Dupilumab therapy of atopic dermatitis of the elderly: a multicentre, real-life study

BACKGROUND

Treatment of moderate-to-severe atopic dermatitis (AD) in the elderly may be challenging, due to side-effects of traditional anti-inflammatory drugs and to comorbidities often found in this age group. Furthermore, efficacy and safety of innovative drugs such as dupilumab are not yet well known.

OBJECTIVES

A multicentre retrospective, observational, real-life study on the efficacy and safety of dupilumab was conducted in a group of patients aged ≥65 years and affected by severe AD. Their main clinical features were also examined.

METHODS

Data of elderly patients with severe (EASI ≥24) AD treated with dupilumab at label dosage for 16 weeks were retrospectively collected. Treatment outcome was assessed by comparing objective (EASI) and subjective (P-NRS, S-NRS and DLQI) scores at baseline and after 16 weeks of treatment.

RESULTS

Two hundred and seventy-six patients were enrolled in the study. They represented 11.37% of all patients with severe AD. Flexural eczema was the most frequent clinical phenotype, followed by prurigo nodularis. The coexistence of more than one phenotype was found in 63/276 (22.82%) subjects. Data on the 16-week treatment with dupilumab were available for 253 (91.67%) patients. Efficacy of dupilumab was demonstrated by a significant reduction of all the scores. No statistically significant difference regarding efficacy was found in elderly patients when compared to the group of our AD patients aged 18-64 years, treated with dupilumab over the same period. Furthermore, only 18 (6.52%) patients discontinued the drug due to inefficacy. Sixty-one (22.51%) patients reported adverse events, conjunctivitis and flushing being the most frequent. One (0.36%) patient only discontinued dupilumab due to an adverse event.

CONCLUSIONS

Therapy with dupilumab led to a significant improvement of AD over a 16-week treatment period, with a good safety profile. Therefore, dupilumab could be considered as an efficacious and safe treatment for AD also in the elderly.

Predictors of response to omalizumab and relapse in chronic spontaneous urticaria: a study of 470 patients

BACKGROUND

Chronic spontaneous urticaria (CSU) is defined as spontaneous occurrence of wheals and/or angioedema for ≥6 weeks. Omalizumab is a monoclonal anti-IgE antibody effective in refractory CSU, but its mechanism of action and markers predictive of response remain not completely defined.

OBJECTIVES

To correlate baseline levels of two proposed biomarkers, total IgE (bIgE) and d-dimer (bd-dimer), and clinical parameters to omalizumab response and to relapses after drug withdrawal.

METHODS

In this retrospective Italian multicentre study, clinical data were collected in 470 CSU patients, and bIgE and bd-dimer were measured in 340 and 342 patients, respectively. Disease activity was determined by Urticaria Activity Score 7 (UAS7) at week 1 and 12 after omalizumab starting. Relapses were evaluated during a 2- and 3-month interval after a first and a second course of treatment, respectively.

RESULTS

bIgE correlated to a good response to omalizumab since levels were significantly higher in responders than non-responders (P = 0.0002). Conversely, bd-dimer did not correlate to response. There was no correlation between both bIgE and d-dimer and either first or second relapse. Disease duration was significantly longer in patients who experienced either first or second relapse (P < 0.0001 and P = 0.0105, respectively), while baseline UAS7 correlated only to first relapse (P = 0.0023).

CONCLUSIONS

Our study confirms bIgE as a reliable biomarker predicting response to omalizumab in CSU, while it does not support the usefulness of bd-dimer unlike previous findings. CSU duration before omalizumab and baseline UAS7 may be clinical markers of relapse risk.

Conctact dermatitis: some important topics

Allergic contact dermatitis (ACD) is a type IV delayed hypersensitivity reaction. The gold standard for diagnosis is patch testing. The prevalence of positive patch tests in referred patients with suspected ACD ranges from 27 to 95.6%. The relationship between ACD and atopic dermatitis (AD) is complicated with conflicting reports of prevalence in the literature; however, in a patient with dermatitis not responding to traditional therapies, or with new areas of involvement, ACD should be considered as part of the work-up.

Development of a clinical score system for the diagnosis of photoallergic contact dermatitis using a consensus process: item selection and reliability

BACKGROUND

Photoallergic contact dermatitis (PACD) is an uncommon condition, and there is a lack of validated criteria for its diagnosis.

OBJECTIVE

To identify a set of relevant criteria to be considered when suspecting a diagnosis of PACD and to assess the reproducibility of these criteria.

METHODS

This was a diagnostic item selection and reliability study performed between July 2012 and October 2012. A panel of seven recognized experts was invited to consecutive rounds of a Delphi survey and to a conclusive face-to-face meeting with the aim of obtaining an agreement on criteria for the diagnosis of PACD. The panel was also provided with a series of 16 reports of suspected PACDs to be classified according to a five-point likelihood scale. Identified criteria with the weights attributed by experts were used to develop a score system for the diagnosis of PACD. Consensus was measured by calculating the Intraclass Correlation Coefficient (ICC). The performance of the score system was evaluated in terms of overall classification accuracy.

RESULTS

Seven criteria were identified by experts as relevant for the diagnosis of PACD. The criteria were related to the type of skin lesions, accompanying symptoms, skin area involved, general medical history, modality of exposure to the culprit substance, history of exposure to the sun or other light sources and photopatch test results. Experts reached a moderate agreement on PACD cases classification, with ICC = 0.69 (95% Confidence Interval, CI, 0.50-0.86). The score system enabled discrimination of probable and definite PACD cases from possible and unlikely or excluded ones, with a nearly perfect agreement being observed between the score system classification and judgment by experts.

CONCLUSION

A diagnostic score was proposed. The score should receive a comprehensive validation on a larger series of cases and with multiple evaluators.

Probiotics: immunomodulatory properties in allergy and eczema

In the last decades the prevalence of allergic diseases and eczema raised significantly, and today they are the most common chronic pathologies affecting children. It has been shown that a functional intestinal mucosa provides a defensive barrier to the host against potential dangerous antigens, regulating the tolerance to them. Some inflammatory diseases of the gut weaken the barrier causing an increase in the mucosa permeability and in antigenic transition. As a consequence, there is an aberrant immune response and the release of pro-inflammatory cytokines further compromises the barrier functionality. It has been demonstrated that a correlation between allergy and eczema onset and the intestinal microflora composition exists, and in particular, it has been showed that some microorganisms are able to influence the immune response. For these reasons it has been hypothesized that probiotics may have a beneficial role in preventing and treating allergies and eczema. However, the benefits of this treatment depend on many factors, such as the bacterial strain, the duration of administration, the pathology, the patient characteristics (age, diet, allergy predisposition). The aim of this work was to review the present knowledge about the use of probiotics in allergic diseases and eczema, highlighting their role in the aforementioned pathologies.

Clinical evaluation of photoprotective effect by a topical antioxidants combination (tocopherols and tocotrienols)

BACKGROUND

Vitamin E is among the earliest recognized antioxidants. Recent findings suggested that tocotrienols have superior activity than tocopherols. Moreover, vitamin A is well-known in dermatology for its actions, including the ultraviolet radiation absorbing property.

OBJECTIVES

In view of experimental evidence for the photoprotective properties of these antioxidants, we evaluated in 30 patients with photosensitivity, the prophylactic efficacy of a new topical agent, containing tocopherols 10% and tocotrienols 0.3%, compared with retinol, simple vehicle and untreated areas.

METHODS

After determination of the minimal UVB erythema dose (MED), two areas of 2 × 2 cm were selected on the buttocks of each subject, one of which was treated with the antioxidant formulation whereas the other field did not undergo any treatment. Therefore, both areas were irradiated with a twofold MED. As further controls, other two similar areas, selected on the forearm of 15 patients, were photo-irradiated similarly, 30 min after application of the simple vehicle to a field and of vitamin A in the same vehicle to the other. Reactions (erythema/oedema/itch/vesciculation) assessment was carried out assigning scores indicative of their intensity; then, mean values +DS of scores were calculated.

RESULTS

The pre-treatment with the vitamin E formulation highly protects against photosensitivity, and all reactions to irradiation were significantly lower in the areas treated with the topical vitamin E formulation compared to those treated with the simple vehicle or vitamin A.

CONCLUSIONS

The use of a new topical formulation containing significant concentrations of tocotrienols and tocopherols represents a promising strategy to reduce the photo-induced skin damage.

Italian position paper on urticaria. Italian Board on Urticaria

The Italian Board on Urticaria has prepared a document focusing on the definition and classification of urticaria, taking into account the recent progress in identifying the causes, eliciting factors, and pathomechanisms of this disease. As urticaria has a profound impact on the quality of life, effective treatment is important. Therefore, specific treatment options for the management of urticaria are evaluated on the basis of the recent literature. Non-sedating H(1) antihistamines are recommended as the first-line treatment as they have proven effective in several randomized double-blind controlled studies. Dosages higher than those recommended may be necessary in some cases. However, additional or alternative therapies may be required for different urticaria subtypes and in view of individual variations in the course of the disease and response to treatment. Immunosuppressive drugs such as corticosteroids are not recommended for long-term treatment due to unavoidable, severe adverse effects.

Atopy and contact sensitization in psoriasis

The allergen-specific IgE antibody was determined in 20 men and 120 women with psoriasis and the results were correlated with a history of current and previous allergic disease. Allergic disease was reported in 21% of the patients, but a positive RAST test was obtained in 44%. In chronic plaque-type psoriasis a positive RAST test was significantly more common (58%) than in active psoriasis (22%). Grass pollen and house dust mite were the most prevalent sensitizing allergens, with frequencies of 64% and 53%, respectively in the sensitized subjects. Sensitization increased with age and polysensitization was common. Contact dermatitis was verified with patch tests in 12 men and 20 woman, of whom 10 had chronic plaque-type psoriasis and 22 active psoriasis. Tar, nickel sulphate, corticosteroid mixture and thiomersal were the most common allergens. No irritant reactions were seen at the concentrations used. Atopic allergic diseases and contact sensitization were therefore common among our psoriatic patients.

Gruppo Italiano Ricerca Dermatiti da Contatto ed Ambientali Italian Multicenter Study of Allergic Contact Photodermatitis: epidemiological aspects

A total of 1,050 patients with histories and clinical pictures suggestive of photoallergic contact dermatitis were seen. All the patients underwent photopatch tests with haptens proposed by the Gruppo Italiano Ricerca Dermatiti da Contatto plus other substances suggested by each patient's history. Two hundred fifty-nine patients (24.6%) were positive to at least one test substance of the standard series or to substances added. Typical photoallergic reactions were seen in 198 subjects (259 minus 40 toxic photodermatitis to chlorpromazine and 21 to promethazine), which represents 18.8% of the total population. Topical drugs represent the most involved substances in photodermatitis. The incidence in our population was about equal for antimicrobial agents, additives to fragrances, and fragrances themselves. Other allergens found were salicylanilides, whereas sun-screening agents were the fifth group of haptens but with clear-cut relevance. This study is a first attempt to organize the data about results of photopatch tests applied to Italian patients.

Densitometry of Pautrier's microabscess cells in cutaneous T cell lymphoma

BACKGROUND

Epidermotropic lymphoid T cell infiltrates are part of a continuous spectrum of lesions ranging from "benign" parapsoriasis to frank cutaneous T cell lymphoma (CTCL, mycosis fungoides). Either the clinical or histologic differentiation between these entities prove often difficult and the prognosis may be difficult to assess.

PATIENTS AND METHODS

We studied 15 patients, men aged 50 to 81 years, mean +/- SD 68 +/- 12 years, with patch-plague CTCL. Sections from punch biopsies from active lesions were stained with Feulgen reagent, coupled with a "twin" adjacent hematoxylin and eosin (H&E)-stained section and analyzed with a VIDAS Zeiss-Kontron Image Analyzer. At least 50 dermal infiltrating cells and 50 epidermotropic Pautrierian cells per specimen were counted and the biopsies were repeated periodically.

RESULTS

Nine patients with aneuploid Pautrierian cell DNA patterns dis well after conventional phototherapy (dermal cell ploidy was irrelevant), whereas six patients with euploid Pautrierian cell DNA patterns had to be treated aggressively (IFN + retinoids, COP). Clinical and histopathologic aspects of the first group were comparable to those of the second group.

CONCLUSIONS

The classical cytophotometric aphorism seems to be reversed in this sample: "The more abnormal the ploidy of epidermotropic Pautrierian cells, the better the prognosis." Euploid epidermotropic cell prove more efficient in invading the skin and other areas and this efficiency may be reflected in more aggressive trends in the evolution of the lymphoma. Thus, DSM analysis of epidermotropic cells could prove very useful as an inexpensive tool for routine CTCL grading.

Intramuscular low dose alpha-2B interferon and etretinate for treatment of mycosis fungoides

BACKGROUND

Mycosis fungoides is a lymphoma of cutaneous origin characterized by a proliferation of cells with a T phenotype.

METHODS

In this pilot study, 13 men with mycosis fungoides in various stages were treated with alpha-2b interferon and etretinate.

RESULTS

In ten of them, such a therapy proved to be effective (7 complete responses, 3 partial responses), sometimes with prolonged remissions (up to 20 months, and still persistent) after suspension of the drugs.

CONCLUSIONS

We chose low-dose interferon administration in order to prevent side effects, which are said to be dose-dependent. In our experience this is not true, but this drawback seems to be overcome by the very good, sometimes spectacular, response to this combination therapy, particularly in low stage forms of the disease. This fact, compared with results provided by other groups, prompts us to plan new research protocols based on associations of retinoids with different interferon types (or even associations of different interferons), because we believe they will have an important place in treatment of cutaneous T-cell lymphoma in future.

Cyclosporin in psoriasis: pathophysiology and experimental data

Cyclosporin has been used efficaciously in recent years for the management of severe psoriasis. The remarkable efficacy of this drug and its known immunosuppressive properties have indicated even more strongly the involvement of the immune system in the induction and maintenance of psoriasis. The present review summarizes the role of cellular immunity in the pathogenesis of psoriasis and possible mechanisms of action of cyclosporin in psoriasis, and describes the laboratory studies performed in our Department under two headings, changes in lesional immune infiltrate (evaluated immunohistologically) and changes in neutrophil chemotaxis during cyclosporin treatment. Our immunohistological study showed that the psoriatic plaques contained an infiltrate composed mainly of activated CD4+ T cells. Cyclosporin treatment significantly decreased T cells and normalized the distribution and antigen expression of intraepidermal Langerhans cells, increasing the number of CD1+ dendritic cells. Our studies on neutrophil chemotaxis showed that cyclosporin reduced the chemotactic activity of neutrophilic polymorphonuclear leukocytes (in vivo but not in vitro), seemingly as a consequence of blocking the production of chemoattracting cytokines by psoriatic monocytes.

[Erosive lichen planus of the glans penis. Treatment with cyclosporin A]

After suffering from chronic and steroid-resistant erosive lichen planus of the glans penis for 2 years, a 42-year-old patient presented to our Institute. The clinical picture was of an erythematous and erosive lesion, superficially covered with sero-fibrinous exudations. Lichen planus was diagnosed by clinical and histological examination. Control routine serum analysis and urinalysis gave normal results, and ciclosporin A was given at a dosage of 3 mg/kg daily. After 2 weeks of therapy, significant regression of erythema and infiltration was seen, so that the patient could be circumcised as planned. After leaving our Institute the patient continued the therapy with ciclosporin A and the monthly controls of kidney and liver function had shown no abnormalities during the 6-month follow-up that had elapsed up to the time of writing.