Quality of life in patients with allergic and immunologic skin diseases: in the eye of the beholder

Burden of Disease and Unmet Needs in the Diagnosis and Management of Atopic Dermatitis in the Arabic Population of the Middle East

Atopic dermatitis (AD) affects diverse ethnic groups with significant disparities in prevalence, disease progression, clinical outcomes, and access to care. There are limited data on AD in the Arabic population of the Middle East, yet there is a substantial economic and psychosocial burden of AD in this region with a large unmet need with regards to disease management that is critical to address. There is a trend of increasing prevalence of AD in the Arab Middle East; however, due to the large environmental, socioeconomic, and sociocultural heterogeneity of this region, prevalence varies greatly across and within countries. Similarly, clinical differences in disease presentations exist across the region, although data are limited. In this review, we will present clinical phenotypes of AD common in different regions of the Arab Middle East, and data on prevalence, genetic variations, and challenges of treatment. Further studies exploring molecular biomarkers, genetic polymorphisms, immune factors, and the microbiome of patients in the region will help to elucidate the mechanism behind ethnic differences in AD in this population as well as to understand susceptibilities and treatment response.

Advancing the understanding of allergic contact dermatitis: from pathophysiology to novel therapeutic approaches

Allergic contact dermatitis (ACD) is a common inflammatory skin disease that, especially when the condition becomes chronic, has a high impact on the quality of life and represents a significant disease burden. ACD represents a type IV delayed-type hypersensitivity reaction that is triggered by contact with an allergen in previously sensitized individuals through the activation of allergen-specific T cells. In the acute phase, it is characterized by eczematous dermatitis, which presents with erythema, edema, vesicles, scaling, and intense itch. Non-eczematous clinical forms are also described (lichenoid, bullous, and lymphomatosis). Lichenification is the most common clinical picture in the chronic phase if the culprit allergen is not found or eliminated. ACD can be associated with both occupational and non-occupational exposure to allergens, representing approximately 90% of occupational skin disorders along with irritant contact dermatitis. Patch testing with suspected allergens is required for a diagnosis. Metals, especially nickel, fragrance mix, isothiazolinones, and para-phenylenediamine, are the most commonly positive allergens in patients patch tested for suspected ACD. The treatment goal is to avoid contact with the culprit agent and use topical and/or systemic corticosteroid therapy.

A Study of Efficacy and Safety of Ashwagandha (Withania somnifera) Lotion on Facial Skin in Photoaged Healthy Adults

Background Facial skin has an essential cosmetic function in both men and women, and photoaged skin can affect the quality of life in healthy people. Ashwagandha (Withania somnifera) which is also called Indian ginseng has adaptogenic properties and is used in traditional Indian medicine to maintain balance, energize, and rejuvenate. Objective This randomized, double-blind, and placebo-controlled study assessed the efficacy and safety of topical application of lotion containing 8% standardized Ashwagandha root extract on improvement of skin parameters in the photoaged facial skin of healthy subjects. Methods Fifty-six healthy men and women aged between 18 and 60 years with Fitzpatrick phototype III-VI skin grade were randomized to receive the topical application (lotion on facial skin) of either Ashwagandha 8% (AG, n=28), or an identical placebo (PL, n=28) for 60 days. The primary outcome was the change from baseline on day 60 in the scores for global physician assessment scoring for the five dermatological signs (skin wrinkles, pores, hydration/moisture, skin brightness/tone, and pigmentation) on facial skin. Secondary outcomes were changes from baseline in the transepidermal water loss (TEWL), melanin index, hydration, and skin elasticity (R2 ratio). Another efficacy outcome was quality of life using the health-specific Short Form Health Survey-12 (SF-12). Safety was assessed using local reactions and adverse events. Three (1 AG, 2 PL) patients were lost to follow-up and per-protocol (PP) data included 53 patients (27 AG, 26 PL). For measurement data, repeated measures analysis of variance (ANOVA) was used to assess treatment effect at different time periods in the PP dataset (n=53). Two groups were compared for differences using a t-test for continuous data or a Mann-Whitney 'U' test for ordinal data. Adverse events were compared between two groups using the chi-square test. Results Greater reduction (p<0.0001) in total physician assessment scores from baseline to day 60 was observed with AG (-74.69%) compared to PL (-48.68%). There was a greater improvement in TEWL, skin hydration, and skin elasticity (R2 ratio) with AG as compared to placebo (p<0.0001). However, the change in melanin index was similar in the two groups at the end of day 60 (p=0.969). The percentage increase in melanin index from baseline to day 60 in the PP dataset was by -2.82% with AG and -1.78% with PL, whereas the percentage reduction in TEWL from baseline to day 60 in the PP dataset was by -15.12% with AG and -8.34% with PL. Similarly, greater percentage improvements were seen with AG as compared to PL for skin hydration (20.66% with AG and 9.5% with PL) and elasticity was assessed by the R2 ratio (16.34% with AG and 3.73% with PL). Adverse events were comparable in the two groups. Conclusions Topical application of a lotion containing Ashwagandha standardized root extract improves the skin condition and quality of life in photoaged healthy individuals. Further studies with different skin types and standard comparators are warranted to substantiate these claims of benefit.

Clinically meaningful improvements in cutaneous lesions and quality of life measures in patients with atopic dermatitis with greater pruritus reductions after treatment with 60 mg nemolizumab subcutaneously every 4 weeks: Subgroup analysis from a phase 3, randomized, controlled trial

BACKGROUND

Data from the Japanese phase 3 Nemolizumab-JP01 study (JapicCTI-173740) found that nemolizumab in combination with topical treatments reduced pruritus associated with atopic dermatitis inadequately controlled with current therapies.

METHODS

This post-hoc analysis examined associations between improvements in pruritus (visual analog scale [VAS]) and eczema (Eczema Area and Severity Index [EASI]), and achievement of other clinically relevant endpoints including the Insomnia Severity Index (ISI), Dermatology Life Quality Index (DLQI), and Patient-Oriented Eczema Measure (POEM).

RESULTS

Pruritus VAS responders (≥50% improvement from baseline to week 16) showed greater improvements from baseline in these additional endpoints as early as week 1, compared with non-responders. Responders also had EASI improvement, and more than 80% achieved an ISI score ≤7, or had improvement in the DLQI or POEM. The percent change from baseline in VAS and EASI scores at week 16 was in favor of nemolizumab in all subgroups based on baseline characteristics. No specific factor affecting treatment response to nemolizumab was identified.

CONCLUSIONS

In this post-hoc analysis, nemolizumab-treated patients who had greater pruritus reductions also showed improvements in other eczema symptoms; pruritus alleviation appeared to be responsible for the improvements in eczema, sleep and daily life.

Therapeutical Targets in Allergic Inflammation

From the discovery of IgE to the in-depth characterization of Th2 cells and ILC2, allergic inflammation has been extensively addressed to find potential therapeutical targets. To date, omalizumab, an anti-IgE monoclonal antibody, and dupilumab, an anti-IL-4 receptor α monoclonal antibody, represent two pillars of biologic therapy of allergic inflammation. Their increasing indications and long-term follow-up studies are shaping the many different faces of allergy. At the same time, their limitations are showing the intricate pathogenesis of allergic diseases.

Urticaria

Urticaria is an inflammatory skin disorder that affects up to 20% of the world population at some point during their life. It presents with wheals, angioedema or both due to activation and degranulation of skin mast cells and the release of histamine and other mediators. Most cases of urticaria are acute urticaria, which lasts ≤6 weeks and can be associated with infections or intake of drugs or foods. Chronic urticaria (CU) is either spontaneous or inducible, lasts >6 weeks and persists for >1 year in most patients. CU greatly affects patient quality of life, and is linked to psychiatric comorbidities and high healthcare costs. In contrast to chronic spontaneous urticaria (CSU), chronic inducible urticaria (CIndU) has definite and subtype-specific triggers that induce signs and symptoms. The pathogenesis of CSU consists of several interlinked events involving autoantibodies, complement and coagulation. The diagnosis of urticaria is clinical, but several tests can be performed to exclude differential diagnoses and identify underlying causes in CSU or triggers in CIndU. Current urticaria treatment aims at complete response, with a stepwise approach using second-generation H1 antihistamines, omalizumab and cyclosporine. Novel treatment approaches centre on targeting mediators, signalling pathways and receptors of mast cells and other immune cells. Further research should focus on defining disease endotypes and their biomarkers, identifying new treatment targets and developing improved therapies.

Clinical phenotypes of adult atopic dermatitis and related therapies

PURPOSE OF REVIEW

To report current knowledge on the different clinical phenotypes of adult atopic dermatitis. Possible therapeutic intervention in relation to phenotype is also evaluated.

RECENT FINDINGS

Atopic dermatitis is a chronic inflammatory disease affecting up to 10% of adults. It can manifest with different clinical phenotypes, causing diagnostic difficulties. Long-term is often required and systemic drugs are needed for moderate-to-severe forms. However, few drugs are registered for atopic dermatitis in many countries. Furthermore, limited data exist regarding the treatment in relation to individual clinical phenotypes.

SUMMARY

Currently, the most relevant data are those for cyclosporine, alitretinoin, and dupilumab. Cyclosporine and dupilumab showed to be effective in the treatment of atopic dermatitis, although in trials and real-life experiences the different phenotypes treated are usually not reported. However, cyclosporine appears to be effective in prurigo nodularis. Alitretinoin is reported to be particularly efficacious for atopic dermatitis of the hands, while it is ineffective for other locations of the disease. Dupilumab demonstrated its efficacy in prurigo nodularis and nummular eczema phenotypes of atopic dermatitis; moreover, especially in elderly patients, its effectiveness seems to be faster if the folds of the limbs are involved.