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Neues und Bewährtes zur Therapie des atopischen Ekzems

Update on the treatment of atopic eczema

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Zusammenfassung

Derzeit steht für das atopische Ekzem (AE) keine kausale Behandlung zur Verfügung. Neben der Meidung individueller Provokationsfaktoren umfasst die symptomatische Lokaltherapie eine stadiengerechte Anwendung pflegender und rückfettender sowie ggf. antiseptischer und antiinflammatorischer Externa. Die medikamentöse Therapie des schweren AE ist eine besondere Herausforderung. Als immunsuppressives Systemtherapeutikum ist in Deutschland derzeit nur Ciclosporin zugelassen; zur Unterbrechung des akuten Schubes können auch orale Glukokortikosteroide eingesetzt werden. Daneben stellen Methotrexat (MTX), Azathioprin, Mycophenolatmofetil und Leflunomid immunsuppressive Therapieoptionen im Einzelfall dar („off-label use“), die jedoch meist nur in kleineren Fallserien oder unkontrollierten Studien untersucht wurden.

Während in den letzten Jahren für die Behandlung der Psoriasis eine Reihe hochwirksamer Biologika entwickelt wurde, gibt es noch kein Medikament aus dieser Gruppe, welches für die Therapie des AE zugelassen ist. In offenen Anwendungsbeobachtungen ergaben sich jedoch Hinweise auf eine Wirksamkeit von Alefacept (Fusionsprotein, Inhibition der T-Zell-Aktivierung), Efalizumab (Anti-LFA-1-Antikörper), Rituximab (Anti-CD-20-Antikörper) und Omalizumab (Anti-IgE-Antikörper) zumindest bei Subgruppen von Patienten. Neben der extrakorporalen Photopherese könnte außerdem die Immunglobulin-Immunadsorption eine Option zur Behandlung des therapierefraktären AE darstellen.

Bei Patienten mit klinisch relevanter Sensibilisierung gegenüber Aeroallergenen ist die spezifische Immuntherapie, auch hinsichtlich des AE, durchaus eine Therapieoption.

Basierend auf zahlreichen neuen Erkenntnissen zur Pathogenese des AE werden derzeit eine Reihe neuer therapeutischer Ansätze verfolgt. Zielstrukturen sind unter anderem Filaggrinstoffwechsel und epidermale Proteasen, Tachykininrezeptoren, Histaminrezeptor 4, Interleukin-31 und Phosphodiesterase-4.

Summary

To date, there is no simple cure for atopic eczema (AE). Besides the avoidance of specific and unspecific trigger factors the stepped approach to management includes a basic emollients therapy and, according to the severity of symptoms, the addition of antiseptic and/or anti-inflammatory topical treatments. In cases of moderate to severe AE additional systemic treatment is needed to control the disease. Currently only cyclosporine is approved in Germany; oral corticosteroids can be used for a short time for severe acute exacerbations. Systemic immunosuppression with methotrexate, azathioprine, mycophenolat mofetil and leflunomide may also be used with success (off-label use), but these agents remain to be assessed in larger randomized trials. While in the past years a number of biologicals have been developed for the treatment of psoriasis vulgaris, there is currently no biological approved for the treatment of AE. Preliminary data points towards a potential efficacy of alefacept [fusion protein of lymphocyte function antigen (LFA)-3], efalizumab (anti-CD11a antibody, no longer available), rituximab (anti-CD20 antibody) and omalizumab (anti-IgE-antibody) at least in subgroups of AE patients. Apart from the extracorporeal photopheresis immunoadsorption could be an option for cases resistant to other treatments, but needs to be assessed in more detail. In patients with a clinically relevant sensitization towards aeroallergens specific immunotherapy might be an option. Based on many new insights into the pathogenesis currently a number of new therapeutic approaches are being developed; among others, target structures are filaggrin, epidermal proteases, tachykinine receptors, histamine receptor 4, interleukin 31 and phosphodiesterase 4.

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Abbreviations

AE:

Atopisches Ekzem

AZ:

Azathioprin

CsA:

Ciclosporin

GPL:

gp 130-like receptor

IgA:

Immunglobulin A

IgE:

Immunglobulin E

IL:

Interleukin

IL-31R:

Interleukin-31-Rezeptoren

LF:

Leflunomid

LFA:

Lymphocyte function antigen

MMF:

Mycophenolatmofetil

MRSA:

Methicillinresistenter Staphylococcus aureus

MTX:

Methotrexat

NK1:

Neurokinin 1

NKR1:

Neurokinin-1-Rezeptor

OM:

Omalizumab

OSMR:

Oncostatin-M-Rezeptor

SP/XKLF:

Spezifische Proteine/Kuppel-like factor

PUVA:

Psoralen plus UVA

RI:

Rituximab

SCORAD:

SCORing Atopic Dermatitis der European Task Force on Atopic Dermatitis

SIT:

Spezifische Immuntherapie

TH:

T-Helferzellen

TIX:

Therapeutischer Index

TNF:

Tumornekrosefaktor

TKS:

Topische Glukokortikosteroide

TPMT:

Thiopurinmethyltransferase

Treg:

Regulatorische T-Zellen

TSLP:

Thymic stromal lymphopoietin

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  1. Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Schittenhelmstr. 7, 24105, Kiel, Deutschland

    Regina Fölster-Holst

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Correspondence to Regina Fölster-Holst.

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Fölster-Holst, R. Neues und Bewährtes zur Therapie des atopischen Ekzems. Allergo J 21, 404–416 (2012). https://doi.org/10.1007/s15007-012-0391-2

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