Debates in allergy medicine: Specific immunotherapy in children with atopic dermatitis, the “con” view

Abstract

Atopic dermatitis (AD) is a common chronic skin condition in children that has a proven association with other atopic conditions and allergies. These associations, like the general pathophysiology of AD, are complex and not fully understood. While there is evidence for the efficacy of specific immunotherapy (SIT) in pediatric asthma and allergic rhinitis (AR), there is a lack of strong data to support its use in AD. IgE has been shown to be elevated in many patients with AD, but it is an unreliable biomarker due to variability and great fluctuation over time, poor positive predictive value for clinically relevant allergy, and poor correlation with disease state. In spite of this, almost all studies of SIT use either positive skin prick testing (SPT) or serum specific IgE levels to guide therapy. Allergen avoidance, with some exceptions, is generally not effective at controlling AD in children. The few studies that have investigated the efficacy of SIT in children with AD have produced conflicting results, and a lack of reproducibility with a standard treatment protocol. Limited studies have shown clinical improvement in mild to moderate AD cases, but no effect on more severe patients. Uncontrolled studies are difficult to interpret, due to the natural history of remission or “outgrowing” of AD over time in many patients without specific interventions. Drawbacks to SIT include the length of treatment, poor compliance, cost, and potential side effect profile. The potential for misdirection of time and energy away from skin directed therapy could negatively impact on AD outcomes.

Atopic dermatitis yardstick: Practical recommendations for an evolving therapeutic landscape

“…Allergen-specific immunotherapy, sublingual or subcutaneous, is currently not a recommended treatment for AD but remains a topic of discussion and study. [99][100][101][102] A trial can be considered for some patients with a positive allergen test (eg, skin prick test, specific IgE) reaction and a history of AD symptoms being triggered by exposure to that allergen. In particular, the Atopic Dermatitis Practice Parameter Update states that the clinician might consider immunotherapy in selected patients with AD and aeroallergen sensitivity, but the data for this option are of limited quality.…”

“…In particular, the Atopic Dermatitis Practice Parameter Update states that the clinician might consider immunotherapy in selected patients with AD and aeroallergen sensitivity, but the data for this option are of limited quality. [99][100][101][102] Most case reports and published studies have described outcomes in patients with documented house dust mite, birch, or grass pollen sensitivities. Sublingual immunotherapy has been studied as an option for patients with milder disease 58,102 ; subcutaneous immunotherapy has shown better results than sublingual immunotherapy for patients with more severe symptoms, particularly those with house dust mite sensitivity.…”

World Allergy Organization Journal: the Editors Look Back at 2016

“…An international group of experts from different continents evaluated the associated risks and proposed optimal safety measures of a high practical value for allergists and other doctors caring for allergic patients [7]. While allergen immunotherapy is well accepted in allergic rhinitis and asthma, its applicability in atopic patients with eczema is still discussed, and this topic was taken up in two opposing articles within the Debates in Allergy Medicine series [8, 9]. The high access numbers for those articles strongly illustrate the interest in this topic among the readership.…”

Management of Children with Atopic Dermatitis: A Narrative Review

“…The summary of the data at present does not warrant the use of SIT in children with AD. Using sub-lingual immunotherapy in AD is under study and more evidence is needed to support its clinical use (42). However, in another study, SIT (especially subcutaneous immunotherapy), was considered for selected patients with house dust mite, birch or grass pollen sensitization, who had severe AD, a positive corresponding atopy patch test and didn't show a good response to conventional treatments.…”