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In people with atopic dermatitis (AD), allergen immunotherapy (AIT) reduced AD severity and improved quality of life, a large literature review has found. The benefits were comparable between subcutaneous and sublingual therapies and consistent across age and disease-severity categories.

The review, which appeared in the , comprised 23 randomized controlled trials and 1,957 adult and pediatric patients. The immunotherapy -- which primarily involved sensitization to house dust mites -- resulted in important improvements in AD severity, defined as a 50% reduction in SCORing Atopic Dermatitis scores (RR 95% CI 1.53 [1.31-1.78]; 26% vs 40%, absolute difference 14%) and quality of life, defined as an improvement in Dermatology Life Quality Index by 4 points or more (RR 95% CI 1.44 [1.03-2.01]; 39% vs 56%, absolute difference 17%).

The findings led researchers to conclude with "moderate certainty" that AIT did play a major role in the improvements.

Both sublingual and subcutaneous AIT increased adverse events (RR 95% CI 1.61 [1.44-1.79]; 66% with subcutaneous vs 41% with placebo; 13% with sublingual vs 8% with placebo; high certainty). AIT's effect on sleep disturbance and eczema flares was uncertain.

Study authors ultimately created a tool for clinicians, which appears with the published review, that helps govern bedside decision-making for AD and AIT.

Co-author Derek Chu, MD, PhD, is an assistant professor of medicine and a physician-scientist with the division of clinical immunology and allergy at McMaster University in Ontario, Canada. Here he discusses the analysis with the Reading Room. The exchange has been edited for length and clarity.

What knowledge gap were you hoping to address?

Chu: With AD research, a critical question has been the role of allergen immunotherapy or allergies, particularly from the environment, in driving AD. And, by extension, what is the clinical utility of using AIT to treat AD? We know there are issues with skin barrier dysfunction and immune dysregulation. What has not been addressed is the role of addressing allergies -- and using AIT to do that.

We set out to systematically review all the randomized trials that looked at sublingual or subcutaneous immunotherapy for atopic dermatitis.

What were your main conclusions?

Chu: Essentially, we found that AIT -- subcutaneous or sublingual -- seemed effective in improving AD severity, based on validated measures. But this was balanced by the very well-known increase in harms of AIT.

For sublingual immunotherapy, most reactions tended to be an itchy mouth. Body-wide reactions were ultra-rare.

AIT likely improved the probability of reducing baseline AD severity by at least 50% compared to no AIT (40% vs 26%, RR 1.53 [95% CI, 1.31-1.78]).

What were your findings around adverse events?

Chu: About 66% had minor adverse events with subcutaneous or sublingual immunotherapy and 11% discontinued the therapy. About 13% had those minor adverse events, and about 0.1% discontinued or had an adverse reaction that would be more generalized.

You and your colleagues developed an infographic for clinicians. Would you describe this tool?

Chu: The infographic and its tables are designed to inform decision-making at the bedside. This tool adds a good layer of complexity to viewing AD as a systemic or a multidisciplinary disease.