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Systemic Therapy of Atopic Dermatitis in Children

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Abstract

Atopic dermatitis (AD) is a common disease in childhood that is a serious burden on patients and their families. Most AD is mild and can be managed with the use of emollients and standard therapy consisting of topical corti-costeroids or topical calcineurin inhibitors. However, in a subgroup of patients with moderate to severe AD, the disease is recalcitrant to topical therapy and systemic treatments become necessary.

Short courses of systemic corticosteroids are often used in clinical practice, but their use is controversial. International guidelines suggest that in the case of acute flare-ups, patients might benefit from a short course of systemic corticosteroids, but long-term use and use in children should be avoided. Ciclosporin is an immunosuppressant agent that acts directly on cells of the immune system, with an inhibitory effect on T cells. When AD cannot be controlled by standard topical therapies, ciclosporin significantly decreases symptom scores, disease extent, pruritus and sleep deprivation, and improves quality of life. The most frequent adverse effects associated with the use of ciclosporin are hypertension and renal dysfunction, but they are usually reversible after drug discontinuation. Ciclosporin has been found to be safely used, effective and well tolerated in children with severe AD. However, studies to assess the long-term effectiveness and safety of ciclosporin in AD are lacking.

In patients for whom ciclosporin is not suitable, or when there is a lack of response, alternative drugs should be considered, such as azathioprine or interferon-g. Intravenous immunoglobulins and the monoclonal antibody infliximab only have a place in the systemic therapy of AD when other drugs have failed. Mycophenolate mofetil has recently been introduced in the treatment of recalcitrant AD. Efalizumab and omalizumab are monoclonal antibodies with a possible future role in the treatment of AD, but further studies are needed.

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References

  1. Asher MI, Montefort S, Björkstén B, et al., on behalf of the ISAAC Phase Three Study Group. Worldwide time trends in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC phases one and three repeat multicountry cross-sectional surveys [published erratum appears in Lancet 2007 Sep 29; 370 (9593): 1128]. Lancet 2006 Aug 26; 368(9537): 733–43

    Article  PubMed  Google Scholar 

  2. Krakowski AC, Eichenfield LF, Dohil MA. Management of atopic dermatitis in the pediatric population. Pediatrics 2008; 122: 812–24

    Article  PubMed  Google Scholar 

  3. Ricci G, Patrizi A, Baldi E, et al. Long-term follow-up of atopic dermatitis: retrospective analysis of related risk factors and association with concomitant allergic diseases. J Am Acad Dermatol 2006 Nov; 55(5): 765–71

    Article  PubMed  Google Scholar 

  4. Ricci G, Bendandi B, Bellini F, et al. Atopic dermatitis: quality of life of young Italian children and their families and correlation with severity score. Pediatr Allergy Immunol 2007 May; 18(3): 245–9

    Article  PubMed  Google Scholar 

  5. Williams HC. Clinical practice: atopic dermatitis. N Engl J Med 2005 Jun 2; 352(22): 2314–24

    Article  PubMed  CAS  Google Scholar 

  6. Ellis C, Luger T, Abeck D, et al., on behalf of the ICCAD II Faculty. International Consensus Conference on Atopic Dermatitis II (ICCAD II). Clinical update and current treatment strategies. Br J Dermatol 2003 May; 148 Suppl. 63: 3–10

    Article  PubMed  Google Scholar 

  7. Ricci G, Dondi A, Patrizi A. Role of topical calcineurin inhibitors on atopic dermatitis of children. Curr Med Chem 2007; 14(14): 1579–91

    Article  PubMed  CAS  Google Scholar 

  8. Orlow SJ. Topical calcineurin inhibitors in pediatric atopic dermatitis: a critical analysis of current issues. Pediatr Drugs 2007; 9(5): 289–99

    Article  Google Scholar 

  9. Williams HC, Grindlay DJC. What’s new in atopic eczema? An analysis of the clinical significance of systematic reviews on atopic eczema published in 2006 and 2007. Clin Exp Dermatol 2008; 33: 685–8

    Article  PubMed  CAS  Google Scholar 

  10. Olesen AB, Bang K, Juul S, et al. Stable incidence of atopic dermatitis among children in Denmark during the 1990s. Acta Derm Venereol 2005; 85(3): 244–7

    PubMed  Google Scholar 

  11. Broberg A, Svensson Å, Borres MP, et al. Atopic dermatitis in 5-6-year-old Swedish children: cumulative incidence, point prevalence, and severity scoring. Allergy 2000; 55: 1025–9

    Article  PubMed  CAS  Google Scholar 

  12. Dotterud K, Kvammen B, Lund E, et al. Prevalence and some clinical aspects of atopic dermatitis in the community of Sør-Varanger. Acta Dermatol Venereol (Stockh) 1995; 75: 50–3

    CAS  Google Scholar 

  13. Popescu CM, Popescu R, Williams H, et al. Community validation of the United Kingdom diagnostic criteria for atopic dermatitis in Romanian schoolchildren. Br J Dermatol 1998; 138: 436–42

    Article  PubMed  CAS  Google Scholar 

  14. Emerson RM, Williams HC, Allen BR. Severity distribution of atopic dermatitis in the community and its relationship to secondary referral. Br J Dermatol 1998; 139: 73–6

    Article  PubMed  CAS  Google Scholar 

  15. Boguniewicz M, Schmid-Grendelmeier P, Leung DYM. Atopic dermatitis. J Allergy Clin Immunol 2006 Jul; 118(1): 40–3

    Article  PubMed  CAS  Google Scholar 

  16. Schmitt J, Schäkel K, Schmitt N, et al. Systemic treatment of severe atopic eczema: a systematic review. Acta Dermatol Venereol 2007; 87(2): 100–11

    Article  CAS  Google Scholar 

  17. Schmitt J, Schmitt N, Meurer M. Cyclosporin in the treatment of patients with atopic eczema: a systematic review and meta-analysis. J Eur Acad Dermatol Venereol 2007 May; 21(5): 606–19

    PubMed  CAS  Google Scholar 

  18. Akdis CA, Akdis M, Bieber T, et al., on behalf of the European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL Consensus Group. Diagnosis and treatment of atopic dermatitis in children and adults: European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL Consensus Report. Allergy 2006 Aug; 61(8): 969–87

    Article  PubMed  CAS  Google Scholar 

  19. European Task Force On Atopic Dermatitis. Severity scoring of atopic dermatitis: the SCORAD index. Consensus report of the European Task Force on Atopic Dermatitis. Dermatology 1993; 186: 23–31

    Article  Google Scholar 

  20. Oranje AP, Glazenburg EJ, Wolkerstorfer A, et al. Practical issues on interpretation of scoring atopic dermatitis: the SCORAD index, objective SCORAD and the three-item severity score. Br J Dermatol 2007; 157: 645–8

    Article  PubMed  CAS  Google Scholar 

  21. Metz BJ. Highlights of the Society for Pediatric Dermatology Annual Meeting, July 12–15 2007, Chicago, Illinois. Conference report. Medscape Dermatology 2007 [online]. Available from URL: http://www.medscape.com/viewarticle/562439[Accessed 2007 Dec 18]

  22. Eichenfield LF, Hanifin JM, Luger TA, et al. Consensus conference on pediatric atopic dermatitis. J Am Acad Dermatol 2003 Dec; 49(6): 1088–95

    Article  PubMed  Google Scholar 

  23. Heddle RJ, Soothill JF, Bulpitt CJ, et al. Combined oral and nasal beclomethasone dipropionate in children with atopic eczema: a randomized controlled trial. Br Med J (Clin Res Ed) 1984 Sep 15; 289(6446): 651–4

    Article  CAS  Google Scholar 

  24. La Rosa M, Musarra I, Ranno C, et al. A randomized, double-blind, placebo-controlled crossover trial for systemic flunisolide in the treatment of children with severe atopic dermatitis. Curr Therap Res 1995; 56: 720–6

    Article  Google Scholar 

  25. Galli E, Chini L, Moschese V, et al. Methylprednisolone bolus: a novel therapy for severe atopic dermatitis. Acta Paediatr 1994 Mar; 83(3): 315–7

    Article  PubMed  CAS  Google Scholar 

  26. Levine LS, White PC. Disorders of Adrenal Glands. In: Behrman RE, Kliegman RM, Jenson HB, editors. Nelson Textbook of Pediatrics, 17th ed. Philadelphia (PA): Saunders, 2004: 1898–913

    Google Scholar 

  27. Deshmukh CT. Minimizing side effects of corticosteroids in children. Indian J Dermatol Venereol Leprol 2007; 73: 218–21

    Article  PubMed  CAS  Google Scholar 

  28. Madan V, Griffiths CEM. Systemic ciclosporin and tacrolimus in dermatology. Dermatol Ther 2007 Jul-Aug; 20(4): 239–50

    Article  PubMed  CAS  Google Scholar 

  29. Griffiths CEM, Katsambas A, Dijkmans BAC, et al. Update on the use of ciclosporin in immune-mediated dermatoses. Br J Dermatol 2006 Jul; 155 Suppl. 2: 1–16

    Article  Google Scholar 

  30. Ho VCY, Griffiths CEM, Albrecht G, et al. Intermittent short courses of cyclosporin (Neoral®) for psoriasis unresponsive to topical therapy: a 1-year multicentre, randomized study. The PISCES Study Group. Br J Dermatol 1999 Aug; 141(2): 283–91

    Article  CAS  Google Scholar 

  31. Griffiths CEM, Durbertret L, Ellis CN, et al. Ciclosporin in psoriasis clinical practice: an international consensus statement. Br J Dermatol 2004; 150 Suppl. 67: S11–23

    Article  Google Scholar 

  32. Harper JI, Ahmed IA, Barclay G, et al. Cyclosporin for severe childhood atopic dermatitis: short course versus continuous therapy. Br J Dermatol 2000; 142: 52–8

    Article  PubMed  CAS  Google Scholar 

  33. Berth-Jones J, Finlay AY, Zaki I, et al. Cyclosporine in severe childhood atopic dermatitis: a multicentre study. J Am Acad Dermatol 1996 Jun; 34(6): 1016–21

    Article  PubMed  CAS  Google Scholar 

  34. Bunikowski R, Staab D, Kussebi F, et al. Low-dose cyclosporin A microemulsion in children with severe atopic dermatitis: clinical and immunological effects. Pediatr Allergy Immunol 2001; 12: 216–23

    Article  PubMed  CAS  Google Scholar 

  35. Ruperto N, Ravelli A, Castell E, et al., Pediatric Rheumatology Collaborative Study Group (PRCSG); Paediatric Rheumatology International Trials Organisation (PRINTO). Cyclosporine A in juvenile idiopathic arthritis: results of the PRCSG/PRINTO phase IV post marketing surveillance study. Clin Exp Rheumatol 2006 Sep–Oct; 24(5): 599–605

    PubMed  CAS  Google Scholar 

  36. Ravelli A, Moretti C, Temporini F, et al. Combination therapy with methotrexate and cyclosporine A in juvenile idiopathic arthritis. Clin Exp Rheumatol 2002 Jul–Aug; 20(4): 569–72

    PubMed  CAS  Google Scholar 

  37. Meggit SJ, Gray JC, Reynolds NJ. Azathioprine dosed by thiopurine methyltransferase activity for moderate-to-severe atopic eczema: a double-blind, randomized controlled trial. Lancet 2006; 367: 839–46

    Article  Google Scholar 

  38. Lipozenèić J, Wolf R. Atopic dermatitis: an update and review of the literature. Dermatol Clin 2007 Oct; 25(4): 605–12

    Article  Google Scholar 

  39. Berth-Jones J, Takwale A, Tan E, et al. Azathioprine in severe adult atopic dermatitis: a double-blind, placebo-controlled, crossover trial. Br J Dermatol 2002 Aug; 147(2): 324–30

    Article  PubMed  CAS  Google Scholar 

  40. Murphy LA, Atherton D. A retrospective evaluation of azathioprine in severe childhood atopic eczema, using thiopurine methyltransferase levels to exclude patients at high risk of myelosuppression. Br J Dermatol 2002 Aug; 147(2): 308–15

    Article  PubMed  CAS  Google Scholar 

  41. Chang TT, Stevens SR. Atopic dermatitis: the role of recombinant interferon-gamma therapy. Am J Clin Dermatol 2002; 3: 175–83

    Article  PubMed  Google Scholar 

  42. Hanifin JM, Schneider LC, Leung DY, et al. Recombinant interferon gamma therapy for atopic dermatitis. J Am Acad Dermatol 1993 Feb; 28 (2 Pt 1): 189–97

    Article  PubMed  CAS  Google Scholar 

  43. Jang IG, Yang JK, Lee HJ, et al. Clinical improvement and immunohistochemical findings in severe atopic dermatitis treated with interferon gamma. J Am Acad Dermatol 2000 Jun; 42(6): 1033–40

    Article  PubMed  CAS  Google Scholar 

  44. Wakim M, Alazard M, Yajima A, et al. High dose intravenous immunoglobulin in atopic dermatitis and hyper-IgE syndrome. Ann Allergy Asthma Immunol 1998 Aug; 81(2): 153–8

    Article  PubMed  CAS  Google Scholar 

  45. Jolles S, Sewell C, Webster D, et al. Adjunctive high-dose intravenous immunoglobulin treatment for resistant atopic dermatitis: efficacy and effects on intracellular cytokine levels and CD4 counts. Acta Derm Venereol 2003; 83(6): 433–7

    Article  PubMed  CAS  Google Scholar 

  46. Paul C, Lahfa M, Bachelez H, et al. A randomized controlled evaluator-blinded trial of intravenous immunoglobulin in adults with severe atopic dermatitis. Br J Dermatol 2002; 147: 518–22

    Article  PubMed  CAS  Google Scholar 

  47. Graves JE, Nunley K, Heffernan MP. Off-label uses of biologics in dermatology: rituximab, omalizumab, infliximab, etanercept, adalimumab, efalizumab, and alefacept (Part 2 of 2). J Am Acad Dermatol 2007 Jan; 56(1): e55–79

    Article  PubMed  Google Scholar 

  48. Berry M, Brightling C, Pavord I, et al. TNF-α in asthma. Curr Opin Pharmacol 2007 Jun; 7(3): 279–82

    Article  PubMed  CAS  Google Scholar 

  49. Brightling C, Berry M, Amrani Y. Targeting TNF-α: a novel therapeutic approach for asthma. J Allergy Clin Immunol 2008 Jan; 121(1): 5–10

    Article  PubMed  CAS  Google Scholar 

  50. Jacobi A, Antoni C, Manger B, et al. Infliximab in the treatment of moderate to severe atopic dermatitis. J Am Acad Dermatol 2005 Mar; 52 (3 Pt 1): 522–6

    Article  PubMed  Google Scholar 

  51. Ricci G, Dondi A, Patrizi A. S. aureus overinfection in atopic dermatitis. J Pediatr Infect Dis 2008; 3: 83–90

    Google Scholar 

  52. Baker BS. The role of microorganisms in atopic dermatitis. Clin Exp Immunol 2006 Apr; 144(1): 1–9

    Article  PubMed  CAS  Google Scholar 

  53. Cork MJ, Robinson DA, Vasilopoulos Y, et al. New perspectives on epidermal barrier dysfunction in atopic dermatitis: gene-environment interactions. J Allergy Clin Immunol 2006 Jul; 118(1): 3–21

    Article  PubMed  CAS  Google Scholar 

  54. Purcell K, Fergie J. The epidemic of methicillin-resistant Staphylococcus aureus colonization and infection in children: implications for community and hospital practice. J Pediatr Infect Dis 2006; 1(1): 7–15

    Google Scholar 

  55. Salomon J, Baran E. The role of selected neuropeptides in pathogenesis of atopic dermatitis. J Eur Acad Dermatol Venereol 2008 Feb; 22(2): 223–8

    PubMed  CAS  Google Scholar 

  56. McHenry PM, Williams HC, Bingham EA. Management of atopic eczema. Joint Workshop of the British Association of Dermatologists and the Research Unit of the Royal College of Physicians of London. BMJ 1995 Apr 1; 310(6983): 843–7

    CAS  Google Scholar 

  57. Riccioni G, Bucciarelli T, Mancini B, et al. Antileukotriene drugs: clinical application, effectiveness and safety. Curr Med Chem 2007; 14(18): 1966–77

    Article  PubMed  CAS  Google Scholar 

  58. Möhrenschlager M, Darsow U, Schnopp C, et al. Atopic eczema: what’s new? J Eur Acad Dermatol Venereol 2006 May; 20(5): 503–11

    Article  PubMed  Google Scholar 

  59. Hsu C-J, Wang L-F. Emerging treatment of atopic dermatitis. Clinic Rev Allerg Immunol 2007; 33: 199–203

    Article  CAS  Google Scholar 

  60. Grundmann-Kollmann K, Behrens L, Krähn K, et al. Successful treatment of severe refractory atopic dermatitis with mycophenolate mophetil. Br JDermatol 1999; 141: 175–6

    Article  CAS  Google Scholar 

  61. Grundmann-Kollmann K, Podda M, Ochsendorf F, et al. Mycophenolate mophetil is effective in the treatment of atopic dermatitis. Arch Dermatol 2001; 137: 870–3

    PubMed  CAS  Google Scholar 

  62. Neuber K, Schwarz I, Itschert G, et al. Treatment of atopic eczema with oral mycophenolate mophetil. Br J Dermatol 2000; 143: 385–91

    Article  PubMed  CAS  Google Scholar 

  63. Benez A, Fierlbeck G. Successful long-term treatment of severe atopic dermatitis with mycophenolate mophetil. Br J Dermatol 2001; 14: 638–9

    Article  Google Scholar 

  64. Hansen ER, Buus S, Deleuran M, et al. Treatment of atopic dermatitis with mycophenolate mophetil. Br J Dermatol 2000; 143: 1324–6

    Article  PubMed  CAS  Google Scholar 

  65. Heller M, Shin HT, Orlow SJ, et al. Mycophenolate mophetil for severe childhood atopic dermatitis: experience in 14 patients. Br J Dermatol 2007; 157: 127–32

    Article  PubMed  CAS  Google Scholar 

  66. Chacko M, Weinberg JM. Efalizumab. Dermatol Ther 2007; 20: 265–9

    Article  PubMed  Google Scholar 

  67. Takiguchi R, Tofte S, Simpson B, et al. Efalizumab for severe atopic dermatitis: a pilot study in adults. J Am Acad Dermatol 2007 Feb; 56(2): 222–7

    Article  PubMed  Google Scholar 

  68. Weinberg JM, Siegfried EC. Successful treatment of severe atopic dermatitis in a child and an adult with the T cell modulator efalizumab. Arch Dermatol 2006; 142: 555–8

    Article  PubMed  Google Scholar 

  69. Beck LA, Saini S. Wanted: a study with Omalizumab to determine the role of IgE-mediated pathways in atopic dermatitis. J Am Acad Dermatol 2006; 55: 540–1

    Article  PubMed  Google Scholar 

  70. Krathen RA, Hsu S. Failure of omalizumab for treatment of severe adult atopic dermatitis. J Am Acad Dermatol 2005 Aug; 53(2): 338–40

    Article  PubMed  Google Scholar 

  71. Lane JE, Cheyney JM, Lane TN, et al. Treatment of recalcitrant atopic dermatitis with omalizumab. J Am Acad Dermatol 2006; 54: 68–72

    Article  PubMed  Google Scholar 

  72. Vigo PG, Girgis KR, Pfuetze BL, et al. Efficacy of anti-IgE therapy in patients with atopic dermatitis. J Am Acad Dermatol 2006; 55: 168–70

    Article  PubMed  Google Scholar 

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No funding was provided for the preparation of this article. The authors have no conflict of interests that are directly relevant to the content of this review.

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Authors and Affiliations

  1. Department of Pediatrics, University of Bologna, Via Massarenti 11, 40138, Bologna, Italy

    Giampaolo Ricci, Arianna Dondi & Massimo Masi

  2. Clinical and Experimental Medicine, Division of Dermatology, University of Bologna, Bologna, Italy

    Annalisa Patrizi

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Correspondence to Giampaolo Ricci.

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Ricci, G., Dondi, A., Patrizi, A. et al. Systemic Therapy of Atopic Dermatitis in Children. Drugs 69, 297–306 (2009). https://doi.org/10.2165/00003495-200969030-00005

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