant heterogeneity (I2 = 61%, Qw = 30.76) in the outcome measure (P = 0.0021); therefore, a random-effect meta-analysis was also completed in which the pooled SMD was - 0.98 (95% CI [- 1.26, - 0.69], τ2 = 0.16).

CONCLUSIONS

This study affirms the current scientific community's stance that immunomodulators effectively treat clinical signs, including blepharitis, conjunctival hyperemia, edema, papillae, and corneal damage in severe ocular allergic disease.

Topical treatments for atopic dermatitis (eczema): Systematic review and network meta-analysis of randomized trials

BACKGROUND

Atopic dermatitis (AD) is a common skin condition with multiple topical treatment options, but uncertain comparative effects.

OBJECTIVE

We sought to systematically synthesize the benefits and harms of AD prescription topical 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, CINAHL, LILACS, ICTRP, and GREAT databases to September 5, 2022, for randomized trials addressing AD topical treatments. 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. We classified topical corticosteroids (TCS) using 7 groups-group 1 being most potent. This review is registered in the Open Science Framework (https://osf.io/q5m6s).

RESULTS

The 219 included trials (43,123 patients) evaluated 68 interventions. With high-certainty evidence, pimecrolimus improved 6 of 7 outcomes-among the best for 2; high-dose tacrolimus (0.1%) improved 5-among the best for 2; low-dose tacrolimus (0.03%) improved 5-among the best for 1. With moderate- to high-certainty evidence, group 5 TCS improved 6-among the best for 3; group 4 TCS and delgocitinib improved 4-among the best for 2; ruxolitinib improved 4-among the best for 1; group 1 TCS improved 3-among the best for 2. These interventions did not increase harm. Crisaborole and difamilast were intermediately effective, but with uncertain harm. Topical antibiotics alone or in combination may be among the least effective. To maintain AD control, group 5 TCS were among the most effective, followed by tacrolimus and pimecrolimus.

CONCLUSIONS

For individuals with AD, pimecrolimus, tacrolimus, and moderate-potency TCS are among the most effective in improving and maintaining multiple AD outcomes. Topical antibiotics may be among the least effective.

Cancer risk with topical calcineurin inhibitors, pimecrolimus and tacrolimus, for atopic dermatitis: a systematic review and meta-analysis

BACKGROUND

Atopic dermatitis is a prevalent condition in children and can be effectively managed with medications such as topical calcineurin inhibitors (pimecrolimus or tacrolimus). A key unresolved safety concern is whether use of topical calcineurin inhibitors is associated with cancer. We systematically reviewed the risk of cancer in patients with atopic dermatitis exposed to topical calcineurin inhibitors.

METHODS

As part of the 2022 American Academy of Allergy, Asthma and Immunology and American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters atopic dermatitis guidelines, we searched MEDLINE, Embase, the Latin American and Caribbean Health Sciences Literature database, the Índice Bibliográfico Espanhol de Ciências da Saúde database, the Global Resource of Eczema Trials database, WHO's International Clinical Trials Registry Platform, the US Food and Drug Administration database, the European Medicines Agency database, company registers, and relevant citations from inception to June 6, 2022. We included randomised controlled trials and comparative and non-comparative non-randomised studies in any language addressing cancer risk in patients with atopic dermatitis using topical calcineurin inhibitors. We excluded split-body studies and studies with less than 3 weeks of follow-up. Paired reviewers independently screened records, extracted data, and assessed risk of bias in duplicate. We used Bayesian models to estimate the probability for cancer due to topical calcineurin inhibitor exposure and the GRADE approach to determine the certainty of the evidence. Patients, advocacy groups, and care providers set a priori thresholds of important effects. This study is registered with Open Science Framework, https://osf.io/v4bfc.

FINDINGS

We identified and analysed 110 unique studies (52 randomised controlled trials and 69 non-randomised studies [11 were non-randomised study extensions of randomised controlled trials]) including 3·4 million patients followed up for a mean of 11 months (range 0·7-120). The absolute risk of any cancer with topical calcineurin inhibitor exposure was not different from controls (absolute risk 4·70 per 1000 with topical calcineurin inhibitors vs 4·56 per 1000 without; odds ratio 1·03 [95% credible interval 0·94-1·11]; moderate certainty). For all age groups and using data from observational studies and randomised controlled trials, the use of pimecrolimus (OR 1·05 [95% credible interval 0·94-1·15]) or tacrolimus (0·99 [0·89-1·09]) is likely to have had little to no association with cancer compared with no topical calcineurin inhibitor exposure. For pimecrolimus versus tacrolimus, the finding was similar (0·95 [95% credible interval 0·83-1·07]). Findings were similar in infants, children, and adults, and robust to trial sequential, subgroup, and sensitivity analyses.

INTERPRETATION

Among individuals with atopic dermatitis, moderate-certainty evidence shows that topical calcineurin inhibitors do not increase the risk of cancer. These findings support the safe use of topical calcineurin inhibitors in the optimal treatment of patients with atopic dermatitis.

FUNDING

American Academy of Allergy, Asthma and Immunology and American College of Allergy, Asthma and Immunology via the Joint Task Force on Practice Parameters.

Experts' Consensus on the Use of Pimecrolimus in Atopic Dermatitis in China: A TCS-Sparing Practical Approach

Introduction

Atopic dermatitis (AD) is a chronic, pruritic, inflammatory skin disease with rising prevalence. Topical corticosteroids (TCS) are recommended as first-line therapy for patients with AD in China; however, corticophobia is a widespread concern, which can manifest as noncompliance: in a previous Chinese study, almost all parents whose children had AD were very concerned about the side effects of TCS and, as a result, nearly half did not use it in the event of recurrence. We propose a TCS-sparing treatment algorithm for the management of infants, children, adolescents, and adults with mild-to-moderate AD, to guide clinical practice in China.

Methods

A panel of eight experts in AD from China and one expert from Germany formed to develop a practical algorithm for the management of mild-to-moderate AD, focusing on pimecrolimus.

Results

Irrespective of body location, all patients with mild AD (including acute flares) and infants with moderate AD should apply the topical calcineurin inhibitor (TCI) pimecrolimus twice daily to the affected area until symptoms disappear. For children, adolescents, and adults with moderate AD, pimecrolimus should be applied twice daily to sensitive skin areas, and a TCI (either pimecrolimus or tacrolimus) should be applied twice daily to other body locations. Short-term administration of TCS, followed by TCI twice daily, is recommended for most patients with moderate AD experiencing acute flares, regardless of lesion site. Emollients should be used regularly.

Conclusions

The algorithm presented intends to simplify treatment of AD in China and guide clinical decision-making.

Matching-Adjusted Indirect Comparison of Crisaborole Ointment 2% vs. Topical Calcineurin Inhibitors in the Treatment of Patients with Mild-to-Moderate Atopic Dermatitis

Introduction

Crisaborole topical ointment, 2%, is a nonsteroidal, topical anti-inflammatory phosphodiesterase-4 (PDE4) inhibitor that is approved for the treatment of mild-to-moderate atopic dermatitis (AD). The objective of the current analysis was to compare the efficacy of crisaborole 2% relative to pimecrolimus 1%, tacrolimus 0.03% and tacrolimus 0.1% in patients aged ≥ 2 years with mild-to-moderate AD by comparing improvement in Investigator’s Static Global Assessment scores ( (ISGA scores of 0/1 indicating “clear or almost clear”). ISGA was selected as the primary efficacy outcome given the US Food and Drug Administration’s recommendations on the use of ISGA for assessment of global severity in AD and to align with efficacy measurements in the crisaborole registration trials. Safety endpoints could not be analyzed due to differences in outcome definitions across studies.

Methods

Efficacy of crisaborole was evaluated using individual patient data (IPD) from two pivotal phase III randomized controlled trials (RCTs), and efficacy of comparators was evaluated using published RCTs included in a previous network meta-analysis. Vehicle controls were not comparable due to differences in ingredients and population imbalance and, therefore, an unanchored matching-adjusted indirect comparison (MAIC) was used, which reweighted IPD for crisaborole to estimate absolute response in comparator populations.

Results

The odds of achieving an improvement in ISGA score was higher with crisaborole 2% versus pimecrolimus 1% (odds ratio [OR] 2.03; 95% confidence interval [CI] 1.45–2.85; effective sample size =  627, reduced from 1021; p value < 0.001) and for crisaborole 2% versus tacrolimus 0.03% (OR 1.50; 95% CI 1.09–2.05; effective sample size = 311, reduced from 1021; p = 0.012).

Conclusion

The unanchored MAIC suggests that the odds of achieving an improvement in ISGA score is greater with crisaborole 2% than with pimecrolimus 1% or tacrolimus 0.03% in patients aged ≥ 2 years with mild-to-moderate AD. These results are consistent with findings from the previously published network meta-analysis, which used a different methodology for performing indirect treatment comparisons.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-021-00646-1.

Safety of tacrolimus 0.03% and 0.1% ointments in young children with atopic dermatitis - a 36-month follow-up study

BACKGROUND

Topical tacrolimus is used off-label in young children, but data remains limited regarding children under 2 years of age and long-term treatment.

OBJECTIVES

To compare safety differences between tacrolimus 0.03% and 0.1% ointments with mild and moderate potency topical corticosteroids in young children with atopic dermatitis.

METHODS

We conducted a 36-month follow-up study with 152 young children from one to three years of age with moderate-to-severe atopic dermatitis. Children were followed prospectively and data concerning infections, disease severity, growth parameters, vaccination responses, and other relevant laboratory tests were gathered.

RESULTS

There were no differences between the treatment groups in skin-related infections (p = 0.198), other infections (p = 0.498), growth parameters height (p = 0.601) and weight (p = 0.812), EASI scores (p = 0.187), vaccination responses (p = 0.620), serum cortisone levels (p = 0.228) and serum levels of IL-4, IL-10, IL-12, IL-31 and IFN gamma. EASI decreased significantly in both groups (p < 0.0001). In the tacrolimus group, nine patients (11.68%) had detectable tacrolimus blood concentrations at the 1-week visit. We observed no malignancies or severe infections during the study. Blood eosinophil counts were similar in both groups.

CONCLUSIONS

Topical tacrolimus (0.03% and 0.1%) and topical corticosteroids (mild and moderate potency) are safe to use in young children with moderate-to severe-atopic dermatitis and have comparable efficacy and safety profiles.

Sensitivity of clinician-assessed efficacy outcome measurement instruments in trials of topical therapies for atopic dermatitis: a systematic review and meta-analysis

The rising prevalence of atopic dermatitis (AD) in developing countries and its substantial socioeconomic impact have furthered research over the last two decades giving way to advances in its aetiopathogenesis and treatment. Topical therapies targeting newly identified AD signalling pathways are being developed. Numerous clinician-assessed disease severity outcome measurement instruments (OMIs) are available to evaluate the efficacy of investigational treatments in proof-of-concept (POC) trials for AD. However, little is known about the comparative sensitivity of these efficacy OMIs. We performed a systematic review and meta-analysis to compare the sensitivity of different OMIs in controlled trials of topical therapies for AD published between January 1, 2000 and April 7, 2020. Treatment effect size of OMIs reported at Week 4 was calculated with 95% Confidence Interval (CI). The sensitivity of OMIs was compared by pooling the standardized difference between means (Cohen's d and Cohen's h) for any two OMI-parameter combinations that were reported in ≥3 studies identified in our systematic review. Assessed parameters were difference between active and vehicle at Week 4 and change from baseline [CFB] and percentage change from baseline [%CFB] at Week 4. We identified a total of 15 studies with 3313 subjects examining 14 different OMIs were included in this quantitative meta-analysis. Continuous OMIs had a significantly higher treatment effect size vs. dichotomous OMIs (P = 0.006). Comparisons of Eczema Area and Severity Index (EASI), Investigator's Global Assessment (IGA), body surface area (BSA) and SCORing Atopic Dermatitis (SCORAD) for available parameters were performed and generally had a similar sensitivity, with BSA showing smaller overall effect size estimates. In conclusion, continuous OMIs used in topical clinical trials for AD had significantly higher treatment effect sizes when compared to dichotomous OMIs. Continuous OMIs could provide more power for POC trials with a small sample size in atopic dermatitis with topical therapies.

Practical algorithm to inform clinical decision-making in the topical treatment of atopic dermatitis

Atopic dermatitis is a chronic relapsing, inflammatory skin disorder associated with skin barrier dysfunction, the prevalence of which has increased dramatically in developing countries. In this article, we propose a treatment algorithm for patients with mild-to-moderate and severe atopic dermatitis flares in daily clinical practice. An international panel of 15 dermatology and allergy experts from eight countries was formed to develop a practical algorithm for the treatment of patients with atopic dermatitis, with a particular focus on topical therapies. In cases of mild-to-moderate atopic dermatitis involving sensitive skin areas, the topical calcineurin inhibitor pimecrolimus should be applied twice daily at the first signs of atopic dermatitis. For other body locations, patients should apply a topical calcineurin inhibitor, either pimecrolimus or tacrolimus, twice daily at the first signs of atopic dermatitis, such as pruritus, or twice weekly in previously affected skin areas. Emollients should be used regularly. Patients experiencing acute atopic dermatitis flares in sensitive skin areas should apply a topical corticosteroid twice daily or alternate once-daily topical corticosteroid/topical calcineurin inhibitor until symptoms improve. Following improvement, topical corticosteroid therapy should be discontinued and patients switched to a topical calcineurin inhibitor. Maintenance therapy should include the use of pimecrolimus once daily for sensitive areas and tacrolimus for other body locations. This treatment algorithm can help guide clinical decision-making in the treatment of atopic dermatitis.

Crisaborole Ointment, 2%, for Treatment of Patients with Mild-to-Moderate Atopic Dermatitis: Systematic Literature Review and Network Meta-Analysis

Introduction

There is a need to compare efficacy and safety profiles of crisaborole ointment, 2%, versus other topical treatments across randomized clinical trials (RCTs). We performed this review/network meta-analysis to evaluate the comparative efficacy and safety of crisaborole versus other topical pharmacologic therapies for mild-to-moderate atopic dermatitis (AD) among patients aged ≥ 2 years.

Methods

Searches were conducted in MEDLINE, Embase, the Cochrane Collection Central Register of Clinical Trials, and the Database of Abstracts of Reviews of Effects using Ovid to identify English language articles reporting RCTs of topical anti-inflammatory agents in patients aged ≥ 2 years with mild-to-moderate AD published between inception and 10 March 2020. This review used a prespecified protocol with eligibility criteria for population, interventions, comparisons, outcomes, and study design. Efficacy was evaluated using the Investigator’s Static Global Assessment (ISGA) of clear (0) or almost clear (1) and expressed by hazard ratios (HR) with 95% credible intervals.

Results

Patients treated with crisaborole or tacrolimus ointment, 0.1% or 0.03%, versus vehicle alone were significantly more likely to achieve ISGA 0/1 at 28–42 days, with the greatest point estimate observed for the crisaborole comparison (hazard ratio: 2.07; 95% credible interval 1.76 to − 2.36; probability HR above 1 [p better]: 100.0%). Patients were also more likely to achieve ISGA 0/1 with crisaborole than with pimecrolimus cream, 1% (HR: 1.62; 95% credible interval 1.04–2.48; p better: 98.3%). While network meta-analysis for safety was not feasible because of data limitations, crisaborole pivotal studies (AD-301/AD-302) showed crisaborole was well tolerated.

Conclusions

Crisaborole was shown to be superior to vehicle and pimecrolimus and comparable to tacrolimus, 0.1% or 0.03%, with respect to ISGA 0/1 at 28–42 days in patients aged ≥ 2 years with mild-to-moderate AD. This evaluation of comparative efficacy of crisaborole further supports use of crisaborole as an effective therapeutic option in this population.

Electronic supplementary material

The online version of this article (10.1007/s13555-020-00389-5) contains supplementary material, which is available to authorized users.

Efficacy and safety of indigo naturalis ointment in Treating Atopic Dermatitis: A randomized clinical trial

ETHNOPHARMACOLOGICAL RELEVANCE

Indigo naturalis, a herbal medicine with a history of use dating back to ancient times, may be a good alternative topical treatment for atopic dermatitis (AD).

AIM OF THE STUDY

To provide empirical evidence of the efficacy and safety of Indigo naturalis ointment in treating AD.

MATERIALS AND METHODS

In this randomized double-blind clinical trial, participants aged 6 to 65 years with AD affecting less than 40% of their body surface area (BSA) and an Investigator's Global Assessment (IGA) score of 2 to 4 were randomized (2:1) to receive either Lindioil ointment or a vehicle ointment twice daily for 6 weeks. The primary endpoint was the percentage change in the Eczema Area Severity Index (EASI) from baseline to week 6. Secondary endpoints were as follows: EASI improvement ≥50%, 75%, and 90%; IGA score; BSA affected by AD; pruritus severity; and Dermatology Life Quality Index. The safety assessment included adverse events (AEs), laboratory tests, and physical examinations.

RESULTS

The Lindioil group (32 participants) and vehicle group (16 participants) achieved mean percentage EASI reductions of 49.9% ± 36.5% (95% CI 36.8%-63.1%) and 19.6% ± 52.2% (95% CI -8.2%-47.4%), respectively (P = 0.0235). The Lindioil group also showed greater improvement in every secondary assessment category. No significant AEs occurred.

CONCLUSION

Indigo naturalis ointment is effective for treating mild to severe AD topically, and appears to be safe. This is the first clinical trial to provide evidence supporting topical indigo-based AD treatment. ClinicalTrials.gov identifier: NCT02669888.

Contemporary Role of Topical Calcineurin Inhibitors: A Pediatric Dermatology Perspective

Atopic dermatitis (AD) is the most common pediatric chronic inflammatory skin disease in North America, often involving complex treatment regimens and impairing the quality of life of affected children and their families. Two topical calcineurin inhibitors (TCIs) have been available for the treatment of AD in pediatric patients for more than 15 years, and they continue to represent an important steroid-sparing option for the management of AD. Despite the large body of evidence and extensive clinical experience with these agents, there remain concerns among parents and clinicians regarding the long-term safety of this class of therapy, particularly with respect to the boxed warning about the potential risk of lymphoma and malignancy associated with TCIs. Concerns about burning or stinging with initial applications are also common. This review examines the literature on the clinical effectiveness of TCIs, with a focus on the pivotal research that supports the efficacy of these agents, and the reassuring body of evidence supporting their long-term safety in pediatric patients. Practical recommendations for maximizing the utility of TCIs in pediatric patients, including discussion points to address with parents, are offered.

The improvement of infantile atopic dermatitis during the maintenance period: A multicenter, randomized, parallel controlled clinical study of emollients in Prinsepia utilis Royle

In order to investigate the effect of daily emollient treatment on infantile atopic dermatitis (AD) during the maintenance period, a total of 309 children younger than 2 years with moderate AD (155 and 154 in the treatment and control groups, respectively) were enrolled in this multicenter, randomized, parallel controlled clinical trial. Subjects were topically treated with desonide cream and emollients in Prinsepia utilis Royle for 2-4 weeks before entering the maintenance period and then differentially treated with either emollients for treatment or none for control. The cumulative maintenance rate, time to flare and improvement of eczema area and severity index (EASI) and infant's dermatitis quality of life index (IDQOL) were evaluated. Results showed that the cumulative maintenance rate of the treatment group (60.5%, 95% CI 50.0-69.4%) was significantly higher than that of the control group (23.5%, 95% CI 15.2-33.0%) (p < .001). The median time to flare in the treatment group was 90 days (interquartile range, IQR 28-90), which was significantly longer than that in the control group (28 days [IQR 18-67]) (p < .001). At Week 4 in the maintenance period, the EASI and IDQOL scores of the treatment group were lower than those of the control group. In conclusion, the application of emollients during the maintenance period of infantile AD can significantly reduce the risk of AD flares, prolong the time to flare and improve the clinical symptoms.

Approach to the Assessment and Management of Adult Patients With Atopic Dermatitis: A Consensus Document. Section II: Tools for Assessing the Severity of Atopic Dermatitis

Clinicians rely on clinical measures to define the severity of atopic dermatitis and assess outcomes of therapy. These measures can be objective (ie, physician assessments of disease severity) or subjective (ie, patient-reported symptoms and quality of life outcomes). In this review, the most commonly used tools for assessing atopic dermatitis severity in adult patients are presented and compared. These include Eczema Area and Severity Index (EASI); SCORing Atopic Dermatitis (SCORAD); Physician Global Assessment (PGA); body surface area (BSA); Atopic Dermatitis Severity Index (ADSI); Six Area, Six Sign Atopic Dermatitis (SASSAD); Patient Oriented Eczema Measure (POEM); Dermatology Life Quality Index (DLQI); and pruritus Numerical Rating Scale (NRS). Available severity strata for the tools are summarized, although the use of severity strata in clinical practice is not recommended. Since both objective and subjective assessments of disease severity are important to assess, consideration of clinical characteristics such as disease recurrence or persistence, as well as location of the affected areas, should be considered in the overall judgement of disease severity and consideration of therapy choice.

Tolerability of Topical Treatments for Atopic Dermatitis

Atopic dermatitis (AD) is a common inflammatory skin disease that is accompanied by increased sensitivity to itch-provoking and pain-provoking stimuli. Patients with AD experience skin pain before initiation of therapy and have also reported painful application site reactions in clinical trials of emollients and prescription topical therapies, including topical corticosteroids (TCSs), topical calcineurin inhibitors (TCIs), and a topical phosphodiesterase 4 (PDE4) inhibitor. To compare the sensory tolerability of prescription topical therapies for AD, a comprehensive literature search and analysis of published clinical trials was conducted. Sensory tolerability issues such as application site pain, burning, stinging, and pruritus were often among the most common adverse events or treatment-related adverse events in clinical trials for prescription topical therapies. Tolerability issues occurred at highest rates in trials of TCIs, followed by trials of the PDE4 inhibitor crisaborole and TCSs, although direct comparisons are not possible because of differences in study design. Tolerability issues in these clinical trials were generally mild to moderate and transient. This article also reviews published strategies for managing sensory tolerability issues in AD patients during treatment with topical therapies.

Funding: Pfizer Inc., New York, NY.

A Systematic Scoping Literature Review of Publications Supporting Treatment Guidelines for Pediatric Atopic Dermatitis in Contrast to Clinical Practice Patterns

INTRODUCTION

Treatment guidelines endorse a variety of strategies for atopic dermatitis (AD) which may vary from published data and clinical practice patterns. The objective of this review was to quantify the volume of available medical literature supporting pediatric AD treatments and compare these patterns to those recommended by published guidelines and/or clinical practice patterns.

METHODS

Searches of Embase (2005-2016) and abstracts from selected meetings (2014-2016) related to AD treatment in patients younger than 17 years of age yielded references that were assessed by study design, primary treatment, age groups, and AD severity.

RESULTS

Published literature partially supports clinical guidelines, with emollients and topical medications being the most investigated. There were disproportionately more publications for topical calcineurin inhibitors (TCI) compared with topical corticosteroids (TCS); however, the search interval may have biased the results toward treatments approved near the beginning of the time frame. In contrast, publications documenting clinical practice patterns reflect greater use of emollients and TCS (over TCI), as well as systemic corticosteroids. Data is relatively limited for long-term and combination treatment, treatment of severe AD, and patients younger than 2 years of age, and completely lacking for systemic corticosteroids.

CONCLUSION

This scoping review demonstrates that available medical literature largely supports published guidelines for topical therapy; however, clinical practice patterns are less aligned. There is a lack of data for older, more frequently used generic treatments, including oral antihistamines, oral antibiotics, and systemic corticosteroids. Overall, literature is lacking for long-term treatment, treatment for patients younger than 2 years of age, and for systemic treatment for severe disease.

FUNDING

Regeneron Pharmaceuticals Inc.

Wet-wrap therapy with halometasone cream for severe adult atopic dermatitis

BACKGROUND

Currently there is no cure for severe atopic dermatitis (AD). Wet-wrap therapy (WWT) has also been used to treat pediatric AD and shown a satisfactory effectiveness, but clinical evidence supporting the use of WWT on severe adult AD is still insufficient.

METHODS

Twelve patients (eight men and four women) with severe AD (SCORing Atopic Dermatitis [SCORAD] score ≥ 50) treated between January 2015 and September 2017 in our hospital were included. The patients underwent WWT (daily dose: 15 g halometasone cream+100g Vaseline ointment) twice daily for 2 h/session for 7 days. SCORAD, visual analog scale (VAS) for pruritus, investigator's global assessment (IGA), dermatology life quality index (DLQI) scores and serum cortisol levels were determined before and after the WWT.

RESULTS

The patients (mean age: 58.9 ± 18.9 years; range: 27-85 years) had a median disease duration of 27.5 months. After the WWT, the average scores of SCORAD (28.79 ± 5.16 vs. 68.59 ± 8.61, 95%CI: 35.18-44.42), VAS (2.75 ± 0.62 vs. 7.5 ± 1.17, 95%CI: 4.14-5.36), IGA (1.83 ± 0.39 vs. 4.08 ± 0.51, 95%CI: 1.96-2.54), and DQLI score (8.33 ± 1.83 vs. 13.83 ± 2.79, 95%CI: 4.16-6.84) reduced significantly compared with the scores before the WWT (All P < 0.001). However, serum cortisol levels were not affected significantly by the WWT. Four patients complained of tolerable wet dressing-associated discomforts, which was resolved after the wet dressing was removed when the WWT was completed. For the 85-year-old man, serum cortisol levels were lower than the normal value after the WWT (3.67 μg/dL) but restored to the normal levels (13.44 μg/dL) 2 weeks after the WWT was ended. No other adverse events occurred.

CONCLUSION

WWT can relieve pruritus, reduce skin lesions, and improve quality of life in adult patients with severe AD. Thus, WWT may be effective and safe for severe adult AD. Trial registration No. is ChiCTR1800014909 ( http://www.chictr.org.cn/index.aspx ).

A novel, topical, nonsteroidal, TRPV1 antagonist, PAC-14028 cream improves skin barrier function and exerts anti-inflammatory action through modulating epidermal differentiation markers and suppressing Th2 cytokines in atopic dermatitis

BACKGROUND

Although it is established that epidermal barrier disturbance and immune dysfunction resulting in IgE sensitization are critical factors in the development of cutaneous inflammation, the pathogenesis and targeted therapy of atopic dermatitis (AD)-specific pathways have still been unknown.

OBJECTIVE

Taking into account the fact that Th2 cytokines in AD have both unique and overlapping functions including increased epidermal thickening, inflammation, and decreased expressing of the barrier proteins keratinocyte differentiation, we sought to clarify our hypothesis that TRPV1 antagonist plays a critical role in skin barrier function and can be a therapeutic target for AD.

METHODS

AD-like dermatitis was induced in hairless mice by repeated oxazolone (Ox) challenges to hairless mice. The functional studies concerning skin barrier function, anti-inflammatory action, and molecular mechanism by TRPV1 antagonism were conducted by histopathological assays, ELISA, qPCR, western blotting, and skin blood flow measurement.

RESULTS

Topically administered TRPV1 antagonist, PAC-14028 (Asivatrep: C21H22F5N3O3S), improved AD-like dermatitis and skin barrier functions, and restored the expression of epidermal differentiation markers. In addition, the PAC-14028 cream significantly inhibited cutaneous inflammation by decreasing the expression of serum IgE, and the epidermal expression of IL-4, and IL-13 in Ox-AD mice. These results may provide a novel insight into the molecular mechanism of PAC-14028 cream involved in anti-inflammatory effects and skin barrier functions by suppressing the multiple signaling pathways including IL-4/-13-mediated activation of JAK/STAT, TRPV1, and neuropeptides.

CONCLUSION

PAC-14028 cream can be a potential therapeutic tool for the treatment of chronic inflammation and disrupted barrier function in patients with AD.

Atopic dermatitis: a review of topical nonsteroid therapy

Background

Atopic dermatitis is a chronic inflammatory skin condition that affects up to 20% of children and 3% of adults globally. Although topical corticosteroids are considered to be the first-line agents, they can be associated with cutaneous and systemic adverse effects. Since the early 2000s, two new classes of nonsteroid topical therapies, topical calcineurin inhibitors and phosphodiesterase 4 (PDE4) inhibitors, have been introduced and provide a safe treatment alternative.

Method

We performed a search and review of clinical trials that examined the safety and efficacy of topical calcineurin inhibitors and PDE4 inhibitors. The search was conducted using the PubMed database as well as preselected keywords and filters. This review focuses on the safety and efficacy of each therapy.

Results

Sixty-nine clinical trials identified in this study have demonstrated the efficacy and safety of topical calcineurin and a single novel PDE4 inhibitor in the treatment of atopic dermatitis. Topical calcineurin inhibitors have been shown to be effective in both achieving lesion clearance as well as reducing relapse when used long-term and proactively. Similarly, in clinical trials the PDE4 inhibitor showed success in lesion clearance and symptom management. All three therapies (pimecrolimus, tacrolimus, crisaborole) are associated with low systemic absorption. No clinical trials to date have shown an increased risk of systemic adverse events or malignancy such as lymphoma. The most commonly reported treatment-related adverse event across all three therapies was application-site discomfort, pain or pruritus. It is important to note that long-term studies are not yet available for the novel PDE4 inhibitor.

Discussion

Topical calcineurin inhibitors provide a safe and effective alternative to topical corticosteroid use in the treatment of atopic dermatitis. Although the US Food and Drug Administration (FDA) black box warning for topical calcineurin inhibitors remains, studies have not shown an increased risk of malignancy. These warnings have caused a decline in use in favor of topical steroids. A novel PDE4 inhibitor has shown efficacy and safety in studies up to one year. Further long-term safety data is needed.

Atopic Dermatitis: Early Treatment in Children

Therapeutic regimens for the treatment and long-term management of AD traditionally had a two-fold objective of decreasing skin inflammation and repairing the defective skin barrier. Essential treatments for AD in children should include topical moisturizers for skin hydration and prevention of flares, topical anti-inflammatory medications (e.g. corticosteroids, calcineurin inhibitors, PDE4 inhibitor), allergen/irritant avoidance, and treatment of skin infections. Treatment regimens should be severity-based, and implemented in a stepwise approach tailored to the individual patient. This stepwise approach includes initial use of emollients, gentle skin care, and escalating to more potent anti-inflammatory treatments as the disease severity increases. Currently available systemic medications should be reserved for the presence of recalcitrance to topical therapies due to associated toxicities. We believe that early treatment of AD is not only essential in treating the skin disease, but also in preventing the development of additional atopic diseases, such as food allergy, asthma and allergic rhinitis. The defective skin barrier of AD permits a route of entry for food and environmental allergens, and upon exposure, keratinocytes secrete TSLP, which activates the T_H2 pathway. This T_H2 differentiation sets off the atopic march and the subsequent diseases that are seen. This review highlights treatment options and strategies in pediatric AD therapy with an emphasis on early therapy. Supporting evidence on the efficacy and safety of each intervention will be discussed.

Adjunctive Management of Itch in Atopic Dermatitis

Itch, or pruritus, is a hallmark feature of atopic dermatitis (AD). The impact of AD-related pruritus can range from mildly distressing or distracting to completely disabling. Traditionally, management of itch in AD patients has focused on restoring the altered skin barrier with topical emollients and/or reducing inflammation. A growing emphasis has been placed on directly targeting the neural transmission pathways that mediate itch signaling. Off-label use of neuromodulatory agents has helped reduce this aggravating symptom in atopic patients. This article reviews the current literature on the use of neuromodulatory agents and nonpharmacologic alternative therapies used to treat AD-related pruritus.

Efficacy and safety of crisaborole ointment, a novel, nonsteroidal phosphodiesterase 4 (PDE4) inhibitor for the topical treatment of atopic dermatitis (AD) in children and adults

BACKGROUND

Additional topical treatments for atopic dermatitis (AD) are needed that provide relief while minimizing risks.

OBJECTIVE

We sought to assess the efficacy and safety of crisaborole ointment, a phosphodiesterase 4 inhibitor, in two phase III AD studies (AD-301: NCT02118766; AD-302: NCT02118792).

METHODS

Two identically designed, vehicle-controlled, double-blind studies enrolled and randomly assigned (2:1, crisaborole:vehicle) patients aged 2 years or older with an Investigator's Static Global Assessment (ISGA) score of mild or moderate for twice-daily application for 28 days. The primary end point was ISGA score at day 29 of clear (0)/almost clear (1) with 2-grade or greater improvement from baseline. Additional analyses included time to success in ISGA score, percentage of patients achieving clear/almost clear, reduction in severity of AD signs, and time to improvement in pruritus.

RESULTS

More crisaborole- than vehicle-treated patients achieved ISGA score success (clear/almost clear with ≥2-grade improvement; AD-301: 32.8% vs 25.4%, P = .038; AD-302: 31.4% vs 18.0%, P < .001), with a greater percentage with clear/almost clear (51.7% vs 40.6%, P = .005; 48.5% vs 29.7%, P < .001). Crisaborole-treated patients achieved success in ISGA score and improvement in pruritus earlier than those treated with vehicle (both P ≤ .001). Treatment-related adverse events were infrequent and mild to moderate in severity.

LIMITATIONS

Short study duration was a limitation.

CONCLUSIONS

Crisaborole demonstrated a favorable safety profile and improvement in all measures of efficacy, including overall disease severity, pruritus, and other signs of AD.

Dupilumab therapy provides clinically meaningful improvement in patient-reported outcomes (PROs): A phase IIb, randomized, placebo-controlled, clinical trial in adult patients with moderate to severe atopic dermatitis (AD)

BACKGROUND

Moderate to severe atopic dermatitis (AD) is associated with substantial patient burden despite current therapies.

OBJECTIVE

We sought to evaluate dupilumab treatment on patient-reported outcomes in adults with moderate to severe AD.

METHODS

Adults (N = 380) with moderate to severe AD inadequately controlled by topical medications were randomized to 16 weeks of double-blind, subcutaneous treatment with dupilumab 100 mg every 4 weeks, 200 mg every 2 weeks, 300 mg every 2 weeks, 300 mg once weekly, or placebo. Patient-reported outcomes included pruritus numeric rating scale; patient-reported sleep item on Scoring AD scale; Patient-Oriented Eczema Measure; Hospital Anxiety and Depression Scale; Dermatology Life Quality Index; and 5-dimension 3-level EuroQol.

RESULTS

Dupilumab reduced peak itch at 16 weeks relative to placebo by 1.1 to 3.2 points on numeric rating scale (P < .0001 all doses, except 100 mg every 4 weeks P < .05); improved sleep and health-related quality of life on Dermatology Life Quality Index and 5-dimension 3-level EuroQol (P < .05 all doses, except 100 mg every 4 weeks); and reduced anxiety and depression symptoms (P < .05 all doses). Dupilumab's effects appeared early and achieved clinically relevant improvements without significant safety concerns.

LIMITATIONS

There are potential cultural differences affecting patient-reported outcome responses. Outcomes were secondary or exploratory end points.

CONCLUSION

Dupilumab produced early and sustained patient-reported and clinically relevant improvements in sleep, mental health, and health-related quality of life; the two 300-mg dose regimens resulted in greatest benefits.

Topical tacrolimus for atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) (or atopic eczema) is a chronic inflammatory skin condition that affects children and adults and has an important impact on quality of life. Topical corticosteroids (TCS) are the first-line therapy for this condition; however, they can be associated with significant adverse effects when used chronically. Tacrolimus ointment (in its 2 manufactured strengths of 0.1% and 0.03%) might be an alternative treatment. Tacrolimus, together with pimecrolimus, are drugs called topical calcineurin inhibitors (TCIs).

OBJECTIVES

To assess the efficacy and safety of topical tacrolimus for moderate and severe atopic dermatitis compared with other active treatments.

SEARCH METHODS

We searched the following databases up to 3 June 2015: the Cochrane Skin Group Specialised Register, CENTRAL in the Cochrane Library (Issue 5, 2015), MEDLINE (from 1946), EMBASE (from 1974), LILACS (from 1982), and the Global Resource of Eczema Trials (GREAT database). We searched six trials registers and checked the bibliographies of included studies for further references to relevant trials. We contacted specialists in the field for unpublished data.A separate search for adverse effects of topical tacrolimus was undertaken in MEDLINE and EMBASE on 30 July 2013. We also scrutinised the U.S. Food and Drug Administration (FDA) websites for adverse effects information.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of participants with moderate to severe atopic dermatitis (both children and adults) using topical tacrolimus at any dose, course duration, and follow-up time compared with other active treatments.

DATA COLLECTION AND ANALYSIS

Two authors independently screened and examined the full text of selected studies for compliance with eligibility criteria, risk of bias, and data extraction. Our three prespecified primary outcomes were physician's assessment, participant's self-assessment of improvement, and adverse effects. Our secondary outcomes included assessment of improvement of the disease by validated or objective measures, such as SCORAD (SCORing Atopic Dermatitis), the EASI (Eczema Area and Severity Index), and BSA (Body Surface Area) scores.

MAIN RESULTS

We included 20 studies, with 5885 participants. The variability of drug doses, outcomes, and follow-up periods made it difficult to carry out meta-analyses.A single trial showed that tacrolimus 0.1% was better than low-potency TCS by the physician's assessment (risk ratio (RR) 3.09, 95% confidence interval (CI) 2.14 to 4.45, 1 study, n = 371, moderate-quality evidence). It was also marginally better than low-potency TCS on face and neck areas and moderate-potency TCS on the trunk and extremities by the physician's assessment (RR 1.32, 95% CI 1.17 to 1.49, 1 study, n = 972, moderate level of evidence) and for some of the secondary outcomes. Compared with pimecrolimus 1%, people treated with tacrolimus were almost twice as likely to improve by the physician's assessment (RR 1.80, 95% CI 1.34 to 2.42, 2 studies, n = 506, moderate quality of evidence). Compared with the lower concentration of 0.03%, the tacrolimus 0.1% formulation reduced the risk of not having an improvement by 18% as evaluated by the physician's assessment (RR 0.82, 95% CI 0.72 to 0.92, 6 studies, n = 1640, high-quality evidence). Tacrolimus 0.1% compared with moderate-to-potent TCS showed no difference by the physician's assessment, and 2 secondary outcomes (1 study, 377 participants) and a marginal benefit favouring tacrolimus 0.1% was found by the participant's assessment (RR 1.21, 95% CI 1.13 to 1.29, 1 study, n = 974, low quality of evidence) and SCORAD.Based on data from 2 trials, tacrolimus 0.03% was superior to mild TCS for the physician's assessment (RR 2.58, 95% CI 1.96 to 3.38, 2 studies, n = 790, moderate-quality evidence) and the participant's self-assessment (RR 1.64, 95% CI 1.41 to 1.90, 1 study, n = 416, moderate quality of evidence). One trial showed moderate benefit of tacrolimus 0.03% compared with pimecrolimus 1% on the physician's assessment (RR 1.42, 95% CI 1.02 to 1.98, 1 study, n = 139, low-quality evidence), but the effects were equivocal when evaluating BSA. In the comparison of tacrolimus 0.03% with moderate-to-potent corticosteroids, no difference was found in most of the outcomes measured (including physician's and participant's assessment and also for the secondary outcomes), but in two studies, a marginal benefit favouring the corticosteroid group was found for the EASI and BSA scores.Burning was more frequent in those using calcineurin inhibitors than those using corticosteroid tacrolimus 0.03% (RR 2.48, 95% CI 1.96 to 3.14, 5 studies, 1883 participants, high-quality evidence), but no difference was found for skin infections. Symptoms observed were mild and transient. The comparison between the two calcineurin inhibitors (pimecrolimus and tacrolimus) showed the same overall incidence of adverse events, but with a small difference in the frequency of local effects.Serious adverse events were rare; occurred in both the tacrolimus and corticosteroid groups; and in most cases, were considered to be unrelated to the treatment. No cases of lymphoma were noted in the included studies nor in the non-comparative studies. Cases were only noted in spontaneous reports, cohorts, and case-control studies. Systemic absorption was rarely detectable, only in low levels, and this decreased with time. Exception is made for diseases with severe barrier defects, such as Netherton's syndrome, lamellar ichthyosis, and a few others, with case reports of a higher absorption. We evaluated clinical trials; case reports; and in vivo, in vitro, and animal studies; and didn't find any evidence that topical tacrolimus could cause skin atrophy.

AUTHORS' CONCLUSIONS

Tacrolimus 0.1% was better than low-potency corticosteroids, pimecrolimus 1%, and tacrolimus 0.03%. Results were equivocal when comparing both dose formulations to moderate-to-potent corticosteroids. Tacrolimus 0.03% was superior to mild corticosteroids and pimecrolimus. Both tacrolimus formulations seemed to be safe, and no evidence was found to support the possible increased risk of malignancies or skin atrophy with their use. The reliability and strength of the evidence was limited by the lack of data; thus, findings of this review should be interpreted with caution. We did not evaluate costs.

Efficacy and Safety of Tacrolimus versus Pimecrolimus for the Treatment of Atopic Dermatitis in Children: A Network Meta-Analysis

OBJECTIVE

Using a network meta-analysis, we aimed to compare the efficacy and safety of tacrolimus and pimecrolimus as treatment options for children with atopic dermatitis (AD).

METHODS

Randomized controlled studies with a modified Jadad score >3 using tacrolimus or pimecrolimus in pediatric patients with AD were studied.

RESULTS

Out of 163 articles, 19 studies enrolling a total of 6,413 pediatric patients were selected. Pooled analysis revealed that tacrolimus 0.03% or 0.1% and pimecrolimus 1% were better at reducing eczema compared with vehicles. No significance was found between tacrolimus and pimecrolimus in improving the severity of eczema. More patients tended to withdraw in the vehicle groups compared to the tacrolimus and pimecrolimus groups. No significant difference existed between total adverse events and withdrawals in the tacrolimus and pimecrolimus groups.

CONCLUSIONS

Pimecrolimus was similar to tacrolimus in both efficacy and safety for AD in children, but both were better than vehicles.

Discordance in neonatal risk factors and early childhood outcomes of very low birth weight (<1.5 kg) twins

OBJECTIVE

To examine the rates of discordance in neonatal risk factors and neurodevelopmental outcomes within very low birth weight twin pairs and the factors associated with discordant outcomes.

STUDY DESIGN

Rates of neonatal risk factors and neurodevelopmental outcomes, and discordance in outcomes were examined for 88 very low birth weight twin pairs born between 1990 and 2005 and followed through 20 months' corrected age.

RESULT

Discordance rates ranged from 17 to 42% for neonatal risk factors and from 18 to 31% for neurodevelopmental outcomes. In regression analysis, affected co-twins were significantly more likely to have had an abnormal cerebral ultrasound than their unaffected co-twins in pairs discordant for cerebral palsy (odds ratio (OR): 13.00, 95% confidence interval (CI): 2.22 to 76.03)) and in pairs discordant for neurodevelopmental impairment (OR: 4.00, 95% CI: 1.13 to 14.18). Outcomes and discordance in outcomes were similar for monochorionic and dichorionic pairs.

CONCLUSION

Despite shared genetics and risk factors, twins may have discordant outcomes. Information on discordant neonatal and neurodevelopmental outcomes is important for counseling families of twins.

Therapeutic implications of a barrier-based pathogenesis of atopic dermatitis

Excessive Th2 cell signaling and IgE production play key roles in the pathogenesis of atopic dermatitis (AD). Yet, recent information suggests that the inflammation in AD instead is initiated by inherited insults to the barrier, including a strong association between mutations in FILAGGRIN and SPINK5 in Netherton syndrome, the latter of which provides an important clue that AD is provoked by excess serine protease activity. But acquired stressors to the barrier may also be required to initiate inflammation in AD, and in addition, microbial colonization by Staphylococcus aureus both amplifies inflammation, but also further stresses the barrier in AD. Therapeutic implications of these insights are as follows: While current therapy has been largely directed toward ameliorating Th2-mediated inflammation and/or pruritus, these therapies are fraught with short-term and potential long-term risks. In contrast, "barrier repair" therapy, with a ceramide-dominant triple-lipid mixture of stratum corneum lipids, is more logical, of proven efficacy, and it provides a far-improved safety profile.

Topical therapies for pruritus

Itch, or pruritus, is the predominant symptom associated with acute and chronic cutaneous disease, and in some cases may be debilitating. To date, there is no single universally effective anti-itch treatment. Because the pathophysiology of itch in most cutaneous or systemic disorders remains unclear, antipruritic therapy is often directed against a variety of targets, including the epidermal barrier, immune system, or the nervous system. Topical therapy is the mainstay of dermatologic management of acute or localized itch or in patients with contraindications to systemic therapies. This review will summarize current topical therapies to treat pruritus and discuss potential future therapies.

The safety and efficacy of tacrolimus ointment in pediatric patients with atopic dermatitis

Atopic dermatitis (AD) is the most common skin disease in children, and its prevalence is increasing. It is a chronic disorder, characterized by intermittent flares and phases of remission. Treatment regimens often require multiple therapies. These can vary between patients, and in an individual patient, depending on the state of disease. The traditional treatment for AD flares is topical corticosteroids, which are fast acting and effective for relief of symptoms, but may cause adverse effects, including those resulting from systemic absorption, particularly in children. Topical calcineurin inhibitors (TCIs) are alternative treatments for AD. Tacrolimus ointment, a TCI, is approved for patients aged 2 years and older. Multiple studies have shown that tacrolimus is effective for short-term relief of symptoms in pediatric patients with AD. Long-term trials have demonstrated that the effectiveness of tacrolimus is maintained for up to 4 years in children. Additional studies have revealed that long-term intermittent use of tacrolimus as part of maintenance therapy can prevent AD flares. Tacrolimus has a low potential for systemic accumulation, and analysis of long-term studies indicates that it has a good safety profile. Treatment with tacrolimus, alone or in combination with topical corticosteroids for acute flares, may be a useful option for long-term management of AD in pediatric patients.

[Safety information for tacrolimus: present and future]

In this article there were regarded the most frequent side effects that appear in the patients who have been treated with topical tacrolimus, and the association between topical tacrolimus and the development of tumors is unfolded. The irritation in the site of application of the tacrolimus can manifiest as pruritus, sensation of burning and/or eritema located to the area of the application. It is the most frequent side effect, independently of the duration of the study. The cutaneous infections, especially the viral ones, tend to be more numerous in patients with atopic dermatitis that receive topic tacrolimus. After reviewing the medical literature one concludes that nowadays there doesn t exist scientific evidence of an increase of skin cancer, lymphomas or systemic immunosuppression in those patients that use or have used topical tacrolimus. Nevertheless, it is not possible to exclude the possibility that there appear cutaneous and/or systemic long-term side effects.

Topical calcineurin inhibitors in atopic dermatitis: a systematic review and meta-analysis

OBJECTIVES

To build a critical appraisal of the available literature to evaluate the effectiveness of topical calcineurin inhibitors in treatment of atopic dermatitis (AD), in comparison to topical corticosteroids (TCs) and/or placebo.

REVIEW METHODS

DESIGN

systematic review and meta-analysis.

DATA SOURCES

electronic search of MEDLINE Pubmed along the last 10 years (1997-2006).

STUDY SELECTION

randomized control trials of TCIs reporting efficacy outcomes, in comparison to TCs or vehicle (placebo) or both.

DATA SYNTHESIS

of 210 articles, 19 studies were included, 10 for tacrolimus and 9 for pimecrolimus, involving 7378 patients of whom 2771 applied tacrolimus, 1783 applied pimecrolimus, and 2824 were controls. Both drugs were significantly more effective than a vehicle. However, two long-term trials comparing demonstrated the value of pimecrolimus in reduction of flares and steroid-sparing effect after 6 months. Compared to TCs, both 0.1% and 0.03% tacrolimus ointments were as effective as moderate potency TCs, and more effective than a combined steroid regimen. Tacrolimus was more effective than mild TCs.

CONCLUSIONS

TCIs in AD are more effective than placebo. Although less effective than TCs, pimecrolimus has its value in long-term maintenance and as a steroid-sparing agent in AD, whenever used early enough, at first appearance of erythema and/or itching. In treatment of moderate to severe AD, topical tacrolimus is as effective as moderately potent TCs, and more effective than mild preparations. Chronic AD lesions of the face and flexures are the most justified indication for topical calcineurin inhibitors.

Tacrolimus ointment in the management of atopic dermatitis

Atopic dermatitis (AD) is a chronic, relapsing, highly pruritic inflammatory skin disease. AD long-term treatment is usually required to control and prevent flares, and patients need a treatment that is safe and efficacious when applied continuously or intermittently over a prolonged period of time. The treatment options should be chosen according to age, clinical features and severity of the disease in every single patient. For the treatment of a chronic disease like AD, sustained tolerability and efficacy of the applied medications are essential. A topical immunomodulator, tacrolimus ointment, provides an alternative to topical corticosteroids without the associated adverse events. Tacrolimus is a macrolide lactone with unique immunomodulatory properties and strong anti-inflammatory activities and can be used without increasing the risk of infection or other non-application site adverse events, and without loss of effectiveness, in patients with AD.

Avaliação da eficácia e segurança do tacrolimo pomada 0,03% no tratamento da dermatite atópica em pacientes pediátricos

FUNDAMENTOS - Tacrolimo pomada é eficaz no tratamento da dermatite atópica. OBJETIVOS - Avaliar a eficácia e segurança do tacrolimo pomada 0,03% (Protopic®) no tratamento de pacientes pediátricos com dermatite atópica. MÉTODOS - Estudo multicêntrico, aberto e não comparativo. Incluídos 174 pacientes (dois a 10 anos)com dermatite atópica. Utilizou-se tacrolimo duas vezes ao dia, por seis semanas. O critério primário de eficácia foi a melhora clínica > a 90% avaliada pelo médico (Escala de Avaliação Global da Resposta Clínica). Outros critérios de eficácia foram a redução no índice de área e gravidade do eczema (EASI), a redução do percentual de superfície corporal afetada (%BSA) e a avaliação do prurido pelo paciente (escala analógica visual). Segurança foi avaliada pela ocorrência de eventos adversos relatados pelos pais e pacientes ou pelos investigadores. RESULTADOS - Trinta e três por cento dos pacientes apresentaram melhora clínica >90%. Quando avaliado o escore EASI, houve redução de 45,5% (primeira semana) e 61,8% (sexta semana) quando comparado com o basal (p<0,001). Em relação a %BSA, houve redução de 30,4% e 55,5%, na primeira e na sexta semana. Houve redução do prurido em relação ao basal (p<0,001).Os eventos adversos mais comuns foram - queimação e prurido localizados. CONCLUSÃO - Tacrolimo pomada 0,03% é terapia segura e efetiva no tratamento da dermatite atópica leve a grave em pacientes pediátricos.

Tacrolimus: approved and unapproved dermatologic indications/uses-physician's sequential literature survey: part II

Tacrolimus has been a useful therapeutic tool in dermatology practice ever since its inception. Accordingly, many "off-label" applications have been reported. Thus, its local immunosuppressive and steroid-sparing action stands recognized. Hence, its indications/uses were extended beyond atopic dermatitis to cover several dermatoses including other types of eczema, papulosquamous disorder of cornification, rosacea, other inflammatory skin conditions, vesicobullous disease, connective tissue disease, graft versus host disease, and follicular disorders. Many such diseases found to respond to tacrolimus therapy have been briefly recounted. It is worthwhile to conceive, however, that this topical immunomodulator should be reserved for use only as an alternative, should the conventional treatment be unresponsive. Hence, guarded use is warranted.

Topical calcineurin inhibitors in pediatric atopic dermatitis: a critical analysis of current issues

Atopic dermatitis (AD) is a common disease in children. Despite good skin care and trigger avoidance, many children with AD require pharmacologic treatment to manage their disease. In recent years, topical calcineurin inhibitors (TCIs) have been used as an alternative to topical corticosteroids to treat some children with AD. However, revisions to the US labeling for TCIs (i.e. a boxed warning and a medication guide) have generated concern among pediatricians regarding TCI safety and raised questions about the appropriate use of TCIs in the pediatric population. Data from several well designed studies support the efficacy of TCIs in the treatment of AD. Safety concerns arise from a small number of reported malignancies, animal toxicology studies, and the potential adverse effects (including immunosuppression and risk of lymphoma) observed in patients who received systemically administered calcineurin inhibitors for suppression of solid-organ transplant rejection. Several factors indicate that these effects do not occur with topical administration: (i) systemic levels following topical administration are at least 10-fold lower than with oral administration; (ii) the small number of lymphomas reported to date in persons exposed to TCI use are not consistent with the types seen in transplant patients or other immunosuppressed patients; and (iii) no adverse effects on the immune system (as assessed by measures including vaccination response and skin delayed-type hypersensitivity reaction) have been observed in clinical trials of TCIs in children with AD. Overall, TCIs have an established safety and efficacy profile as long-term maintenance therapy in children with AD.

Meta-analysis of tacrolimus ointment for atopic dermatitis in pediatric patients

We evaluated the efficacy and safety of tacrolimus ointment in the treatment of the pediatric patients with atopic dermatitis. Tacrolimus ointment therapy resulted in the remission of atopic dermatitis, this effect of tacrolimus ointment strengths 0.03% and 0.1% were better than those of 1% hydrocortisone acetate and 1% pimecrolimus. Difference between the 0.03% tacrolimus group and the 0.1% tacrolimus group was not statistically significant.

The safety of tacrolimus ointment for the treatment of atopic dermatitis: a review

Tacrolimus ointment is a topical calcineurin inhibitor (TCI) that was developed specifically for the treatment of atopic dermatitis (AD). It is one of the most extensively tested dermatological products, with more than 19 000 patients (including approximately 7600 children) having participated in the tacrolimus ointment clinical development programme. Recent regulatory reviews have focused on the potential risk of malignancy with TCIs, based on their mode of action and the effects of systemic tacrolimus when given to transplant recipients. Studies have shown, however, that the systemic absorption of tacrolimus when applied topically is very low, with blood concentrations being below the level of quantification in most patients. Moreover, TCIs are not associated with a decrease in immunocompetence in the skin and there is no increase in the incidence of infections with long-term treatment. More than 5.4 million prescriptions for tacrolimus ointment have been issued worldwide, with no evidence of an increased risk of malignancy in adults or children compared with the general population. Similarly, epidemiological studies have failed to demonstrate an increased incidence of skin cancer in patients using TCIs. The most common adverse events (AEs) that occur with tacrolimus ointment treatment are transient application-site reactions, such as burning or pruritus. These complications are related to disease severity, and decrease in frequency over time as AD improves. The incidence of nonapplication-site AEs does not increase with long-term treatment, and most such events occurring in clinical trials were considered to be unrelated to therapy. Although it is important that clinicians are aware of the recent changes in product labelling, extensive clinical trials continue to show that tacrolimus ointment is well tolerated, and is generally an effective therapy for suitable patients with AD.

What are the best outcome measurements for atopic eczema? A systematic review

BACKGROUND

Valid and reliable outcome measurements are a prerequisite for evidence-based practice. The comparative validity and reliability of outcome measurements for assessing atopic eczema (AE) severity is unclear.

OBJECTIVE

We sought to assess the validity, reliability, sensitivity to change, and ease of use of outcome measurements for AE. We also sought to give recommendations on which outcomes to use in clinical research and for clinical monitoring.

METHODS

We performed a systematic review and survey of clinical experts and patients.

RESULTS

Twenty published outcome measurements were identified. There is evidence of adequate construct validity for 3 measurements (Severity Scoring of Atopic Dermatitis index [SCORAD], Eczema Area and Severity Index [EASI], and Three Item Severity Score), adequate internal consistency of 1 scale (Patient-oriented Eczema Measure [POEM]), adequate interobserver reliability of 5 measurements (Basic Clinical Scoring System; Nottingham Eczema Severity Score; Objective Severity Assessment of Atopic Dermatitis; Six Area, Six Sign Atopic Dermatitis severity score; and SCORAD), adequate test-retest reliability of 1 scale (POEM), and adequate sensitivity to change of 3 measurements (EASI, SCORAD, and Investigators' Global Atopic Dermatitis Assessment). Most outcome measurements have adequate content validity, as assessed by patients and experts. Data on the time to perform the assessment was identified for 8 outcome measurements. Only SCORAD, EASI, and POEM have been tested sufficiently and performed adequately.

CONCLUSION

There are too many published outcome measures for AE. Most have not been tested properly or perform adequately when tested, and their continued use hampers scientific communication.

CLINICAL IMPLICATIONS

Only SCORAD, EASI, and POEM currently perform adequately. These scales should be used in future studies.