Pruebas de parche y dupilumab

Published in Dermatology

Journal Scan / Research · October 14, 2019

The Impact of Dupilumab on Patch Testing and the Prevalence of Co-Morbid ACD in Recalcitrant Atopic Dermatitis

Journal of the American Academy of Dermatology

TAKE-HOME MESSAGE

• This retrospective chart review included patients with moderate to severe atopic dermatitis (AD) who had been patch tested prior to starting dupilumab. Of the 125 patch test pairs (those tested both before starting dupilumab and while on dupilumab), only 13 patch test reactions were considered lost (10.4%). These patch tests spanned a wide range of allergen groups. Of the 35 patients patch tested while on dupilumab, 32 had comorbid allergic contact dermatitis and 92.3% of these patients experienced further clinical improvement with allergen avoidance.

• Based on this study, the Th-2–specific immunosuppressive action of dupilumab does not appear to interfere with patch testing. Patch testing should be considered for patients who have dermatitis refractory to dupilumab as comorbid allergic contact dermatitis is highly prevalent in this population and allergen avoidance leads to further clinical improvement.

– Margaret Hammond, MD

Written by

 

 

Stephen E Helms MD

Written by

 

 

Thy N Huynh MD

Since Jadassohn described contact allergy to mercury in 1895, dermatologists have been working hard to determine the exact mechanisms of sensitization and elicitation of allergic contact dermatitis.1 Mosmann and colleagues defined two subtypes of CD4T cells (Th1 and Th2) that secrete distinctive cytokines.2 Heightened interest has occurred with the development of dupilumab, which specifically targets Th2 cells and their cytokines. Discussion has focused on allergic contact dermatitis, which is generally considered to be a Th1-related disease, whereas atopic dermatitis is a Th2-related disease. However, evidence has been building that Th2 may play a greater role in allergic dermatitis and may be improved with dupilumab therapy. Interestingly, this brings up another question: does dupilumab interfere with patch testing results? This article was designed to evaluate this exact question.

The authors feel that dupilumab does not "significantly" alter final patch testing results: the "lost positive rate" is only 10.4%. If this is correct, the consequence of 1 in 10 false-negative results would be persistent eczema of unknown cause in patients where a relevant antigen would otherwise have been identified. This could be compared with the statistics related to delayed patch test readings. One study demonstrated that 12.8% (7%–14%) of positives may be missed if only 3- or 5-day readings are performed.3 Other studies have shown that up to 30% of corticosteroid allergies may be missed.4,5 Moreover, we considered that some lost allergens could be due to potent induction of Th2 pathway, which is blocked by dupilumab in patients with lost reaction to fragrances.6

Overall, this is a very well–done and interesting manuscript. It shows the necessity of further studies to determine if false-negative patch testing does, in fact, occur in patients treated with dupilumab and whether certain specific antigens are more likely to be associated with false-negative results. Further work is also required to elucidate whether suppression of the immune response to common allergens suggests a role of dupilumab and other Th2 biologics in treating allergic contact dermatitis and other inflammatory skin disorders.

References

1. Jadassohn J. Zure Kenntnis der medikanmentosen Deratosen. Verh Dtsch Derm Gesellschaft V Kongress. 1895;103.
2. Li L, Sad S, Kagi D, Mosmann TR. CD8 Tc1 and Tc2 cells secrete distinct cytokine patterns in vitro and in vivo but induce similar inflammatory reactions. J Immunol. 1997;158(9):4152-4161. https://www.jimmunol.org/content/158/9/4152.long
3. Higgins E, Collins P. The relevance of 7 day patch test reading. Dermatitis. 2013;24(5):237-240. https://journals.lww.com/dermatitis/Abstract/2013/09000/The Relevance of 7 Day Patch Test Reading.6.aspx
4. Isaksson M, Andersen KE, Brandao FM, et al. Patch testing with corticosteroid mixes in Europe. A multicenter study of the EECDRG. Contact Dermatitis. 2000;42(1):27-35. https://onlinelibrary.wiley.com/doi/abs/10.1034/j.1600-0536.2000.042001027.x
5. Isaksson M. Corticosteroids. Dermatol Ther. 2004;17(4):314-320. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1396-0296.2004.04036.x
6. Owen J, Vakharia P, Silverberg J. The role and diagnosis of allergic contact dermatitis in patients with atopic dermatitis. Am J Clin Dermatol. 2018;19(3):293-302. https://link.springer.com/article/10.1007%2Fs40257-017-0340-7

Abstract

BACKGROUND

It is unclear whether the Th2-specific immunosuppressive action of dupilumab interferes with patch testing.

OBJECTIVES

Evaluate the reliability of patch testing on dupilumab and the contribution of allergic contact dermatitis (ACD) to complex dermatitis in patients with residual dermatitis on dupilumab.

METHODS

This is a retrospective chart review of 48 patients with atopic dermatitis (AD) treated with dupilumab. We compare results of patch tests performed before and after initiation of dupilumab and the prevalence of comorbid ACD in patch tested individuals.

RESULTS

A minority of patch test reactions were "lost" on dupilumab (13/125 or 10.4%). 5 of 13 lost reaction occurred in individuals with documented immunodeficiency. 32 of 35 patch tested patients (91.4%) had comorbid ACD; 92.3% of individuals patch tested on dupilumab experienced further clinical improvement with allergen avoidance.

LIMITATIONS

This is a non-randomized study in a small cohort of patients. Clearance of dupilumab was assessed by subjective patient reports.

CONCLUSIONS

Dupilumab does not appear to exert a dampening effect on patch test results. AD with comorbid ACD was highly prevalent and allergen avoidance resulted in significant improvement in residual dermatitis that had not resolved with not dupilumab therapy.

Journal of the American Academy of Dermatology

The Impact of Dupilumab on Patch Testing and the Prevalence of Co-Morbid ACD in Recalcitrant Atopic Dermatitis: A Retrospective Chart Review

J Am Acad Dermatol 2019 Sep 25;[EPub Ahead of Print], J Raffi, R Suresh, N Botto, JE Murase 

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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