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Abstract
Atopic dermatitis is a complex, chronic inflammatory skin disorder with significant morbidity. It is often a frustrating condition for both children and parents due to chronic and relapsing course. There is now an increasing understanding of the disease pathogenesis resulting in discovery of much wanted newer therapeutics and targeted therapies after a long time. Whether these interventions will result in sustained benefits or long term cure remains to be seen.
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Affiliation(s)
- Shweta Saini
- Division of Allergy and Immunology, Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Pediatric Specialty Center, Suite # 4018, 3950 Beaubien Boulevard, Detroit, MI 48201, USA
| | - Milind Pansare
- Division of Allergy and Immunology, Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Pediatric Specialty Center, Suite # 4018, 3950 Beaubien Boulevard, Detroit, MI 48201, USA.
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Abstract
Atopic dermatitis (AD) is a relapsing or chronic heterogeneous inflammatory skin disorder with a substantial economic and social impact. AD is a multifactorial disease regulated by a diverse set of environmental and genetic determinants. The main factors involved in the pathogenesis of AD are epidermal barrier dysfunction, immune dysregulation, and dysbiosis. Current data have valued interleukin (IL)-13 as conceivably the crucial cytokine in the underlying inflammation of AD. Advances in understanding AD pathophysiology have driven the progress of targeted immunomodulatory treatments for the treatment of AD, including tralokinumab, a selective IL-13 inhibitor. A phase IIb clinical trial showed that a dosing regimen of 150 or 300 mg every 2 weeks effectively treated moderate-to-severe AD in adults with an acceptable tolerability profile. Phase III clinical trials demonstrated that results with tralokinumab in monotherapy were superior to those with placebo at 16 weeks of treatment. It was also well tolerated up to 52 weeks in the vast majority of patients. In addition, in association with topical corticosteroids, tralokinumab was well tolerated and effective and had a favorable risk-benefit profile. These data provide additional evidence that IL-13 is central to AD pathogenesis, suggesting that tralokinumab may be seen as an innovative option for the treatment of moderate-to-severe AD.
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Dubin C, Del Duca E, Guttman-Yassky E. The IL-4, IL-13 and IL-31 pathways in atopic dermatitis. Expert Rev Clin Immunol 2021; 17:835-852. [PMID: 34106037 DOI: 10.1080/1744666x.2021.1940962] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Atopic dermatitis (AD) is the most common inflammatory skin disease. It has a complex pathophysiology, with a combination of immune dysregulation and intrinsic barrier defects driving cutaneous inflammation and allergic symptomatology. The IL-4, IL-13 and IL-31 inflammatory pathways have been identified as hallmark features in the pathogenesis of the disease, contributing uniquely and synergistically to immune and barrier abnormalities as well as the key symptoms, such as pruritis. Novel therapeutics that target these pathways have been under development to find treatments for AD.Areas covered: This review discusses the IL-4, IL-13 and IL-31 pathways in AD. We will also detail novel targeted therapeutics that have recently been or are currently in clinical trials for AD. A literature search was conducted by querying Scopus, Google Scholar, PubMed, and Clinicaltrials.gov up to January 2021 using combinations of the search terms 'IL-4' 'IL-13' 'IL-31' 'atopic dermatitis' 'immune pathway' 'biologics' 'novel therapeutics' 'JAK/STAT inhibitors.'Expert opinion: The complex pathophysiology of AD advocates for innovation. Novel minimally invasive sampling modalities such as tape stripping will allow for a broader characterization of the immunomechanisms behind AD pathophysiology. This will allow for the continued development of a personalized medicine approach to treat AD.
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Affiliation(s)
- Celina Dubin
- Department of Dermatology, And Laboratory of Inflammatory Skin Diseases, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Ester Del Duca
- Department of Dermatology, And Laboratory of Inflammatory Skin Diseases, Icahn School of Medicine at Mount Sinai, New York, USA.,Department of Dermatology, Magna Graecia, Catanzaro, IT, Calabria
| | - Emma Guttman-Yassky
- Department of Dermatology, And Laboratory of Inflammatory Skin Diseases, Icahn School of Medicine at Mount Sinai, New York, USA.,Laboratory for Investigative Dermatology, The Rockefeller University, New York, New York USA
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Abstract
PURPOSE OF REVIEW Atopic dermatitis (AD), chronic spontaneous urticaria (CSU), and allergic contact dermatitis (ACD) represent three important allergic dermatoses with many unmet therapeutic needs. The development of biologic agents has opened the door to both new treatment options and improved understanding of the underlying pathophysiology, both shared and unique for these entities. With several FDA-approved medications available and many more in development, the biologic revolution has begun for allergic dermatoses. RECENT FINDINGS This is a narrative review on the current state of pathomechanisms and appropriately targeted biologic agents for these three common allergic skin conditions. The importance of Th2 inflammation and the effect of inflammatory cytokines on the skin barrier may help explain the impressive efficacy of biologic agents, while maintaining relative safety. While some of the biologic agents show efficacy across multiple allergic dermatoses, more often it seems these more targeted pathways show accordingly precise efficacy. However, in each disease, multiple agents hold promise, and may be differentiated by safety and adverse effect profile rather than simply by efficacy. New understanding of the pathogenesis of the allergic dermatoses has ushered in a new era of biologic therapies. Competing mechanisms and molecules will continue to be developed and vetted in trials with hopes of continuously refined precision therapies with optimized safety and efficacy profiles.
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Affiliation(s)
- Sara N Bilimoria
- Northwestern University Feinberg School of Medicine, 363 W. Erie Street, Suite 350, Chicago, IL, 60616, USA
| | - Peter A Lio
- Northwestern University Feinberg School of Medicine, 363 W. Erie Street, Suite 350, Chicago, IL, 60616, USA.
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5
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Abstract
Atopic dermatitis is a complex, chronic inflammatory skin disorder with significant morbidity. It is often a frustrating condition for both children and parents due to chronic and relapsing course. There is now an increasing understanding of the disease pathogenesis resulting in discovery of much wanted newer therapeutics and targeted therapies after a long time. Whether these interventions will result in sustained benefits or long term cure remains to be seen.
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Affiliation(s)
- Shweta Saini
- Division of Allergy and Immunology, Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Pediatric Specialty Center, Suite # 4018, 3950 Beaubien Boulevard, Detroit, MI 48201, USA
| | - Milind Pansare
- Division of Allergy and Immunology, Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Pediatric Specialty Center, Suite # 4018, 3950 Beaubien Boulevard, Detroit, MI 48201, USA.
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Guttman-Yassky E, Bissonnette R, Ungar B, Suárez-Fariñas M, Ardeleanu M, Esaki H, Suprun M, Estrada Y, Xu H, Peng X, Silverberg JI, Menter A, Krueger JG, Zhang R, Chaudhry U, Swanson B, Graham NMH, Pirozzi G, Yancopoulos GD, D Hamilton JD. Dupilumab progressively improves systemic and cutaneous abnormalities in patients with atopic dermatitis. J Allergy Clin Immunol 2018; 143:155-172. [PMID: 30194992 DOI: 10.1016/j.jaci.2018.08.022] [Citation(s) in RCA: 377] [Impact Index Per Article: 62.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 07/19/2018] [Accepted: 08/14/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Dupilumab is an IL-4 receptor α mAb inhibiting signaling of IL-4 and IL-13, key drivers of type 2-driven inflammation, as demonstrated by its efficacy in patients with atopic/allergic diseases. OBJECTIVE This placebo-controlled, double-blind trial (NCT01979016) evaluated the efficacy, safety, and effects of dupilumab on molecular/cellular lesional and nonlesional skin phenotypes and systemic type 2 biomarkers of patients with moderate-to-severe atopic dermatitis (AD). METHODS Skin biopsy specimens and blood were evaluated from 54 patients randomized 1:1 to weekly subcutaneous doses of 200 mg of dupilumab or placebo for 16 weeks. RESULTS Dupilumab (vs placebo) significantly improved clinical signs and symptoms of AD, was well tolerated, and progressively shifted the lesional transcriptome toward a nonlesional phenotype (weeks 4-16). Mean improvements in a meta-analysis-derived AD transcriptome (genes differentially expressed between lesional and nonlesional skin) were 68.8% and 110.8% with dupilumab and -10.5% and 55.0% with placebo (weeks 4 and 16, respectively; P < .001). Dupilumab significantly reduced expression of genes involved in type 2 inflammation (IL13, IL31, CCL17, CCL18, and CCL26), epidermal hyperplasia (keratin 16 [K16] and MKi67), T cells, dendritic cells (ICOS, CD11c, and CTLA4), and TH17/TH22 activity (IL17A, IL-22, and S100As) and concurrently increased expression of epidermal differentiation, barrier, and lipid metabolism genes (filaggrin [FLG], loricrin [LOR], claudins, and ELOVL3). Dupilumab reduced lesional epidermal thickness versus placebo (week 4, P = .001; week 16, P = .0002). Improvements in clinical and histologic measures correlated significantly with modulation of gene expression. Dupilumab also significantly suppressed type 2 serum biomarkers, including CCL17, CCL18, periostin, and total and allergen-specific IgEs. CONCLUSION Dupilumab-mediated inhibition of IL-4/IL-13 signaling through IL-4 receptor α blockade significantly and progressively improved disease activity, suppressed cellular/molecular cutaneous markers of inflammation and systemic measures of type 2 inflammation, and reversed AD-associated epidermal abnormalities.
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Affiliation(s)
- Emma Guttman-Yassky
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY; Laboratory for Investigative Dermatology, Rockefeller University, New York, NY.
| | | | - Benjamin Ungar
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY; Laboratory for Investigative Dermatology, Rockefeller University, New York, NY
| | - Mayte Suárez-Fariñas
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY; Laboratory for Investigative Dermatology, Rockefeller University, New York, NY; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Hitokazu Esaki
- Department of Dermatology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Maria Suprun
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yeriel Estrada
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hui Xu
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Xiangyu Peng
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jonathan I Silverberg
- Department of Dermatology, Preventive Medicine and Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Alan Menter
- Department of Dermatology, Baylor University Medical Center, Dallas, Tex
| | - James G Krueger
- Laboratory for Investigative Dermatology, Rockefeller University, New York, NY
| | - Rick Zhang
- Regeneron Pharmaceuticals, Tarrytown, NY
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Erickson S, Nahmias Z, Rosman IS, Kim BS. Immunomodulating Agents as Antipruritics. Dermatol Clin 2018; 36:325-334. [DOI: 10.1016/j.det.2018.02.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Abstract
Atopic dermatitis (AD) is the most common chronic inflammatory skin disease, with a lifetime prevalence of up to 20% and substantial effects on quality of life. AD is characterized by intense itch, recurrent eczematous lesions and a fluctuating course. AD has a strong heritability component and is closely related to and commonly co-occurs with other atopic diseases (such as asthma and allergic rhinitis). Several pathophysiological mechanisms contribute to AD aetiology and clinical manifestations. Impairment of epidermal barrier function, for example, owing to deficiency in the structural protein filaggrin, can promote inflammation and T cell infiltration. The immune response in AD is skewed towards T helper 2 cell-mediated pathways and can in turn favour epidermal barrier disruption. Other contributing factors to AD onset include dysbiosis of the skin microbiota (in particular overgrowth of Staphylococcus aureus), systemic immune responses (including immunoglobulin E (IgE)-mediated sensitization) and neuroinflammation, which is involved in itch. Current treatments for AD include topical moisturizers and anti-inflammatory agents (such as corticosteroids, calcineurin inhibitors and cAMP-specific 3',5'-cyclic phosphodiesterase 4 (PDE4) inhibitors), phototherapy and systemic immunosuppressants. Translational research has fostered the development of targeted small molecules and biologic therapies, especially for moderate-to-severe disease.
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Guttman-Yassky E, Brunner PM, Neumann AU, Khattri S, Pavel AB, Malik K, Singer GK, Baum D, Gilleaudeau P, Sullivan-Whalen M, Rose S, Jim On S, Li X, Fuentes-Duculan J, Estrada Y, Garcet S, Traidl-Hoffmann C, Krueger JG, Lebwohl MG. Efficacy and safety of fezakinumab (an IL-22 monoclonal antibody) in adults with moderate-to-severe atopic dermatitis inadequately controlled by conventional treatments: A randomized, double-blind, phase 2a trial. J Am Acad Dermatol 2018; 78:872-881.e6. [PMID: 29353025 PMCID: PMC8711034 DOI: 10.1016/j.jaad.2018.01.016] [Citation(s) in RCA: 214] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/05/2018] [Accepted: 01/09/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Interleukin 22 promotes epidermal hyperplasia and inhibits skin barrier function. OBJECTIVE Evaluate interleukin 22 blockade in adults with moderate-to-severe atopic dermatitis (AD). METHODS We performed a randomized, double-blind, placebo-controlled trial with intravenous fezakinumab monotherapy every 2 weeks for 10 weeks, with follow-up assessments until 20 weeks. The change in SCOring AD (SCORAD) score from baseline at 12 weeks served as the primary end point. RESULTS At 12 weeks, the mean declines in SCORAD for the entire study population were 13.8 ± 2.7 in the fezakinumab arm and 8.0 ± 3.1 in the placebo arm (P = .134). In the severe AD patient subset (with a baseline SCORAD of ≥50), SCORAD decline was significantly stronger in the drug-treated patients than placebo-treated patients at 12 weeks (21.6 ± 3.8 vs 9.6 ± 4.2, P = .029) and 20 weeks (27.4 ± 3.9 vs 11.5 ± 5.1, P = .010). At 12 weeks, improvements in body surface area involvement in the entire population were significantly stronger in the drug-treated than placebo-treated patients (12.4% ± 2.4 vs 6.2% ± 2.7; P = .009), and in the severe AD subset, the decline in Investigator Global Assessment was significantly higher in the drug-treated than placebo-treated patients (0.7 ± 0.2 vs 0.3 ± 0.1; P = .034). All scores showed progressive improvements after last dosing (10 weeks) until end of study (20 weeks). Common adverse events were upper respiratory tract infections. LIMITATIONS The limited sample size and lack of assessment with Eczema Area and Severity Index and a pruritus numerical rating scale were limiting factors. Significance was primarily obtained in severe AD. CONCLUSION Fezakinumab was well-tolerated, with sustained clinical improvements after last drug dosing.
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Affiliation(s)
- Emma Guttman-Yassky
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York; Laboratory for Investigative Dermatology, The Rockefeller University, New York, New York.
| | - Patrick M Brunner
- Laboratory for Investigative Dermatology, The Rockefeller University, New York, New York
| | - Avidan U Neumann
- Institute of Environmental Medicine, University Center for Health Sciences at the Klinikum Augsburg, Technical University Munich and Helmholtz Zentrum München - German Research Center for Environmental Health, Augsburg, Germany; Swiss Institute of Allergy and Asthma Research, University of Zürich, Davos, Switzerland; Berlin-Brandenburg Center for Regenerative Therapies, Charité University Hospital Berlin, Berlin, Germany
| | - Saakshi Khattri
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ana B Pavel
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kunal Malik
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Giselle K Singer
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Danielle Baum
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Patricia Gilleaudeau
- Laboratory for Investigative Dermatology, The Rockefeller University, New York, New York
| | - Mary Sullivan-Whalen
- Laboratory for Investigative Dermatology, The Rockefeller University, New York, New York
| | - Sharon Rose
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shelbi Jim On
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Xuan Li
- Laboratory for Investigative Dermatology, The Rockefeller University, New York, New York
| | | | - Yeriel Estrada
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sandra Garcet
- Laboratory for Investigative Dermatology, The Rockefeller University, New York, New York
| | - Claudia Traidl-Hoffmann
- Institute of Environmental Medicine, University Center for Health Sciences at the Klinikum Augsburg, Technical University Munich and Helmholtz Zentrum München - German Research Center for Environmental Health, Augsburg, Germany; Christine Kühne - Center for Allergy Research and Education, Davos, Switzerland
| | - James G Krueger
- Laboratory for Investigative Dermatology, The Rockefeller University, New York, New York
| | - Mark G Lebwohl
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
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11
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Systemic Therapy of Atopic Dermatitis: When, How, for How Long? CURRENT DERMATOLOGY REPORTS 2017. [DOI: 10.1007/s13671-017-0176-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The Role of Interleukins 4 and/or 13 in the Pathophysiology and Treatment of Atopic Dermatitis. Dermatol Clin 2017; 35:327-334. [PMID: 28577802 DOI: 10.1016/j.det.2017.02.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Moderate to severe atopic dermatitis (AD) can be debilitating and often requires use of systemic immunosuppressant therapy to achieve adequate disease control. There are currently no US Food and Drug Administration-approved systemic agents for the long-term treatment of AD. Recent insight has identified the T helper 2 cytokines, interleukins 4 and 13, as playing a major role in the pathogenesis of AD. There are multiple novel biologic agents in development that target interleukins 4 and/or 13 for the treatment of moderate to severe AD. The age of targeted biologics for AD has arrived.
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