Exacerbation of atopic dermatitis symptoms by ustekinumab in psoriatic patients with elevated serum immunoglobulin E levels: Report of two cases

Biologics for Psoriasis

Biologic therapies targeting tumor necrosis factor alpha (TNF-α) (infliximab, adalimumab, certolizumab, etanercept), the p40 subunit shared by IL-12 and IL-23 (ustekinumab), the p19 subunit of IL-23 (guselkumab, tildrakizumab, risankizumab), IL-17A (secukinumab, ixekizumab), IL-17-RA (brodalumab) and both IL-17A and IL-17F (bimekizumab) have revolutionized the treatment of psoriasis. In both the short and long term, risankizumab had highest Psoriasis Area and Severity Index 90 scores compared to other oral and injectable biologics. IL-23 inhibitors had lowest rates of short-term and long-term adverse events and most favorable long-term risk-benefit profile compared to IL-17, IL-12/23, and TNF-α inhibitors.

Development of a clinical algorithm to predict phenotypic switches between atopic dermatitis and psoriasis (the "Flip-Flop" phenomenon)

BACKGROUND

Atopic dermatitis (AD) and psoriasis vulgaris (PV) are almost mutually exclusive diseases with different immune polarizations, mechanisms and therapeutic targets. Switches to the other disease ("Flip-Flop" [FF] phenomenon) can occur with or without systemic treatment and are often referred to as paradoxical reactions under biological therapy.

METHODS

The objective was to develop a diagnostic algorithm by combining clinical criteria of AD and PV to identify FF patients. The algorithm was prospectively validated in patients enrolled in the CK-CARE registry in Bonn, Germany. Afterward, algorithm refinements were implemented based on machine learning.

RESULTS

Three hundred adult Caucasian patients were included in the validation study (n = 238 with AD, n = 49 with PV, n = 13 with FF; mean age 41.2 years; n = 161 [53.7%] female). The total FF scores of the PV and AD groups differed significantly from the FF group in the validation data (p < .001). The predictive mean generalized Youden-Index of the initial model was 78.9% [95% confidence interval 72.0%-85.6%] and the accuracy was 89.7%. Disease group-specific sensitivity was 100% (FF), 95.0% (AD), and 61.2% (PV). The specificity was 89.2% (FF), 100% (AD), and 100% (PV), respectively.

CONCLUSION

The FF algorithm represents the first validated tool to identify FF patients.

Development of IL-17A inhibitor-induced atopic dermatitis-like rash in psoriasis patients: Insights into immune shift

Cases of atopic dermatitis (AD)-like rash induced by IL-17A inhibitor secukinumab treatment (SI-AD) have been recently reported in psoriasis patients. To identify immune and inflammatory factors expression in SI-AD. A panel of 15 immune and inflammatory factors in peripheral blood samples from various groups, including patients with patients with SI-AD, psoriasis with secukinumab (S-stable), advanced psoriasis patients (Advanced) and healthy controls (HC). Interleukin-10 (IL-10), IL-4 and IL-17A were detected in skin tissue biopsy samples by immunohistochemistry and real-time quantitative polymerase chain reaction. The immunoglobulin E levels in the SI-AD patients exceeded normal values. The IL-10 levels in SI-AD patients were higher than those in S-stable patients, advanced patients and HC. The IL-4 levels in SI-AD patients were higher than that in S-stable patients and HC. The IL-17A levels in SI-AD patients were higher than those in advanced psoriasis patients and HC, but no significant differences were observed between SI-AD patients and S-stable patients. IL-10 and IL-4 levels were higher in AD-like rashes than in healthy skin, while IL-17A did not differ significantly between the two. Upon discontinuing secukinumab, and switching to oral cyclosporine, antihistamines, Janus kinase 1 inhibitor and topical glucocorticoids, SI-AD patients experienced significant improvement in their skin lesions. Upon reexamination, all 15 immune and inflammatory factors returned to normal levels. Immune shift from Th17 towards Th2 may occur in SI-AD, as indicated by abnormal expression of multiple immune and inflammatory factors observed in peripheral blood and skin tissues.

Tofacitinib for the Treatment of Psoriasiform Dermatitis Caused by IL-17 Inhibitors: A Case Report

Psoriasis is a recurring systemic disease that can be treated with biologics to some effect. However, precisely targeting inflammatory mediators may disrupt immune system homeostasis and lead to new conditions. Here, we report a case of psoriasiform dermatitis (PsoD) caused by IL-17 inhibitors (IL-17i) namely secukinumab treatment for psoriasis. This case proposes an effective use of Janus kinase inhibitor (JAKi) tofacitinib to confront lesions induced by IL-17i. This is the first case report of PsoD caused by secukinumab treated with tofacitinib.

Elevation of IgE in patients with psoriasis: Is it a paradoxical phenomenon?

Immunoglobulin E (IgE) elevation is a hallmark of allergic conditions such as atopic dermatitis (AD). The pathogenesis of AD is typically associated with high levels of IL-4 and IL-13 produced by activated T helper 2 (Th2) cells. Psoriasis, on the other hand, is an inflammatory skin disease mainly driven by Th17 cells and their related cytokines. Although the immunopathologic reactions and clinical manifestations are often easily distinguished in the two skin conditions, patients with psoriasis may sometimes exhibit AD-like manifestations, such as elevated IgE and persistent pruritic lesions. Given the fact that the effective T cells have great plasticity to re-differentiate in response to innate and environmental factors, this unusual skin condition could be a consequence of a cross-reaction between distinct arms of T-cell and humoral immunity. Here we review the literature concerning the roles of IgE in the development of AD and psoriasis, showing that elevated IgE seems to be an important indicator for this non-typical psoriasis.

Exacerbation of Atopic Dermatitis Associated with Ustekinumab Treatment in Crohn's Disease

Ustekinumab inhibits interleukins 12 and 23 and modulates the T helper cell-mediated immune response of Crohn's disease. However, ustekinumab may also exacerbate atopic disease by increasing the T helper 2 cell-mediated pathway. We present the first known case of exacerbation of atopic dermatitis in a patient with Crohn's disease receiving ustekinumab. Additional associations in dose frequency, peripheral eosinophilia, and elevated serum IgE were observed. However, while novel in Crohn's disease, exacerbation of atopy after ustekinumab infusion has been observed in patients with psoriasis and psoriatic arthritis.

Paradoxical Reactions to Biologicals in Chronic Inflammatory Systemic Diseases

BACKGROUND

Biological agents that contain substances affecting the immune system are increasingly being used to treat chronic inflammatory systemic diseases. Aside from the expected adverse effects, they can also induce unexpected paradoxical reactions (PR). A reaction is called paradoxical when a substance that is generally therapeutically effective induces the opposite of what is intended, with the new appearance or exacerbation of inflammatory changes in the skin and other organs.

METHODS

The paradoxical reactions that have been described since 1997 are presented here on the basis of the available literature on the main types of chronic inflammatory systemic disease, which was retrieved by a selective search in the PubMed and Google Scholar databases.

RESULTS

Many studies and registers to date contain no mention of paradoxical reactions. Anti- TNF-alpha treatment for patients with ankylosing spondylitis leads to paradoxical reactions in 19 per 1000 patient years, compared to 11 per 1000 patient years with conventional treatment; the corresponding frequency for paradoxical psoriasis in patients with other chronic inflammatory systemic diseases are 1.04-3.68 versus 1.45 per 1000 patient years. Paradoxical reactions tend to be more common with anti-TNF-alpha treatment than, for example, with the administration of ustekinumab, vedolizumab, and other agents. It is unclear whether some drugs have been noted to cause PR more commonly than others because of varying times since their approval, differences in immunogenicity, and differences between their target structures.

CONCLUSION

Paradoxical reactions induced by biological agents are a problem confronting physicians in multiple specialties. They need to be distinguished from infectious and neoplastic diseases and from autoimmune conditions of other types. The treatment options for paradoxical reactions include local treatment, symptomatic therapy, prednisolone administration, and the discontinuation or switching of the biological agent, although some patients will react with a further paradoxical reaction to a different biological agent that is used instead.

Biological medication in atopic dermatitis

INTRODUCTION

Atopic dermatitis (AD) is a chronic inflammatory skin disorder associated with intense itch/pruritus and skin lesions. Several modalities of treatment including topical therapy, systemic agents, and biologics are available for the treatment of disease. Despite this, management poses challenge due to chronic nature and recurrent episodes in many patients. Biologics represent an important option of treatment for patients who do not respond to the traditional treatment.

AREAS COVERED

In this article, we focused on efficacy and safety of biologics in the treatment of atopic dermatitis. Other therapies are out of the scope of this review. Articles from PubMed and Google scholar and cross references of retrieved articles were used to write the narrative review.

EXPERT OPINION

Biologics play an important role in the treatment of atopic dermatitis. Every biologic has its own place in the treatment considering pharmacological profile, efficacy, and safety. Several biologics have been studied in the treatment of moderate-to-severe cases who failed to provide adequate response to traditional treatment. Dupilumab, is approved for the treatment of moderate-to-severe atopic dermatitis. Tralokinumab and nemolizumab have shown promising results in patients with atopic dermatitis.

When topical therapy of atopic dermatitis fails: a guide for the clinician

INTRODUCTION

While topical medications are the first line of treatment for mild-to-moderate atopic dermatitis, they are ineffective in individuals with diffuse disease and moderate-to-severe atopic itch. For these individuals, as well as those who do not respond to topical treatments, systemic medicines are typically essential and helpful.

AREAS COVERED

We conducted a review of the literature to identify established systemic therapies, novel biologic agents, and recent advances in the pathophysiology of atopic dermatitis. The review discusses these data, which show that the majority of atopic itch medications now in development target the type 2 immune axis and brain sensitization, two main etiologies of atopic itch. We emphasize the evidence, efficacy, and side effect profiles of currently available systemic medications for atopic itch, as well as future potential for tailored therapy.

EXPERT OPINION

We give our professional opinion on the current state of knowledge about atopic eczema pathogenesis and the innovative targets and therapies for atopic itch that include MRGPRX2, periostin, gabaergic medicines, and JAK/STAT inhibitors. Additionally, we discuss patient populations that stand to benefit the most from targeting these molecules or utilizing these drugs, as well as those who may face a disproportionate weight of adverse effects.

Atopic Dermatitis as a Paradoxical Effect of Secukinumab for the Treatment of Psoriasis

In the therapeutic arsenal to treat moderate to severe psoriasis, the new agents are secukinumab and ustekinumab, which are fully human monoclonal antibodies, directed against IL-17A and IL-12/23, respectively, which have been shown to be effective and safe in several studies. Their side effects are rare, and the most frequently reported side effects were infection, especially nasopharyngitis, headache, pruritus, high blood pressure, and low back pain. Unlike the side effects, the paradoxical reaction can be defined by the appearance or exacerbation of a pathological condition that usually responds to a certain class of drug. The appearance of this reaction in patients using anti-interleukins is poorly described; however, as they are new drugs, they may be more common than the literature reports. We describe a case of a paradoxical reaction, with the appearance of atopic dermatitis, after using secukinumab to treat psoriasis.

Alternative uses of ustekinumab for non-indicated dermatological conditions: a systematic review

Ustekinumab is approved for the treatment of psoriasis and Crohn's disease. Because many dermatological conditions are due to immune-mediated development, ustekinumab may be effective in other conditions. A systematic review of the off-label uses of ustekinumab, as well as on-label adverse effect, was performed, reporting on clinical improvement. MEDLINE, Embase, Web of Science, and Cochrane databases were searched for studies regarding ustekinumab treatment of rativa (HS), lichen planus (LP), pyoderma gangrenosum (PG), pityriasis rubra pilaris (PRP), cutalopecia areata (AA), atopic dermatitis (AD), Bechet's disease, bullous pemphigoid (BP), hidradenitis suppuaneous sarcoidosis, cutaneous systemic lupus erythematosus (SLE), and vitiligo. Descriptive statistics were performed. 74 articles of 4596 screened were included, and reported on 212 patients receiving ustekinumab treatment. Across all studies, ustekinumab showed promise in treating patients: AA (10/12 patients; 83.3% improvement), AD (28/74 patients; 37.8% improvement), HS (42/52 patients; 80.8% improvement), and PRP (25/27 patients; 92.6% improvement), among others. Adverse events were noted with the use of ustekinumab, including development of AA (four patients), AD (three patients), and BP (four patients), among others. Ustekinumab can be a promising option for patients with dermatological conditions refractory to traditional therapies. Adverse events must be monitored in certain patients.

New Biologics for the Treatment of Atopic Dermatitis: Analysis of Efficacy, Safety, and Paradoxical Atopic Dermatitis Acceleration

Atopic dermatitis (AD) is a chronic, inflammatory skin disease with an eczematous rash and itching. Due to undesired adverse effects of traditional systemic treatment, there is still an unmet need for safe and effective long-term therapy for refractory AD. As our understanding of the pathogenesis underlying AD grows, novel treatments targeting specific molecules have been developed. Here, we discuss the efficacy and safety profiles of these drugs in recent clinical trials. Among their adverse effects, of particular note is AD acceleration. Although there is still debate about whether certain adverse reactions can be said to be paradoxical adverse events (PAEs), a wide range of PAEs have been reported during biological treatment for chronic immune-mediated diseases. Close surveillance of novel biologics is crucial to detect new undescribed paradoxical reactions and to shed light on the convoluted pathogenesis of AD.

Effectiveness of ustekinumab in patients with atopic dermatitis: analysis of real-world evidence

INTRODUCTION

Atopic dermatitis (AD) is a very common chronic inflammatory skin disease. Ustekinumab is a human monoclonal antibody approved for psoriasis, that targets the p40 subunit shared by interleukin (IL)-12 and IL-23, cytokines which may also play a role in AD. Administration of ustekinumab in AD has been presented in anecdotal reports with conflicting results. Our aim was to evaluate the precise value of this biologic drug on AD in real-world setting.

MATERIAL AND METHOD

We sistematically reviewed published data and analyzed aggregated results involving AD treated with ustekinumab. The main outcome was clinical improvement reported by each record. We classified this in three categories: "complete response", "partial response" and "no response". A multivariant model was used to assess association between response to ustekinumab and the following potential predictive factors: gender, age (age < or >50), duration of AD, history of asthma, previous use of biologic drugs, number of previous systemic therapies, serum levels of IgE and duration of ustekinumab therapy.

RESULTS

Data on 23 patients from eight articles were analyzed. Complete AD remission was reported in 8 patients (34.8%), while abscense of response was observed also in 8 patients (34.8%). Partial response was reported in 7 patients (30.4%). No differences were observed with respect to age, gender, history of asthma, naïve patient, duration of AD or duration of ustekinumab therapy.

CONCLUSION

We conclude from available data the IL-12/23 pathway is likely not an atractive target for AD. More no convincing data exist arguing against consideration of ustekinumab in AD patients. Other effective treatments are available and should be prioritized with good safety profile. Limitations are yet low number of studies and patients.WHAT'S ALREADY KNOWN ABOUT THIS TOPIC?Administration of ustekinumab in AD (atopic dermatitis) has been presented in anecdotical reports with conflicting resultsWHAT DOES THIS STUDY ADD?This work presents the largest cohort of AD patients treated with ustekinumab in a real-world setting.Ustekinumab resulted in similar rates of complete, partial and negative responses.Our findings demonstrate the IL-12/23 pathway is not an atractive target in AD.More novel and effective treatments for AD are available and should be prioritized.The impact of anti IL-12/IL-23p40 therapy in AD is still unclarified due to limited controlled trials.

Seborrhoeic dermatitis and sebopsoriasis developing in patients on dupilumab: Two case reports

Cutaneous adverse events to dupilumab can be varied; this necessitates keeping a broad differential diagnosis to identify seemingly paradoxical reactions. It may be possible to treat the adverse event concurrently without stopping dupilumab.

Psoriasis appearing after dupilumab therapy in atopic dermatitis: A case report

A 36-year-old Caucasian female with a long history of atopic dermatitis presented with multiple flares eventually leading to dupilumab therapy. Five months into the dupilumab therapy, she presented with well-demarcated erythematous plaques with silvery scale resembling psoriasis on her knees and shins (body surface area 2%, Psoriasis Area Severity Index 1.6, Investigator' Global Assessment 2). Biopsies were taken to confirm the diagnosis of classic psoriasis. Dupilumab was continued for another month while using clobetasol 0.05% ointment. The patient reported poor adherence to clobetasol therapy, and the lesions persisted. When dupilumab was discontinued, her psoriasis resolved over 6 weeks, but her atopic dermatitis returned. Dupilumab was restarted for atopic dermatitis management, and her psoriasis returned. There appears to be a rare causal association between dupilumab and psoriasis in this case. The mechanism of the drug reaction is yet to be discovered.

Phenotypic switch to eczema in patients receiving biologics for plaque psoriasis: a systematic review

The use of biologic therapies for the treatment of chronic plaque psoriasis has been linked to the development of atopic eczema, amongst other cutaneous adverse events. This can cause diagnostic confusion and create difficulty in the management of patients with plaque psoriasis. The main objective of this systematic review was to review all cases of eczema, including atopic eczema, reported in patients treated with biologics for chronic plaque psoriasis. PubMed, Medline and Embase databases were used to identify studies reporting eczema in patients treated with biologic therapy for chronic plaque psoriasis. A total of 92 patients were identified from 24 studies, with patients treated with either: adalimumab; etanercept; infliximab; ixekizumab; secukinumab; or ustekinumab. Factors common to some reported cases include: a prior history of atopy; eosinophilia; raised serum immunoglobulin E. Twenty-three had documented treatment outcomes; 14 had biologic therapy discontinued or switched. Management strategies included topical or oral corticosteroids, and treatment with alternative systemic agents such as ciclosporin or apremilast. This adverse event occurred in 1.0-12.1% of patients within trial data and observational studies. This review demonstrates that there are consistent reports of a switch to an atopic eczema phenotype from psoriasis in patients taking biologics inhibiting tumour necrosis factor alpha and the interleukin (IL)-17/IL-23 axis. The majority stopped the implicated biologic, but conservative management was successful in some cases. Those with an atopic diathesis may be more at risk. Elucidation of mechanisms and risk factors would contribute to optimal therapy selection for individual patients.

The Role of Th17-Related Cytokines in Atopic Dermatitis

T helper-17 (Th17) cells, which mainly produce IL-17, are associated with development of various autoimmune diseases such as rheumatoid arthritis, inflammatory bowel diseases, multiple sclerosis, and psoriasis. IL-17 and related cytokines are therapeutic targets of these diseases. In atopic dermatitis (AD), Th2 cytokines such as IL-4 and IL-13 are regarded to be the main player of the disease; however, Th17 cytokines are also expressed in AD skin lesions. Expression of IL-22 rather than IL-17 is predominant in AD skin, which is contrary to cytokine expression in psoriasis skin. Relatively low IL-17 expression in AD skin can induce relatively low antimicrobial peptide expression, which may be a reason why bacterial infection is frequently seen in AD patients. Failure of clinical trials for investigating the efficacy of anti-IL-12/23 p40 in AD has suggested that IL-17 expressed in skin lesions should not be the main player but a bystander responding to barrier dysfunction.