Are the concepts of induction of remission and treatment of subclinical inflammation in atopic dermatitis clinically useful?

The Journal of allergy and clinical immunology (Impact Factor: 11.48). 06/2014; 133(6). DOI: 10.1016/j.jaci.2013.12.1079


Atopic dermatitis (AD) treatment is often initiated by symptoms or visible erythema. The role of induction of remission or treatment of inflammation that is not visible is unclear.

We investigated whether (1) the notion of subclinical inflammation is scientifically sound, (2) treatment corrects subclinical inflammation, and (3) different strategies for initial clearance of AD affect long-term disease control.

We conducted a systematic review based on searching MEDLINE, Embase, the Cochrane register of randomized controlled trials, and the Global Resource of Eczema Trials from inception to the end of October 2012.

Twenty of 26 included studies presented evidence of subclinical inflammation, with a continuum of changes in skin barrier dysfunction, the proinflammatory cytokine milieu, and lymphocytic infiltration from normal-appearing skin to posttreatment lesional skin to active skin lesions in patients with AD. Such subclinical inflammation is improved, with proactive treatment aimed at maintaining remission. Failure to achieve control of AD symptoms with initial therapy was associated with a higher risk of relapse in 14 randomized controlled trials (fluticasone: risk ratio, 1.31; 95% CI, 1.02-1.68; tacrolimus: risk ratio, 1.36; 95% CI, 1.12-1.66). Three trials on systemic therapy/phototherapy suggested that induction of remission resulted in long-term remission without maintenance therapy in approximately 15% of patients.

Induction of remission followed by maintenance therapy might prove to be an integral part of a disease-modifying strategy for treating atopic diseases.

1 Follower
29 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: Atopic dermatitis (AD) is a chronic, relapsing inflammatory skin disease. To improve the patient's quality of life (QOL),preventing relapse after remission of skin eruption is one of the critical concerns. We investigated the effect of proactive (PRO) therapy using betamethasone butyrate propionate (BBP) ointment in moderate or severe AD patients. Following stabilization of skin eruption after daily application of BBP, patients were divided into two groups : the PRO group that received twice weekly topical application of BBP ointment based on daily topical application of a moisturizing agent and the control (CON) group that received topical monotherapy with a moisturizing agent. The effects on relapse prevention and QOLs were compared between the groups. Significant improvement in the scores of cutaneous findings from the baseline was observed in the PRO group after 8 weeks treatment or completion of the study. The scores of cutaneous findings after 4 weeks or 8 weeks treatment, or completion of the study were significantly lower in the PRO group than in the CON group. Based on the changes in daytime itching measures using the visual analog scale and Dermatology Life Quality Index, the symptoms were significantly improved in the PRO group after completion of the study. According to the weekly cumulative convergent maintenance duration of inflammation, significant prolongation was noted in the PRO group compared with in the CON group after 3 weeks treatment. The convergent maintenance rate was significantly higher in the PRO group than in the CON group. These results showed that PRO therapy using twice weekly topical application of BBP ointment was effective in moderate or severe AD patients for relapse prevention after stabilization of cutaneous inflammation and delayed relapse of inflammation. Thus, our results suggested that this PRO therapy is an effective topical strategy to reduce itching and improve patients' QOLs.
    No preview · Article · Jan 2014 · Nishi Nihon Hifuka
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Moderate to severe forms of atopic dermatitis (AD) have a substantial impact on the quality of life of patients and their relatives, carrying a significant socio-economic burden. They often require a systemic therapy and ciclosporine A (CsA) is the only medicinal product approved for this indication in a limited number of European countries. However, due to the safety profile of CsA and its approval conditions, this treatment can only be prescribed for a limited period of time. Thus, moderate to severe forms of AD represent a significant unmet medical need and are subject to off-label prescriptions. Besides giving some insights into the approval procedures for medicinal products in the European Union, this short review is aimed to provide some relevant background information for off-label prescription in AD. It also provides a clinical algorithm for the off-label prescription of systemic immunosuppressants in AD, discusses the apparent dilemma between approval and guidelines, and finally suggests practical rules to be considered in the context of off-label prescription.This article is protected by copyright. All rights reserved.
    Preview · Article · Jul 2014 · Allergy
  • [Show abstract] [Hide abstract]
    ABSTRACT: Serum levels of thymus and activation-regulated chemokine (TARC/CCL17) have served as a reliable biomarker of disease progression of atopic dermatitis (AD). However, it remains to be scientifically explained why serum TARC levels correlate well with the degree of AD progression.
    No preview · Article · Aug 2014 · Journal of Dermatological Science
Show more