Dupilumab progressively improves systemic and cutaneous abnormalities in patients with atopic dermatitis

Upadacitinib Drug Survival in the Management of Patients With Moderate to Severe Atopic Dermatitis: Real-Time Data From the Biogrid Database Registry

BACKGROUND/OBJECTIVES

Atopic dermatitis (AD) is a chronic inflammatory skin disorder significantly affecting quality of life and healthcare resources. Upadacitinib has been recently approved for ad treatment in Australia and offers a promising alternative to traditional systemic therapies. However, real-world data on their long-term effectiveness, particularly drug survival (the time from treatment initiation to discontinuation), remain scarce. This study aims to investigate the drug survival rate and factors affecting the drug survival of Upadacitinib in ad patients.

METHOD

In this retrospective analysis, we included 21 adults with moderate to severe AD from the Royal Melbourne Hospital electronic medical records. Drug survival rates were analysed using Kaplan-Meier survival estimates, reasons for discontinuation were examined, and cox-proportional analysis was utilised to investigate factors affecting drug survival.

RESULTS

Upadacitinib demonstrated a high treatment retention rate, with a survival probability of 90.5% by the end of the 4-week mark. Reasons for discontinuation included factors affecting drug survival, concurrent infections, side effects, and loss of efficacy.

CONCLUSION

These findings indicate that Upadacitinib may offer a longer-lasting treatment option with good overall retention in ad management. Real-world data such as these provide crucial insights for dermatologists in choosing appropriate therapies, potentially enhancing patient satisfaction, adherence, and long-term outcomes. Further studies with larger sample sizes and diverse populations are recommended to validate these findings and guide treatment strategies.

Stapokibart for moderate-to-severe seasonal allergic rhinitis: a randomized phase 3 trial

Seasonal allergic rhinitis (SAR) places a significant socioeconomic burden, particularly on individuals with poorly managed recurrent and severe symptoms despite standard-of-care treatment. Stapokibart, a humanized monoclonal antibody that targets the interleukin (IL)-4 receptor subunit alpha, inhibits its interaction with both IL-4 and IL-13 in type 2 inflammation. Here we aim to assess the efficacy and safety of stapokibart as an add-on therapy in adults with moderate-to-severe SAR. The study was a phase 3 multicenter, randomized, double-blind, placebo-controlled clinical trial with 108 patients diagnosed with moderate-to-severe SAR and having baseline blood eosinophil counts ≥300 cells μl-1. Participants were randomized (1:1) to receive 600 mg (loading dose) to 300 mg stapokibart subcutaneously or a placebo every 2 weeks for 4 weeks. The primary endpoint was mean change from baseline in daily reflective total nasal symptom score (rTNSS) over the first 2 weeks. Multiplicity-tested secondary endpoints included changes in rTNSS over 4 weeks, reflective total ocular symptom score and Rhinoconjunctivitis Quality of Life Questionnaire score over 2 weeks and 4 weeks. Compared with the placebo, stapokibart led to a significant improvement in the mean change from baseline in daily rTNSS during the 2-week (least-squares mean difference, -1.3; 95% confidence interval, -2.0 to -0.6; P = 0.0008) and 4-week (least-squares mean difference, -1.7; 95% confidence interval, -2.5 to -0.8; P = 0.0002) treatments. Stapokibart significantly improved the multiplicity-tested secondary endpoints. Treatment-emergent adverse events were comparable between the groups. Pharmacodynamics and exploratory analyses indicated that the observed improvements in outcomes during pollen season may be attributed to the reduction of type 2 inflammation in response to stapokibart treatment. The results of this trial show that pollen seasonal administration of stapokibart improved both nasal and ocular symptoms and quality of life in patients with moderate-to-severe SAR. ClinicalTrials.gov registration: NCT05908032 .

Incidence of upper respiratory tract infections with biological therapies in moderate to severe atopic dermatitis: a systematic review and meta-analysis

Introduction

Atopic dermatitis (AD) is a chronic inflammatory skin condition affecting 5%-20% of children and 2%-10% of adults worldwide. Treatment for moderate-to-severe AD includes biologics like dupilumab, tralokinumab, lebrikizumab, and JAK inhibitors (abrocitinib, upadacitinib). However, upper respiratory tract infections (URTIs) are commonly reported adverse events for these therapies. This meta-analysis aims to estimate the pooled incidence of URTIs associated with these treatments compared to topicals.

Methods

A systematic search was conducted across PubMed, MEDLINE, DOAJ, and ClinicalTrials.gov for randomized controlled trials (RCTs) involving AD patients treated with dupilumab, tralokinumab, lebrikizumab, abrocitinib, or upadacitinib, excluding studies of patients treated with topicals, Studies on other dermatitis types and biologics. Data on URTI events, sample sizes, and incidence were extracted. Study quality was assessed using the Cochrane Risk of Bias Tool (RoB 2). A random-effects meta-analysis was conducted using the Netmeta package in R, calculating odds ratios (ORs) with 95% confidence intervals (CIs).

Results

From 413 retrieved records, 21 studies met the inclusion criteria. URTI incidence of the treatment group in the included studies ranged from 0.35% to 41.5%, while control groups showed rates between 0% and 40%. Across all studies, URTI incidence was 9.70% in intervention groups and 8.03% in placebo groups (MH OR = 1.18, 95% CI: 0.98-1.42). Heterogeneity was low (I 2 = 20.14%), with no evidence of publication bias (p = 0.83). There were no significant subgroup differences between patients taking different biological therapies (Q = 3.90, p = 0.42).

Conclusion

While URTIs are common adverse events for AD therapies, their incidence in intervention groups is similar to control, suggesting no significant increase in risk. These findings provide critical insights for clinicians in balancing efficacy and safety when selecting therapies for AD patients. Further research should explore patient-specific risk factors for URTIs.

Systematic review registration

Prospero registration code: [392093]. PROSPERO, Centre for Reviews and Dissemination: CRD42023392093.

Head and neck dermatitis: a variant of atopic dermatitis

Atopic dermatitis involves the head and neck area across all age groups. This manifestation is frequently referred to as "the head and neck dermatitis." Aside from a considerable deterioration of the quality of life, it poses a significant diagnostic and therapeutic challenge. The head and neck dermatitis may be mimicked by other inflammatory conditions such as seborrheic dermatitis or contact dermatitis. Furthermore, it can be associated with a wide range of infectious, ocular, psychiatric and hair disorders, which should raise clinical alertness and encourage a multidisciplinary management of the affected individuals. Skin lesions in the head and neck area are often difficult to treat, particularly because of a considerable exposure of this region to exacerbating factors and limitations regarding the use of some pharmaceuticals. Although several hypotheses explaining the recalcitrant course of head and neck dermatitis have been proposed, none of them provide successful solutions applicable in the daily clinical practice. This comprehensive review comprises the current insights on the pathogenesis, clinical presentation, and comorbidities of the head and neck dermatitis. Recommendations regarding possible treatments of this condition such as antifungals, as well as special considerations for the choice of biologics or JAK inhibitors in the candidates for systemic treatment are outlined.

Tralokinumab Treatment in Adult Atopic Dermatitis Patients: 28-Week Evaluation of Clinical Effectiveness, Safety, Serum Proteins and Total IgE Levels

INTRODUCTION AND OBJECTIVES

Tralokinumab-a biological that specifically targets interleukin-13-is one of the newer advanced systemic treatments for patients with moderate-to-severe atopic dermatitis (AD). Although safety and efficacy have been shown in phase-III clinical trials, daily practice data are needed. Therefore, the aim of this study was to evaluate 28-week safety and effectiveness, serum proteins and total IgE levels in adult AD patients treated with tralokinumab in daily practice.

MATERIALS AND METHODS

Data of all adult AD patients who started treatment with tralokinumab and participated in the BioDay registry were collected at baseline, and after 4,16 and 28 weeks of treatment. Clinical efficacy was evaluated by clinical outcome measures, such as the Eczema Area and Severity Index (EASI) as well as patient-reported outcome measures, such as the numerical rating scale (NRS) for pruritus. Adverse events were evaluated. In a subgroup of patients, 18 proteins as well as total IgE levels were measured in serum.

RESULTS

A total of 84 patients were included, of whom 39 were dupilumab-naïve (D-naïve) and 45 were dupilumab non-naïve (D-non-naïve) patients. All primary outcomes significantly improved during 28 weeks of tralokinumab treatment and the probability of achieving EASI ≤ 7 and NRS-pruritis ≤ 4 was 75.8% (56.9-88.2) and 51.4% (28.0-74.2), respectively. The disease severity-associated proteins TARC/CCL17 and PARC/CCL18 decreased during treatment, and total IgE levels significantly decreased in the D-naïve patients. The most reported adverse events were eye disorders (n = 24, 28.6%). A total of 23 patients (27.4%) discontinued treatment due to adverse events and/or ineffectiveness, with hair loss being the most common adverse event leading to treatment discontinuation (n = 6).

CONCLUSION

Tralokinumab is an effective treatment for moderate-to-severe AD in adult patients, in both dupilumab-naïve patients and patients who previously failed on dupilumab treatment. The clinical effect is supported by the biological data.

Regulatory role of annexin A1 in NLRP3 inflammasome activation in atopic dermatitis: insights from keratinocytes in human and murine studies

Despite the well-documented regulatory role of annexin A1 (ANXA1) in numerous stages of the inflammatory response, its involvement in regulating the NLRP3 inflammasome in the context of allergic responses has not been extensively investigated to date. This study evaluated the expression patterns of the ANXA1 and NLRP3 proteins in human skin samples obtained from patients with atopic dermatitis (AD) and in mice with ovalbumin (OVA)-induced experimental AD. Furthermore, the in vitro effect of the ANXA1 mimetic peptide Ac2-26 on IL-4-stimulated human keratinocytes was evaluated. IL-4-stimulated keratinocytes were treated with Ac2-26 (a mimetic peptide of ANXA1) in two different concentrations: 5 and 25 ng/mL. Additionally, some cells were treated with the pan-formyl peptide receptor antagonist Boc2 at a concentration of 10 µM, administered 15 min before Ac2-26. The NLRP3 protein demonstrated intense immunoreactivity in both murine and human AD skin samples, with NLRP3 and ANXA1 exhibiting particularly high coexpression in keratinocytes. A significant increase in ANXA1 and NLRP3 transcripts was observed in AD skins (GSE16161 study). ANXA1 transcript levels were elevated in the AD epidermis relative to the non-lesional epidermis, while NLRP3 transcript levels were reduced in the AD epidermis (GSE120721 study). The Ac2-26 treatment reduced the proliferation rate of IL-4-stimulated keratinocytes, an effect abolished by Boc2 and IL-1β and ROS production. In conclusion, our findings indicate that ANXA1 plays a role in regulating NLRP3 activation in keratinocytes, contributing to the pathogenesis of AD. KEY MESSAGES: ANXA1 and NLRP3 levels are upregulated and exhibit coexpression in murine and human AD skins. ANXA1-FPR axis regulates the proliferation of human keratinocytes under IL-4 stimulation. ANXA1-derived peptide Ac2-26 regulates oxidative stress and NLRP3 activation in human keratinocytes.

Phenotype-endotype relationship in elderly atopic dermatitis and effects of dupilumab therapy: prospective study

Atopic dermatitis is a chronic inflammatory systemic disease that can persist or start in adulthood, even in elderly age, with several clinical phenotypes. The aim of this study was to evaluate the relationship between phenotype and endotype in elderly patients, and the long-term effects of dupilumab on molecular signature in these patients. A total of 50 elderly patients had been treated with dupilumab during the follow up period. Regarding effectiveness parameters, mean EASI score at Week 0 was 25.12 ± 4.23 and significantly reduced to 2.42 ± 3.15 at Week 52 (p < 0.05). Regarding safety, none of the registered adverse events led to the discontinuation of dupilumab therapy. Moreover, after 52 weeks of dupilumab treatment, Th2 cytokines expression was decreased, with IL-13 and IL-31 downregulated in both patient groups at Week 52, at both gene and protein levels when compared with Week 0. Our data also revealed a significant increase in both IL-4 gene expression and protein production at Week 52 when compared with Week 0. Unexpectedly, our results also revealed that IL-22 cutaneous expression was significantly increased, while circulating levels were decreased at Week 52 when compared to Week 0. In conclusion, our results highlight the effectiveness of dupilumab at a late time point as Week 52. Of note, a dumping of the Th2- and Th17- immune response at both systemic and in situ level and a possible remodelling role of IL-22 in the skin is suggested.

Systemic barrier dysfunction in type 2 inflammation diseases: perspective in the skin, airways, and gastrointestinal tract

The epithelial barrier in different organs is the first line of defense against environmental insults and allergens, with type 2 immunity serving as a protective function. Genetic factors, and biological and chemical insults from the surrounding environment altered regulate epithelial homeostasis through disruption of epithelial tight junction proteins or dilated intercellular spaces. Recent studies suggest that epithelial barrier dysfunction contributes to pathologic alteration in diseases with type 2 immune dysregulation including (but not limited to) atopic dermatitis, prurigo nodularis, asthma, chronic rhinosinusitis with nasal polyps, and eosinophilic esophagitis. In this review, we summarized current understanding of dysfunction of barrier and its interaction with type 2 inflammation across different organs, and discussed the role of epithelial barrier disruption in the pathogenesis of type 2 inflammation. In addition, recent progresses of emerging barrier restorative therapies are reviewed.

AP2M1 as the potential biomarker for prediction of the response of atopic dermatitis to Dupilumab therapy: Multi-omics analysis and evidence

Many atopic dermatitis (AD) patients have suboptimal responses to Dupilumab therapy. This study identified key genes linked to this resistance using multi-omics approaches to benefit more patients. We selected a prospective cohort of 54 AD treated with Dupilumab from the GEO database. After identifying resistant genes via WGCNA and differential expression analysis, we used machine learning techniques to screen key genes and develop a predictive model. It was found that four key genes (AP2M1, BMP4, DNM1, and RHEB) were identified, showing excellent diagnostic performance for Dupilumab resistance (AUC = 0.832-0.861, P < 0.05) and validated in AD patients via RT-qPCR (P < 0.05). Among them, AP2M1 was significantly correlated with the clinical severity of AD (R = 0.5,P = 0.04) and identified as a potential risk factor (HR = 13.45, 95%CI(1.71-105.65), P = 0.02). The results of immunohistochemistry also revealed overexpression of AP2M1 in AD tissue (P = 0.002). Additionally, immune infiltration analysis suggested that AP2M1-mediated Dupilumab resistance may involve mast cells (R = -0.51, P = 0.02), which also supported by single-cell analysis. And we constructed a regulatory network of AP2M1. Finally, we explored the drug Fostamatinib, targeting AP2M1. In conclusion, AP2M1 may serve as a biomarker for those AD patients exhibiting suboptimal responses to Dupilumab.

Interleukin-4 and Atopic Dermatitis: Why Does it Matter? A Narrative Review

Atopic dermatitis (AD) is a common chronic inflammatory skin condition that significantly impairs patients' quality of life as a result of intense itching and persistent eczematous lesions. Although AD has a multifaceted etiology-including genetic predisposition, environmental triggers, barrier dysfunction, and dysregulated immune responses-interleukin-4 (IL-4) has a recognized central role in its pathogenesis. This narrative review explores the role of IL-4 in the pathophysiology of AD, its contribution to the atopic march, and the therapeutic impact of IL-4 inhibition. IL-4 plays a critical role in skin barrier dysfunction, dysbiosis, pruritus, and inflammation, all of which contribute to the debilitating symptoms of AD. Moreover, IL-4 is implicated in other atopic conditions, such as asthma, allergic rhinitis, and food allergies, underscoring its role beyond AD and its importance in the atopic march. Recent advances in targeted therapies, particularly IL-4/IL-13 signaling inhibitors, have changed AD management. Dupilumab, an IL-4 receptor antagonist, has demonstrated significant efficacy in reducing AD symptoms and enhancing patient outcomes in both children and adults. In addition to symptomatic relief, suppressing IL-4 signaling may also offer potential for disease modification, altering AD's progression and possibly preventing the onset of other atopic conditions. This review highlights the crucial role of IL-4 as a therapeutic target in AD. By understanding the role of IL-4 in AD pathogenesis and exploring the therapeutic implications of targeting IL-4 pathways, this work can contribute to guide future research concerning treatment approaches and also emphasize the need for early and targeted interventions to mitigate disease impact and ultimately improve patient quality of life.

Allergen immunotherapy and dupilumab in atopic dermatitis: Clinical efficacy and disparities in immunological indicators

Objective

Allergen immunotherapy (AIT) and dupilumab have been confirmed to improve symptoms of atopic dermatitis (AD); however, the precise immune mechanisms underlying their efficacy and whether they can elicit synergistic immune effects remain not fully elucidated. We aimed to investigate the clinical efficacy and immunological changes in AD patients undergoing AIT, dupilumab, and a combination of AIT and dupilumab treatment.

Methods

Clinical data, serum samples, and peripheral blood mononuclear cells (PBMC) were collected from house dust mite (HDM)-sensitized AD patients receiving AIT and/or dupilumab at baseline and 6 months. Changes in clinical efficacy, HDM-specific IgE and IgG4, serum cytokines, and lymphocyte subgroups were compared among the treatment groups.

Results

A total of 77 AD patients were included, with 39 in the AIT group, 19 in the dupilumab group, and 19 in the AIT combined dupilumab group. The SCORAD scores significantly improved in all groups after 6 months. Levels of HDM-specific IgE and total IgE remained stable in the AIT group but decreased in the dupilumab and combination groups. Levels of IgG4 against major mite components Der p1 and Der p23 increased in the AIT group and combined treatment group. Serum cytokine levels showed no significant changes, except for a decrease in CCL17 in the dupilumab group. Th1/Th2 and Th17/Th2 ratios increased after dupilumab treatment. There were notable differences in T cell subpopulations when PBMCs were stimulated with HDM extracts after 6-month treatment, tSNE analysis showed the proportion of IL-4+IL-13+CRTH2+T cells increased in the dupilumab group but had no changes in the AIT and combination group.

Conclusions

AIT, dupilumab, and their combination improved clinical symptoms and quality of life in AD patients. AIT promoted allergen-specific IgG4 production, while dupilumab modulated T cell responses and reduced allergen-specific IgE synthesis. The combination of AIT and dupilumab exhibited the immunological parameter changes characteristic of both treatments but did not result in a significantly greater improvement in AD symptoms.

Dupilumab successfully controlled eczema in Wiskott-Aldrich Syndrome over 52 weeks

IMPACT STATEMENT

Wiskott-Aldrich syndrome (WAS) is a rare genetic disorder characterized by immunodeficiency, thrombocytopenia, and eczema. The Management of eczema remains still a major clinical challenge. We present a rare case of eczema associated with WAS in an 8-year-old boy whose lesions significantly improve after a 4-week treatment of dupilumab, a interleukin(IL)-4α receptor monoclonal antibody. Although eczema relapsed after stopping dupilumab, and alleviated after dupilumab was resumed. Finally, the Eczema Area and Severity Index (EASI) score decreased to less than 7 after the patient receive dupilumab 300 mg every 4 weeks over 52 weeks. This case suggests that dupilumab is a promising therapy alternative for patient with eczema in WAS.

Efficacy and Safety of Dupilumab in Treating Intrinsic and Extrinsic Atopic Dermatitis in Older Patients With and Without Atopic Comorbidities: A Retrospective Study

Background: Despite the widespread use of dupilumab in atopic dermatitis (AD) treatment, evidence supporting its use in older patients with intrinsic AD (IAD) versus those with extrinsic AD (EAD) and in those with and without atopic comorbidities remains limited. Objective: We aimed to assess the clinical efficacy and safety of dupilumab treatment in elderly patients with IAD versus EAD and in those with and without atopic comorbidities. Methods: We enrolled 113 older patients with severe AD who received dupilumab for 48 weeks. The inclusion criteria were age ≥60 years and Scoring Atopic Dermatitis ≥25. Patients were classified as IAD or EAD and based on the presence of atopic comorbidities. The primary outcome was a reduction in the Eczema Area and Severity Index, Numeric Rating Scale, Dermatology Life Quality Index, and Atopic Dermatitis Control Test. Secondary measures were the types and rates of adverse events. Results: Dupilumab treatment resulted in a substantial improvement in AD symptoms, with no significant difference between patients with IAD and EAD or those with and without atopic comorbidities. Conclusions: Dupilumab showed good efficacy and safety in improving AD symptoms in older patients, irrespective of IAD or EAD subtypes and the presence of atopic comorbidities.

Tape-strip profiling identifies unique immune and lipid dysregulation in patients with seborrheic dermatitis

BACKGROUND

Seborrheic dermatitis (SD) is a common, chronic inflammatory skin disease with limited understanding of its pathophysiology. Molecular profiling has been limited by invasiveness of sampling methods.

OBJECTIVE

To analyze the molecular skin profile of adult patients with SD using tape strips.

METHODS

Tape-strips obtained from facial lesions of 26 adult SD patients and 18 demographically matched healthy controls were evaluated with RNA sequencing.

RESULTS

SD molecular skin fingerprint was characterized by strong and significant upregulation of interleukin (IL)23/T-helper (Th)17 and Th22 (i.e. IL23A, IL22, PI3, LL37, S100A8, S100A12), some Th1 skewing (OASL, STAT1, CXCL9), and limited Th2 modulation. A parallel downregulation of barrier markers (CLDN1/8, FA2H, ELOVL3) was also observed.

LIMITATIONS

Limited representation of mild and severe SD patients.

CONCLUSION

These data deepen our understanding of SD suggesting that it has robust Th17/Th22, some Th1 skewing, and minimal Th2 activation, and associated skin barrier alterations. This provides rationale for novel immunomodulatory treatment approaches for SD patients targeting IL23/Th17 and/or Th22 pathways.

Biologics and airway remodeling in asthma: early, late, and potential preventive effects

Although airway remodeling in severe and/or fatal asthma is still considered irreversible, its individual components as a cause of clinical symptoms and/or lung function changes remain largely unknown. While inhaled glucocorticoids have not consistently been shown to affect airway remodeling, biologics targeting specific pathways of airway inflammation have been shown to improve lung function, mucus plugging, and airway structural changes that can exceed those seen with glucocorticoids. This superiority of biologic treatment, which cannot be solely explained by insufficient doses or limited durations of glucocorticoid therapies, needs to be further explored. For this field of research, we propose a novel classification of the potential effects of biologics on airway remodeling into three temporal effects: early effects (days to weeks, primarily modulating inflammatory processes), late effects (months to years, predominantly affecting structural changes), and potential preventive effects (outcomes of early treatment with biologics). For the identification of potential preventive effects of biologics, we call for studies exploring the impact of early biological treatment on airway remodeling in patients with moderate-to-severe asthma, which should be accompanied by a long-term evaluation of clinical parameters, biomarkers, treatment burden, and socioeconomic implications.

Emerging biological treatments for asthma

INTRODUCTION

Severe asthma is a chronic airway disease characterized by many pathomechanisms known as endotypes. Biological therapies targeting severe asthma endotypes have significantly improved the treatment of this disease, thus remarkably bettering patient quality of life.

AREAS COVERED

This review aims to describe current biological therapies for severe asthma, highlighting emerging ones. Several studies have confirmed the beneficial effects of currently available monoclonal antibodies targeting immunoglobulin E (IgE), interleukin-5 (IL-5) or its receptor, and interleukin-4 (IL-4)/interleukin-13 (IL-13) receptors (IL-4R/IL-13R). However, patients with T2-low asthma are not eligible for the above biological therapies.

EXPERT OPINION

New treatments are now moving toward targeting the upstream pathways of asthma pathogenesis, coordinated by innate cytokines such as alarmins. These key proinflammatory mediators orchestrate the activation of complex cellular networks including both innate and adaptive immune responses. Alarmins include thymic stromal lymphopoietin (TSLP), interleukin-25 (IL-25), and interleukin-33 (IL-33), which are released from injured airway epithelial cells. TSLP and the other alarmins are suitable targets of biological therapies which are effective for add-on treatment of type 2 asthma. Moreover, anti-alarmin monoclonal antibodies can be also beneficial for patients with T2-low, poorly controlled severe asthma.

Longitudinal integrated proteomic and metabolomic skin changes in patients with atopic dermatitis treated with dupilumab

BACKGROUND

Inhibition of IL-4/IL-13-driven inflammation by dupilumab has shown significant clinical benefits in treatment of atopic dermatitis (AD).

OBJECTIVE

Our aim was to assess longitudinal protein and metabolite composition in AD skin during dupilumab treatment.

METHODS

Skin tape strips (STSs) were collected from lesional/nonlesional skin of 20 patients with AD during a 16-week dupilumab treatment course and from 20 healthy volunteers (HVs) followed for 16 weeks. STS extracts were examined by liquid chromatography-mass spectrometry proteomic analysis and targeted metabolomics.

RESULTS

Approximately 2500 individual proteins were identified in the STS extracts. Of those proteins, 490 were present in at least 80% of the AD and HV skin samples and differentially expressed in the AD skin; the levels of 249 proteins were significantly reduced (cluster 1), and the levels of 136 were significantly increased (cluster 2) in the AD skin versus in the HV skin (both P < .0001). Functionally, cluster 1 included proteins involved in epidermal barrier formation, lysosomal enzymes required for lamellae assembly, and oxidative response. Cluster 2 was enriched for markers of epidermal hyperplasia, glycolytic enzymes, and actin filament proteins. A significant increase in cluster 1 and a significant inhibition of cluster 2 proteins expression were achieved in AD skin by 16 weeks of dupilumab treatment (P < .0001 for both vs baseline), approaching the levels in HV skin. These improvements were also revealed in differential metabolite changes in the STS extracts, including amino acids, nucleotide breakdown products, and antioxidants.

CONCLUSION

Longitudinal integrated assessment of the skin proteome and metabolome in patients with AD who were treated with dupilumab established significant inhibition of epidermal hyperplasia and improvement in epidermal differentiation. The identified changes were linked to improvements in clinical AD skin assessments, including improvements in transepidermal water loss and disease severity.

The cardiometabolic safety of dupilumab in atopic dermatitis: A global large-scale cohort study

BACKGROUND

A low risk of cardiovascular and metabolic outcomes was found in the randomized clinical trials of dupilumab in atopic dermatitis (AD). Dupilumab-associated real-life long-term cardiometabolic risk relative to other systemic agents is yet to be precisely investigated.

OBJECTIVE

To assess the risk of cardiometabolic outcomes in patients with AD treated with dupilumab relative to those treated with methotrexate and cyclosporine.

METHODS

A global retrospective cohort study comprised two distinct analyses comparing patients with AD under different treatments: (i) initiators of dupilumab (n = 10,151) versus methotrexate (n = 10,151) and (ii) initiators of dupilumab (n = 6,629) versus TNFi (n = 6,629). Study groups were compared regarding the risk of 8 cardiovascular and 4 metabolic outcomes during the initial three years following drug initiation. Propensity score matching was conducted to optimize inter-group comparability.

RESULTS

Compared to methotrexate, dupilumab was associated with a decreased risk of peripheral vascular disease (PVD; hazard ratio [HR], 0.64; 95% confidence interval CI 0.45-0.90; P = 0.011), deep vein thrombosis (DVT; HR, 0.42; 95% CI, 0.26-0.69; P < 0.001), hypertension (HR, 0.67; 95% CI, 0.58-0.79; P < 0.001), type-2 diabetes mellitus (T2DM; HR, 0.53; 95% CI, 0.42-0.68; P < 0.001), and obesity (HR, 0.70; 95% CI, 0.58-0.86; P = 0.001) within the first year of treatment. Relative to cyclosporine, dupilumab conferred a lower risk of hypertension (HR, 0.52; 95% CI, 0.45-0.62; P < 0.001), hyperlipidemia (HR, 0.59; 95% CI, 0.49-0.71; P < 0.001), and T2DM (HR, 0.62; 95% CI, 0.48-0.81; P < 0.001), CONCLUSION: Dupilumab possesses a favorable cardiometabolic safety profile and might be preferred in patients with susceptibility and risk factors of these conditions.

Skin microbiota: pathogenic roles and implications in atopic dermatitis

Atopic dermatitis (AD) is a chronic and inflammatory skin disorder characterized by impaired barrier function and imbalanced immunity. Recent advances have revealed that dysbiosis of skin microbiota plays important roles in the pathogenesis and development of AD. Meanwhile, endogenous and external factors contribute to the dysbiosis of skin microbiota in AD. Additionally, various treatments, including topical treatments, phototherapy, and systemic biologics, have demonstrated positive impacts on the clinical outcomes, alongside with the modulations of cutaneous microbiota in AD patients. Importantly, therapeutics or products regulating skin microbiota homeostasis have demonstrated potential for AD treatment in early clinical studies. In this review, we underline changes of the skin microbiota correlated with AD. Meanwhile, we provide an overview of the skin microbiota regarding its roles in the pathogenesis and development of AD. Finally, we summarize therapeutic strategies restoring the skin microbial homeostasis in AD management.

Preventing NLRP3 inflammasome activation: Therapeutic atrategy and challenges in atopic dermatitis

Atopic dermatitis (AD) is a prevalent inflammatory skin disorder characterized by its chronic, persistent, and recurrent nature. The pathophysiology of this condition is complex, involving various factors including cell-mediated immune responses, compromised skin barrier function, and alterations in hypersensitivity reactions. These components synergistically contribute to the perpetuation of the bothersome "itch-scratch-itch" cycle. Recent research has highlighted the significant role of the NLRP3 inflammasome in the development of AD and other inflammatory conditions. Current research indicates that the NLRP3 inflammasome plays a pivotal role in both the acute and chronic phases of AD by modulating the Th2/Th1 immune deviation. Moreover, the pharmacological suppression of NLRP3 has shown promising results in mitigating the pathological aspects of AD. This review outlines potential drug development strategies that target the NLRP3 inflammasome as a therapeutic approach for AD and the challenges faced in this endeavor.

Multiomics dissection of human RAG deficiency reveals distinctive patterns of immune dysregulation but a common inflammatory signature

Human recombination-activating gene (RAG) deficiency can manifest with distinct clinical and immunological phenotypes. By applying a multiomics approach to a large group of RAG-mutated patients, we aimed at characterizing the immunopathology associated with each phenotype. Although defective T and B cell development is common to all phenotypes, patients with hypomorphic RAG variants can generate T and B cells with signatures of immune dysregulation and produce autoantibodies to a broad range of self-antigens, including type I interferons. T helper 2 (TH2) cell skewing and a prominent inflammatory signature characterize Omenn syndrome, whereas more hypomorphic forms of RAG deficiency are associated with a type 1 immune profile both in blood and tissues. We used cellular indexing of transcriptomes and epitopes by sequencing (CITE-seq) analysis to define the cell lineage-specific contribution to the immunopathology of the distinct RAG phenotypes. These insights may help improve the diagnosis and clinical management of the various forms of the disease.

The Association of Inflammatory Indexes Derived from Peripheral Blood Cell Count and Clinical Signs with Response to Treatment with Dupilumab in Pediatric Patients with Moderate-to-Severe Atopic Dermatitis

Background

Dupilumab is a safe and effective treatment for moderate to severe atopic dermatitis (AD), but real-world data in pediatric patients in China are limited. Currently, there is no exploration of changes in blood cell counts derived indexes in pediatric patients, especially under 6 years old.

Purpose

To investigate the changes in blood cell counts derived indexes before and after dupilumab treatment in Chinese children with AD, the relationship with clinical scores, and the potential role of these indexes on treatment efficacy.

Patients and Methods

We conducted a retrospective study of 109 children with moderate to severe AD treated with dupilumab. Derived inflammatory indexes, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), eosinophil-to-lymphocyte ratio (ELR), eosinophil-to-neutrophil Ratio (ENR), monocyte-to-lymphocyte ratio (MLR), inflammation response index (SIRI), systemic inflammation index (SII), and aggregate inflammation systemic index (AISI) were calculated. The correlation between clinical scores and inflammatory indexes at different treatment time points were analyzed. Logistic regression and ROC curve was employed to explore factors associated with treatment efficacy.

Results

Baseline ELR and ENR were positively correlated with the baseline Eczema Area and Severity Index (EASI) and the Scoring Atopic Dermatitis (SCORAD). Additionally, baseline ENR levels showed a positive correlation with the baseline Peak Pruritus Numeric Rating Scale (PP-NRS). At 4 and 16 weeks of treatment, the percentage reduction in ELR was significantly associated with the percentage reduction in EASI and PP-NRS. Logistic regression results indicated that high baseline ELR could predict a poor response to dupilumab treatment.

Conclusion

ELR was significantly correlated with disease severity score during the treatment with dupilumab. Baseline ELR could act as a predictor of the efficacy of dupilumab in the treatment of children with atopic dermatitis under 6 years of age.

The Role of OX40-OX40L Axis in the Pathogenesis of Atopic Dermatitis

OX40 is a co-stimulatory immune checkpoint molecule that promotes the activation and the effector function of T lymphocytes through interaction with its ligand (OX40L) on antigen-presenting cells. OX40-OX40L axis plays a crucial role in Th1 and Th2 cell expansion, particularly during the late phases or long-lasting response. Atopic dermatitis is characterized by an immune dysregulation of Th2 activity and by an overproduction of proinflammatory cytokines such as interleukin (IL)-4 and IL-13. Other molecules involved in its pathogenesis include thymic stromal lymphopoietin, IL-33, and IL-25, which contribute to the promotion of OX40L expression on dendritic cells. Lesional skin in atopic dermatitis exhibits a higher level of OX40L+-presenting cells compared with other dermatologic diseases or normal skin. Recent clinical trials using antagonizing anti-OX40 or anti-OX40L antibodies have shown symptom improvement and cutaneous manifestation alleviation in patients with atopic dermatitis. These findings suggest the relevance of the OX40-OX40L axis in atopic dermatitis pathogenesis.

Drug Survival, Retention, and Persistence of Dupilumab in Adults and Adolescents with Atopic Dermatitis: A Narrative Literature Review

Atopic dermatitis (AD) is a chronic, relapsing inflammatory skin condition that can have a negative impact on a patient's quality of life. Long-term effectiveness is required to manage the symptoms of AD (skin inflammation, eczematous lesions, and itching). Because some of the systemic immunosuppressants used to treat AD have been associated with serious adverse events (AEs), other safer, more effective options, including dupilumab, have been proven effective long-term for treatment of adult and adolescent patients with moderate-to-severe AD. The long-term safety and effectiveness of a drug are usually confirmed in real-world studies by evaluating its performance over time. Measures such as drug survival, drug retention, drug persistence, or retention rates reflect whether treatment may be considered as satisfactory by both patients and physicians, meeting key clinical needs. This review aimed to describe the survival, retention, or persistence of dupilumab therapy in adults and adolescents with moderate-to-severe AD by conducting a PubMed search in March 2023 and screening for relevant publications. Globally, real-world studies with dupilumab have regularly reported high drug survival rates after 1, 2, and 3 years of observation, being consistently at 80-90%, with low rates of treatment discontinuation due to lack of efficacy or AEs. These findings are notably higher than 1- and 2-year drug survival rates of systemic immunosuppressants (including cyclosporine [37% and 20%, respectively] and methotrexate [41% and 33%, respectively]). Overall, real-world data on drug survival have confirmed that dupilumab provides long-term sustained efficacy and acceptable safety in patients with moderate-to-severe AD.

Tralokinumab Treatment of Atopic Dermatitis Induces a Progressive Transcriptomic Response

Atopic dermatitis is characterized by a complex epidermal barrier deficiency and exaggerated immune responses dominated by type 2 mechanisms with variable contributions of additional immune axes. IL-13 is overexpressed in atopic dermatitis skin and a key driver of both barrier dysfunction and inflammation. In this study, we prospectively studied the effects of IL-13 inhibition with tralokinumab on cutaneous transcriptome profiles using RNA sequencing of biopsies from 16 patients with moderate-to-severe atopic dermatitis obtained at baseline, week 2, and week 16. Tralokinumab therapy induced early and delayed expression changes and progressively shifted the transcriptomic profile of lesional toward nonlesional skin by modulating both genes associated with keratinocyte proliferation and differentiation, itch signaling, and downstream inflammatory responses. At week 16, 751 genes were still significantly dysregulated compared with those in healthy control skin, reinforcing the need for long-term immunomodulatory therapy of moderate-to-severe atopic dermatitis to achieve deep responses. The study was registered with ClinicalTrials.gov (NCT04556461).

Histological features of immune cell infiltrate in lesional skin correlate with therapeutic response to dupilumab

Over the past decade, dupilumab, a monoclonal human antibody that inhibits interleukin (IL)-4 and IL-13 signalling, has revolutionized the therapeutic management of moderate-to-severe atopic dermatitis (AD), facilitating long-term control of its signs and symptoms. The aim of this study was to identify histological predictors of the efficacy of dupilumab after 16 weeks of treatment in a cohort of 40 adults with moderate-to-severe AD who had undergone a skin biopsy for diagnostic purposes before treatment initiation. We found that Eczema Area and Severity Index (EASI) 75 and EASI 90 responses at week 16 were significantly associated with perivascular localization [odds ratio (OR) 17.6; P = 0.04] and lichenoid distribution (OR 31.8; P = 0.03) of the immune infiltrate. Moreover, for each unit increase in the number (cells mm-2) of CD4+ cells, the likelihood of achieving an EASI 75 response decreased by 1% (OR 0.99; P = 0.04). In conclusion, our study found promising pretreatment immunohistochemical markers that could predict how well patients with AD respond to dupilumab.

The changes of intestinal flora and metabolites in atopic dermatitis mice

Introduction

Atopic dermatitis (AD) is an allergic disease caused by various factors that can affect an individual's appearance and cause psychological stress. Therefore, it is necessary to investigate the underlying mechanisms and develop effective treatment strategies. The gut microbiota and bacterial metabolism play crucial roles in human diseases. However, their specific role in AD remains unclear.

Methods

In this study, we established a mouse model of AD and found that 2,4-dinitrofluorobenzene disrupted the skin barrier in mice. The species composition of intestinal bacteria was then analyzed by fecal 16s rRNA sequencing. The metabolic level of mice was analyzed by untargeted and targeted metabolomics in stool.

Results

The levels of filaggrin and aquaporin 3 proteins in the model mice and total superoxide dismutase, catalase and malondialdehyde levels were significantly altered. Additionally, inflammatory factors such as tumor necrosis factor-alpha showed a significant increase. Using 16S rRNA gene sequencing, we identified 270 bacterial species with altered abundances of Ruminococcaceae and Bifidobacteriaceae. The untargeted metabolomic analysis detected 1,299 metabolites. Targeted analysis of free fatty acids revealed 49 metabolites with notable increases in linoleic and linolenic acid levels. Fecal bacterial transplantation experiments have demonstrated that oxidative stress, inflammation, and skin barrier damage were alleviated after transplantation.

Discussion

These findings suggested that the metabolite linoleic acid negatively correlated with Ruminococcaceae and Bifidobacteriaceae may influence AD development. Perturbations in the intestinal bacteria and flora contributed to the development of AD, and the mouse model could serve as a valuable tool for further investigation of therapeutic approaches for managing ADS.

Evaluation of Risk Factors for Dupilumab-Associated Ocular Sequelae in the Treatment of Atopic Dermatitis

Dupilumab is a monoclonal antibody that inhibits interleukin-4 (IL-4) and interleukin-13 (IL-13) signaling and is used in the treatment of moderate-to-severe atopic dermatitis (AD) in those six months or older who are uncontrolled on or cannot tolerate topical treatments. Ocular surface disease is a recognized adverse effect of dupilumab, yet few studies describe the risk factors for developing ocular adverse effects. There are no standardized recommendations for monitoring patients on this medication. This study aims to highlight the risk factors associated with the development of dupilumab-associated ocular surface disease (DAOSD) described in the literature. The PubMed and ScienceDirect databases were searched in April 2024 using key search terms. Nine articles were included after deduplication, title/abstract screening, full-text review, and quality appraisal. Studies were included if they were written in English and discussed risk factors for the ocular side effects of dupilumab. Studies were excluded if they discussed other biological agents or ocular conditions of other origins. Out of the nine studies analyzed, six described prior history of ocular disease as a risk factor for developing DAOSD. Severe AD was highlighted as a risk factor in five out of nine studies. Elevated total immunoglobulin E (IgE) levels and eosinophil count were described as risk factors in four out of nine studies. Three studies cited facial or eyelid eczema, and two studies highlighted family history of atopy as having an association with the development of DAOSD. One study described high levels of chemokines, as well as the personal history of other atopic conditions, as independent risk factors. While the etiology of DAOSD is not fully understood, past studies have elucidated potential risk factors for its development. Those being treated with dupilumab for AD have higher severity or refractory disease, and the discontinuation of treatment due to ocular side effects may have implications on the quality of life for these patients. Additional studies are needed to better understand the risk factors for DAOSD and prevent further complications.

Atopic dermatitis: pathogenesis and therapeutic intervention

The skin serves as the first protective barrier for nonspecific immunity and encompasses a vast network of skin-associated immune cells. Atopic dermatitis (AD) is a prevalent inflammatory skin disease that affects individuals of all ages and races, with a complex pathogenesis intricately linked to genetic, environmental factors, skin barrier dysfunction as well as immune dysfunction. Individuals diagnosed with AD frequently exhibit genetic predispositions, characterized by mutations that impact the structural integrity of the skin barrier. This barrier dysfunction leads to the release of alarmins, activating the type 2 immune pathway and recruiting various immune cells to the skin, where they coordinate cutaneous immune responses. In this review, we summarize experimental models of AD and provide an overview of its pathogenesis and the therapeutic interventions. We focus on elucidating the intricate interplay between the immune system of the skin and the complex regulatory mechanisms, as well as commonly used treatments for AD, aiming to systematically understand the cellular and molecular crosstalk in AD-affected skin. Our overarching objective is to provide novel insights and inform potential clinical interventions to reduce the incidence and impact of AD.

Alopecia areata exhibits cutaneous and systemic OX40 activation across atopic backgrounds

BACKGROUND

Alopecia areata (AA) is a chronic, nonscarring hair-loss disorder associated with significant quality-of-life impairment and limited treatment options. AA has been recently linked to atopy and shown to exhibit both Th1- and Th2-driven inflammation. However, a comprehensive molecular and cellular characterization across blood and scalp compartments in both atopic and nonatopic patients is lacking.

METHODS

Lesional and nonlesional scalp biopsies obtained from AA patients with (n = 16) or without (n = 20) atopic history, and 17 demographically matched healthy controls were analyzed with RNA-seq, RT-PCR, and immunohistochemistry. Flow cytometry was also performed on peripheral blood mononuclear cells (PBMCs) from a subset of patients. Differential expression was defined using |fold-change| > 1.5 and false-discovery rate <0.05.

RESULTS

AA scalp exhibited robust upregulation of Th1- (IFNG, CXCL9, CXCL10, CXCL11) and Th2-related products (CCL26, CCR4, IL10, IL13, TSLP, TNFRSF4/OX40) and shared downregulation of hair keratins, regardless of atopic background, with variable Th17/Th22 modulation. AA patients with atopy exhibited greater inflammatory tone and Th2-skewing (IL10, IL13, IL33, CCR4, CCL26). Disease severity correlated significantly with immune and hair keratin biomarkers and with perifollicular cellular infiltrates. Cutaneous OX40/OX40L upregulation was paralleled by increases in circulating OX40+ and OX40L+ leukocytes, regardless of atopic background.

CONCLUSION

Our results suggest some atopy-associated immune differences in AA and highlight the OX40 axis as a potential novel therapeutic target that may broadly benefit AA patients.

Dupilumab impact on psychiatric and sleep disorder risk reduction in atopic dermatitis: A population-based cohort study

BACKGROUND

Patients with atopic dermatitis (AD) have a higher risk of developing psychiatric and sleep disorders.

OBJECTIVE

To compare the risk of psychiatric and sleep disorders in patients with AD treated with dupilumab vs those on conventional drugs (systemic corticosteroids, methotrexate, cyclosporin, and azathioprine).

METHODS

This retrospective cohort study used the TriNetX Global Collaborative Network (LLC, Cambridge, MA) and included adult patients with AD newly prescribed dupilumab (DUPI-cohort) or conventional drugs without previous dupilumab exposure (CONV-cohort). Propensity score matching was performed for age, sex, race, comorbidities, and laboratory measures. Risks of various psychiatric disorders, such as anxiety, depressive disorders, adjustment disorders, and attention deficit hyperactivity disorder, including sleep disorders, were compared between cohorts, with hazard ratios determined using Cox regression.

RESULTS

After matching, both the DUPI- and CONV-cohorts included 6114 patients each, with an average age of 44 years and 53% female. The racial distribution in both cohorts was approximately 49% White, 15% Black or African American, and 12% Asian. During the 3-year follow-up, the DUPI-cohort had reduced risks of anxiety (hazard ratio 0.76, 95% CI 0.64-0.89), depressive disorders (0.70, 0.58-0.86), adjustment disorders (0.535, 0.37-0.78), and sleep disorders (0.78, 0.65-0.94), whereas the risk of attention deficit hyperactivity disorder was not significantly affected (0.92, 0.61-1.38). These findings were consistent across age groups, sexes, races, and atopic comorbidities, with a more pronounced effect in Black or African American patients.

CONCLUSION

Patients with AD prescribed dupilumab exhibited a lower risk of psychiatric and sleep disorders, with the effect being more evident within the Black or African American subgroup.

Changes in skin barrier integrity by electrical impedance spectroscopy during dupilumab treatment on a child with severe atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease characterized by epidermal skin barrier dysfunction and altered immune response. Electrical impedance spectroscopy (EIS) has been used as a novel tool to detect skin barrier changes in AD. EIS is a non-invasive measure of the electrical impedance of tissue and is sensitive to cellular structure and extracellular environment.

CASE PRESENTATION

An 8-year-old girl presented with severe AD, starting at 3 years of age. She also had allergic rhinitis, food allergies, and sensitization to mites, eggs, and nuts. Unresponsive to other treatments, she was administered 300 mg of dupilumab, a monoclonal antibody inhibiting IL-4 and IL-13 activity. Patient's response to the treatment and skin barrier integrity was followed for 6 months: First at the baseline (before dupilumab) and then again at the 1st, 2nd, 3rd, and 5.5th month after dupilumab with SCORing Atopic Dermatitis (SCORAD), as well as measurements of moisture by MoistureMeterSC (Delfin®) and EIS by Nevisense® (SciBase) on the forearm and antecubital fossa of the same arm. At the end of 6 months, her SCORAD improved from 96 to 37. The moisture measurements were variable. The EIS by Z1 score in the forearm increased from 72 to 141 and EIS by MIX scores increased from 2.7 to 6.2. The correlation between SCORAD and forearm EIS by Z1 and MIX scores were significant: r=-0.913, (p=0.03) and r=-0.881, (p=0.049). The correlation between forearm MIX scores with sleeplessness and itching was significant: r=-0.956, (p=0.011), r=-0.942, (p=0.017).

CONCLUSION

As higher EIS scores reflect stronger barrier integrity, the increase in Z1 and MIX obtained from Nevisense® implies an improvement in the skin barrier integrity during dupilumab treatment. This report highlights the potential use of EIS in atopic dermatitis patients to evaluate treatment efficacy. We urge rapid and non-invasive use of EIS in pediatrics to be further investigated in clinical settings.

Long-term efficacy and safety of dupilumab for moderate-to-severe atopic dermatitis: a prospective real-world cohort study in China

Backgrounds

Dupilumab has demonstrated remarkable efficacy and safety in clinical trials for moderate-to-severe atopic dermatitis (AD). However, long-term real-world evidence, especially in the Chinese population, remains limited.

Objective

To investigate the long-term efficacy and safety of dupilumab for moderate-to-severe AD in a real-world clinical setting in China and analyze factors that may influence its long-term treatment outcomes.

Methods

This prospective, observational real-world study included moderate-to-severe AD patients from the AD cohort of the dermatology department of Chongqing Hospital of Traditional Chinese Medicine who received dupilumab treatment for≥52 weeks. Efficacy and adverse events were assessed at baseline, weeks 4, 16, 24, and 52. Multivariate logistic regression analysis was used to identify predictive factors for achieving EASI 50 and EASI 75 at week 52.

Results

A total of 124 patients were included. At week 52, EASI, SCORAD, IGA, NRS, and DLQI scores were significantly improved compared to baseline. The proportions of patients achieving EASI-50/75 were 50.81%/29.84%, 72.58%/42.74%, 75%/53.23%, and 67.74%/41.94% at weeks 4, 16, 24 and 52, respectively. Female sex, absence of atopic comorbidities, higher baseline EASI, and medication compliance were positive predictive factors for 52-week EASI-50/75. Eosinophil elevation predicted lower EASI-50 attainment. Nineteen adverse events occurred during the 52-week period (incidence rate: 14.52%), mostly mild and manageable.

Conclusions

Dupilumab demonstrated significant efficacy and a low incidence of adverse events over 52 weeks in Chinese patients with moderate-to-severe AD, making it an effective and safe long-term treatment option. Predictive factors were identified to guide treatment optimization.

Real-World Experience of 3-Year Treatment With Dupilumab: Significant Decrease in Circulating Neutrophils and Eosinophils in Japanese Patients With Atopic Dermatitis

Dupilumab, an anti-interleukin (IL)-4 receptor α-antibody, was approved in 2018 for the treatment of moderate-to-severe atopic dermatitis (AD) in Japan. Although real-world data have accumulated on the effectiveness and safety of dupilumab in patients with AD in the short term, real-world data on its long-term use are limited. In this study, we retrospectively investigated its effectiveness, safety and laboratory data in patients with AD who received dupilumab for 3 years. All adult patients with moderate-to-severe AD who were administered dupilumab between June 2018 and December 2020 and were treated with dupilumab for more than 3 years were included in this study. Sixty Japanese patients with AD (male, 48; female, 12) were included in this study. Their mean age was 36.6 ± 11.0 (standard deviation) years. The mean Eczema Area and Severity Index (EASI) was 29.9 ± 9.2. The clinical severity scales, including Investigator's Global Assessment (IGA), EASI and affected body surface area (BSA), and patient-reported outcomes, such as Dermatology Quality Life Index (DLQI), Patient-Oriented Eczema Measure (POEM) and visual analogue scale (VAS) of pruritus, significantly improved at 3 months, and at 1, 2 and 3 years after initiating dupilumab. The total EASI score significantly decreased by a mean of 66.8% at 3 months, 81.0% at 1 year, 85.3% at 2 years and 90.0% at 3 years after initiating dupilumab. The serum levels of thymus and activation-regulated chemokine (TARC), immunoglobulin E (IgE) and lactate dehydrogenase (LDH) significantly decreased at 1, 2 and 3 years. A slight decrease in circulating neutrophils was observed in patients with AD treated with dupilumab over periods from 3 months to 3 years. The number of circulating eosinophils significantly decreased at 2 and 3 years after initiating dupilumab. The most common adverse event was ocular disorders observed in 23 patients (38.3%). Our study shows the sustained effectiveness and tolerable safety of 3-year usage of dupilumab in Japanese patients with atopic dermatitis. Furthermore, dupilumab decreased neutrophil values at 3 months and later, and reduced the number of circulating eosinophils after long-term use (≧ 2 years).

Integrating chemokines and machine learning algorithms for diagnosis and bleeding assessment in primary immune thrombocytopenia: A prospective cohort study

Primary immune thrombocytopenia (ITP) is an autoimmune bleeding disorder, and chemokines have been shown to be dysregulated in autoimmune disorders. We conducted a prospective analysis to identify potential chemokines that could enhance the diagnostic accuracy and bleeding evaluation in ITP patients. In the discovery cohort, a Luminex-based assay was employed to quantify concentrations of plasma multiple chemokines. These levels were subjected to comparative analysis using a cohort of 60 ITP patients and 17 patients with thrombocytopenia other than ITP (non-ITP). Additionally, comparative evaluation was conducted between a subgroup of 12 ITP patients characterised by bleeding episodes (ITP-B, as defined by an ITP-2016 bleeding grade ≥2) and 33 ITP patients without bleeding episodes (ITP-NB, as defined by an ITP-2016 bleeding grade ≤1). Machine learning algorithms further identified CCL20, interleukin-2, CCL26, CCL25, and CXCL1 as promising indicators for accurate diagnosis of ITP and CCL21, CXCL8, CXCL10, CCL8, CCL3, and CCL15 as biomarkers for assessing bleeding risk in ITP patients. The results were confirmed using enzyme-linked immunosorbent assays in a validation cohort (43 ITP patients and 19 non-ITP patients). Overall, the findings suggest that specific chemokines show promise as potential biomarkers for diagnosis and bleeding evaluation in ITP patients.

Eblasakimab, an Anti-IL‑13Rα1 Antibody, Reduces Atopy-Associated Serum Biomarkers in Moderate‑to‑Severe Atopic Dermatitis

INTRODUCTION

Eblasakimab, a first-in-class monoclonal antibody with a unique mechanism to target the interleukin (IL)-13 receptor alpha 1 (IL-13Rα1), inhibits IL-4/IL-13 signaling in the pathophysiology of atopic dermatitis (AD). This study investigates the impact of eblasakimab on type 2 inflammatory biomarkers in patients with moderate-to-severe AD.

METHODS

A double‑blind, multiple ascending dose, phase Ib study evaluated the effect of eblasakimab (200, 400, 600 mg) or placebo administered subcutaneously once weekly for 8 weeks in patients with moderate‑to‑severe AD. Serum levels of thymus and activation-regulated chemokine (TARC), total immunoglobulin E (IgE), and lactate dehydrogenase (LDH) were assessed.

RESULTS

Eblasakimab suppressed TARC, IgE, and LDH in the 400-mg and 600-mg groups over 8 weeks of treatment. Patients in the 400-mg and 600-mg groups experienced a reduction of 72.8% (p = 0.004) and 62.9% (p = 0.003), respectively, for TARC, 35.1% (p = 0.006) and 20.9% (not significant; NS), respectively, for IgE, and 24.6% (NS) and 23.1% (NS), respectively, for LDH between baseline and Week 8. Reduction in serum TARC in the 400-mg group was significantly greater than placebo as early as Week 1, whereas reductions in total IgE were more gradual. Serum TARC and total IgE remained suppressed in the 400-mg and 600-mg eblasakimab groups for 4-6 weeks following the last administered dose.

CONCLUSION

The effect of eblasakimab on circulating AD‑associated biomarker levels was accompanied by improvements in signs and symptoms of AD, consistent with the inhibition of IL-13 and IL-4 signaling via the type 2 receptor.

TRIAL REGISTRATION NUMBER

NCT04090229.

The role of the skin in the atopic march

Atopic diseases, including atopic dermatitis (AD), food allergy (FA), asthma, and allergic rhinitis (AR) are closely related to inflammatory diseases involving different body sites (i.e. the skin, airway, and digestive tract) with characteristic features including specific IgE to allergens (so-called "atopy") and Th2 cell-mediated inflammation. It has been recognized that AD often precedes the development of other atopic diseases. The progression from AD during infancy to FA or asthma/AR in later childhood is referred to as the "atopic march" (AM). Clinical, genetic, and experimental studies have provided evidence that allergen sensitization occurring through AD skin could be the origin of the AM. Here, we provide an updated review focusing on the role of the skin in the AM, from genetic mutations and environmental factors associated with epidermal barrier dysfunction in AD and the AM to immunological mechanisms for skin sensitization, particularly recent progress on the function of key cytokines produced by epidermal keratinocytes or by immune cells infiltrating the skin during AD. We also highlight the importance of developing strategies that target AD skin to prevent and attenuate the AM.

NLRP10 maintains epidermal homeostasis by promoting keratinocyte survival and P63-dependent differentiation and barrier function

Atopic dermatitis (AD) is a common chronic inflammatory skin disorder characterized by disrupted epidermal barrier function and aberrant immune responses. Despite recent developments in new therapeutics for AD, there is still a large unmet medical need for disease management due to the complex and multifactorial nature of AD. Recent genome-wide association studies (GWAS) have identified NLRP10 as a susceptible gene for AD but the physiological role of NLRP10 in skin homeostasis and AD remains unknown. Here we show that NLRP10 is downregulated in AD skin samples. Using an air-lift human skin equivalent culture, we demonstrate that NLRP10 promotes keratinocyte survival and is required for epidermal differentiation and barrier function. Mechanistically, NLRP10 limits cell death by preventing the recruitment of caspase-8 to the death inducing signaling complex (DISC) and by inhibiting its subsequent activation. NLRP10 also stabilizes p63, the master regulator of keratinocyte differentiation, to drive proper keratinocyte differentiation and to reinforce the barrier function. Our findings underscore NLRP10 as a key player in atopic dermatitis pathogenesis, highlighting NLRP10 as a potential target for therapeutic intervention to restore skin barrier function and homeostasis in AD.

BNIP3+ fibroblasts associated with hypoxia and inflammation predict prognosis and immunotherapy response in pancreatic ductal adenocarcinoma

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is one of the most malignant tumors that lacks effective treatment options. Cancer-associated fibroblasts (CAFs), an important component of the tumor microenvironment, associated with tumor progression, prognosis, and treatment response. This work aimed to explore the novel CAFs-associated target to improve treatment strategies in PDAC.

METHODS

The PDAC single-cell sequencing data (CRA001160, n = 35) were downloaded and integrated based on GSA databases to classify fibroblasts into fine subtypes. Functional enrichment analysis and coexpression regulatory network analysis were used to identify the functional phenotypes and biological properties of the different fibroblast subtypes. Fibroblast differentiation trajectories were constructed using pseudochronological analysis to identify initial and terminally differentiated subtypes of fibroblasts. The changes in the proportions of different fibroblast subtypes before and after PDAC immunotherapy were compared in responsive and nonresponding patients, and the relationships between fibroblast subtypes and PDAC immunotherapy responsiveness were determined based on GSA and GEO database. Using molecular biology methods to confirm the effects of BNIP3 on hypoxia and inflammation in CAFs. CAFs were co cultured with pancreatic cancer cells to detect their effects on migration and invasion of pancreatic cancer.

RESULTS

Single-cell data analysis divided fibroblasts into six subtypes. The differentiation trajectory suggested that BNIP3+ Fibro subtype exhibited terminal differentiation, and the expression of genes related to hypoxia and the inflammatory response increased gradually with differentiation time. The specific overexpressed genes in the BNIP3+ Fibro subtype were significantly associated with overall and disease progression-free survival in the patients with PDAC. Interestingly, the greater the proportion of the BNIP3+ Fibro subtype was, the worse the response of PDAC patients to immunotherapy, and the CRTL treatment regimen effectively reduced the proportion of the BNIP3+ Fibro subtype. After knocking out BNIP3, the hypoxia markers and inflammatory factors of CAFs were inhibited. Co-culture of CAFs with pancreatic cancer cells can increase the migration and invasion of pancreatic cancer, but this could be reversed by knocking out BNIP3.

CONCLUSIONS

This study revealed the BNIP3+ Fibro subtype associated with hypoxia and inflammatory responses, which was closely related to the poor prognosis of patients with PDAC, and identified signature genes that predict the immunotherapy response in PDAC.

CTPAD: an interactive web application for comprehensive transcriptomic profiling in allergic diseases

BACKGROUND

Allergic diseases are systemic chronic inflammatory diseases associated with multiorgan damage and complex pathogenesis. Several studies have revealed the association of gene expression abnormalities with the development of allergic diseases, but the biomedical field still lacks a public platform for comprehensive analysis and visualization of transcriptomic data of allergic diseases.

OBJECTIVE

The aim of the study is to provide a comprehensive web tool for multiple analysis in allergic diseases.

METHODS

We retrieved and downloaded human and mouse gene expression profile data associated with allergic diseases from the Gene Expression Omnibus (GEO) database and standardized the data uniformly. We used gene sets obtained from the MSigDB database for pathway enrichment analysis and multiple immune infiltration algorithms for the estimation of immune cell proportion. The basic construction of the web pages was based on the Shiny framework. Additionally, more convenient features were added to the server to improve the efficiency of the web pages, such as jQuery plugins and a comment box to collect user feedback.

RESULTS

We developed CTPAD, an interactive R Shiny application that integrates public databases and multiple algorithms to explore allergic disease-related datasets and implement rich transcriptomic visualization capabilities, including gene expression analysis, pathway enrichment analysis, immune infiltration analysis, correlation analysis, and single-cell RNA sequencing analysis. All functional modules offer customization options and can be downloaded in PDF format with high-resolution images.

CONCLUSIONS

CTPAD largely facilitates the work of researchers without bioinformatics background to enable them to better explore the transcriptomic features associated with allergic diseases. CTPAD is available at https://smuonco.shinyapps.io/CTPAD/ .

Identification of novel hub genes and immune infiltration in atopic dermatitis using integrated bioinformatics analysis

The aim of this study was to identify key genes and investigate the immunological mechanisms of atopic dermatitis (AD) at the molecular level via bioinformatics analysis. Gene expression profiles (GSE32924, GSE107361, GSE121212, and GSE230200) were obtained for screening common differentially expressed genes (co-DEGs) from the gene expression omnibus database. Functional enrichment analysis, protein-protein interaction network and module construction, and identification of common hub genes were performed. Hub genes were validated using receiver operating characteristic curve analysis based on GSE130588 and GSE16161. NetworkAnalyst was used to detect microRNAs (miRNAs) and transcription factors (TFs) associated with the hub genes. The immune cell infiltration was analyzed using the CIBERSORT algorithm to further analyze the correlation between hub genes and immune cells. A total of 146 co-DEGs were obtained, showing significant enrichment in cytokine-cytokine receptor interaction and JAK-STAT signaling pathway. Seven hub genes were identified by Cytoscape and validated with external datasets. Subsequent prediction of miRNAs and TFs targeting these hub genes revealed their regulatory roles. Analysis of immune cell infiltration and correlation revealed a significant positive correlation between CCL22 expression and the number of dendritic cells activated. The identified hub genes represent potential diagnostic and therapeutic targets in the immunological pathogenesis of AD.

The Role of Food Allergy in Atopic Dermatitis

Atopic dermatitis (AD) and food allergies are 2 atopic conditions that tend to develop early in life. Their interrelationship has been a topic of controversy and many studies. The presence of atopic dermatitis in infancy and early childhood, particularly if severe, is a risk factor for the development of immunoglobulin E (IgE) -mediated food allergies. While it is common for children with AD to demonstrate extensive sensitization to foods, serum IgE testing is not always indicative of clinical allergy.

Co-Expression Network and Machine Learning Analysis of Transcriptomics Data Identifies Distinct Gene Signatures and Pathways in Lesional and Non-Lesional Atopic Dermatitis

BACKGROUND

Atopic dermatitis (AD) is a common inflammatory skin condition with complex origins. Current treatments often yield suboptimal results due to an incomplete understanding of its underlying mechanisms. This study aimed to identify pathway and gene signatures that distinguish between lesional AD, non-lesional AD, and healthy skin.

METHOD

We conducted differential gene expression and co-expression network analyses to identify differentially co-expressed genes (DCEGs) in lesional AD vs. healthy skin, lesional vs. non-lesional AD, and non-lesional AD vs. healthy skin. Modules associated with lesional and non-lesional AD were identified based on the correlation coefficients between module eigengenes and clinical phenotypes (|R| ≥ 0.5, p-value < 0.05). Subsequently, we employed Ingenuity Pathway Analysis (IPA) on the identified DCEGs, followed by machine learning (ML) analysis within the pathway expression framework. The ML analysis of pathway expressions, selected by IPA and derived from gene expression data, identified relevant pathway signatures, which were validated using an independent dataset and correlated with AD severity measures (EASI and SCORAD).

RESULTS

We identified 975, 441, and 40 DCEGs in lesional vs. healthy skin, lesional vs. non-lesional, and non-lesional vs. healthy skin, respectively. IPA and ML analyses revealed 25 relevant pathway signatures, including wound healing, glucocorticoid receptor signaling, and S100 gene family signaling pathways. Validation confirmed the significance of 10 pathway signatures, which were correlated with the AD severity measures. DCEGs such as MMP12 and S100A8 demonstrated high diagnostic efficacy (AUC > 0.70) in both the discovery and validation datasets.

CONCLUSIONS

Differential gene expression, co-expression networks and ML analyses of pathway expression have unveiled relevant pathways and gene signatures that distinguish between lesional, non-lesional, and healthy skin, providing valuable insights into AD pathogenesis.

Disease modification in chronic spontaneous urticaria

Chronic spontaneous urticaria (CSU) is a debilitating, inflammatory skin condition characterized by infiltrating immune cells. Available treatments are limited to improving the signs and symptoms. There is an unmet need to develop therapies that target disease-driving pathways upstream of mast cell activation to inhibit or delay the progression of CSU and associated comorbidities. Here, we aim to define disease modification due to a treatment intervention and criteria that disease-modifying treatments (DMTs) must meet in CSU. We have defined disease modification in CSU as a favorable treatment-induced change in the underlying pathophysiology and, therefore, the disease course, which is clinically beneficial and enduring. A DMT must fulfil the following criteria: (1) prevents or delays the progression of CSU, (2) induces long-term, therapy-free clinical remission, which is the sustained absence of CSU signs and symptoms without the need for treatment, and (3) affects the underlying mechanism of CSU, as demonstrated by an effect on disease-driving signals and/or a biomarker. DMTs in CSU should slow disease progression, achieve long-lasting disease remission, target disease-driving mechanisms, reduce mast cell-activating IgE autoantibodies, target cytokine profile polarization, and normalize the gut microbiome and barrier. Treating CSU at the immune system level could provide valuable alternatives to pharmacotherapy in CSU management. Specific DMTs in CSU are yet to be developed, but some show potential benefits, such as inhibitors of Bruton's Tyrosine Kinase, IL-4 and IL-13. Future therapies could prevent CSU signs and symptoms, achieve long-term clinical benefits after discontinuing treatment, and prevent associated concomitant disorders.

Reduced atopic march risk in pediatric atopic dermatitis patients prescribed dupilumab versus conventional immunomodulatory therapy: A population-based cohort study

BACKGROUND

Dupilumab effectively treats atopic dermatitis (AD); however, its role in halting the atopic march remains uncertain.

OBJECTIVE

To investigate dupilumab's effect on atopic march in pediatric AD patients versus conventional immunomodulators.

METHODS

This retrospective cohort study utilized data from the TriNetX US Collaborative Network (2011-2024). Pediatric AD patients (≤18 years) were categorized into DUPI-cohort (newly prescribed dupilumab) or CONV-cohort (prescribed conventional immunomodulators without dupilumab). After 1:1 propensity-score matching, we analyzed atopic march progression, defined by the incident asthma or allergic rhinitis (AR). Cumulative incidence was plotted using Kaplan-Meier, with risk assessment via Cox regression.

RESULTS

The study included 2192 patients in each cohort. The 3-year cumulative incidence of atopic march progression was lower in the DUPI-cohort than the CONV-cohort (20.09% vs 27.22%; P < .001). The DUPI-cohort demonstrated significant risk reduction in atopic march progression (hazard ratio [HR] 0.68, 95% CI 0.55-0.83), individual asthma (HR 0.60, 0.45-0.81), and individual AR (HR 0.69, 0.54-0.88). Younger patients on dupilumab exhibited a greater risk reduction for atopic march progression and individual asthma, contrasting with the opposite age-related pattern for individual AR.

LIMITATIONS

Observational study.

CONCLUSION

Among pediatric AD patients, dupilumab was associated with reduced risk of atopic march progression compared with conventional therapies.

Systemic Immunomodulatory Treatments for Atopic Dermatitis: Living Systematic Review and Network Meta-Analysis Update

Importance

There are multiple approved systemic treatments for atopic dermatitis. Lebrikizumab is a newly licensed biologic medication that has been compared to placebo in clinical trials but not to other systemic treatments.

Objective

To compare reported measures of efficacy and safety of lebrikizumab to other systemic treatments for atopic dermatitis in a living systematic review and network meta-analysis.

Data Sources

The Cochrane Central Register of Controlled Trials, MEDLINE, Embase, the Latin American and Caribbean Health Science Information database, the Global Resource of Eczema Trials database, and trial registries were searched from inception through November 3, 2023.

Study Selection

Randomized clinical trials evaluating 8 or more weeks of treatment with systemic immunomodulatory medications for moderate to severe atopic dermatitis. Titles, abstracts, and full texts were screened in duplicate.

Data Extraction and Synthesis

Data were abstracted in duplicate and random-effects bayesian network meta-analyses were performed. Minimal important differences were used to define important differences between medications. Certainty of evidence was assessed using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation). The updated analysis was completed from December 13, 2023, to February 20, 2024.

Main Outcome Measures

Efficacy outcomes were the Eczema Area and Severity Index (EASI), the Patient Oriented Eczema Measure (POEM) Dermatology Life Quality Index (DLQI), and Peak Pruritus Numeric Rating Scales (PP-NRS) and were compared using mean difference (MD) with 95% credible intervals (CrI). Safety outcomes were serious adverse events and withdrawal due to adverse events. Other outcomes included the proportion of participants with 50%, 75%, and 90% improvement in EASI (EASI-50, -75, -90) and the proportion with success on the Investigator Global Assessment compared using odds ratios with 95% CrI.

Results

The study sample included 97 eligible trials, with a total of 24 679 patients. Lebrikizumab was associated with no important difference in change in EASI (MD, -2.0; 95% CrI, -4.5 to 0.3; moderate certainty), POEM (MD, -1.1; 95% CrI -2.5 to 0.2; moderate certainty), DLQI (MD, -0.2; 95% CrI -2.1 to 1.6; moderate certainty), or PP-NRS (MD, 0.1; 95% CrI -0.4, 0.6; high certainty) compared to dupilumab among adults with atopic dermatitis who were treated for up to 16 weeks. Dupilumab was associated with higher odds of efficacy in binary outcomes compared with lebrikizumab. The relative efficacy of other approved systemic medications was similar to that found by previous updates of this living study, with high-dose upadacitinib and abrocitinib demonstrating numerically highest relative efficacy. For safety outcomes, low event rates limited useful comparisons.

Conclusions and Relevance

In this living systematic review and network meta-analysis, lebrikizumab was similarly effective to dupilumab for the short-term treatment of atopic dermatitis in adults. Clinicians and patients can use these comparative data to inform treatment decisions.

Integrating multi-omics approaches in deciphering atopic dermatitis pathogenesis and future therapeutic directions

Atopic dermatitis (AD), a complex and heterogeneous chronic inflammatory skin disorder, manifests in a spectrum of clinical subtypes. The application of genomics has elucidated the role of genetic variations in predisposing individuals to AD. Transcriptomics, analyzing gene expression alterations, sheds light on the molecular underpinnings of AD. Proteomics explores the involvement of proteins in AD pathophysiology, while epigenomics examines the impact of environmental factors on gene expression. Lipidomics, which investigates lipid profiles, enhances our understanding of skin barrier functionalities and their perturbations in AD. This review synthesizes insights from these omics approaches, highlighting their collective importance in unraveling the intricate pathogenesis of AD. The review culminates by projecting future trajectories in AD research, particularly the promise of multi-omics in forging personalized medicine and novel therapeutic interventions. Such an integrated multi-omics strategy is poised to transform AD comprehension and management, steering towards more precise and efficacious treatment modalities.