Consensus on the therapeutic management of atopic dermatitis - Brazilian Society of Dermatology

The wide variety of methotrexate dosing regimens for the treatment of atopic dermatitis: a systematic review

Background:Methotrexate is an off-label therapy for atopic dermatitis. A lack of consensus on dosing regimens poses a risk of underdosing and ineffective treatment or overdosing and increased risk of side effects. This systematic review summarizes the available evidence on dosing regimens.Materials and methods:A literature search was conducted, screening all randomized controlled trials (RCTs) and guidelines published up to 6 July 2023, in the MEDLINE, Embase, and Cochrane Library databases.Results:Five RCTs and 21 guidelines were included. RCTs compared methotrexate with other treatments rather than different methotrexate dosing regimens. The start and maintenance doses in RCTs varied between 7.5-15 mg/week and 14.5-25 mg/week, respectively. Despite varied dosing, all RCTs demonstrated efficacy in improving atopic dermatitis signs and symptoms. Guidelines exhibited substantial heterogeneity but predominantly proposed starting doses of 5-15 mg/week for adults and 10-15 mg/m2/week for children. Maintenance doses suggested were 7.5-25 mg/week for adults and 0.2-0.7 mg/kg/week for children. One guideline suggested a test dose and nearly half advised folic acid supplementation.Conclusion:This systematic review highlights the lack of methotrexate dosing guidelines for atopic dermatitis. It identifies commonly recommended and utilized dosing regimens, serving as a valuable resource for clinicians prescribing methotrexate off-label and providing input for an upcoming consensus study.

International consensus on methotrexate dosing for patients with atopic dermatitis: An eDelphi study

BACKGROUND

Despite the widespread off-label use of methotrexate (MTX) for the treatment of atopic dermatitis (AD), there is limited high-quality evidence on dosing regimens and existing guidelines do not provide clear recommendations regarding dosing strategies.

OBJECTIVE

The aim of this study was to achieve international consensus among AD experts to standardize the dosing regimen for MTX treatment in adults and children with AD.

METHODS

An electronic Delphi (eDelphi) study was conducted from October 2021 to September 2022. Recruitment was conducted through dermatology societies and AD interest groups. Participation was open to dermatologists and dermatology residents experienced in treating AD patients with MTX. The study consisted of three online rounds. The first round was informed by a systematic review of relevant literature, and subsequent rounds were adjusted based on the results of the previous round. Participants voted on 19 proposals using a 9-point scale (1-3 disagree, 4-6 neither agree nor disagree, 7-9 agree). Consensus was achieved when at least 70% of participants agreed, and less than 15% disagreed. Proposals that did not reach consensus in the first three rounds were discussed in a consensus meeting, where consensus was defined as less than 30% disagreement.

RESULTS

In total, 152 participants completed Round 1, 104 (68%) completed all survey rounds, and 43 (28%) joined the consensus meeting. Consensus was achieved on 7 proposals in Round 1, 4 in Round 2 and 6 in Round 3. The final 2 proposals reached consensus during the consensus meeting. Consensus topics include test dose, start dose, maximum dose, administration route, dosing schedule, management of stopping treatment, treatment duration and folic acid supplementation.

CONCLUSIONS

This eDelphi study achieved consensus on 19 proposals related to MTX dosing for adults and children with AD. These results aim to guide prescribing decisions and encourage a standardized global approach to MTX use in AD.

Methotrexate for refractory adult atopic dermatitis leads to alterations in cutaneous IL-31 and IL-31RA expression

BACKGROUND

Methotrexate (MTX) is an alternative treatment for patients with moderate/severe atopic dermatitis (AD).

OBJECTIVE

The authors evaluated the effect of MTX on the cutaneous expression of cytokines and chemokines that are involved in the inflammatory response in adult AD patients who received treatment with methotrexate for 24 weeks.

METHODS

The authors conducted a prospective single-institution cohort study with 12 adults with moderate/severe AD who received oral MTX (15 mg/wk for 24 wks) and 10 non-atopic matched controls. The comparison was made of skin biopsies of lesional and non-lesional skin, pre- and post MTX treatment. The authors analyzed mean epidermal thickness and expression of IL-31, IL-31RA, OSMR, TSLP, Ki67, IL-4 mRNA, IL-6, IL-10, TNF-α, IFN-γ, TARC, and CCL-22.

RESULTS

There was a reduction in mean epidermal thickness (p = 0.021), an increase in IL-31RA expression (immunohistochemistry) in the epidermis (p = 0.016) and a decrease in IL-31 gene expression (p = 0.019) on lesional AD skin post-MTX treatment. No significant changes in the cutaneous expression of the other evaluated markers were identified.

STUDY LIMITATIONS

Small sample size and limited length of follow-up.

CONCLUSIONS

Treatment with MTX in adults with moderate/severe AD reduced epidermal hyperplasia and changed the cutaneous expression of inflammatory cytokines and receptors that are mainly related to pruritus, including IL-31 and IL-31RA.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03327116.

Consensus on the therapeutic management of atopic dermatitis ‒ Brazilian Society of Dermatology: an update on phototherapy and systemic therapy using e-Delphi technique

This publication is an update of the "Consensus on the therapeutic management of atopic dermatitis - Brazilian Society of Dermatology" published in 2019, considering the novel, targeted-oriented systemic therapies for atopic dermatitis. The initial recommendations of the current consensus for systemic treatment of patients with atopic dermatitis were based on a recent review of scientific published data and a consensus was reached after voting. The Brazilian Society of Dermatology invited 31 experts from all regions of Brazil and 2 international experts on atopic dermatitis who fully contributed to the process. The methods included an e-Delphi study to avoid bias, a literature search and a final consensus meeting. The authors added novel approved drugs in Brazil and the indication for phototherapy and systemic therapy for AD. The therapeutical response to systemic treatment is hereby reported in a suitable form for clinical practice and is also part of this updated manuscript.

The PI3K-Akt-mTOR and Associated Signaling Pathways as Molecular Drivers of Immune-Mediated Inflammatory Skin Diseases: Update on Therapeutic Strategy Using Natural and Synthetic Compounds

The dysregulated phosphatidylinositol-3-kinase (PI3K)-Akt-mammalian target of rapamycin (mTOR) signaling pathway has been implicated in various immune-mediated inflammatory and hyperproliferative dermatoses such as acne, atopic dermatitis, alopecia, psoriasis, wounds, and vitiligo, and is associated with poor treatment outcomes. Improved comprehension of the consequences of the dysregulated PI3K/Akt/mTOR pathway in patients with inflammatory dermatoses has resulted in the development of novel therapeutic approaches. Nonetheless, more studies are necessary to validate the regulatory role of this pathway and to create more effective preventive and treatment methods for a wide range of inflammatory skin diseases. Several studies have revealed that certain natural products and synthetic compounds can obstruct the expression/activity of PI3K/Akt/mTOR, underscoring their potential in managing common and persistent skin inflammatory disorders. This review summarizes recent advances in understanding the role of the activated PI3K/Akt/mTOR pathway and associated components in immune-mediated inflammatory dermatoses and discusses the potential of bioactive natural products, synthetic scaffolds, and biologic agents in their prevention and treatment. However, further research is necessary to validate the regulatory role of this pathway and develop more effective therapies for inflammatory skin disorders.

Atopic Dermatitis in Latin America: Considerations on Epidemiology, Clinical and Laboratory Features, Ethnic/Racial Variations, and Therapeutic Management

Latin America (LA) encompasses about 8.5% of the world's population, exhibits ethnic/racial heterogeneity and social inequality. We hereby present a 20-year literature review (2004-2023) on epidemiology, diagnosis, clinical and laboratory features, quality of life and management of atopic dermatitis (AD) in LA. Highest AD prevalence for children aged 6-7 years was reported in Ecuador (22.5%) and Colombia (20.9%), for adolescents in Colombia (24.6%) and for all ages, in Brazil (20.1%). Regions with a predominantly Black population in LA varied significantly, ranging from 4.4% in Northern Brazil to 10.1% in Cuba, indicating genetic variation among African subgroups. Filaggrin loss-of-function mutations showed variants seen in Europeans in 9.3% of Chilean patients and studies in Brazil revealed impaired expression of filaggrin and claudin-1 in the skin but increased expression in conjunctival epithelia of AD patients. The most reported AD features included erythema, pruritus, and dry skin, with marked lichenification. Severe pruritus was reported by 54.4% of patients and a high impact on quality of life was detected in 50% of adults with AD. In Brazilian referral hospitals, 65.6% of patients were classified as having severe AD, and 56% had one or more hospitalizations during their lifetime, indicating a need for better disease control. Diagnosing AD is challenging due to broad clinical features, ethnoracial variations and lack of universal diagnostic criteria. Furthermore, lack of physician training, barriers to medication access, and socioeconomic inequalities hinder effective disease management in LA.

Healthcare Disparities in Atopic Dermatitis in Latin America: A Narrative Review

INTRODUCTION

Atopic dermatitis (AD) is a chronic, pruritic skin disease caused by a mixture of genetic, immunological, and environmental factors, characterized by periods of inflammation and remission. In Latin America (LA), the prevalence of AD ranges up to 25% in children and 1-3% in adults. The natural history of the disease for most patients is that AD goes into remission in adolescence and adult life. Only 10-30% of patients continue to have symptoms of the disease in adulthood. There are patients (3-4%) who have the onset of AD during adolescence or after adulthood. Those with limited access to healthcare services, such as diagnosis and treatment, have increased difficulties coping with AD. Healthcare disparities are a complex topic that include social, political, racial/ethnic, and geographical factors. Publications about healthcare disparities in AD in LA are scarce. As a result, recognizing and resolving healthcare inequalities is critical to improving the treatment and quality of life (QoL) of individuals with AD.

METHODS

A panel of Latin American experts in dermatology and allergies was provided with a series of relevant questions to address before a multiday conference. During this conference, the entire group discussed and edited each narrative through numerous drafts and rounds of discussion until they reached a consensus.

RESULTS

This paper examines the barriers to equal access to care and recommends realistic actions to overcome them. Inadequate disease knowledge, cultural and linguistic barriers, stigmatization, maldistribution of resources, absence of local clinical practice guidelines, arduous patient journey, and limited consultation time were identified as causes of health inequality.

CONCLUSIONS

Among the suggested solutions are enhanced education for healthcare professionals, patients, and the general public, a focus on underprivileged communities, telemedicine and telementoring, translators, multidisciplinary teams, and local living clinical practice guidelines.

Global Guidelines in Dermatology Mapping Project (GUIDEMAP) - a systematic review of atopic dermatitis clinical practice guidelines: are they clear, unbiased, trustworthy and evidence based (CUTE)?

BACKGROUND

Clinical practice guidelines (CPGs) are essential in delivering optimum health care, such as for atopic dermatitis (AD), a highly prevalent skin disease. Although many CPGs are available for AD, their quality has not been critically appraised.

OBJECTIVE

To identify CPGs on AD worldwide and assess with validated instruments if those CPGs are clear, unbiased, trustworthy and evidence based (CUTE).

METHODS

We searched MEDLINE, Embase, PubMed, Web of Science, Cochrane Library, Emcare, Epistemonikos, PsycINFO and Academic Search Premier for CPGs on AD published between 1 April 2016 and 1 April 2021. Additionally we hand searched prespecified guideline resources. Screening, data extraction and quality assessment of eligible guidelines were independently carried out by two authors. Instruments used for quality assessment were the Appraisal of Guidelines for Research and Evaluation (AGREE) II Reporting Checklist, the U.S. Institute of Medicine's (IOM) criteria of trustworthiness and Lenzer's Red Flags.

RESULTS

Forty CPGs were included, mostly from countries with a high socio-demographic index. The reported quality varied enormously. Three CPGs scored 'Excellent' on all AGREEII-domains: Columbia, the Netherlands and United Kingdom (UK; antimicrobials). Three CPGs scored 'Poor' on all domains: Poland (phototherapy), Romania and Serbia. We found no association between AGREEII-scores and a country's gross domestic product. One CPG fully met all nine IOM criteria (Malaysia) and two fully met eight (European dupilumab and UK antimicrobials). Three CPGs had no red flags: Malaysia, South Korea and UK antimicrobials. 'Applicability' and 'Rigour of development' were the lowest scoring AGREEII domains; 'Lack of external review', 'Updating procedures' and 'Rating strength of recommendations' met the least IOM criteria; and most red flags were for 'Limited or no involvement of methodological expertise' and 'No external review'. Management of conflict of interests (COI) appeared challenging. When constructs of the instruments overlapped, they showed high concordance, strengthening our conclusions.

CONCLUSIONS

Overall, many CPGs are not clear, unbiased, trustworthy or evidence based (CUTE) enough and lack applicability. Therefore improvement is warranted, for which using the AGREEII instrument is recommended. Some improvements can be easily accomplished through robust reporting. Others, such as transparency, applicability, evidence foundation and managing COI, might require more effort.

Different Approaches to Atopic Dermatitis by Allergists, Dermatologists, and Pediatricians

OBJECTIVES

Atopic dermatitis (AD) is the most prevalent chronic inflammatory skin disease, with a vast drug arsenal and guidelines available for its management and diagnosis and different medical specialties engaged in providing care. This study aimed to outline the therapeutic and diagnostic approaches to the AD of allergists, dermatologists, and pediatricians and verify whether they are compliant with the guidelines.

METHODS

A cross-sectional study using an electronic questionnaire administered through the SurveyMonkey® platform was disclosed by participating medical societies to their medical associates.

RESULTS

Of the 1,473 participating physicians, the use of moisturizers as part of AD treatment was observed among pediatricians (91.9%), dermatologists (97.5%), and allergists (100%; p=0.07). The preference for the use of new emollients was lower among pediatricians (57%) than dermatologists (75.9%) and allergists (71.4%; p < 0.001). The prevalence of wet-wrap therapy was lower among dermatologists (16.3%) than allergists (51%; p < 0.001). The recommendation of proactive treatment with topical corticosteroids was more frequently reported by allergists (65.3%) than pediatricians (43.3%) and dermatologists (40.8%; p < 0.001), and the same trend was observed in relation to proactive treatment using calcineurin inhibitors. The use of oral anti-histamines to control pruritus was mainly considered by pediatricians (69.2%) and dermatologists (59.2% p < 0.001). Clinical experience with systemic immunomodulating agents was greater among allergists (77.5%) and dermatologists (60.8%; p < 0.001), with cyclosporine being the most cited systemic immunomodulating agent. Environmental control of aeroallergens was recommended by pediatricians (89.8%), dermatologists (86.9%), and allergists (100%; p=0.01).

CONCLUSION

There were differences in the therapeutic and diagnostic approaches to AD used by allergists, dermatologists, and pediatricians and those recommended by the guidelines, especially regarding the use of wet-wrap therapy, proactive treatment with topical corticosteroids or calcineurin inhibitors, prescription of anti-histamines, recommendation of phototherapy, and control of aeroallergens.

Suppressive effect of 1,4-anhydro-4-seleno-D-talitol (SeTal) on atopic dermatitis-like skin lesions in mice through regulation of inflammatory mediators

BACKGROUND

Atopic dermatitis (AD) is a multifactorial chronic inflammatory disease that affects ∼20 % of children and 3% of adults globally and is generally treated by the topical application of steroidal drugs that have undesirable side-effects. The development of alternative therapies is therefore an important objective. The present study investigated the effects of topical treatment with a novel water-soluble selenium-containing carbohydrate derivative (4-anhydro-4-seleno-D-tatitol, SeTal) on the symptoms and inflammatory parameters in an AD mouse model.

METHODS

Mice were sensitized by applying 2,4-dinitrochlorobenzene (DNCB) to their dorsal skin on days 1-3, then further challenged on their ears and dorsal skin on days 14, 17, 20, 23, 26, and 29. SeTal (1 and 2%) or hydrocortisone (1%) was applied topically to the backs of the mice from days 14-29, and skin severity scores and scratching behavior determined on day 30. The mice were euthanized, and their ears and dorsal skin removed to quantify inflammatory parameters, edema, myeloperoxidase (MPO) activity, and AD-associated cytokines (tumor necrosis factor alpha (TNF-α), interleukins (IL)-18, and IL-33).

RESULTS

DNCB treatment induced skin lesions and increased the scratching behavior, ear edema, MPO activity (ear and dorsal skin), and cytokine levels in dorsal skin. Topical application of SeTal improved inflammatory markers (cytokine levels and MPO activity), cutaneous severity scores, and scratching behavior.

CONCLUSION

The efficacy of SeTal was satisfactory in the analyzed parameters, showing similar or better results than hydrocortisone. SeTal appears to be therapeutically advantageous for the treatment and control of AD.

The Unmet Needs in Atopic Dermatitis Control in Latin America: A Multidisciplinary Expert Perspective

Introduction

Adoption of control tools for atopic dermatitis (AD) in Latin America (LA) is currently very limited. Clinical assessment tools represent a practical method to measure the impact of treatment on disease activity and on the quality of life of patients. However, the use of these tools in the LA clinical practice setting is limited.

Methods

A selected panel of Latin American experts in fields related to atopic dermatitis were provided with a series of relevant questions to address prior to the multi-day conference. Within this conference, each narrative was discussed and edited by the entire group, through numerous drafts and rounds of discussion, until a consensus was achieved.

Results

The panel proposes specific and realistic recommendations for implementing control tools for AD care in LA. In creating these recommendations, the authors strove to address all barriers to the widespread use of these tools.

Conclusion

This article includes a narrative analysis of barriers to AD control in LA and provides necessary recommendations to integrate and increase the use of validated AD control assessment tools throughout the region.

Efficacy and safety of dupilumab in two adolescents with severe atopic dermatitis

We report the cases of two adolescent siblings with severe atopic dermatitis, who, despite weighing approximately 40kg, presented a good response to dupilumab with the off-label dose for individuals aged 12 years and weighing 60kg. Both had already used cyclosporine, azathioprine, methotrexate and oral corticosteroids for long periods, plus topical treatments with no adequate disease control. Skin lesions were constant and widespread, with frequent skin infections and very poor quality of life, with numerous physical and psychosocial consequences, such as dropping out of school activities due to severe itching, appearance and bullying. They also showed delayed growth and development. In 2018, dupilumab, an immunobiological agent, was approved for treatment of moderate to severe atopic dermatitis in adults and, in 2019, extended to the 12-17-year age group. Although it had already been approved by the Brazilian Health Surveillance Agency, the 200mg presentation (indicated for the weight of patients) was not available, with no expected arrival date. Therefore, weighing the risks and benefits of the situation of both, we chose to treat them with an adult dose (loading dose of 600mg subcutaneously, and 300mg subcutaneously every 2 weeks) despite the low weight. So far, they have received eight injections, showing significant improvement of disease and quality of life. There were no major adverse effects, only worsening of allergic conjunctivitis in one of them. The patients and their family are very satisfied, and we believe that the therapy has been successful.

Atopic dermatitis: Tofacitinib, an option for refractory disease

Atopic dermatitis (AD) is a common skin disease, associated with high burden impact in quality of live, in moderate-severe disease severity. Several targeted drugs are under development for AD. Here, we present a patient with refractory disease to systemic traditional immunosuppressive drugs, treated successfully with oral tofacitinib, with complete response.

Real-life efficiency and safety comparison study of emollient ointment based on glycerophosphoinositol (GPI) salt of choline and other emollient products in patients with atopic dermatitis

INTRODUCTION

The aim of this study was to investigate the effectiveness and safety of emollient preparations in comparison with the emollient ointment containing glycerophosphoinositol salt of choline in patients with atopic dermatitis (AD).

METHODS

In a 'real-life' study, 300 patients with moderate AD were age-stratified and divided into two groups: patients applying GPI emollient and the comparator. We evaluated the effectiveness of AD treatment using: Eczema Area and Severity Index (EASI), Three Item Severity (TIS), Visual Analogue Scale (VAS) and Four-Item Itch Questionnaire.

RESULTS

The GPI emollient was superior in reduction AD symptoms in children: VAS (-2.58 ± 0.25), TIS (-2.22 ± 0.22), EASI (-15.27 ± 1.77), and adults: VAS (-2.42 ± 0.19), TIS (-2.22 ± 0.17), EASI (-13.22 ± 1.53), as compared to the other emollient in children: VAS (-0.67 ± 0.19), TIS (0.47 ± 0.19), EASI (-3.71 ± 1.01) and adults: VAS (-0.86 ± 0.09), TIS (0.77 ± 0.09), EASI (-2.95 ± 0.46), p < .001. Similar results were observed in Four Item Itch Questionnaire.

CONCLUSION

Both emollients showed good safety and tolerance profile and reduced AD symptoms. The GPI emollient seems to be more slightly effective in reducing AD symptoms as compared to the other commercially available emollient.

Mesenchymal Stem Cells and Atopic Dermatitis: A Review

Mesenchymal stem/stromal cells (MSCs) are stromal-derived non-hematopoietic progenitor cells that reside in and can be expanded from various tissues sources of adult and neonatal origin, such as the bone marrow, umbilical cord, umbilical cord blood, adipose tissue, amniotic fluid, placenta, dental pulp and skin. The discovery of the immunosuppressing action of MSCs on T cells has opened new perspectives for their use as a therapeutic agent for immune-mediated disorders, including allergies. Atopic dermatitis (AD), a chronic and relapsing skin disorder that affects up to 20% of children and up to 3% of adults worldwide, is characterized by pruritic eczematous lesions, impaired cutaneous barrier function, Th2 type immune hyperactivation and, frequently, elevation of serum immunoglobulin E levels. Although, in the dermatology field, the application of MSCs as a therapeutic agent was initiated using the concept of cell replacement for skin defects and wound healing, accumulating evidence have shown that MSC-mediated immunomodulation can be applicable to the treatment of inflammatory/allergic skin disorders. Here we reviewed the pre-clinical and clinical studies and possible biological mechanisms of MSCs as a therapeutic tool for the treatment of atopic dermatitis.

Conjugated linoleic acid attenuates 2,4-dinitrofluorobenzene-induced atopic dermatitis in mice through dual inhibition of COX-2/5-LOX and TLR4/NF-κB signaling

Conjugated linoleic acid (CLA), commonly found in beef, lamb and dairy products, has been reported to exhibit anti-inflammatory and antipruritus effects and to inhibit the release of chemical mediators such as histamine and eicosanoid in laboratory rodents. The chief objective of the study is to assess the efficacy of CLA on atopic dermatitis (AD) in mice and to explore possible mechanisms with CLA treatments. To develop a new therapy for AD, the anti-AD potential of CLA was investigated by inducing AD-like skin lesions in mice using 2,4-dinitrofluorobenzene. We evaluated dermatitis severity; histopathological changes; serum levels of T helper (Th) cytokines (interferon-γ, interleukin-4); changes in protein expression by western blotting and immunohistochemistry staining for cyclooxygenase-2 (COX-2), 5-lipoxygenase (5-LOX), toll like receptor 4 (TLR-4), myeloid differentiation factor 88 (MyD88), nuclear factor-κB (NF-κB) and tumor necrosis factor α (TNF-α); and production of the proinflammatory lipid mediators, such as prostaglandin E₂ and leukotriene B4, in the skin lesions. Treatment with CLA ameliorated the development of AD-like clinical symptoms and effectively inhibited epidermal hyperplasia and infiltration of mast cells and CD4⁺ T cells in the AD mouse skin. Total serum immunoglobulin E levels and the expression levels of Th1/Th2 cytokines and lipid mediators in dorsal skin were dramatically suppressed by CLA. Furthermore, CLA down-regulated the expressions of COX-2, 5-LOX, TLR4, MyD88, NF-κB and TNF-α. Taken together, our findings demonstrate the potential usefulness of CLA as an anti-inflammatory dietary supplement or drug for the prevention and management of AD skin diseases by modulating the COX-2/5-LOX and TLR4/MyD88/NF-κB signaling pathways.