Inge M. Haeck

Enteric-coated mycophenolate sodium versus cyclosporin A as long-term treatment in adult patients with severe atopic dermatitis: A randomized controlled trial

BACKGROUND Cyclosporin A (CsA) is frequently used in the treatment of severe atopic dermatitis (AD). Enteric-coated mycophenolate sodium (EC-MPS) may be an alternative with equal efficacy and fewer side effects. OBJECTIVE The aim of this observer-blinded randomized controlled trial was to compare EC-MPS with CsA as long-term treatment in adult patients with severe AD. METHODS Fifty five patients with AD were treated with CsA (5 mg/kg) in a 6-week run-in period. Thereafter, patients either received CsA (3 mg/kg; n = 26) or EC-MPS (1440 mg; n = 24) during a maintenance phase of 30 weeks and there was a 12-week follow-up period. Disease activity was measured using the objective SCORAD and serum thymus and activation-regulated chemokine (TARC) levels and side effects were registered. RESULTS During the first 10 weeks the objective SCORAD and serum TARC levels in the EC-MPS study arm were higher in comparison with the CsA study arm. In addition, 7 of the 24 patients treated with EC-MPS required short oral corticosteroid courses. During maintenance phase disease activity was comparable in both study arms. Side effects in both study arms were mild and transient. After study medication withdrawal, disease activity of the patients in the CsA study arm significantly increased compared with the EC-MPS study arm. LIMITATION The nonblinding of patients and prescriber of rescue medication are limitations. CONCLUSIONS This study shows that EC-MPS is as effective as CsA as maintenance therapy in patients with AD. However, clinical improvement with EC-MPS is delayed in comparison with CsA. Clinical remission after stopping EC-MPS lasts longer compared with CsA.

Moderate correlation between quality of life and disease activity in adult patients with atopic dermatitis

Background  Studies assessing the relationship between disease activity and quality of life (QoL) in adults with atopic dermatitis (AD), before and after therapy are lacking. The relation between disease activity and QoL in AD patients was evaluated before (t = 0) and after 6 weeks (t = 6) of treatment with cyclosporin 5 mg/kg.

Low bone mineral density in adult patients with moderate to severe atopic dermatitis

Background  Atopic dermatitis (AD) is a chronic inflammatory skin disease commonly treated with topical corticosteroids. The inflammatory nature of this disorder and the use of topical corticosteroids represent potential risk factors for bone loss.

Bone mineral density in children with moderate to severe atopic dermatitis

BACKGROUND Low bone mineral density (BMD) has been reported in 30.4% of adult patients with atopic dermatitis (AD). OBJECTIVE The aim of this study was to determine the prevalence of low BMD in children with moderate to severe AD and to investigate the relation between BMD and corticosteroid and cyclosporine therapy. METHODS Lumbar spine BMD was measured by dual-energy X-ray absorptiometry in 60 children (age 5-16 years) with moderate to severe AD. BMD (in g/cm(2)) was expressed in Z-scores, the number of SD above or below the mean value of an age- and sex-matched reference population. In children, low BMD was defined as a Z-score less than -2. Information on lifestyle parameters and bone fractures were collected by use of a standardized questionnaire. The cumulative dose of corticosteroids and cyclosporine therapy was calculated for the previous 5-year period. RESULTS Three patients (5%) had low BMD; one patient (1.7%) had osteoporosis. The observed prevalence of low BMD in this study (6.7%; 95% confidence interval 1.8%-16.2%) does not differ from the expected prevalence of low BMD in the general population (P = .06). Overall, use of topical corticosteroids in the previous 5 years was not associated with a decrease in BMD (Z-score). When children received additional systemic treatment (oral corticosteroids and/or cyclosporine) in the previous 5 years, BMD decreased, although the decrease was not statistically significant. Correction for lifestyle parameters did not change these associations. LIMITATIONS The number of patients studied was limited. The cumulative dose of corticosteroids and cyclosporine therapy was only registered for the previous 5 years, and relatively low amounts of topical corticosteroids were used. The definition of low BMD differs between adults (Z-score < -1) and children (Z-score < -2). Because there is no Dutch BMD reference population for children, normative BMD references were obtained from a different population (US children). CONCLUSIONS Low BMD did not occur more frequently in this population of children with moderate to severe AD compared with the general population. Use of topical corticosteroids in the previous 5 years was not associated with a decrease in BMD.

Low basal serum cortisol in patients with severe atopic dermatitis: potent topical corticosteroids wrongfully accused

Background  Topical corticosteroids are used extensively to treat inflammatory skin disorders including atopic dermatitis (AD). Several studies have described temporary reversible suppression of hypothalamic–pituitary–adrenal function. However, sound evidence of permanent disturbance of adrenal gland function is lacking.

First experience with enteric-coated mycophenolate sodium (Myfortic®) in severe recalcitrant adult atopic dermatitis: an open label study

Background  Severe atopic dermatitis (AD) is often treated successfully with oral immunosuppressive drugs such as ciclosporin (CsA) or oral corticosteroids. However, some patients develop adverse effects or are unresponsive to these first‐choice oral immunosuppressive drugs.

Percutaneous absorption of potent topical corticosteroids in patients with severe atopic dermatitis

Agustı́ Toll, MD, Rocı́o Salgado, MSc, Blanca Espinet, PhD, and Ramon M. Pujol, MD Department of Dermatology, Hospital del Mar, Institut Municipal d’Investigació Mèdica (IMIM), Barcelona, and the Department of Pathology, Molecular Cytogenetics Laboratory, Institut Municipal d’Investigació Sanitària (IMIM), Hospital del Mar, Grup de Recerca Translacional en Neoplàssies Hematològiques (GRETNHE), Barcelona, Spain.

Severe atopic dermatitis treated with everolimus

Background: Patients with severe atopic dermatitis (AD) often require treatment with oral immunosuppressive drugs. Everolimus is a rapamycin-derived macrolide with immunosuppressive and antiproliferative effects. Everolimus demonstrated efficacy not only in the prophylaxis of organ rejection in kidney transplant patients, but also in decreasing disease activity in psoriasis patients. Objective: To evaluate whether everolimus is an effective treatment in patients with severe AD. Methods: Two patients with severe AD were treated with everolimus in combination with low-dose cyclosporin A (CsA) or prednisone. During treatment, a disease activity and safety laboratory examination was performed. Results: Everolimus either in combination with prednisone or with CsA did not result in improvement of disease activity in two patients with severe AD. Conclusion: Everolimus does not seem to be an effective treatment in these two AD patients, either in combination with prednisone or with CsA.

Two-year assessment of effect of topical corticosteroids on bone mineral density in adults with moderate to severe atopic dermatitis

morphea are summarized in Table I. The incidence of comedo-like openings (P 1⁄4 .006) and whitish patches (P1⁄4 .038) was significant in LSAwhereas the incidence of fibrotic beams (P 1⁄4 .038) was distinct in morphea. The incidence of pigment network-like structures (P 1⁄4 .170) and linear branching (P 1⁄4 .455) was not significantly different between the groups. Commalike vessels (n 1⁄4 2, 11.1%), hairpin vessels (n1⁄4 2, 11.1%), and dotted vessels (n1⁄4 1, 5.6%) were observed only in the LSA group, not in the morphea group. Very few have reported the use of dermatoscopy to differentiate LSA and morphea. Garrido-Rios et al reported characteristic dermatoscopic findings of extragenital LSA, such as the comedo-like openings and the whitish patches, and Campione et al described the dermatoscopic feature of morphea as accentuated fibrotic beams crossed by spreading telangiectasia. However, no other studies emphasized the dermatoscopic differences between the two diseases. In this study, we found that the significant dermatoscopic features of LSA were comedo-like openings and whitish patches (Fig 1, A) whereas that of morpheawas fibrotic beams (Fig 1, B). Our results show a close correlation between dermatoscopic patterns and their underlying histologic features. The comedo-like openings represent follicular plugging and the whitish patches indicate atrophy of the epidermisetypical histopathologic features of LSA. The fibrotic beams observed in morphea indicate sclerotic dermis. Our study was uncontrolled and nondouble-blinded and the results do not reflect variability in age, sex, location, or activity of the lesion.

The potency of clobetasol propionate: Serum levels of clobetasol propionate and adrenal function during therapy with 0.05% clobetasol propionate in patients with severe atopic dermatitis

Abstract Background: Percutaneous absorption of topically applied 0.05% clobetasol propionate (CLO) can be assessed indirectly by measuring cortisol levels. A direct way is to measure systemic levels of topically applied CLO. Methods: Serum concentrations of CLO were measured by liquid chromatography-tandem mass spectrometry (LC/MS/MS), and were related to serum cortisol levels in 25 patients with an exacerbation of atopic dermatitis (AD) before and after the first day of treatment with 0.05% CLO in hospital. The body surface area (BSA) affected by AD was measured. Results: Before the start of 0.05% CLO treatment, normal cortisol levels were measured (0.47 ± 0.18 μmol/l) and CLO concentrations could not be detected. After the first day of treatment, cortisol levels decreased to 0.04 ± 0.05 μmol/l. Serum concentrations of CLO could be detected in all patients (0.112–4.504 ng/ml). Levels did not differ between patients who had received two applications versus one application of 0.05% CLO. There was no correlation between the affected BSA and serum concentrations of CLO. Conclusion: Serum levels of CLO can be measured by LC/MS/MS. When prescribing 0.05% CLO, one must bear in mind that, even after an application of 20–30 g, CLO is systemically available and potent enough to induce adrenal gland suppression.