Anti-immunoglobulin E in the treatment of refractory atopic dermatitis

Abstract

Atopic dermatitis (AD) is a chronic and relapsing inflammatory skin disease affecting > 10% of children and 1-3% of adults, and can cause significant morbidity. The incidence of AD seems to be increasing. Omalizumab, a monoclonal antibody, has recently been suggested as a potential new systemic treatment for patients with recalcitrant AD with elevated IgE levels, based on its efficacy in treating asthma and allergic rhinitis. We report a study of 10 patients with AD (aged 19-35 years) who received anti-IgE treatment for persistent asthma. All patients, regardless of IgE value, were treated with a fixed schedule of eight cycles of omalizumab 300 mg administered subcutaneously at intervals of 2 weeks. Eczema symptoms were scored at baseline and after 2, 4 and 6 months of treatment. There was a steady improvement in the objective SCORAD (SCORing Atopic Dermatitis), with significantly lower scores observed at the 6-month evaluation. At 2 months after the end of treatment, two patients had a very good result (SCORAD reduction of > 50%), five patients had a satisfactory result (reduction of 25-50%), and three patients had no clinically relevant result (reduction of 25-50%). No patient had worsening of the AD (increase of > 25% in SCORAD), and once a clinical improvement occurred, none of the patients experienced worsening of their eczema symptoms while on omalizumab. With the caveats of the financial expense and unknown long-term risks of malignancy associated with omalizumab, this drug should be considered for treatment-resistant patients with AD, particularly patients with high IgE level whose symptoms are not controlled by routine therapies. Omalizumab has proven useful in treating asthma, but it may also prove valuable for other conditions, such as allergic rhinitis, food allergies, chronic urticaria, and AD, as shown by the present study.

The translational revolution and use of biologics in patients with inflammatory skin diseases

“…142 However, its efficacy in patients with AD is controversial despite its ability to displace FcεRI on target cells. [143][144][145][146] This again supports the argument against IgE as a key driver of AD. Moreover, treatment of patients with severe AD with cyclosporine resulted in clearance of disease despite unchanged serum IgE levels.…”

Intrinsic atopic dermatitis shows similar TH2 and higher TH17 immune activation compared with extrinsic atopic dermatitis

“…Although we did not detect increased protein expression of the high affinity IgE receptor (FcεRI) in lesional extrinsic AD skin, its increased expression, previously noted on IDECs by flow cytometry, 3,54,55 might provide a molecular target for IgE binding that potentially influences more complex immunological circuits in the skin. Although a few reports showed inconclusive effects of anti IgE targeting, 56–58 the benefit from such an intervention still needs to be determined, particularly for extrinsic AD.…”

Systemic Treatment of Adult Atopic Dermatitis: A Review

“…Conversely, more significant results in limiting AD skin symptoms have been reported in patients with concomitant AD and bronchial asthma by small case series involving almost 40 subjects [120–124]. For example, Kim et al reported that 7/10 (70%) of patients with AD who received omalizumab for persistent asthma experienced improvement in SCORAD scores; however, no placebo group was included in the study [123]. Moreover, a prospective analysis including 21 patients (14–64 years old) with moderate-to-severe persistent allergic asthma and AD showed a statistically significant clinical improvement of AD in all patients [124].…”