Updated treatment of atopic dermatitis Prof. Ortega Martell
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This document provides an overview of updated treatment approaches for atopic dermatitis. It discusses the pathophysiology involving both skin barrier defects and immune dysregulation. Treatment options reviewed include emollients, anti-inflammatory agents, wet wrap therapy, and biological therapies targeting specific cytokines and immune cells. Dupilumab, an antibody blocking IL-4 and IL-13, is highlighted as an effective new treatment for moderate to severe atopic dermatitis. The document emphasizes the importance of personalized treatment approaches based on disease severity and biomarkers.
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Updated treatment of atopic dermatitis Prof. Ortega Martell
- 2. José Antonio Ortega Martell, M.D. • La Salle University • National Institute of Pediatrics • Autonomous University of Hidalgo State, México • National Board of Clinical Immunology and Allergy • Mexican College of Pediatricians Specialized in Clinical Immunology and Allergy (COMPEDIA) • World Allergy Organization (WAO) Medicine Allergy Immunology Pediatrics
- 3. José Antonio Ortega Martell, M.D. • Participation as Speaker and Advisory Groups: § COMPEDIA § CMICA § CONICA § SLAAI § CONAPEME § WAO § Vifor Pharma § UCB Pharma § Sanofi Aventis § Astra Zeneca § Glaxo Smith Kline § Pierre Fabre Med Medical Societies Pharmaceutical Industry
- 8. • Hypothesis: “outside g inside” 1. Skin barrier defect 2. Allergen sensitization / microbe invasion 3. Immune system activation g inflammation • Supporting evidence: • Genetic factors in severe AD • Example: Filaggrin gene mutations Allergy Asthma Immunol Res. 2018 May; 10(3): 207–215.
- 9. • Hypothesis: “inside g outside” 1. Immune system control failure (iTreg) 2. Response: hTh2 g hTh1, hTh17, hTh22 3. Pro-Inflammatory cytokines g skin damage • Supporting evidence: • Genetic factors in severe AD (gen FOXP3) • T lymphocytes: h even in non-lesional skin Allergy Asthma Immunol Res. 2018 May; 10(3): 207–215.
- 13. J Allergy Clin Immunol 2017;140:633-43 IL-4 & IL-13 • IL-4Rα: type I and II receptors • Effects on: • Keratinocytes, lymphocytes, afferent nerve fibers
- 17. AD and allergic diseases • Asthma, Allergic Rhinitis, Food Allergy
- 19. J Allergy Clin Immunol 2017;139:1723-34 • Eczema • Food allergy • Asthma • Rhinitis ISSN 0091-6749 V O L U M E 1 3 9 N O . 6 J U N E 2 0 1 7 www.jacionline.org THE JOURNAL OF AllergyAND Clinical Immunology CURRENT PERSPECTIVES Etiology of epithelial barrier dysfunction in patients with type 2 inflammatory diseases Calpain-14 and its association with eosinophilic esophagitis Autoimmune chronic spontaneous urticaria: What we know and what we do not know PARADIGMS AND PERSPECTIVES Thunderstorm-related asthma attacks CLINICAL REVIEWS Novel concepts of prevention and treatment of atopic dermatitis through barrier and immune manipulations with implications for the atopic march MECHANISMS OF ALLERGIC DISEASES Phenotypic and genetic aspects of epithelial barrier function in asthmatic patients AN OFFICIAL JOURNAL OF
- 22. Differential Diagnosis • Contact Dermatitis • Seborrhoeic Dermatitis • Scabies • Psoriasis • Ichthyosis • Photosensibility • Skin Lymphoma • Primary I.D. • More causes of erythrodermia …
- 23. Ann Allergy Asthma Immunol 120 (2018) 23-33. • 9m old boy, Eczema since 2m • Staph aureus Cellulitis, Tx with i.v. clindamycin, Met PDN • IgE (+) egg, milk, peanut, soy, elimination: no improvement • SCORAD = 57 • Wet wraps, emolient, cephalexin, topical steroids, TCI • IgG = < 75 mg/dL, IgE = 593 IU/ml CD19 = 49%, IgD+CD27+B = 3.7%
- 26. Evaluate g better Treatment • Find myths and barriers • Find common triggers • Investigate sleep disturbance • Psychological affectation Success in Tx Quality of life Br J Dermatol 2017, 177 (5): 1316 – 1321.
- 27. AD: Main Treatment Goals • Prevent exacerbations 1 • Tx to comorbidities 2 • Tx to complications 3 • Minimal adverse effects 4 • Improve quality of life 5 J Am Acad Dermatol 2016, 74 (3): 491-8.
- 29. Recommendations for patients with AD
- 30. AD: Bleach baths and Wet wraps i Staphylococcus aureus, Malassezia … Variable results
- 33. Ann Allergy Asthma Immunol 120 (2018) 23-33. Wet Wrap Therapy: g H2O g emolient g TCS g wet g dry
- 35. Crisaborole: PDE4 inhibitor • PDE4: (Phosphodiesterase 4) • AMPc g AMP g h inflammatory cytokines J Drugs Dermatol. 2016;15(4):390-396.
- 37. Crisaborole: mild – moderate AD • Significant improvement in Tx group
- 41. AD: mild g moderate Ann Allergy Asthma Immunol 120 (2018) 10-22.
- 42. AD: moderate g severe Ann Allergy Asthma Immunol 120 (2018) 10-22.
- 43. Immunotherapy: Ag – specific J Allergy Clin Immunol 2016;138:1541-7
- 44. Immunotherapy: Ag – specific J Allergy Clin Immunol 2016;138:1541-7
- 48. J Allergy Clin Immunol 2017;139:S65-76
- 49. J Allergy Clin Immunol 2017;139:S65-76
- 51. AD: Biological Agents • Dupilumab • Human monoclonal antibody • Anti IL-4Rα (IL-4 & IL-13 receptor ) • FDA: adults with moderate or severe AD • Initial Dose = 600 mg SC • Maintenance Dose = 300 mg SC every 2 weeks N Engl J Med 2016; 375 (24): 2335 – 48.
- 53. J Allergy Clin Immunol 2017;139:S65-76 Blocking IL-4 / IL-13 • h Filaggrin expression • h Defensin production • i CC-Chemokine synthesis • i IgE production • i Type 2 response (Th2, ILC2)
- 54. J Allergy Clin Immunol 2017;139:S65-76 Therapy with Dupilumab
- 55. Dupilumab 16 weeks: moderate – severe AD • Clinical improvement in Dupilumab group N Engl J Med 2016; 375 (24): 2335 – 48.
- 56. Dupilumab 52 weeks: moderate – severe AD • Clinical improvement in Dupilumab group N Engl J Med 2016; 375 (24): 2335 – 48.
- 57. New Agents in the pipeline • Anti IL-31 • Anti IL-13 • Anti IL-13 Clinical Issues in Atopic Dermatitis. Lisa A. Beck. AAAAI-WAO Meeting. Orlando, Fl. 2018