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Treatment of Severe Atopic Dermatitis with Omalizumab: Experience of a Portuguese Immunoallergology Department
Abstracts AB149
J ALLERGY CLIN IMMUNOL VOLUME 137, NUMBER 2
Treatment of Severe Atopic Dermatitis with Omalizumab: Experience of a Portuguese Immunoallergology Department
Ana M. Mendes, MD1, Leticia Pestana, MD2, Rita Aguiar, MD1, Ana Celia Costa, MSc1, Elisa Pedro, MD1, Anabela Lopes, MD1, Maria A. Spinola Santos, MD3, Estrella Alonso, MD4, M. A. Pereira-Barbosa, PhD5; 1 Hospital de Santa Maria - Immunoallergology Department, Lisbon, Portugal, 2Hospital de santa Maria-Immunoallergology Department, 3 Hospital de Santa Maria-Immunoallergology Department, Lisbon, Portugal, 4Hospital de Santa Maria-Immunoallergology Department, 5 Hospital de Santa Maria-Immunoallergology Departement, Lisbon, Portugal. RATIONALE: Omalizumab is a humanized, monoclonal anti-IgE antibody that interrupts the allergic cascade which suggests that it can be effective in the treatment of several allergic conditions, including atopic dermatitis (AD). We describe our Department’s experience in treating patients with severe AD and high levels of total IgE with omalizumab. METHODS: Twenty-four patients (14 male 10 female) 30,8 year-old average with severe AD,allergic respiratory disease and high levels of IgE (>2000 UI/L) not responding to conventional therapies were proposed for omalizumab treatment.They were evaluated for SCORAD index and daily/ rescue medication before,during and after treatment.Omalizumab was administrated subcutaneously at doses range from 150 to 600 mg every 2 weeks for 19,6 months average treatment. RESULTS: Before treatment all patients were medicated with anti-H1 and H2 antihistamine (maximum dose), montelukast 10 mg/day, topical and oral steroids (average dose 20mg/prednisolone/day) and topical primacrolimus. Seven patients were also medicated with cyclosporine and one of them was previously medicated with intravenous immunoglobulin G (1000 mg/kg/month) with no response. After treatment,all except one patient improved,although the onset for initial improvement was variable. The daily/rescue medication decreased in both dose and number of drugs. Systemic steroids were stopped with no relapse of symptoms. SCORAD index was 63,8 average at the beginning and 28,1 after treatment. Only one patient experienced exuberant local reactions and stopped omalizumab. CONCLUSIONS: Our data suggests that Omalizumab is a safe and effective alternative in the treatment of severe AD in allergic patients.
487
Patch Testing in Pediatric Patients with Atopic Disease
Irum Noor, DO, Melanie Chong, MD, Mark A. Davis-Lorton, MD, FAAAAI, Marcella R. Aquino, MD, FAAAAI, Luz S. Fonacier, MD, FAAAAI; Winthrop University Hospital, Allergy & Immunology, Mineola, NY. RATIONALE: Allergic contact dermatitis (ACD) accounts for 20% of childhood dermatitis. ACD is under diagnosed in patients with atopic disease. Our objective was to examine patch testing outcomes in atopic children. METHODS: A retrospective analysis of 23 children (ages 5-18) who underwent patch testing (PT) in our allergy practice from 2009 to 2014 was performed. PT was performed with either Thin-layer Rapid Use Epicutaneous Test (T.R.U.E. test), North American Contact Dermatitis Group Standard (NACDG), and/or allergens customized from patient history. Data collected included the location of dermatitis, duration of dermatitis prior to patch test, presence of atopy (eczema, allergic rhinitis, asthma), positive allergens, and improvement of dermatitis post-PT. RESULTS: All patients had a history of atopy (18 eczema, 19 allergic rhinitis, 6 asthma). The face was the most common location (60.8% 5 14/ 23) followed by scattered generalized (39.1% 5 9/23). A positive PT was observed in 86.9% (20/23) of patients. The most common clinically relevant allergens were nickel sulfate (13%), wool wax alcohols (13%), and fragrance mix I (13%). The final diagnosis in the majority of patients
(19/23) was ACD. The remaining four patients had either irritant contact dermatitis or just atopic dermatitis. With allergen avoidance and adherence to medical therapy, all patients (14/14) with documented follow up noted dermatitis improvement. CONCLUSIONS: Patch testing is an important diagnostic tool in pediatric patients with a history of atopic disease. In our cohort of patients, the vast majority had at least one positive clinically relevant allergen and allergen avoidance led to improvement of dermatitis.
488
The Atypical Itch That Rashes– Disseminated and Recurrent Infundibulofolliculitis (DRIF) in an Atopic African American Male
Katherine S. Tille, MD1, Tonya S. Rans, MD2; 1Wilford Hall Ambulatory Surgical Center, Lackland AFB, TX, 2Wilford Hall Ambulatory Surgical Center, San Antonio, TX. RATIONALE: Disseminated and recurrent infundibulofolliculitis (DRIF) is a rare and infrequently reported cause of papular dermatitis. METHODS: Extensive laboratory and radiographic evaluation for underlying etiology of rash and dyesthesia. Skin biopsy demonstrated mild lymphocytic spongiosis of infundibular region of hair follicle with parakeratosis at orifice of follicle opening consistent with DRIF. RESULTS: A 45 year-old African American male presented to our Allergy clinic with complaints of intense persistent upper and lower extremity burning and pruritis, chronic allergic rhinitis (mountain cedar and molds), and atopic dermatitis. Physical exam demonstrated intermittent wide spread flesh-colored 1-2 mm papules with superficial flaking. Over a two year period, the patient underwent an extensive work up in consultation with Allergy/Immunology, Dermatology, Rheumatology, Infectious Disease and Neurology services without elucidation of diagnosis. Management involved high dose anti-histamines, topical steroids, leukotriene modifier, nortriptyline, gabapentin, phototherapy and allergy immunotherapy without significant benefit. Following initiation of a prolonged doxycycline trial, the patient finally consented to skin biopsy after previously declining. Biopsy results were consistent with DRIF, and based on successful case reports, the patient was recently transitioned to isotretinoin. CONCLUSIONS: Disseminated and recurrent infundibulofolliculitis is an uncommon entity of unknown etiology most frequently occurring in young African American males, although it has been reported in females and other races spanning all age groups. Unlike classic atopic dermatologic disease, antihistamines and topical steroids are of minimal benefit in this disease process. We encourage Allergists to consider DRIF and emphasize the benefit of obtaining a skin biopsy in patients who present with refractory papular rashes.
SUNDAY
486
J ALLERGY CLIN IMMUNOL VOLUME 137, NUMBER 2
Treatment of Severe Atopic Dermatitis with Omalizumab: Experience of a Portuguese Immunoallergology Department
Ana M. Mendes, MD1, Leticia Pestana, MD2, Rita Aguiar, MD1, Ana Celia Costa, MSc1, Elisa Pedro, MD1, Anabela Lopes, MD1, Maria A. Spinola Santos, MD3, Estrella Alonso, MD4, M. A. Pereira-Barbosa, PhD5; 1 Hospital de Santa Maria - Immunoallergology Department, Lisbon, Portugal, 2Hospital de santa Maria-Immunoallergology Department, 3 Hospital de Santa Maria-Immunoallergology Department, Lisbon, Portugal, 4Hospital de Santa Maria-Immunoallergology Department, 5 Hospital de Santa Maria-Immunoallergology Departement, Lisbon, Portugal. RATIONALE: Omalizumab is a humanized, monoclonal anti-IgE antibody that interrupts the allergic cascade which suggests that it can be effective in the treatment of several allergic conditions, including atopic dermatitis (AD). We describe our Department’s experience in treating patients with severe AD and high levels of total IgE with omalizumab. METHODS: Twenty-four patients (14 male 10 female) 30,8 year-old average with severe AD,allergic respiratory disease and high levels of IgE (>2000 UI/L) not responding to conventional therapies were proposed for omalizumab treatment.They were evaluated for SCORAD index and daily/ rescue medication before,during and after treatment.Omalizumab was administrated subcutaneously at doses range from 150 to 600 mg every 2 weeks for 19,6 months average treatment. RESULTS: Before treatment all patients were medicated with anti-H1 and H2 antihistamine (maximum dose), montelukast 10 mg/day, topical and oral steroids (average dose 20mg/prednisolone/day) and topical primacrolimus. Seven patients were also medicated with cyclosporine and one of them was previously medicated with intravenous immunoglobulin G (1000 mg/kg/month) with no response. After treatment,all except one patient improved,although the onset for initial improvement was variable. The daily/rescue medication decreased in both dose and number of drugs. Systemic steroids were stopped with no relapse of symptoms. SCORAD index was 63,8 average at the beginning and 28,1 after treatment. Only one patient experienced exuberant local reactions and stopped omalizumab. CONCLUSIONS: Our data suggests that Omalizumab is a safe and effective alternative in the treatment of severe AD in allergic patients.
487
Patch Testing in Pediatric Patients with Atopic Disease
Irum Noor, DO, Melanie Chong, MD, Mark A. Davis-Lorton, MD, FAAAAI, Marcella R. Aquino, MD, FAAAAI, Luz S. Fonacier, MD, FAAAAI; Winthrop University Hospital, Allergy & Immunology, Mineola, NY. RATIONALE: Allergic contact dermatitis (ACD) accounts for 20% of childhood dermatitis. ACD is under diagnosed in patients with atopic disease. Our objective was to examine patch testing outcomes in atopic children. METHODS: A retrospective analysis of 23 children (ages 5-18) who underwent patch testing (PT) in our allergy practice from 2009 to 2014 was performed. PT was performed with either Thin-layer Rapid Use Epicutaneous Test (T.R.U.E. test), North American Contact Dermatitis Group Standard (NACDG), and/or allergens customized from patient history. Data collected included the location of dermatitis, duration of dermatitis prior to patch test, presence of atopy (eczema, allergic rhinitis, asthma), positive allergens, and improvement of dermatitis post-PT. RESULTS: All patients had a history of atopy (18 eczema, 19 allergic rhinitis, 6 asthma). The face was the most common location (60.8% 5 14/ 23) followed by scattered generalized (39.1% 5 9/23). A positive PT was observed in 86.9% (20/23) of patients. The most common clinically relevant allergens were nickel sulfate (13%), wool wax alcohols (13%), and fragrance mix I (13%). The final diagnosis in the majority of patients
(19/23) was ACD. The remaining four patients had either irritant contact dermatitis or just atopic dermatitis. With allergen avoidance and adherence to medical therapy, all patients (14/14) with documented follow up noted dermatitis improvement. CONCLUSIONS: Patch testing is an important diagnostic tool in pediatric patients with a history of atopic disease. In our cohort of patients, the vast majority had at least one positive clinically relevant allergen and allergen avoidance led to improvement of dermatitis.
488
The Atypical Itch That Rashes– Disseminated and Recurrent Infundibulofolliculitis (DRIF) in an Atopic African American Male
Katherine S. Tille, MD1, Tonya S. Rans, MD2; 1Wilford Hall Ambulatory Surgical Center, Lackland AFB, TX, 2Wilford Hall Ambulatory Surgical Center, San Antonio, TX. RATIONALE: Disseminated and recurrent infundibulofolliculitis (DRIF) is a rare and infrequently reported cause of papular dermatitis. METHODS: Extensive laboratory and radiographic evaluation for underlying etiology of rash and dyesthesia. Skin biopsy demonstrated mild lymphocytic spongiosis of infundibular region of hair follicle with parakeratosis at orifice of follicle opening consistent with DRIF. RESULTS: A 45 year-old African American male presented to our Allergy clinic with complaints of intense persistent upper and lower extremity burning and pruritis, chronic allergic rhinitis (mountain cedar and molds), and atopic dermatitis. Physical exam demonstrated intermittent wide spread flesh-colored 1-2 mm papules with superficial flaking. Over a two year period, the patient underwent an extensive work up in consultation with Allergy/Immunology, Dermatology, Rheumatology, Infectious Disease and Neurology services without elucidation of diagnosis. Management involved high dose anti-histamines, topical steroids, leukotriene modifier, nortriptyline, gabapentin, phototherapy and allergy immunotherapy without significant benefit. Following initiation of a prolonged doxycycline trial, the patient finally consented to skin biopsy after previously declining. Biopsy results were consistent with DRIF, and based on successful case reports, the patient was recently transitioned to isotretinoin. CONCLUSIONS: Disseminated and recurrent infundibulofolliculitis is an uncommon entity of unknown etiology most frequently occurring in young African American males, although it has been reported in females and other races spanning all age groups. Unlike classic atopic dermatologic disease, antihistamines and topical steroids are of minimal benefit in this disease process. We encourage Allergists to consider DRIF and emphasize the benefit of obtaining a skin biopsy in patients who present with refractory papular rashes.
SUNDAY
486