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Yang L, Li D, Sun S, Liu D, Wang Y, Liu X, Zhou B, Nie W, Li L, Wang Y, Sha S, Li Y, Shen C, Tao J. Dupilumab therapy improves gut microbiome dysbiosis and tryptophan metabolism in Chinese patients with atopic dermatitis. Int Immunopharmacol 2024; 131:111867. [PMID: 38493690 DOI: 10.1016/j.intimp.2024.111867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Dupilumab has demonstrate its potential to orchestrate inflammatory skin microenvironment, enhance skin barrier and shift skin microbiome dysbiosis, collectively contributing to clinical improvement in patients with atopic dermatitis (AD). As the second genome of human body, growing evidence suggests that the gut microbiome might relate to the host response to treatments. Little is known about the association between dupilumab treatment and gut microbiome in AD patients. OBJECTIVE We aimed to characterize the gut microbiome among Chinese subjects with or without AD and determine the potential effect of dupilumab on the gut microbiome. RESULTS The 16 s rRNA gene sequencing was conducted on 48 healthy controls (HC), 44 AD patients and 27 AD patients who received dupilumab for 16 weeks. Prior to treatment, we identified the changed beta-diversity, increased Firmicutes/Bacteroidetes ratio, decreased Bifidobacterium and expanded Faecalibacterium among the AD patients compared to HC. After 16 weeks of dupilumab treatment, gut microbiome dysbiosis of the AD patients improved with reversed beta-diversity, closer bacterial connections, increased colonization of Bifidobacterium, Ruminococcus gnavus, and Coprococcus, which were negatively correlated with disease severity indicators. This shift was largely independent of the degree of clinical improvement. Bacterial function analysis revealed further metabolic alterations following dupilumab treatment, including up-regulated expression of genes involved in the indole pathway of tryptophan metabolism, corroborated by quantitative UHPLC-MS/MS analysis. CONCLUSION Dupilumab treatment tends to help shift the gut microbial dysbiosis in AD patients to a healthier state, along with improved intestinal tryptophan metabolism, suggesting the gut flora and its metabolites may mediate part of the synergistic therapeutic effects on the host.
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Affiliation(s)
- Liu Yang
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Engineering Research Center for Skin Repair and Theranostics, Wuhan 430022, China
| | - Danqi Li
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Engineering Research Center for Skin Repair and Theranostics, Wuhan 430022, China
| | - Shuomin Sun
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Engineering Research Center for Skin Repair and Theranostics, Wuhan 430022, China
| | - Danping Liu
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yi Wang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Xiaohuan Liu
- Department of Endocrinology, The Third Xiangya Hospital, Central South University, Changsha 410007, Hunan, China
| | - Bin Zhou
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Engineering Research Center for Skin Repair and Theranostics, Wuhan 430022, China
| | - Wenjia Nie
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Engineering Research Center for Skin Repair and Theranostics, Wuhan 430022, China
| | - Lu Li
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Engineering Research Center for Skin Repair and Theranostics, Wuhan 430022, China
| | - Yifei Wang
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Engineering Research Center for Skin Repair and Theranostics, Wuhan 430022, China
| | - Shanshan Sha
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Engineering Research Center for Skin Repair and Theranostics, Wuhan 430022, China
| | - Yan Li
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Engineering Research Center for Skin Repair and Theranostics, Wuhan 430022, China
| | - Chen Shen
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Engineering Research Center for Skin Repair and Theranostics, Wuhan 430022, China
| | - Juan Tao
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Engineering Research Center for Skin Repair and Theranostics, Wuhan 430022, China.
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Greenzaid JD, Chan LJ, Chandani BM, Kiritsis NR, Feldman SR. Microbiome modulators for atopic eczema: a systematic review of experimental and investigational therapeutics. Expert Opin Investig Drugs 2024; 33:415-430. [PMID: 38441984 DOI: 10.1080/13543784.2024.2326625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 02/29/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION Atopic dermatitis (AD) is a common inflammatory cutaneous disease that arises due to dysregulation of the Th2 immune response, impaired skin barrier integrity, and dysbiosis of the skin and gut microbiota. An abundance of Staphylococcus aureus biofilms in AD lesions increases the Th2 immune response, and gut bacteria release breakdown products such as Short Chain Fatty Acids that regulate the systemic immune response. AREAS COVERED We aim to evaluate therapies that modulate the microbiome in humans and discuss the clinical implications of these treatments. We performed a review of the literature in which 2,673 records were screened, and describe the findings of 108 studies that were included after full-text review. All included studies discussed the effects of therapies on the human microbiome and AD severity. Oral probiotics, topical probiotics, biologics, and investigational therapies were included in our analysis. EXPERT OPINION Oral probiotics demonstrate mixed efficacy at relieving AD symptoms. Topical probiotics reduce S. aureus abundance in AD lesional skin, yet for moderate-severe disease, these therapies may not reduce AD severity scores to the standard of biologics. Dupilumab and tralokinumab target key inflammatory pathways in AD and modulate the skin microbiome, further improving disease severity.
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Affiliation(s)
- Jonathan D Greenzaid
- Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Lina J Chan
- Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Brittany M Chandani
- Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Nicholas R Kiritsis
- Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Steven R Feldman
- Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Social Sciences & Health Policy, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Yang K, Yong JY, He Y, Yu L, Luo GN, Chen J, Ge YM, Yang YJ, Ding WJ, Hu YM. Melatonin restores DNFB-induced dysbiosis of skin microbiota in a mouse model of atopic dermatitis. Life Sci 2024; 342:122513. [PMID: 38387700 DOI: 10.1016/j.lfs.2024.122513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 02/04/2024] [Accepted: 02/19/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND The epidermic microbiota plays crucial roles in the pathogenesis of atopic dermatitis (AD), a common inflammatory skin disease. Melatonin (MLT) has been shown to ameliorate skin damage in AD patients, yet the underlying mechanism is unclear. METHODS Using 2,4-dinitrofluorobenzene (DNFB) to induce an AD model, MLT intervention was applied for 14 days to observe its pharmaceutical effect. Skin lesions were observed using HE staining, toluidine blue staining and electron microscopy. Dermal proinflammatory factor (IL-4 and IL-13) and intestinal barrier indices (ZO1 and Occludin) were assessed by immunohistochemistry and RT-qPCR, respectively. The dysbiotic microbiota was analyzed using 16S rRNA sequencing. RESULTS MLT significantly improved skin lesion size; inflammatory status (mast cells, IgE, IL-4, and IL-13); and the imbalance of the epidermal microbiota in AD mice. Notably, Staphylococcus aureus is the key bacterium associated with dysbiosis of the epidermal microbiota and may be involved in the fine modulation of mast cells, IL-4, IL-13 and IgE. Correlation analysis between AD and the gut revealed that intestinal dysbiosis occurred earlier than that of the pathological structure in the gut. CONCLUSION Melatonin reverses DNFB-induced skin damage and epidermal dysbiosis, especially in S. aureus.
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Affiliation(s)
- Kun Yang
- Chengdu University of Traditional Chinese Medicine, 1166 Liutai Avenue, Chengdu, Sichuan 611137, China
| | - Jiang-Yan Yong
- Chengdu University of Traditional Chinese Medicine, 1166 Liutai Avenue, Chengdu, Sichuan 611137, China; Hospital of Chengdu University of Traditional Chinese Medicine, No.39 Shi-er-qiao Road, Chengdu, 610072, SichuanProvince, China
| | - Yan He
- Chengdu University of Traditional Chinese Medicine, 1166 Liutai Avenue, Chengdu, Sichuan 611137, China
| | - Lu Yu
- Chengdu University of Traditional Chinese Medicine, 1166 Liutai Avenue, Chengdu, Sichuan 611137, China
| | - Gui-Ning Luo
- Chengdu University of Traditional Chinese Medicine, 1166 Liutai Avenue, Chengdu, Sichuan 611137, China
| | - Jilan Chen
- Chengdu University of Traditional Chinese Medicine, 1166 Liutai Avenue, Chengdu, Sichuan 611137, China
| | - Yi-Man Ge
- Chengdu University of Traditional Chinese Medicine, 1166 Liutai Avenue, Chengdu, Sichuan 611137, China; Hospital of Chengdu University of Traditional Chinese Medicine, No.39 Shi-er-qiao Road, Chengdu, 610072, SichuanProvince, China
| | - You-Jun Yang
- Chengdu University of Traditional Chinese Medicine, 1166 Liutai Avenue, Chengdu, Sichuan 611137, China
| | - Wei-Jun Ding
- School of Basic Medical Sciences, Chengdu University of Traditional Chinese Medicine, 1166 Liutai Avenue, Chengdu, Sichuan 611137, China.
| | - Yi-Mei Hu
- Chengdu University of Traditional Chinese Medicine, 1166 Liutai Avenue, Chengdu, Sichuan 611137, China; Hospital of Chengdu University of Traditional Chinese Medicine, No.39 Shi-er-qiao Road, Chengdu, 610072, SichuanProvince, China.
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Ferrucci SM, Tavecchio S, Ceresa A, Angileri L, Berti E, Marzano AV, Buoli M. Which Factors Are Associated with Persistence of Depressive and Anxiety Symptoms in Patients Affected by Atopic Dermatitis despite 2-Year Treatment with Dupilumab? J Clin Med 2024; 13:1980. [PMID: 38610745 PMCID: PMC11012912 DOI: 10.3390/jcm13071980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Atopic Dermatitis (AD) is a prevalent inflammatory skin disease whose course is often complicated by the presence of concomitant anxiety and depressive disorders. Dupilumab has been demonstrated to be largely effective in AD. The aims of the present study were to (1) to verify the effectiveness of 2-year dupilumab treatment on the depressive and anxiety symptoms of patients affected by AD and (2) to identify predictors of the persistence of psychiatric symptoms despite maintenance treatment with dupilumab. Methods: A total of 331 patients with severe AD were assessed at baseline and at different times over 2 years by a large set of rating scales, including the Eczema Area and Severity Index (EASI), the Hospital Anxiety and Depression Scale (HADS), and the Dermatology Life Quality Index (DLQI). Paired sample t-tests were performed to verify the effectiveness of dupilumab on the severity of AD and mental health items. Two binary logistic regression models were then used to identify the predictors of the persistence of clinically significant depression and anxiety, defined by a score ≥ 8 on each sub-scale of the HADS. Results: After 2 years of treatment with dupilumab, the patients benefited, showing a significant improvement in both the dermatological disease and comorbid depression/anxiety (p < 0.001 for all scales). Overall, 17.5% and 13% of patients, respectively, reported residual depressive and anxiety symptoms after the 2-year treatment with dupilumab. The baseline predictors of the persistence of clinically significant depressive symptoms after the 2-year treatment with dupilumab were found to be a higher body mass index (BMI) (p = 0.012), a lower impact of dermatological disease on quality of life (p = 0.015), and more severe depressive symptoms (p < 0.01), while for anxiety, the only predictor was found to be female gender (p = 0.03). Conclusions: Using a multidisciplinary approach, at baseline, dermatologists should more closely monitor patients who are at a greater risk of maintaining residual psychiatric symptoms despite therapy, such as those with more severe depressive symptoms and those who are overweight.
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Affiliation(s)
- Silvia Mariel Ferrucci
- Dermatology Section, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy; (S.M.F.)
| | - Simona Tavecchio
- Dermatology Section, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy; (S.M.F.)
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy;
| | - Alessandro Ceresa
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milan, Italy
| | - Luisa Angileri
- Dermatology Section, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy; (S.M.F.)
| | - Emilio Berti
- Dermatology Section, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy; (S.M.F.)
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy;
| | - Angelo Valerio Marzano
- Dermatology Section, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy; (S.M.F.)
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy;
| | - Massimiliano Buoli
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy;
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milan, Italy
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Wang M, Gao XH, Zhang L. A Review of Dupilumab in the Treatment of Atopic Dermatitis in Infants and Children. Drug Des Devel Ther 2024; 18:941-951. [PMID: 38560522 PMCID: PMC10981892 DOI: 10.2147/dddt.s457761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/18/2024] [Indexed: 04/04/2024] Open
Abstract
Atopic dermatitis (AD), a common pruritic and chronic inflammatory skin disease, has a major impact on a patient's quality of life. It is characterized by dry, itchy, and eczema-like rashes. AD is more prevalent in young children and has been linked to a variety of other allergy disorders. Traditional drug therapy has certain limitations for treating young children with AD. However, biologics have good clinical application prospects in the medical treatment of young patients. Dupilumab, a fully human monoclonal antibody, specifically binds to the IL-4 Rα subunit, inhibiting IL-4 and IL-13 signaling and blocking the occurrence of type 2 inflammatory response. It has a good effect on treating infants and children with moderate-to-severe AD. This review explores the safety and efficacy of dupilumab in the treatment of AD in infants and children and the impact of early intervention on AD progression, with the aim of informing clinical practice in the use of dupilumab for the treatment of young patients with AD.
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Affiliation(s)
- Mingyue Wang
- Department of Dermatology, the First Hospital of China Medical University, Shenyang, 110001, People’s Republic of China
- NHC Key Laboratory of Immunodermatology, China Medical University, Shenyang, People’s Republic of China
- Key Laboratory of Immunodermatology, China Medical University, Ministry of Education, Shenyang, People’s Republic of China
- National and Local Joint Engineering Research Center of Immunodermatological Theranostics, Shenyang, People’s Republic of China
| | - Xing-Hua Gao
- Department of Dermatology, the First Hospital of China Medical University, Shenyang, 110001, People’s Republic of China
- NHC Key Laboratory of Immunodermatology, China Medical University, Shenyang, People’s Republic of China
- Key Laboratory of Immunodermatology, China Medical University, Ministry of Education, Shenyang, People’s Republic of China
- National and Local Joint Engineering Research Center of Immunodermatological Theranostics, Shenyang, People’s Republic of China
| | - Li Zhang
- Department of Dermatology, the First Hospital of China Medical University, Shenyang, 110001, People’s Republic of China
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Umemoto N, Kakurai M, Matsumoto T, Mizuno K, Cho O, Sugita T, Demitsu T. Dupilumab Alters Both the Bacterial and Fungal Skin Microbiomes of Patients with Atopic Dermatitis. Microorganisms 2024; 12:224. [PMID: 38276210 PMCID: PMC10820602 DOI: 10.3390/microorganisms12010224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 01/08/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
The skin microbiome at lesion sites in patients with atopic dermatitis (AD) is characterized by dysbiosis. Although the administration of dupilumab, an IL-4Rα inhibitor, improves dysbiosis in the bacterial microbiome, information regarding the fungal microbiome remains limited. This study administered dupilumab to 30 patients with moderate-to-severe AD and analyzed changes in both fungal and bacterial skin microbiomes over a 12-week period. Malassezia restricta and M. globosa dominated the fungal microbiome, whereas non-Malassezia yeast species increased in abundance, leading to greater microbial diversity. A qPCR analysis revealed a decrease in Malassezia colonization following administration, with a higher reduction rate observed where the pretreatment degree of colonization was higher. A correlation was found between the group classified by the Eczema Area and Severity Index, the group categorized by the concentration of Thymus and activation-regulated chemokine, and the degree of skin colonization by Malassezia. Furthermore, an analysis of the bacterial microbiome also confirmed a decrease in the degree of skin colonization by the exacerbating factor Staphylococcus aureus and an increase in the microbial diversity of the bacterial microbiome. Our study is the first to show that dupilumab changes the community structure of the bacterial microbiome and affects the fungal microbiome in patients with AD.
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Affiliation(s)
- Naoka Umemoto
- Department of Dermatology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama 330-8503, Japan; (N.U.); (M.K.); (T.M.); (K.M.); (T.D.)
| | - Maki Kakurai
- Department of Dermatology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama 330-8503, Japan; (N.U.); (M.K.); (T.M.); (K.M.); (T.D.)
| | - Takanao Matsumoto
- Department of Dermatology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama 330-8503, Japan; (N.U.); (M.K.); (T.M.); (K.M.); (T.D.)
| | - Kenta Mizuno
- Department of Dermatology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama 330-8503, Japan; (N.U.); (M.K.); (T.M.); (K.M.); (T.D.)
| | - Otomi Cho
- Department of Microbiology, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose 204-8588, Japan;
| | - Takashi Sugita
- Department of Microbiology, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose 204-8588, Japan;
| | - Toshio Demitsu
- Department of Dermatology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama 330-8503, Japan; (N.U.); (M.K.); (T.M.); (K.M.); (T.D.)
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Ding Z, Mulder J, Robinson MJ. The origins and longevity of IgE responses as indicated by serological and cellular studies in mice and humans. Allergy 2023; 78:3103-3117. [PMID: 37417548 PMCID: PMC10952832 DOI: 10.1111/all.15799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/02/2023] [Accepted: 06/16/2023] [Indexed: 07/08/2023]
Abstract
The existence of long-lived IgE antibody-secreting cells (ASC) is contentious, with the maintenance of sensitization by the continuous differentiation of short-lived IgE+ ASC a possibility. Here, we review the epidemiological profile of IgE production, and give an overview of recent discoveries made on the mechanisms regulating IgE production from mouse models. Together, these data suggest that for most individuals, in most IgE-associated diseases, IgE+ ASC are largely short-lived cells. A subpopulation of IgE+ ASC in humans is likely to survive for tens of months, although due to autonomous IgE B cell receptor (BCR) signaling and antigen-driven IgE+ ASC apoptosis, in general IgE+ ASC probably do not persist for the decades that other ASC are inferred to do. We also report on recently identified memory B cell transcriptional subtypes that are the likely source of IgE in ongoing responses, highlighting the probable importance of IL-4Rα in their regulation. We suggest the field should look at dupilumab and other drugs that prohibit IgE+ ASC production as being effective treatments for IgE-mediated aspects of disease in most individuals.
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Affiliation(s)
- Zhoujie Ding
- Department of ImmunologyMonash UniversityMelbourneVictoriaAustralia
| | - Jesse Mulder
- Department of ImmunologyMonash UniversityMelbourneVictoriaAustralia
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