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Role of Allergen Immunotherapy in Atopic Dermatitis

Question

Is there a role for allergen immunotherapy in atopic dermatitis?

Answer

By Mona Al-Ahmad, MD

The role for specific allergen immunotherapy (AIT) has not been as clear in atopic dermatitis (AD) as compared to that in asthma, rhinoconjunctivitis and allergic rhinitis. Few heterogenous and limited studies have proven any efficacy in AD. Conflicting evidence has reported desirable results mainly in those with house dust mite sensitization, strengthening the rationale for detailed treatment guidelines.

Questions that need to be answered are: Is AIT effective for AD patients? If so, is AIT effective for all AD patients or only a subpopulation?  Also, is AIT effective for AD for all aeroallergens or only specific ones (such as house dust mites (HDM))?

An analysis of a small number of randomized controlled trials concluded moderate evidence for specific immunotherapy in atopic dermatitis patients1. Bae et al performed a metanalysis including 385 patients and found that AIT was beneficial in AD management including long term treatment in severe AD2. A RCT including 56 children treated for 18months with HDM SLIT showed significant improvement in SCORAD4. Other RCTs have concluded that AIT (both SCIT and SLIT) are effective treatment for AD patients.

Novak et al looked at atopic dermatitis patients sensitised to house dust mites and found no statistically significant differences between active treatment with HDM AIT and placebo groups.  They did, however, report that a subgroup of patients with severe AD (SCORAD>50) showed statistically significant improvement in SCORAD scores5.

In studies that have concluded benefit from AIT in AD, there is lack in identifying the population that will benefit most (eg. moderate versus severe AD)3 . Furthermore, identifying a biomarker that will predict and standardize treatment response, will prove challenging in atopic dermatitis patients.

References

  1. Cox, Linda et al. Allergen Immunotherapy for Atopic Dermatitis: Is There Room for Debate?. The Journal of Allergy and Clinical Immunology: In Practice, 2016; Volume 4, Issue 3 , 435 – 444
  2. Bae, Jung Min et al. Efficacy of allergen-specific immunotherapy for atopic dermatitis: A systematic review and meta-analysis of randomized controlled trials. Journal of Allergy and Clinical Immunology, 2013; Volume 132 , Issue 1 , 110 – 117
  3. Lee J, Park CO, Lee KH. Specific immunotherapy in atopic dermatitisAllergy Asthma Immunol Res. 2014;7(3):221-9.
  4. Pajno GB, Caminiti L, Vita D, Barberio G, Salzano G, Lombardo F, et al. Sublingual immunotherapy in mite-sensitized children with atopic dermatitis: a randomized, double-blind, placebo-controlled study. J Allergy Clin Immunol 2007;120:164-70
  5. Novak N, Bieber T, Hoffmann M, Fölster-Holst R, Homey B, Werfel T, Sager A, Zuberbier T. Efficacy and safety of subcutaneous allergen-specific immunotherapy with depigmented polymerized mite extract in atopic dermatitis. J Allergy Clin Immunol, 2012; Oct;130(4):925-31.e4.