Moderate to severe atopic dermatitis in adolescents treated with dupilumab: a multicenter Italian real-world experience

Background

Moderate‐to‐severe atopic dermatitis (AD) in the adolescence is a high burden disease, and its treatment can be very challenging due to paucity of approved systemic drugs for this age and their side‐effects. Dupilumab was recently approved for treatment of adolescent AD.

Objectives

A multicentre, prospective, real‐world study on the effectiveness and safety of dupilumab in adolescents (aged from ≥12 to <18 years) with moderate‐to‐severe AD was conducted. The main AD clinical phenotypes were also examined.

Methods

Data of adolescents with moderate‐to‐severe AD treated with dupilumab at label dosage for 16 weeks were collected. Treatment outcome was assessed by EASI, NRS itch, NRS sleep loss and CDLQI scores at baseline and after 16 weeks of treatment. The clinical scores were also evaluated according to clinical phenotypes.

Results

One hundred and thirty‐nine adolescents were enrolled in the study. Flexural eczema and head and neck eczema were the most frequent clinical phenotypes, followed by hand eczema and portrait‐like dermatitis. Coexistence of more than 1 phenotype was documented in 126/139 (88.5%) adolescents. Three patients (2.1%) contracted asymptomatic SARS‐CoV‐2 infection and 1 of the discontinued dupilumab treatment before the target treatment period. A significant improvement in EASI, NRS itch, NRS sleep loss and CDLQI was observed after 16 weeks of treatment with dupilumab. This outcome was better than that observed in clinical trials. Dupilumab resulted effective in all AD phenotypes, especially in diffuse eczema. Twenty‐eight (20.1%) patients reported adverse events, conjunctivitis and flushing being the most frequent. None of patients discontinued dupilumab due to adverse event.

Conclusions

Dupilumab in adolescent AD showed excellent effectiveness at week 16 with consistent improvement of all clinical scores. Moreover, dupilumab showed a good safety profile also in this COVID‐19 pandemic era.

Towards a better understanding of the use of additives in tattoos

BACKGROUND

Tattooing is a popular practice worldwide, this practice is not free from complications and the last few decades have seen the raising occurrence of complications and adverse reactions.

METHODS

The aim of this study is to evaluate which substances are commonly used as additives among a group of tattoo artists working in Florence, to understand if mixing of colors and dilution of inks can be considered a potential source of infection or hypersensitivity reaction. A questionnaire containing a list of substances suspected to be added during the process of tattooing, was administered in presence of an investigator.

RESULTS

Forty-one licensed tattoo artists participated in the study. The cosmetic most frequently used as additive, resulted a rinse on cosmetic (36%) followed by distilled water (34%) and hamamelis lotion (17%).

CONCLUSIONS

Our study provides new insights about the procedure of ink dilution and mixing of colors, shedding light on the possible risks related to the use of non-sterile products. The results of our study suggest that mixing of colors and ink dilution can be consider a potential source of infection and hypersensitivity reactions. Additional actions are necessary to strengthen and protect public health.

Effect of dupilumab on sleep disturbances in adult patients with severe atopic dermatitis

BACKGROUND

Sleep disturbances are common in patients with atopic dermatitis (AD). Considering their relevant burden on health, routine screening of sleep disturbances seems to be very useful in AD adults management. However, few studies have evaluated the association between sleep disturbances and AD in adults and real-life data are lacking. The aim is to assess the effect of treatment with dupilumab on sleep disturbances in adult patients with severe atopic dermatitis.

METHODS

Retrospective, multicenter study including patients (age≥18 yr.s) with severe atopic dermatitis who were treated with dupilumab for at least 8 months from January 2019 to January 2020. Patients were evaluated three times: at treatment initiation (T0) and at 4 (T4) and 8 months (T8) from the start of treatment. At each visit disease activity was assessed by severity score (Eczema Area and Severity Index, EASI), patient-reported outcomes (Pruritus Numerical Rating Scale, NRS, Dermatology Life Quality Index,DLQI, and Pittsburgh Sleep Quality Index, PSQI). Kolmogorov-Smirnov test was performed to evaluate the normality distribution, Bartlett's test for homoscedasticity. Since the assumptions were met, ANOVA for repeated measures was performed to evaluate the mean difference of PSQI, EASI, DLQI and Pruritus NRS between baseline, 4th month and 8th month. In addition, Chi-square for Trend test was performed to evaluate the increasing/decreasing prevalence of poor sleepers.

RESULTS

A total of 36 patients (15 females and 21 males) with a mean age of 42.5±14.3 (range 20-67) were included in the study. The mean score for PSQI at TO was 9.0 ±3.6. At week 16 (T4) the mean score for PSQI was 4.92±2.99 and at week 32 (T8), the mean score for PSQI was 4.3± 3.0. EASI, NRS pruritus and DLQI significantly improved during follow up (p<0.001) whereas PSQI improved significantly at 16 weeks (T4) but no significant further improvement was observed at 32 weeks. Of the 31 patients (86%) with baseline PSQI≥5, 17 (54%)experienced sleep quality improvement during treatment. Overall, we observed a total of 22 patients (61.1%) having a PSQI <5 at 32 weeks CONCLUSIONS: Our data show effectiveness of Dupilumab in improving sleep disturbances in adult patients with severe AD. However, further studies are required to uPnSdQeIr sctoaunld isf erve as useful evaluating tool.

Management of patients with atopic dermatitis undergoing systemic therapy during COVID-19 pandemic in Italy: Data from the DA-COVID-19 registry

Background

Few and small studies have described the management of immunomodulant/immunosuppressive therapies or phototherapy in atopic dermatitis (AD) patients during coronavirus disease 2019 (COVID‐19) pandemic.

Methods

A national registry, named DA‐COVID‐19 and involving 35 Italian dermatology units, was established in order to evaluate the impact of COVID‐19 pandemic on the management of adult AD patients treated with systemic immunomodulant/immunosuppressive medications or phototherapy. Demographic and clinical data were obtained at different timepoints by teledermatology during COVID‐19 pandemic, when regular visits were not allowed due to sanitary restrictions. Disease severity was assessed by both physician‐ and patient‐reported assessment scores evaluating itch intensity, sleep disturbances, and AD severity.

Results

A total of 1831 patients were included, with 1580/1831 (86.3%) continuing therapy during pandemic. Most patients were treated with dupilumab (86.1%, 1576/1831) that was interrupted in only 9.9% (156/1576) of cases, while systemic immunosuppressive compounds were more frequently withdrawn. Treatment interruption was due to decision of the patient, general practitioner, or dermatologist in 39.9% (114/286), 5.6% (16/286), and 30.1% (86/286) of cases, respectively. Fear of increased susceptibility to SARS‐CoV‐2 infection (24.8%, 71/286) was one of the main causes of interruption. Sixteen patients (0.9%) resulted positive to SARS‐CoV‐2 infection; 3 of them (0.2%) were hospitalized but no cases of COVID‐related death occurred.

Conclusions

Most AD patients continued systemic treatments during COVID pandemic and lockdown period, without high impact on disease control, particularly dupilumab‐treated patients.

Novel pyrimidine and 1,3,5-triazine hypolipidemic agents

New compounds were synthesized by changing the substituents of a trisubstituted pyrimidine, i.e., [[4-chloro-6-[(2,3-dimethylphenyl)amino]-2-pyrimidinyl]thio] acetic acid, a potent hypolipidemic agent, impaired, however, by a marked hepatomegaly-inducing effect. The structural variations led to the subsidence (14b, i.e., 4-chloro-2-(dimethylamino)-6-[(2,3-dimethylphenyl)amino]pyrimidine) or to the reduction (18b, [[4-chloro-6-[(2,3-dimethylphenyl)amino]-2-pyrimidinyl]amino] acetic acid) of said untoward effect but still maintained the hypolipidemic effect that, although markedly decreased, still proves significant for serum cholesterol and triglycerides (18b) or for serum triglycerides only (14b).

Synthesis of 2-carboxy-11 beta, 17 beta-dihydroxy-17-methyl-1, 4-androstadien-3-one and related compounds

A series of 2-carboxy-1, 4-androstadien-3-one derivatives and their alkyl esters, were prepared by high-yield syntheses. The compounds were structurally identified by physical methods. All these steroids are characterized by a marked antiglucocorticoid activity that proved long-acting in the case of the ester derivatives. 2-Carboxy-11 beta, 17 beta-dihydroxy-17-methyl-1, 4-androstadien-3-one or roxibolone, and its n-decylester or decylroxibolone, are the most promising derivatives in consideration of their pharmacological properties.

[Bacteriological study at the vaginal level in sexually active women]

We have studied the microbiological environment of the vagina in 202 sexually active women when they came into an outpatient gynecological hospital. By some specific bacterioscopic and cultural examinations we have tried to understand the pathological role of some microrganism in sexually transmitted diseases. An elevated incidence of mycoplasm in asymptomatic subjects has shed light on the probable saprophytic behaviour of these microrganisms.

Inhibition of puerperal lactation by metergoline: interactions with methylergobasine maleate

Metergoline, a prolactin (PRL) lowering drug, is used in the puerperal period to inhibit lactation. Methylergobasine maleate (MEM), widely employed in the puerperium to promote uterine contractions, has also been reported to decrease PRL release and to reduce lactation. To evaluate the possible interactions of the two drugs, groups of 6-11 puerperae each received no treatment, metergoline alone (8 or 12 mg/day for 5 days), MEM alone (0.2 mg i.v. at delivery followed by 0.5 mg/day p.o. for 5 days) and metergoline plus MEM. Metergoline fully prevented lactation and significantly reduced PRL release, the higher dose inducing effects faster. MEM was without effect on PRL release and lactation, and did not modify the effect of metergoline.

Metergoline versus bromocriptine in the prevention of puerperal lactation. A double-blind clinical trial

In a double blind study of the prevention of puerperal lactation, the clinical efficacy of two antiprolactin drugs was compared: metergoline 4 mg tid and bromocriptine 2.5 mg bid were both given for 7 days. An additional 7 days of treatment was administered to 16 patients in whom mammary activity was still present or appeared in the following 3 days. The first 7 day period of treatment was effective in 16/20 women receiving metergoline and in 7/20 on bromocriptine (p less than 0.02); the second period of treatment was effective in all remaining patients. These data indicate that metergoline acts rapidly to arrest puerperal lactation, possibly by a mechanism different from that of bromocriptine.

Spontaneous preterm delivery in pregnant diabetics: a high risk hitherto "unrecognized"

Preterm delivery (PD)--before the 259th day from the beginning of the last menstrual period--is very frequent in pregnant diabetics (from 50% to 80% or more, personal investigation in progress). In these patients a policy is generally followed of a systematically controlled early delivery. Therefore, one is inclined to think that the high frequency of PD is mainly the consequence of this policy. However, it has been recently pointed out [5] that spontaneous labor accounts for half or more of PD in pregnant diabetics. Moreover in pregnant women with gestational diabetes PD rate due to spontaneous labor is three times higher than in the general obstetric population [5]. A different result emerges from our case study, 1963-1975. Insulin was administered to the maximal tolerated dose both in case of gestational and clinical diabetes [1, 6, 7, 8, 9, 10, 11, 12]. The incidence of PD due to spontaneous labor is 6.7% (7.1% in gestational and 6.1% in clinical diabetes), i.e. no difference from PD rate in general. Since 1974 M. Chartier, Paris, has been adopting the same therapeutic criteria [2]. His results seem to confirm that the risk of PD due to spontaneous labor drastically reduces in pregnant diabetics strictly controlled.

Maximal tolerated insulin therapy in gestational diabetes

Beginning in 1963 we have administered fast-acting insulin in three daily injections up to the maximal tolerated dose (M.T.D.), which can be defined as the highest quantity that can be given without bringing about hypoglycemic disturbances. This therapeutic criteria was applied both to gestational (280 pregnant women) and clinical (199 pregnant women) diabetes. M.T.D. was established on first admission to hospital and afterward controlled weekly in the outpatient clinic and during short periods of hospitalization (average of 53 days per patient). The average increase of the M.T.D. was 38 IU from 15 wk until delivery. As regards maternal blood sugar, at the M.T.D. average values at fasting and over the 24-h period were very close to the corresponding values of the control group (normal pregnancy). Total perinatal mortality (P.M.) was 2.9%; in the gestational diabetes group it was 2%. The incidence of congenital malformations (C.M.) (2.4%) increased with the severity of diabetes. No congenital defects were observed in 96 infants of patients treated before the 15th wk. Labor started spontaneously in 90.4% of the cases. The incidence of cesarean section was 21% in patients in White's Classes Al and A2 (as recently redefined by Freinkel and Metzger8) and 28% in other classes and that of forceps and vacuum extraction was 1% and 6%, respectively. The incidence of small-for-dates and overweight newborns from mothers with gestational and clinical diabetes without vascular complications is consistent with normal figures (macrosomia 3.4%). Small-for-dates newborns from pregnant diabetic women with vascular complications had a significant incidence. Respiratory distress syndrome (RDS) was 0.6% and hypoglycemia was 13.4%. No case of death was due to these two causes. Clinical results are discussed.

Pharmacological profile of BR-931, a new hypolipidemic agent that increases high-density lipoproteins

BR-931 [4-chloro-6-(2,3-xylidino)-2-pyrimidinylthio-(N-beta-hydroxyethyl)-acetamide], a new hypolipidemic agent of low toxicity, was evaluated in several tests of lipolysis and hyperlipidemia in rats, and in the cholesterol-induced atherosclerosis in rabbits. Significant hypolipidemic activity was observed in rats with doses of the agent at 12.5--50 mg/kg. In the Triton-induced hyperlipidemia, 50 mg BR-931 per kg was equieffective as 200 mg of clofibrate (CPIB) per kg. In contrast with CPIB, BR-931 exerted a powerful antilipolytic activity against epinephrine, ACTH, nicotine and cold exposure. BR-931 was particularly effective in diet-induced hyperlipidemias. Ethanol lipemia was totally prevented by the agent at 100 mg/kg. With Nath's diet, doses as low as 25 mg/kg significantly reduced hypercholesterolemia and hypertriglyceridemia. In these last two tests, the distribution of lipoprotein cholesterol was also determined. CPIB did not affect HDL cholesterol levels that had been decreased by the diets; in contrast, BR-931, already at doses of 50 mg/kg, brought the HDL/total cholesterol ratio back toward normal. A significant HDL cholesterol increase, together with some reduction of atheromatosis, was also observed in cholesterol-fed rabbits. BR-931, a potent inducer of liver peroxisones and of mitochondrial carmitine acetyltransferase, appears to be a hypolipidemic agent of high efficacy and low toxicity for the clinical treatment of hyperlipidemias and atherosclerosis.