Atopic Dermatitis

Key clinical point: Both oral and topical Janus kinase inhibitors (JAKi) led to clinically meaningful improvement in the severity of atopic dermatitis (AD), with topical JAKi demonstrating an excellent safety profile and oral JAKi demonstrating an adverse effect (AE) profile that warrants monitoring.

Major finding: Patients receiving JAKi vs. placebo showed a significant improvement in the Eczema Area and Severity Index score (standardized mean difference [SMD] −0.79) and the pruritus numerical rating scale score (SMD −0.49; both P < .00001). Although patients in topical JAKi groups experienced no significant AE; however, those in oral JAKi groups were at an increased risk for ≥1 AE (odds ratio 1.23; P < .0001) with the most frequent AE being gastrointestinal disorders (P < .00001) and headache (P = .0003).

Study details: Findings are from a meta-analysis of 25 studies including 9931 patients with AD, of which 2383 and 7548 participants were involved in topical and oral JAKi studies, respectively.

Disclosures: This study did not receive any funding. No conflicts of interest were reported.

Source: Chen J et al. the efficacy and safety of Janus kinase inhibitors in patients with atopic dermatitis: A systematic review and meta-analysis. J Am Acad Dermatol. 2022 (Mar 28). Doi: 10.1016/j.jaad.2022.03.039

Key clinical point: Both oral and topical Janus kinase inhibitors (JAKi) led to clinically meaningful improvement in the severity of atopic dermatitis (AD), with topical JAKi demonstrating an excellent safety profile and oral JAKi demonstrating an adverse effect (AE) profile that warrants monitoring.

Major finding: Patients receiving JAKi vs. placebo showed a significant improvement in the Eczema Area and Severity Index score (standardized mean difference [SMD] −0.79) and the pruritus numerical rating scale score (SMD −0.49; both P < .00001). Although patients in topical JAKi groups experienced no significant AE; however, those in oral JAKi groups were at an increased risk for ≥1 AE (odds ratio 1.23; P < .0001) with the most frequent AE being gastrointestinal disorders (P < .00001) and headache (P = .0003).

Study details: Findings are from a meta-analysis of 25 studies including 9931 patients with AD, of which 2383 and 7548 participants were involved in topical and oral JAKi studies, respectively.

Disclosures: This study did not receive any funding. No conflicts of interest were reported.

Source: Chen J et al. the efficacy and safety of Janus kinase inhibitors in patients with atopic dermatitis: A systematic review and meta-analysis. J Am Acad Dermatol. 2022 (Mar 28). Doi: 10.1016/j.jaad.2022.03.039

Key clinical point: Both oral and topical Janus kinase inhibitors (JAKi) led to clinically meaningful improvement in the severity of atopic dermatitis (AD), with topical JAKi demonstrating an excellent safety profile and oral JAKi demonstrating an adverse effect (AE) profile that warrants monitoring.

Major finding: Patients receiving JAKi vs. placebo showed a significant improvement in the Eczema Area and Severity Index score (standardized mean difference [SMD] −0.79) and the pruritus numerical rating scale score (SMD −0.49; both P < .00001). Although patients in topical JAKi groups experienced no significant AE; however, those in oral JAKi groups were at an increased risk for ≥1 AE (odds ratio 1.23; P < .0001) with the most frequent AE being gastrointestinal disorders (P < .00001) and headache (P = .0003).

Study details: Findings are from a meta-analysis of 25 studies including 9931 patients with AD, of which 2383 and 7548 participants were involved in topical and oral JAKi studies, respectively.

Disclosures: This study did not receive any funding. No conflicts of interest were reported.

Source: Chen J et al. the efficacy and safety of Janus kinase inhibitors in patients with atopic dermatitis: A systematic review and meta-analysis. J Am Acad Dermatol. 2022 (Mar 28). Doi: 10.1016/j.jaad.2022.03.039

Key clinical point: Dupilumab lowered SARS-CoV-2 immunoglobulin G (IgG) antibody levels in unvaccinated patients with atopic dermatitis (AD) and COVID-19 infection; however, it did not impair antibody response in mRNA vaccinated patients with AD.

Major finding: SARS-CoV-2 IgG antibody levels were significantly lower in unvaccinated patients with COVID-19 infection receiving dupilumab vs. systemic medications (P = .01) for AD, whereas they were similar in all vaccinated patients across the dupilumab, systemic medication, and topical therapy treatment groups (P > .18).

Study details: This study included patients with moderate-to-severe AD who were either infected with COVID-19 and were unvaccinated (n = 54) or had received a second mRNA vaccine dose ≥14 days before serum samples were collected (n = 180).

Disclosures: This work was supported by the Department of Dermatology at the Icahn School of Medicine at Mount Sinai in New York City, Regeneron, Sanofi, and the US National Institute of Allergy and Infectious Diseases. E Guttman-Yassky declared being an employee of Mount Sinai, receiving research funds, and serving as a consultant for several sources. AB Pavel declared having a research contract with Mount Sinai.

Source: Ungar B et al. The impact of dupilumab treatment on severe acute respiratory syndrome coronavirus 2-coronavirus disease 2019 antibody responses in patients with atopic dermatitis. Ann Allergy Asthma Immunol. 2022 (Mar 25). Doi: 10.1016/j.anai.2022.03.019

Key clinical point: Dupilumab lowered SARS-CoV-2 immunoglobulin G (IgG) antibody levels in unvaccinated patients with atopic dermatitis (AD) and COVID-19 infection; however, it did not impair antibody response in mRNA vaccinated patients with AD.

Major finding: SARS-CoV-2 IgG antibody levels were significantly lower in unvaccinated patients with COVID-19 infection receiving dupilumab vs. systemic medications (P = .01) for AD, whereas they were similar in all vaccinated patients across the dupilumab, systemic medication, and topical therapy treatment groups (P > .18).

Study details: This study included patients with moderate-to-severe AD who were either infected with COVID-19 and were unvaccinated (n = 54) or had received a second mRNA vaccine dose ≥14 days before serum samples were collected (n = 180).

Disclosures: This work was supported by the Department of Dermatology at the Icahn School of Medicine at Mount Sinai in New York City, Regeneron, Sanofi, and the US National Institute of Allergy and Infectious Diseases. E Guttman-Yassky declared being an employee of Mount Sinai, receiving research funds, and serving as a consultant for several sources. AB Pavel declared having a research contract with Mount Sinai.

Source: Ungar B et al. The impact of dupilumab treatment on severe acute respiratory syndrome coronavirus 2-coronavirus disease 2019 antibody responses in patients with atopic dermatitis. Ann Allergy Asthma Immunol. 2022 (Mar 25). Doi: 10.1016/j.anai.2022.03.019

Key clinical point: Dupilumab lowered SARS-CoV-2 immunoglobulin G (IgG) antibody levels in unvaccinated patients with atopic dermatitis (AD) and COVID-19 infection; however, it did not impair antibody response in mRNA vaccinated patients with AD.

Major finding: SARS-CoV-2 IgG antibody levels were significantly lower in unvaccinated patients with COVID-19 infection receiving dupilumab vs. systemic medications (P = .01) for AD, whereas they were similar in all vaccinated patients across the dupilumab, systemic medication, and topical therapy treatment groups (P > .18).

Study details: This study included patients with moderate-to-severe AD who were either infected with COVID-19 and were unvaccinated (n = 54) or had received a second mRNA vaccine dose ≥14 days before serum samples were collected (n = 180).

Disclosures: This work was supported by the Department of Dermatology at the Icahn School of Medicine at Mount Sinai in New York City, Regeneron, Sanofi, and the US National Institute of Allergy and Infectious Diseases. E Guttman-Yassky declared being an employee of Mount Sinai, receiving research funds, and serving as a consultant for several sources. AB Pavel declared having a research contract with Mount Sinai.

Source: Ungar B et al. The impact of dupilumab treatment on severe acute respiratory syndrome coronavirus 2-coronavirus disease 2019 antibody responses in patients with atopic dermatitis. Ann Allergy Asthma Immunol. 2022 (Mar 25). Doi: 10.1016/j.anai.2022.03.019

Key clinical point: In patients with atopic dermatitis (AD), once-daily 200 mg abrocitinib or 30 mg upadacitinib more effectively improved Eczema Area and Severity Index (EASI) scores than dupilumab, whereas improvement with baricitinib and tralokinumab were comparable to dupilumab.

Major finding: Compared with dupilumab, up to 16 weeks of treatment with 200 mg abrocitinib (mean difference [MD] 2.2; 95% credible interval [CrI] 0.2-4.0) or 30 mg upadacitinib (MD 2.7; 95% CrI 0.6-4.7) led to greater reduction in EASI scores, whereas 600 mg tralokinumab followed by 300 mg every 2 weeks (MD −3.5; 95% CrI −5.8 to −1.3) and 2 mg baricitinib daily (MD −5.2; 95% CrI −7.5 to −2.9) and 4 mg baricitinib daily (MD −3.2; 95% CrI −5.7 to −0.8) were associated with a lesser reduction.

Study details: Findings are from a meta-analysis of 60 trials including 16,579 children and adults with moderate-to-severe AD.

Disclosures: This work was supported by the UK National Institute for Health Research Career Development Fellowship. The authors declared serving as consultants, co-principal/chief investigators, or employees or receiving compensation, research grants, fees, and funding from several sources.

Source: Drucker AM et al. Systemic immunomodulatory treatments for atopic dermatitis: Update of a living systematic review and network meta-analysis. JAMA Dermatol. 2022 (Mar 16). Doi: 10.1001/jamadermatol.2022.0455

Key clinical point: In patients with atopic dermatitis (AD), once-daily 200 mg abrocitinib or 30 mg upadacitinib more effectively improved Eczema Area and Severity Index (EASI) scores than dupilumab, whereas improvement with baricitinib and tralokinumab were comparable to dupilumab.

Major finding: Compared with dupilumab, up to 16 weeks of treatment with 200 mg abrocitinib (mean difference [MD] 2.2; 95% credible interval [CrI] 0.2-4.0) or 30 mg upadacitinib (MD 2.7; 95% CrI 0.6-4.7) led to greater reduction in EASI scores, whereas 600 mg tralokinumab followed by 300 mg every 2 weeks (MD −3.5; 95% CrI −5.8 to −1.3) and 2 mg baricitinib daily (MD −5.2; 95% CrI −7.5 to −2.9) and 4 mg baricitinib daily (MD −3.2; 95% CrI −5.7 to −0.8) were associated with a lesser reduction.

Study details: Findings are from a meta-analysis of 60 trials including 16,579 children and adults with moderate-to-severe AD.

Disclosures: This work was supported by the UK National Institute for Health Research Career Development Fellowship. The authors declared serving as consultants, co-principal/chief investigators, or employees or receiving compensation, research grants, fees, and funding from several sources.

Source: Drucker AM et al. Systemic immunomodulatory treatments for atopic dermatitis: Update of a living systematic review and network meta-analysis. JAMA Dermatol. 2022 (Mar 16). Doi: 10.1001/jamadermatol.2022.0455

Key clinical point: In patients with atopic dermatitis (AD), once-daily 200 mg abrocitinib or 30 mg upadacitinib more effectively improved Eczema Area and Severity Index (EASI) scores than dupilumab, whereas improvement with baricitinib and tralokinumab were comparable to dupilumab.

Major finding: Compared with dupilumab, up to 16 weeks of treatment with 200 mg abrocitinib (mean difference [MD] 2.2; 95% credible interval [CrI] 0.2-4.0) or 30 mg upadacitinib (MD 2.7; 95% CrI 0.6-4.7) led to greater reduction in EASI scores, whereas 600 mg tralokinumab followed by 300 mg every 2 weeks (MD −3.5; 95% CrI −5.8 to −1.3) and 2 mg baricitinib daily (MD −5.2; 95% CrI −7.5 to −2.9) and 4 mg baricitinib daily (MD −3.2; 95% CrI −5.7 to −0.8) were associated with a lesser reduction.

Study details: Findings are from a meta-analysis of 60 trials including 16,579 children and adults with moderate-to-severe AD.

Disclosures: This work was supported by the UK National Institute for Health Research Career Development Fellowship. The authors declared serving as consultants, co-principal/chief investigators, or employees or receiving compensation, research grants, fees, and funding from several sources.

Source: Drucker AM et al. Systemic immunomodulatory treatments for atopic dermatitis: Update of a living systematic review and network meta-analysis. JAMA Dermatol. 2022 (Mar 16). Doi: 10.1001/jamadermatol.2022.0455

My inspiration to write about cupping this month stems from the perception that everyone seems to be talking about it, from a facialist who suggested it for me to a coworker who swears by cupping to treat her allergies. Cupping is by no means a novel procedure. Its use as a health therapy dates back thousands of years to ancient Egypt (1500 BCE), ancient Greece (described by Hippocrates), ancient Rome (described by the Greek physician Galen), China (during the Han dynasty, 206 BCE to 220 CE) and traditional Islamic culture.¹ Over the past decade, the popularity of this ancient procedure has been increasing in the United States.¹ Cupping has been applied as a remedy for various dermatologic and medical conditions, including herpes zoster, headaches, diminished appetite, maldigestion, abscess evacuation, narcolepsy, pain, fever, dysmenorrhea, and gout.^1,2

Theories on the mechanism(s) of action

The practice of cupping is differentiated into dry and wet cupping.^1,2 Traditionally, with dry cupping, a flame is applied to heat the air inside a thick glass cup (rather than the cup itself).¹ The cup is placed on the skin surface, and negative pressure suctions the skin into the cup. Wet cupping differs mainly from dry cupping in that it involves blood-letting. Cups made of either silicone or glass of varying size and shapes are used. Modern adaptations to cupping include needle, herbal, and pulsatile cupping, as well as a “moving cupping” technique (vs. traditionally stationary cups).¹

Thinkstock

There are several theories, many of which are derived from the nondermatologic literature (that is, pain management), as to how cupping may deliver a clinical benefit. Some theories are based in scientific and medical principles, whereas other theories are more whimsical – specifically, that cupping draws out evil spirits.² Studies of dry cupping have suggested that the procedure results in increased oxygenation of muscles via a local increase in oxygenated hemoglobin, which may help improve muscular activity and reduce pain.¹ As theorized by Lowe in 2017, negative pressure exerted by dry cupping leads to stretching and dilation of capillaries, which increases blood flow.³ Wet cupping has been shown to increase heat shock protein 70 (HSP70) and beta-endorphin expression in rat models, which is thought to facilitate pain management.1 Removal of oxidants and reduction of reactive oxygen species in the blood is believed to be among the benefits of wet cupping.¹
 

Cupping in general dermatology

While cupping has been used to treat a wide array of medical conditions, the ancient practice has been utilized in dermatology as a therapy mainly for herpes zoster and associated postherpetic neuralgia, as well as various inflammatory conditions.

Herpes zoster

In 2010, Cao et al. reported on their systematic review of wet cupping after completing searches of multiple databases (that is, PubMed, the Cochrane Library [Issue 3, 2008], China Network Knowledge Infrastructure, Chinese Scientific Journal Database, and Wan Fang Database). They identified eight randomized controlled trials involving 651 patients, with meta-analyses revealing that wet cupping performed better than medications in terms of the number of “cured” patients, number of patients with improved symptoms, and a lower incidence of postherpetic neuralgia. Wet cupping, in addition to medication, was also found to be superior to medication alone in multiple patients. The researchers concluded that wet cupping appears to effectively treat herpes zoster.⁴ However, the study failed to identify which medications were used to treat herpes zoster. In the United States, common medications for herpes zoster include acyclovir, valacyclovir, steroids, gabapentin, and other neuromodulators. Without knowing which medications were used, it is difficult to compare cupping to medication in terms of efficacy in treating herpes zoster.

Urticaria

Urticaria (hives) is an inflammatory skin condition that can be very uncomfortable for patients but often resolves without intervention within several months after onset. In 2001, Li and Ding reported on the treatment with cupping of 40 patients with urticaria. The cure rate among the treatment group was cited as 55%, compared with 30% in the control group, who were treated with a traditional Chinese remedy and an unidentified first-generation antihistamine.^1,5 In 2020, Xiao et al. conducted a systematic review and meta-analysis of cupping therapy for patients with chronic urticaria. They identified 13 comparisons from 12 randomized controlled trials involving 842 subjects. The investigators found no significant differences between wet cupping and medication usage. They also found that cupping combined with antihistamine treatment was superior to antihistamines alone, and cupping therapy with acupuncture was more effective than acupuncture alone. The investigators did call for caution, citing the poor quality of the studies reviewed.⁶

It is important to note that it is difficult to attribute resolution of urticaria to the use of cupping given the self-resolution often associated with this condition. Antihistamines are the mainstay of therapy for urticaria, but in my personal experience, patients are not entirely satisfied with the level of symptom control with antihistamines alone and often search for alternative therapies to control the pesky hives and associated itch. In 2014, omalizumab (Xolair) was approved for treating chronic idiopathic urticaria, which has helped patients control symptoms of chronic idiopathic urticaria without needing to take antihistamines. There was no indication that the studies reviewed by Xiao et al. compared cupping against this new effective treatment. Therefore, these studies comparing cupping to medical management are outdated.

Acne, eczema, and psoriasis

Soliman’s 2018 review of cupping in dermatology included a few studies on these common cutaneous conditions. For instance, a 2013 single-blind prospective study by Xu et al. reported on the results of patients with moderate acne who received wet cupping (in the form of prickling bloodletting) twice weekly for 6 weeks.⁷ They reported that patients demonstrated improvement in the global acne grading system (GAGS) score by the end of the trial.^1,7 Unfortunately, cupping was not compared with standard acne treatments (that is, benzoyl peroxide, topical and oral antibiotics, isotretinoin, topical retinoids, spironolactone).

In evaluating cupping for acute eczema, wet cupping was compared with oral loratadine and topical ointments in a 2007 study by Yao and Li. They divided 88 cases into treatment and control groups, with the former group (n = 46) receiving bloodletting puncturing and cupping and the control group (n = 42) receiving oral loratadine and topical Pairuisong (an herbal ointment used in Chinese medicine). The investigators observed no significant difference in total effective rates but a superior difference in the rates of responses that were considered “cured” and “markedly effective” in favor of the cupping treatment.^1,8 However, a case report by Hon et al. has indicated that cupping therapy may be associated with more harm than benefit when used as an eczema treatment.^1,9

In addition, it is important to note that the past 5 years have been gamechanging in the management of chronic eczema in terms of the array of novel and effective therapies (e.g., dupilumab and JAK inhibitors) and chronic moderate-to-severe eczema has become very treatable. Similarly, acute eczema is often successfully managed with topical steroids, calcineurin inhibitors, and emollients. As such, there is no compelling reason to consider an unproven treatment such as cupping.

In 2020, Xing et al. reviewed 16 randomized controlled trials assessing the use of “moving cupping” for plaque psoriasis, with 1,164 patients meeting inclusion criteria. Moving cupping was found to be significantly more effective than “no-moving” cupping therapy, and moving cupping, combined with medications, performed better than medications alone.¹⁰ None of the trials evaluated in this study included randomized controlled trials that compared patients using any of the more modern psoriasis medications, specifically biologics. And, again, the studies evaluated were not of the highest quality.

The data that support cupping, as summarized above, are based mostly on case reports, and strong double-blind prospective studies are lacking. Additionally, most of the studies cited gauged the efficacy of cupping using qualitative endpoints, rather than standardized quantitative endpoints and scales. Moreover, spontaneous remission of various dermatoses can occur, or they can improve over time, including acute eczema, psoriasis, and, especially, urticaria.
 

Adverse effects of cupping

Often alternative therapies are seen as “benign” and without adverse effects. However, complications can result from cupping. Trauma can be induced from the cupping itself by damaging superficial blood vessels and causing bruising.^1,11 Blistering can also occur secondary to the suction effect, and the epidermal and dermal layers of the skin can be separated.^1,11 Further, burns and discoloration have also been noted secondary to heat, trauma, and post inflammatory pigmentary changes.^1,11 Another risk of cupping is the Koebner phenomenon, which occurs with psoriasis, with new lesions appearing in traumatized skin.¹² Other adverse outcomes that have been reported with cupping include reactivation of herpes simplex virus secondary to skin trauma, iron deficiency anemia (secondary to blood loss), panniculitis, infections, and residual marks mistaken for signs of child abuse.^1,11

Cupping in aesthetic dermatology

Facial cupping, a distinct practice from body cupping used to treat general dermatology conditions described previously, is also increasing in popularity. This practice is usually conducted in association with a facial or facial acupuncture by an aesthetician or other licensed professional. It can also be performed using at-home kits. The marketing claims for facial cupping cite improved tightening and contouring of facial skin, increased facial microcirculation and collagen synthesis, and enhanced lymphatic flow to aid with facial puffiness or swelling. One supposed mechanism for these benefits is that cupping increases blood flow. Interestingly, there was a 2020 animal study in which photoacoustic imaging of a mouse ear revealed increased temporary blood flow in the cupping microenvironment.¹³ Currently, however, there is no evidence in the English scientific literature that supports facial cupping. The benefits attributed to facial cupping for aesthetic purposes have emerged only in personal anecdotes. The temporary increase in blood flow may induce inflammation and swelling that adds volume to the face and temporarily diminishes wrinkles. However, this temporary plumpness may be associated with adverse effects, such as local trauma, irritation, bruising, postinflammatory pigmentary alteration, or even herpes reactivation. In my opinion, the possible adverse effects of cupping outweigh any potential benefit, especially given the insufficient evidence supporting the utility of cupping for cosmetic enhancement.

Summary

There is increasing interest among patients to incorporate complementary and alternative medicine – including the ancient tradition of cupping – in managing medical dermatologic conditions. However, current evidence supporting cupping as an effective therapeutic strategy is not strong, with most studies to date appearing to be of poor quality or not sufficiently convincing to displace standard therapies. Our medical strategies for managing chronic dermatologic conditions, particularly inflammatory disorders, continue to improve from both a safety and a proven efficacy standpoint. Therefore, I would not forgo medical management in favor of cupping. While cupping can be used as an adjunct therapy, I would caution patients about possible adverse side effects. In the aesthetic world, cupping is also gaining popularity, but this trend is also not supported by current evidence or studies, at least in the Western literature.

Dr. Goldman is a dermatologist in private practice in Miami and specializes in cosmetic and general dermatology. She practices at Baumann Cosmetic & Research Institute and is also opening a general dermatology practice. Write to her at [email protected] or message her on Instragram @DrChloeGoldman. Dr. Goldman receives compensation to create social media content for Replenix, a skin care company. She has no other disclosures.

References

1. Soliman Y et al. Acta Dermatovenerol Alp Pannonica Adriat. 2018 Jun;27(2):103-7.

2. França K and Lotti T. Advances in Integrative Dermatology. John Wiley & Sons, 2019.

3. Lowe DT. Complement Ther Clin Pract. 2017 Nov;29:162-8.

4.Cao H et al. Altern Ther Health Med. 2010 Nov-Dec;16(6):48-54.

5. Li L and Ding J. J Tradit Chin Med. 2001 Mar;21(1):37-8.

6. Xiao XJ et al. J Integr Med. 2020 Jul;18(4):303-12.

7. Xu J et al. J Tradit Chin Med. 2013 Dec;33(6):752-6.

8. Yao J et al. Zhongguo Zhen Jiu. 2007; Jun;27(6):424-6.

9. Hon KL et al. Case Rep Pediatr. 2013;2013:605829.

10. Xing M et al. Medicine (Baltimore). 2020 Oct 9;99(41):e22539.

11. Kim TH et al. Eur J Integr Med. 2014 Aug 1;6(4):434-40.

12. Vender R and Vender R. J Cutan Med Surg. 2015 May-Jun;19(3):320-2.

13. Zhou Y et al. Biomed Opt Express. 2020 Apr 6;11(5):2394-401.

This article was updated 4/25/22.

My inspiration to write about cupping this month stems from the perception that everyone seems to be talking about it, from a facialist who suggested it for me to a coworker who swears by cupping to treat her allergies. Cupping is by no means a novel procedure. Its use as a health therapy dates back thousands of years to ancient Egypt (1500 BCE), ancient Greece (described by Hippocrates), ancient Rome (described by the Greek physician Galen), China (during the Han dynasty, 206 BCE to 220 CE) and traditional Islamic culture.¹ Over the past decade, the popularity of this ancient procedure has been increasing in the United States.¹ Cupping has been applied as a remedy for various dermatologic and medical conditions, including herpes zoster, headaches, diminished appetite, maldigestion, abscess evacuation, narcolepsy, pain, fever, dysmenorrhea, and gout.^1,2

Theories on the mechanism(s) of action

The practice of cupping is differentiated into dry and wet cupping.^1,2 Traditionally, with dry cupping, a flame is applied to heat the air inside a thick glass cup (rather than the cup itself).¹ The cup is placed on the skin surface, and negative pressure suctions the skin into the cup. Wet cupping differs mainly from dry cupping in that it involves blood-letting. Cups made of either silicone or glass of varying size and shapes are used. Modern adaptations to cupping include needle, herbal, and pulsatile cupping, as well as a “moving cupping” technique (vs. traditionally stationary cups).¹

Thinkstock

There are several theories, many of which are derived from the nondermatologic literature (that is, pain management), as to how cupping may deliver a clinical benefit. Some theories are based in scientific and medical principles, whereas other theories are more whimsical – specifically, that cupping draws out evil spirits.² Studies of dry cupping have suggested that the procedure results in increased oxygenation of muscles via a local increase in oxygenated hemoglobin, which may help improve muscular activity and reduce pain.¹ As theorized by Lowe in 2017, negative pressure exerted by dry cupping leads to stretching and dilation of capillaries, which increases blood flow.³ Wet cupping has been shown to increase heat shock protein 70 (HSP70) and beta-endorphin expression in rat models, which is thought to facilitate pain management.1 Removal of oxidants and reduction of reactive oxygen species in the blood is believed to be among the benefits of wet cupping.¹
 

Cupping in general dermatology

While cupping has been used to treat a wide array of medical conditions, the ancient practice has been utilized in dermatology as a therapy mainly for herpes zoster and associated postherpetic neuralgia, as well as various inflammatory conditions.

Herpes zoster

In 2010, Cao et al. reported on their systematic review of wet cupping after completing searches of multiple databases (that is, PubMed, the Cochrane Library [Issue 3, 2008], China Network Knowledge Infrastructure, Chinese Scientific Journal Database, and Wan Fang Database). They identified eight randomized controlled trials involving 651 patients, with meta-analyses revealing that wet cupping performed better than medications in terms of the number of “cured” patients, number of patients with improved symptoms, and a lower incidence of postherpetic neuralgia. Wet cupping, in addition to medication, was also found to be superior to medication alone in multiple patients. The researchers concluded that wet cupping appears to effectively treat herpes zoster.⁴ However, the study failed to identify which medications were used to treat herpes zoster. In the United States, common medications for herpes zoster include acyclovir, valacyclovir, steroids, gabapentin, and other neuromodulators. Without knowing which medications were used, it is difficult to compare cupping to medication in terms of efficacy in treating herpes zoster.

Urticaria

Urticaria (hives) is an inflammatory skin condition that can be very uncomfortable for patients but often resolves without intervention within several months after onset. In 2001, Li and Ding reported on the treatment with cupping of 40 patients with urticaria. The cure rate among the treatment group was cited as 55%, compared with 30% in the control group, who were treated with a traditional Chinese remedy and an unidentified first-generation antihistamine.^1,5 In 2020, Xiao et al. conducted a systematic review and meta-analysis of cupping therapy for patients with chronic urticaria. They identified 13 comparisons from 12 randomized controlled trials involving 842 subjects. The investigators found no significant differences between wet cupping and medication usage. They also found that cupping combined with antihistamine treatment was superior to antihistamines alone, and cupping therapy with acupuncture was more effective than acupuncture alone. The investigators did call for caution, citing the poor quality of the studies reviewed.⁶

It is important to note that it is difficult to attribute resolution of urticaria to the use of cupping given the self-resolution often associated with this condition. Antihistamines are the mainstay of therapy for urticaria, but in my personal experience, patients are not entirely satisfied with the level of symptom control with antihistamines alone and often search for alternative therapies to control the pesky hives and associated itch. In 2014, omalizumab (Xolair) was approved for treating chronic idiopathic urticaria, which has helped patients control symptoms of chronic idiopathic urticaria without needing to take antihistamines. There was no indication that the studies reviewed by Xiao et al. compared cupping against this new effective treatment. Therefore, these studies comparing cupping to medical management are outdated.

Acne, eczema, and psoriasis

Soliman’s 2018 review of cupping in dermatology included a few studies on these common cutaneous conditions. For instance, a 2013 single-blind prospective study by Xu et al. reported on the results of patients with moderate acne who received wet cupping (in the form of prickling bloodletting) twice weekly for 6 weeks.⁷ They reported that patients demonstrated improvement in the global acne grading system (GAGS) score by the end of the trial.^1,7 Unfortunately, cupping was not compared with standard acne treatments (that is, benzoyl peroxide, topical and oral antibiotics, isotretinoin, topical retinoids, spironolactone).

In evaluating cupping for acute eczema, wet cupping was compared with oral loratadine and topical ointments in a 2007 study by Yao and Li. They divided 88 cases into treatment and control groups, with the former group (n = 46) receiving bloodletting puncturing and cupping and the control group (n = 42) receiving oral loratadine and topical Pairuisong (an herbal ointment used in Chinese medicine). The investigators observed no significant difference in total effective rates but a superior difference in the rates of responses that were considered “cured” and “markedly effective” in favor of the cupping treatment.^1,8 However, a case report by Hon et al. has indicated that cupping therapy may be associated with more harm than benefit when used as an eczema treatment.^1,9

In addition, it is important to note that the past 5 years have been gamechanging in the management of chronic eczema in terms of the array of novel and effective therapies (e.g., dupilumab and JAK inhibitors) and chronic moderate-to-severe eczema has become very treatable. Similarly, acute eczema is often successfully managed with topical steroids, calcineurin inhibitors, and emollients. As such, there is no compelling reason to consider an unproven treatment such as cupping.

In 2020, Xing et al. reviewed 16 randomized controlled trials assessing the use of “moving cupping” for plaque psoriasis, with 1,164 patients meeting inclusion criteria. Moving cupping was found to be significantly more effective than “no-moving” cupping therapy, and moving cupping, combined with medications, performed better than medications alone.¹⁰ None of the trials evaluated in this study included randomized controlled trials that compared patients using any of the more modern psoriasis medications, specifically biologics. And, again, the studies evaluated were not of the highest quality.

The data that support cupping, as summarized above, are based mostly on case reports, and strong double-blind prospective studies are lacking. Additionally, most of the studies cited gauged the efficacy of cupping using qualitative endpoints, rather than standardized quantitative endpoints and scales. Moreover, spontaneous remission of various dermatoses can occur, or they can improve over time, including acute eczema, psoriasis, and, especially, urticaria.
 

Adverse effects of cupping

Often alternative therapies are seen as “benign” and without adverse effects. However, complications can result from cupping. Trauma can be induced from the cupping itself by damaging superficial blood vessels and causing bruising.^1,11 Blistering can also occur secondary to the suction effect, and the epidermal and dermal layers of the skin can be separated.^1,11 Further, burns and discoloration have also been noted secondary to heat, trauma, and post inflammatory pigmentary changes.^1,11 Another risk of cupping is the Koebner phenomenon, which occurs with psoriasis, with new lesions appearing in traumatized skin.¹² Other adverse outcomes that have been reported with cupping include reactivation of herpes simplex virus secondary to skin trauma, iron deficiency anemia (secondary to blood loss), panniculitis, infections, and residual marks mistaken for signs of child abuse.^1,11

Cupping in aesthetic dermatology

Facial cupping, a distinct practice from body cupping used to treat general dermatology conditions described previously, is also increasing in popularity. This practice is usually conducted in association with a facial or facial acupuncture by an aesthetician or other licensed professional. It can also be performed using at-home kits. The marketing claims for facial cupping cite improved tightening and contouring of facial skin, increased facial microcirculation and collagen synthesis, and enhanced lymphatic flow to aid with facial puffiness or swelling. One supposed mechanism for these benefits is that cupping increases blood flow. Interestingly, there was a 2020 animal study in which photoacoustic imaging of a mouse ear revealed increased temporary blood flow in the cupping microenvironment.¹³ Currently, however, there is no evidence in the English scientific literature that supports facial cupping. The benefits attributed to facial cupping for aesthetic purposes have emerged only in personal anecdotes. The temporary increase in blood flow may induce inflammation and swelling that adds volume to the face and temporarily diminishes wrinkles. However, this temporary plumpness may be associated with adverse effects, such as local trauma, irritation, bruising, postinflammatory pigmentary alteration, or even herpes reactivation. In my opinion, the possible adverse effects of cupping outweigh any potential benefit, especially given the insufficient evidence supporting the utility of cupping for cosmetic enhancement.

Summary

There is increasing interest among patients to incorporate complementary and alternative medicine – including the ancient tradition of cupping – in managing medical dermatologic conditions. However, current evidence supporting cupping as an effective therapeutic strategy is not strong, with most studies to date appearing to be of poor quality or not sufficiently convincing to displace standard therapies. Our medical strategies for managing chronic dermatologic conditions, particularly inflammatory disorders, continue to improve from both a safety and a proven efficacy standpoint. Therefore, I would not forgo medical management in favor of cupping. While cupping can be used as an adjunct therapy, I would caution patients about possible adverse side effects. In the aesthetic world, cupping is also gaining popularity, but this trend is also not supported by current evidence or studies, at least in the Western literature.

Dr. Goldman is a dermatologist in private practice in Miami and specializes in cosmetic and general dermatology. She practices at Baumann Cosmetic & Research Institute and is also opening a general dermatology practice. Write to her at [email protected] or message her on Instragram @DrChloeGoldman. Dr. Goldman receives compensation to create social media content for Replenix, a skin care company. She has no other disclosures.

References

1. Soliman Y et al. Acta Dermatovenerol Alp Pannonica Adriat. 2018 Jun;27(2):103-7.

2. França K and Lotti T. Advances in Integrative Dermatology. John Wiley & Sons, 2019.

3. Lowe DT. Complement Ther Clin Pract. 2017 Nov;29:162-8.

4.Cao H et al. Altern Ther Health Med. 2010 Nov-Dec;16(6):48-54.

5. Li L and Ding J. J Tradit Chin Med. 2001 Mar;21(1):37-8.

6. Xiao XJ et al. J Integr Med. 2020 Jul;18(4):303-12.

7. Xu J et al. J Tradit Chin Med. 2013 Dec;33(6):752-6.

8. Yao J et al. Zhongguo Zhen Jiu. 2007; Jun;27(6):424-6.

9. Hon KL et al. Case Rep Pediatr. 2013;2013:605829.

10. Xing M et al. Medicine (Baltimore). 2020 Oct 9;99(41):e22539.

11. Kim TH et al. Eur J Integr Med. 2014 Aug 1;6(4):434-40.

12. Vender R and Vender R. J Cutan Med Surg. 2015 May-Jun;19(3):320-2.

13. Zhou Y et al. Biomed Opt Express. 2020 Apr 6;11(5):2394-401.

This article was updated 4/25/22.

My inspiration to write about cupping this month stems from the perception that everyone seems to be talking about it, from a facialist who suggested it for me to a coworker who swears by cupping to treat her allergies. Cupping is by no means a novel procedure. Its use as a health therapy dates back thousands of years to ancient Egypt (1500 BCE), ancient Greece (described by Hippocrates), ancient Rome (described by the Greek physician Galen), China (during the Han dynasty, 206 BCE to 220 CE) and traditional Islamic culture.¹ Over the past decade, the popularity of this ancient procedure has been increasing in the United States.¹ Cupping has been applied as a remedy for various dermatologic and medical conditions, including herpes zoster, headaches, diminished appetite, maldigestion, abscess evacuation, narcolepsy, pain, fever, dysmenorrhea, and gout.^1,2

Theories on the mechanism(s) of action

The practice of cupping is differentiated into dry and wet cupping.^1,2 Traditionally, with dry cupping, a flame is applied to heat the air inside a thick glass cup (rather than the cup itself).¹ The cup is placed on the skin surface, and negative pressure suctions the skin into the cup. Wet cupping differs mainly from dry cupping in that it involves blood-letting. Cups made of either silicone or glass of varying size and shapes are used. Modern adaptations to cupping include needle, herbal, and pulsatile cupping, as well as a “moving cupping” technique (vs. traditionally stationary cups).¹

Thinkstock

There are several theories, many of which are derived from the nondermatologic literature (that is, pain management), as to how cupping may deliver a clinical benefit. Some theories are based in scientific and medical principles, whereas other theories are more whimsical – specifically, that cupping draws out evil spirits.² Studies of dry cupping have suggested that the procedure results in increased oxygenation of muscles via a local increase in oxygenated hemoglobin, which may help improve muscular activity and reduce pain.¹ As theorized by Lowe in 2017, negative pressure exerted by dry cupping leads to stretching and dilation of capillaries, which increases blood flow.³ Wet cupping has been shown to increase heat shock protein 70 (HSP70) and beta-endorphin expression in rat models, which is thought to facilitate pain management.1 Removal of oxidants and reduction of reactive oxygen species in the blood is believed to be among the benefits of wet cupping.¹
 

Cupping in general dermatology

While cupping has been used to treat a wide array of medical conditions, the ancient practice has been utilized in dermatology as a therapy mainly for herpes zoster and associated postherpetic neuralgia, as well as various inflammatory conditions.

Herpes zoster

In 2010, Cao et al. reported on their systematic review of wet cupping after completing searches of multiple databases (that is, PubMed, the Cochrane Library [Issue 3, 2008], China Network Knowledge Infrastructure, Chinese Scientific Journal Database, and Wan Fang Database). They identified eight randomized controlled trials involving 651 patients, with meta-analyses revealing that wet cupping performed better than medications in terms of the number of “cured” patients, number of patients with improved symptoms, and a lower incidence of postherpetic neuralgia. Wet cupping, in addition to medication, was also found to be superior to medication alone in multiple patients. The researchers concluded that wet cupping appears to effectively treat herpes zoster.⁴ However, the study failed to identify which medications were used to treat herpes zoster. In the United States, common medications for herpes zoster include acyclovir, valacyclovir, steroids, gabapentin, and other neuromodulators. Without knowing which medications were used, it is difficult to compare cupping to medication in terms of efficacy in treating herpes zoster.

Urticaria

Urticaria (hives) is an inflammatory skin condition that can be very uncomfortable for patients but often resolves without intervention within several months after onset. In 2001, Li and Ding reported on the treatment with cupping of 40 patients with urticaria. The cure rate among the treatment group was cited as 55%, compared with 30% in the control group, who were treated with a traditional Chinese remedy and an unidentified first-generation antihistamine.^1,5 In 2020, Xiao et al. conducted a systematic review and meta-analysis of cupping therapy for patients with chronic urticaria. They identified 13 comparisons from 12 randomized controlled trials involving 842 subjects. The investigators found no significant differences between wet cupping and medication usage. They also found that cupping combined with antihistamine treatment was superior to antihistamines alone, and cupping therapy with acupuncture was more effective than acupuncture alone. The investigators did call for caution, citing the poor quality of the studies reviewed.⁶

It is important to note that it is difficult to attribute resolution of urticaria to the use of cupping given the self-resolution often associated with this condition. Antihistamines are the mainstay of therapy for urticaria, but in my personal experience, patients are not entirely satisfied with the level of symptom control with antihistamines alone and often search for alternative therapies to control the pesky hives and associated itch. In 2014, omalizumab (Xolair) was approved for treating chronic idiopathic urticaria, which has helped patients control symptoms of chronic idiopathic urticaria without needing to take antihistamines. There was no indication that the studies reviewed by Xiao et al. compared cupping against this new effective treatment. Therefore, these studies comparing cupping to medical management are outdated.

Acne, eczema, and psoriasis

Soliman’s 2018 review of cupping in dermatology included a few studies on these common cutaneous conditions. For instance, a 2013 single-blind prospective study by Xu et al. reported on the results of patients with moderate acne who received wet cupping (in the form of prickling bloodletting) twice weekly for 6 weeks.⁷ They reported that patients demonstrated improvement in the global acne grading system (GAGS) score by the end of the trial.^1,7 Unfortunately, cupping was not compared with standard acne treatments (that is, benzoyl peroxide, topical and oral antibiotics, isotretinoin, topical retinoids, spironolactone).

In evaluating cupping for acute eczema, wet cupping was compared with oral loratadine and topical ointments in a 2007 study by Yao and Li. They divided 88 cases into treatment and control groups, with the former group (n = 46) receiving bloodletting puncturing and cupping and the control group (n = 42) receiving oral loratadine and topical Pairuisong (an herbal ointment used in Chinese medicine). The investigators observed no significant difference in total effective rates but a superior difference in the rates of responses that were considered “cured” and “markedly effective” in favor of the cupping treatment.^1,8 However, a case report by Hon et al. has indicated that cupping therapy may be associated with more harm than benefit when used as an eczema treatment.^1,9

In addition, it is important to note that the past 5 years have been gamechanging in the management of chronic eczema in terms of the array of novel and effective therapies (e.g., dupilumab and JAK inhibitors) and chronic moderate-to-severe eczema has become very treatable. Similarly, acute eczema is often successfully managed with topical steroids, calcineurin inhibitors, and emollients. As such, there is no compelling reason to consider an unproven treatment such as cupping.

In 2020, Xing et al. reviewed 16 randomized controlled trials assessing the use of “moving cupping” for plaque psoriasis, with 1,164 patients meeting inclusion criteria. Moving cupping was found to be significantly more effective than “no-moving” cupping therapy, and moving cupping, combined with medications, performed better than medications alone.¹⁰ None of the trials evaluated in this study included randomized controlled trials that compared patients using any of the more modern psoriasis medications, specifically biologics. And, again, the studies evaluated were not of the highest quality.

The data that support cupping, as summarized above, are based mostly on case reports, and strong double-blind prospective studies are lacking. Additionally, most of the studies cited gauged the efficacy of cupping using qualitative endpoints, rather than standardized quantitative endpoints and scales. Moreover, spontaneous remission of various dermatoses can occur, or they can improve over time, including acute eczema, psoriasis, and, especially, urticaria.
 

Adverse effects of cupping

Often alternative therapies are seen as “benign” and without adverse effects. However, complications can result from cupping. Trauma can be induced from the cupping itself by damaging superficial blood vessels and causing bruising.^1,11 Blistering can also occur secondary to the suction effect, and the epidermal and dermal layers of the skin can be separated.^1,11 Further, burns and discoloration have also been noted secondary to heat, trauma, and post inflammatory pigmentary changes.^1,11 Another risk of cupping is the Koebner phenomenon, which occurs with psoriasis, with new lesions appearing in traumatized skin.¹² Other adverse outcomes that have been reported with cupping include reactivation of herpes simplex virus secondary to skin trauma, iron deficiency anemia (secondary to blood loss), panniculitis, infections, and residual marks mistaken for signs of child abuse.^1,11

Cupping in aesthetic dermatology

Facial cupping, a distinct practice from body cupping used to treat general dermatology conditions described previously, is also increasing in popularity. This practice is usually conducted in association with a facial or facial acupuncture by an aesthetician or other licensed professional. It can also be performed using at-home kits. The marketing claims for facial cupping cite improved tightening and contouring of facial skin, increased facial microcirculation and collagen synthesis, and enhanced lymphatic flow to aid with facial puffiness or swelling. One supposed mechanism for these benefits is that cupping increases blood flow. Interestingly, there was a 2020 animal study in which photoacoustic imaging of a mouse ear revealed increased temporary blood flow in the cupping microenvironment.¹³ Currently, however, there is no evidence in the English scientific literature that supports facial cupping. The benefits attributed to facial cupping for aesthetic purposes have emerged only in personal anecdotes. The temporary increase in blood flow may induce inflammation and swelling that adds volume to the face and temporarily diminishes wrinkles. However, this temporary plumpness may be associated with adverse effects, such as local trauma, irritation, bruising, postinflammatory pigmentary alteration, or even herpes reactivation. In my opinion, the possible adverse effects of cupping outweigh any potential benefit, especially given the insufficient evidence supporting the utility of cupping for cosmetic enhancement.

Summary

There is increasing interest among patients to incorporate complementary and alternative medicine – including the ancient tradition of cupping – in managing medical dermatologic conditions. However, current evidence supporting cupping as an effective therapeutic strategy is not strong, with most studies to date appearing to be of poor quality or not sufficiently convincing to displace standard therapies. Our medical strategies for managing chronic dermatologic conditions, particularly inflammatory disorders, continue to improve from both a safety and a proven efficacy standpoint. Therefore, I would not forgo medical management in favor of cupping. While cupping can be used as an adjunct therapy, I would caution patients about possible adverse side effects. In the aesthetic world, cupping is also gaining popularity, but this trend is also not supported by current evidence or studies, at least in the Western literature.

Dr. Goldman is a dermatologist in private practice in Miami and specializes in cosmetic and general dermatology. She practices at Baumann Cosmetic & Research Institute and is also opening a general dermatology practice. Write to her at [email protected] or message her on Instragram @DrChloeGoldman. Dr. Goldman receives compensation to create social media content for Replenix, a skin care company. She has no other disclosures.

References

1. Soliman Y et al. Acta Dermatovenerol Alp Pannonica Adriat. 2018 Jun;27(2):103-7.

2. França K and Lotti T. Advances in Integrative Dermatology. John Wiley & Sons, 2019.

3. Lowe DT. Complement Ther Clin Pract. 2017 Nov;29:162-8.

4.Cao H et al. Altern Ther Health Med. 2010 Nov-Dec;16(6):48-54.

5. Li L and Ding J. J Tradit Chin Med. 2001 Mar;21(1):37-8.

6. Xiao XJ et al. J Integr Med. 2020 Jul;18(4):303-12.

7. Xu J et al. J Tradit Chin Med. 2013 Dec;33(6):752-6.

8. Yao J et al. Zhongguo Zhen Jiu. 2007; Jun;27(6):424-6.

9. Hon KL et al. Case Rep Pediatr. 2013;2013:605829.

10. Xing M et al. Medicine (Baltimore). 2020 Oct 9;99(41):e22539.

11. Kim TH et al. Eur J Integr Med. 2014 Aug 1;6(4):434-40.

12. Vender R and Vender R. J Cutan Med Surg. 2015 May-Jun;19(3):320-2.

13. Zhou Y et al. Biomed Opt Express. 2020 Apr 6;11(5):2394-401.

This article was updated 4/25/22.

Giving the probiotic supplement Lactobacillus rhamnosus GG (LGG) to high-risk infants in the first 6 months of life is not effective in lessening incidence of eczema, asthma, or rhinitis in later childhood, researchers have found.

The researchers, led by Michael D. Cabana, MD, MPH, with the Children’s Hospital of Montefiore, New York, said they cannot support its use in this population of children at high risk for allergic disease. Findings were published in Pediatrics.

Jonathan Spergel, MD, PhD, chief of the allergy program at Children’s Hospital of Philadelphia, who was not part of the study, said the “small, but very interesting study adds to the literature indicating that allergy prevention needs to be a multifactorial approach and simply adding LGG in a select population makes no difference.”

He noted that the study of probiotics for allergic conditions is complex as it depends on many factors, such as the child’s environment, including exposure to pets and pollution, and whether the child was delivered vaginally or by cesarean section.

Study builds on previous work

The new study builds on the same researchers’ randomized, double-masked, parallel-arm, controlled Trial of Infant Probiotic Supplementation (TIPS). That study investigated whether daily administration of LGG in the first 6 months to children at high risk for allergic disease because of asthma in a parent, could decrease their cumulative incidence of eczema. Investigators found LGG had no effect.

These additional results included participants at least 7 years old and also included physician-diagnosed asthma and physician-diagnosed rhinitis as secondary outcomes.

Retention rate over the 7-year follow-up was 56%; 49 (53%) of 92 in the intervention group and 54 (59%) of 92 in the control group.

The researchers performed modified intention-to-treat analyses with all children who received treatment in the study arm to which they had been randomized.

Eczema was diagnosed in 78 participants, asthma in 32, and rhinitis in 15. Incidence of eczema was high in infancy, but low thereafter. Incidence rates for asthma and rhinitis were constant throughout childhood.

The researchers used modeling to compare the incidence of each outcome between the intervention and control groups, adjusting for mode of delivery and how long a child was breastfed.

Cesarean delivery was linked to a greater incidence of rhinitis, with a hazard ratio of 3.33 (95% confidence interval, 1.21-9.21).

Finding the right strain

Heather Cassell, MD, a pediatric allergist and immunologist at University of Arizona, Tucson, who was not part of the study, said in an interview that many researchers, including those at her institution, are trying to find which strain of probiotic might be beneficial in lowering risk for allergic disease.

Though it appears LGG doesn’t have an effect, she said, another strain might be successful and this helps zero in on the right one.

The TIPS trial showed that there were no significant side effects from giving LGG early, which is good information to have as the search resumes for the right strain, she said.

“We know that there’s probably some immune dysregulation in kids with asthma, eczema, other allergies, but we don’t fully know the extent of it,” she said, adding that it may be that skin flora or respiratory flora and microbiomes in other parts of the body play a role.

“We don’t have bacteria just in our guts,” she noted. “It may be a combination of strains or a combination of bacteria.”

The authors, Dr. Spergel, and Dr. Cassell reported no relevant financial relationships.

Giving the probiotic supplement Lactobacillus rhamnosus GG (LGG) to high-risk infants in the first 6 months of life is not effective in lessening incidence of eczema, asthma, or rhinitis in later childhood, researchers have found.

The researchers, led by Michael D. Cabana, MD, MPH, with the Children’s Hospital of Montefiore, New York, said they cannot support its use in this population of children at high risk for allergic disease. Findings were published in Pediatrics.

Jonathan Spergel, MD, PhD, chief of the allergy program at Children’s Hospital of Philadelphia, who was not part of the study, said the “small, but very interesting study adds to the literature indicating that allergy prevention needs to be a multifactorial approach and simply adding LGG in a select population makes no difference.”

He noted that the study of probiotics for allergic conditions is complex as it depends on many factors, such as the child’s environment, including exposure to pets and pollution, and whether the child was delivered vaginally or by cesarean section.

Study builds on previous work

The new study builds on the same researchers’ randomized, double-masked, parallel-arm, controlled Trial of Infant Probiotic Supplementation (TIPS). That study investigated whether daily administration of LGG in the first 6 months to children at high risk for allergic disease because of asthma in a parent, could decrease their cumulative incidence of eczema. Investigators found LGG had no effect.

These additional results included participants at least 7 years old and also included physician-diagnosed asthma and physician-diagnosed rhinitis as secondary outcomes.

Retention rate over the 7-year follow-up was 56%; 49 (53%) of 92 in the intervention group and 54 (59%) of 92 in the control group.

The researchers performed modified intention-to-treat analyses with all children who received treatment in the study arm to which they had been randomized.

Eczema was diagnosed in 78 participants, asthma in 32, and rhinitis in 15. Incidence of eczema was high in infancy, but low thereafter. Incidence rates for asthma and rhinitis were constant throughout childhood.

The researchers used modeling to compare the incidence of each outcome between the intervention and control groups, adjusting for mode of delivery and how long a child was breastfed.

Cesarean delivery was linked to a greater incidence of rhinitis, with a hazard ratio of 3.33 (95% confidence interval, 1.21-9.21).

Finding the right strain

Heather Cassell, MD, a pediatric allergist and immunologist at University of Arizona, Tucson, who was not part of the study, said in an interview that many researchers, including those at her institution, are trying to find which strain of probiotic might be beneficial in lowering risk for allergic disease.

Though it appears LGG doesn’t have an effect, she said, another strain might be successful and this helps zero in on the right one.

The TIPS trial showed that there were no significant side effects from giving LGG early, which is good information to have as the search resumes for the right strain, she said.

“We know that there’s probably some immune dysregulation in kids with asthma, eczema, other allergies, but we don’t fully know the extent of it,” she said, adding that it may be that skin flora or respiratory flora and microbiomes in other parts of the body play a role.

“We don’t have bacteria just in our guts,” she noted. “It may be a combination of strains or a combination of bacteria.”

The authors, Dr. Spergel, and Dr. Cassell reported no relevant financial relationships.

Giving the probiotic supplement Lactobacillus rhamnosus GG (LGG) to high-risk infants in the first 6 months of life is not effective in lessening incidence of eczema, asthma, or rhinitis in later childhood, researchers have found.

The researchers, led by Michael D. Cabana, MD, MPH, with the Children’s Hospital of Montefiore, New York, said they cannot support its use in this population of children at high risk for allergic disease. Findings were published in Pediatrics.

Jonathan Spergel, MD, PhD, chief of the allergy program at Children’s Hospital of Philadelphia, who was not part of the study, said the “small, but very interesting study adds to the literature indicating that allergy prevention needs to be a multifactorial approach and simply adding LGG in a select population makes no difference.”

He noted that the study of probiotics for allergic conditions is complex as it depends on many factors, such as the child’s environment, including exposure to pets and pollution, and whether the child was delivered vaginally or by cesarean section.

Study builds on previous work

The new study builds on the same researchers’ randomized, double-masked, parallel-arm, controlled Trial of Infant Probiotic Supplementation (TIPS). That study investigated whether daily administration of LGG in the first 6 months to children at high risk for allergic disease because of asthma in a parent, could decrease their cumulative incidence of eczema. Investigators found LGG had no effect.

These additional results included participants at least 7 years old and also included physician-diagnosed asthma and physician-diagnosed rhinitis as secondary outcomes.

Retention rate over the 7-year follow-up was 56%; 49 (53%) of 92 in the intervention group and 54 (59%) of 92 in the control group.

The researchers performed modified intention-to-treat analyses with all children who received treatment in the study arm to which they had been randomized.

Eczema was diagnosed in 78 participants, asthma in 32, and rhinitis in 15. Incidence of eczema was high in infancy, but low thereafter. Incidence rates for asthma and rhinitis were constant throughout childhood.

The researchers used modeling to compare the incidence of each outcome between the intervention and control groups, adjusting for mode of delivery and how long a child was breastfed.

Cesarean delivery was linked to a greater incidence of rhinitis, with a hazard ratio of 3.33 (95% confidence interval, 1.21-9.21).

Finding the right strain

Heather Cassell, MD, a pediatric allergist and immunologist at University of Arizona, Tucson, who was not part of the study, said in an interview that many researchers, including those at her institution, are trying to find which strain of probiotic might be beneficial in lowering risk for allergic disease.

Though it appears LGG doesn’t have an effect, she said, another strain might be successful and this helps zero in on the right one.

The TIPS trial showed that there were no significant side effects from giving LGG early, which is good information to have as the search resumes for the right strain, she said.

“We know that there’s probably some immune dysregulation in kids with asthma, eczema, other allergies, but we don’t fully know the extent of it,” she said, adding that it may be that skin flora or respiratory flora and microbiomes in other parts of the body play a role.

“We don’t have bacteria just in our guts,” she noted. “It may be a combination of strains or a combination of bacteria.”

The authors, Dr. Spergel, and Dr. Cassell reported no relevant financial relationships.

To the Editor:

Atopic dermatitis (AD) affects an estimated 7.2% of adults and 10.7% of children in the United States; however, AD might affect different races at a varying rate.¹ Compared to their European American counterparts, Asian/Pacific Islanders and African Americans are 7 and 3 times more likely, respectively, to be given a diagnosis of AD.²

Despite being disproportionately affected by AD, minority groups might be underrepresented in clinical trials of AD treatments.³ One explanation for this imbalance might be that ethnoracial representation differs across regions in the United States, perhaps in regions where clinical trials are conducted. Price et al³ investigated racial representation in clinical trials of AD globally and found that patients of color are consistently underrepresented.

Research on racial representation in clinical trials within the United States—on national and regional scales—is lacking from the current AD literature. We conducted a study to compare racial and ethnic disparities in AD clinical trials across regions of the United States. 

Using the ClinicalTrials.gov database (www.clinicaltrials.gov) of the National Library of Medicine, we identified clinical trials of AD treatments (encompassing phases 1 through 4) in the United States that were completed before March 14, 2021, with the earliest data from 2013. Search terms included atopic dermatitis, with an advanced search for interventional (clinical trials) and with results.

In total, 95 completed clinical trials were identified, of which 26 (27.4%) reported ethnoracial demographic data. One trial was excluded due to misrepresentation regarding the classification of individuals who identified as more than 1 racial category. Clinical trials for systemic treatments (7 [28%]) and topical treatments (18 [72%]) were identified.

All ethnoracial data were self-reported by trial participants based on US Food and Drug Administration guidelines for racial and ethnic categorization.⁴ Trial participants who identified ethnically as Hispanic or Latino might have been a part of any racial group. Only 7 of the 25 included clinical trials (28%) provided ethnic demographic data (Hispanic [Latino] or non-Hispanic); 72% of trials failed to report ethnicity. Ethnic data included in our analysis came from only the 7 clinical trials that included these data. International multicenter trials that included a US site were excluded.

Ultimately, the number of trials included in our analysis was 25, comprised of 2443 participants. Data were further organized by US geographic region (Northeast, Midwest, South, West, and multiregion trials [ie, conducted in ≥2 regions]). No AD clinical trials were conducted solely in the Midwest; it was only included within multiregion trials.

Compared to their representation in the 2019 US Census, most minority groups were overrepresented in clinical trials, while White individuals were underrepresented (eTable). The percentages of our findings on representation for race are as follows (US Census data are listed in parentheses for comparison⁵):

• White: 56.8% (72.5%)
• Black/African American: 28.3% (12.7%)
• Asian: 10.3% (5.5%)
• Multiracial: 1.1% (3.3%)
• Native Hawaiian or other Pacific Islander: 0.3% (0.2%)
• American Indian or Alaska Native: 0.2% (0.8%)
• Other: 0.5% (4.9%).

Our findings on representation for ethnicity are as follows (US Census data is listed in parentheses for comparison⁵):

• Hispanic or Latino: 21.4% (18.0%)

Although representation of Black/African American and Asian participants in clinical trials was higher than their representation in US Census data and representation of White participants was lower in clinical trials than their representation in census data, equal representation among all racial and ethnic groups is still lacking. A potential explanation for this finding might be that requirements for trial inclusion selected for more minority patients, given the propensity for greater severity of AD among those racial groups.² Another explanation might be that efforts to include minority patients in clinical trials are improving.

There were great differences in ethnoracial representation in clinical trials when regions within the United States were compared. Based on census population data by region, the West had the highest percentage (29.9%) of Hispanic or Latino residents; however, this group represented only 11.7% of participants in AD clinical trials in that region.⁵

The South had the greatest number of participants in AD clinical trials of any region, which was consistent with research findings on an association between severity of AD and heat.⁶ With a warmer climate correlating with an increased incidence of AD, it is possible that more people are willing to participate in clinical trials in the South.

The Midwest was the only region in which region-specific clinical trials were not conducted. Recent studies have shown that individuals with AD who live in the Midwest have comparatively less access to health care associated with AD treatment and are more likely to visit an emergency department because of AD than individuals in any other US region.⁷ This discrepancy highlights the need for increased access to resources and clinical trials focused on the treatment of AD in the Midwest.

In 1993, the National Institutes of Health Revitalization Act established a federal legislative mandate to encourage inclusion of women and people of color in clinical trials.⁸ During the last 2 decades, there have been improvements in ethnoracial reporting. A 2020 global study found that 81.1% of randomized controlled trials (phases 2 and 3) of AD treatments reported ethnoracial data.³

Equal representation in clinical trials allows for further investigation of the connection between race, AD severity, and treatment efficacy. Clinical trials need to have equal representation of ethnoracial categories across all regions of the United States. If one group is notably overrepresented, ethnoracial associations related to the treatment of AD might go undetected.⁹ Similarly, if representation is unequal, relationships of treatment efficacy within ethnoracial groups also might go undetected. None of the clinical trials that we analyzed investigated treatment efficacy by race, suggesting that there is a need for future research in this area.

It also is important to note that broad classifications of race and ethnicity are limiting and therefore overlook differences within ethnoracial categories. Although representation of minority patients in clinical trials for AD treatments is improving, we conclude that there remains a need for greater and equal representation of minority groups in clinical trials of AD treatments in the United States.

To the Editor:

Atopic dermatitis (AD) affects an estimated 7.2% of adults and 10.7% of children in the United States; however, AD might affect different races at a varying rate.¹ Compared to their European American counterparts, Asian/Pacific Islanders and African Americans are 7 and 3 times more likely, respectively, to be given a diagnosis of AD.²

Despite being disproportionately affected by AD, minority groups might be underrepresented in clinical trials of AD treatments.³ One explanation for this imbalance might be that ethnoracial representation differs across regions in the United States, perhaps in regions where clinical trials are conducted. Price et al³ investigated racial representation in clinical trials of AD globally and found that patients of color are consistently underrepresented.

Research on racial representation in clinical trials within the United States—on national and regional scales—is lacking from the current AD literature. We conducted a study to compare racial and ethnic disparities in AD clinical trials across regions of the United States. 

Using the ClinicalTrials.gov database (www.clinicaltrials.gov) of the National Library of Medicine, we identified clinical trials of AD treatments (encompassing phases 1 through 4) in the United States that were completed before March 14, 2021, with the earliest data from 2013. Search terms included atopic dermatitis, with an advanced search for interventional (clinical trials) and with results.

In total, 95 completed clinical trials were identified, of which 26 (27.4%) reported ethnoracial demographic data. One trial was excluded due to misrepresentation regarding the classification of individuals who identified as more than 1 racial category. Clinical trials for systemic treatments (7 [28%]) and topical treatments (18 [72%]) were identified.

All ethnoracial data were self-reported by trial participants based on US Food and Drug Administration guidelines for racial and ethnic categorization.⁴ Trial participants who identified ethnically as Hispanic or Latino might have been a part of any racial group. Only 7 of the 25 included clinical trials (28%) provided ethnic demographic data (Hispanic [Latino] or non-Hispanic); 72% of trials failed to report ethnicity. Ethnic data included in our analysis came from only the 7 clinical trials that included these data. International multicenter trials that included a US site were excluded.

Ultimately, the number of trials included in our analysis was 25, comprised of 2443 participants. Data were further organized by US geographic region (Northeast, Midwest, South, West, and multiregion trials [ie, conducted in ≥2 regions]). No AD clinical trials were conducted solely in the Midwest; it was only included within multiregion trials.

Compared to their representation in the 2019 US Census, most minority groups were overrepresented in clinical trials, while White individuals were underrepresented (eTable). The percentages of our findings on representation for race are as follows (US Census data are listed in parentheses for comparison⁵):

• White: 56.8% (72.5%)
• Black/African American: 28.3% (12.7%)
• Asian: 10.3% (5.5%)
• Multiracial: 1.1% (3.3%)
• Native Hawaiian or other Pacific Islander: 0.3% (0.2%)
• American Indian or Alaska Native: 0.2% (0.8%)
• Other: 0.5% (4.9%).

Our findings on representation for ethnicity are as follows (US Census data is listed in parentheses for comparison⁵):

• Hispanic or Latino: 21.4% (18.0%)

Although representation of Black/African American and Asian participants in clinical trials was higher than their representation in US Census data and representation of White participants was lower in clinical trials than their representation in census data, equal representation among all racial and ethnic groups is still lacking. A potential explanation for this finding might be that requirements for trial inclusion selected for more minority patients, given the propensity for greater severity of AD among those racial groups.² Another explanation might be that efforts to include minority patients in clinical trials are improving.

There were great differences in ethnoracial representation in clinical trials when regions within the United States were compared. Based on census population data by region, the West had the highest percentage (29.9%) of Hispanic or Latino residents; however, this group represented only 11.7% of participants in AD clinical trials in that region.⁵

The South had the greatest number of participants in AD clinical trials of any region, which was consistent with research findings on an association between severity of AD and heat.⁶ With a warmer climate correlating with an increased incidence of AD, it is possible that more people are willing to participate in clinical trials in the South.

The Midwest was the only region in which region-specific clinical trials were not conducted. Recent studies have shown that individuals with AD who live in the Midwest have comparatively less access to health care associated with AD treatment and are more likely to visit an emergency department because of AD than individuals in any other US region.⁷ This discrepancy highlights the need for increased access to resources and clinical trials focused on the treatment of AD in the Midwest.

In 1993, the National Institutes of Health Revitalization Act established a federal legislative mandate to encourage inclusion of women and people of color in clinical trials.⁸ During the last 2 decades, there have been improvements in ethnoracial reporting. A 2020 global study found that 81.1% of randomized controlled trials (phases 2 and 3) of AD treatments reported ethnoracial data.³

Equal representation in clinical trials allows for further investigation of the connection between race, AD severity, and treatment efficacy. Clinical trials need to have equal representation of ethnoracial categories across all regions of the United States. If one group is notably overrepresented, ethnoracial associations related to the treatment of AD might go undetected.⁹ Similarly, if representation is unequal, relationships of treatment efficacy within ethnoracial groups also might go undetected. None of the clinical trials that we analyzed investigated treatment efficacy by race, suggesting that there is a need for future research in this area.

It also is important to note that broad classifications of race and ethnicity are limiting and therefore overlook differences within ethnoracial categories. Although representation of minority patients in clinical trials for AD treatments is improving, we conclude that there remains a need for greater and equal representation of minority groups in clinical trials of AD treatments in the United States.

To the Editor:

Atopic dermatitis (AD) affects an estimated 7.2% of adults and 10.7% of children in the United States; however, AD might affect different races at a varying rate.¹ Compared to their European American counterparts, Asian/Pacific Islanders and African Americans are 7 and 3 times more likely, respectively, to be given a diagnosis of AD.²

Despite being disproportionately affected by AD, minority groups might be underrepresented in clinical trials of AD treatments.³ One explanation for this imbalance might be that ethnoracial representation differs across regions in the United States, perhaps in regions where clinical trials are conducted. Price et al³ investigated racial representation in clinical trials of AD globally and found that patients of color are consistently underrepresented.

Research on racial representation in clinical trials within the United States—on national and regional scales—is lacking from the current AD literature. We conducted a study to compare racial and ethnic disparities in AD clinical trials across regions of the United States. 

Using the ClinicalTrials.gov database (www.clinicaltrials.gov) of the National Library of Medicine, we identified clinical trials of AD treatments (encompassing phases 1 through 4) in the United States that were completed before March 14, 2021, with the earliest data from 2013. Search terms included atopic dermatitis, with an advanced search for interventional (clinical trials) and with results.

In total, 95 completed clinical trials were identified, of which 26 (27.4%) reported ethnoracial demographic data. One trial was excluded due to misrepresentation regarding the classification of individuals who identified as more than 1 racial category. Clinical trials for systemic treatments (7 [28%]) and topical treatments (18 [72%]) were identified.

All ethnoracial data were self-reported by trial participants based on US Food and Drug Administration guidelines for racial and ethnic categorization.⁴ Trial participants who identified ethnically as Hispanic or Latino might have been a part of any racial group. Only 7 of the 25 included clinical trials (28%) provided ethnic demographic data (Hispanic [Latino] or non-Hispanic); 72% of trials failed to report ethnicity. Ethnic data included in our analysis came from only the 7 clinical trials that included these data. International multicenter trials that included a US site were excluded.

Ultimately, the number of trials included in our analysis was 25, comprised of 2443 participants. Data were further organized by US geographic region (Northeast, Midwest, South, West, and multiregion trials [ie, conducted in ≥2 regions]). No AD clinical trials were conducted solely in the Midwest; it was only included within multiregion trials.

Compared to their representation in the 2019 US Census, most minority groups were overrepresented in clinical trials, while White individuals were underrepresented (eTable). The percentages of our findings on representation for race are as follows (US Census data are listed in parentheses for comparison⁵):

• White: 56.8% (72.5%)
• Black/African American: 28.3% (12.7%)
• Asian: 10.3% (5.5%)
• Multiracial: 1.1% (3.3%)
• Native Hawaiian or other Pacific Islander: 0.3% (0.2%)
• American Indian or Alaska Native: 0.2% (0.8%)
• Other: 0.5% (4.9%).

Our findings on representation for ethnicity are as follows (US Census data is listed in parentheses for comparison⁵):

• Hispanic or Latino: 21.4% (18.0%)

Although representation of Black/African American and Asian participants in clinical trials was higher than their representation in US Census data and representation of White participants was lower in clinical trials than their representation in census data, equal representation among all racial and ethnic groups is still lacking. A potential explanation for this finding might be that requirements for trial inclusion selected for more minority patients, given the propensity for greater severity of AD among those racial groups.² Another explanation might be that efforts to include minority patients in clinical trials are improving.

There were great differences in ethnoracial representation in clinical trials when regions within the United States were compared. Based on census population data by region, the West had the highest percentage (29.9%) of Hispanic or Latino residents; however, this group represented only 11.7% of participants in AD clinical trials in that region.⁵

The South had the greatest number of participants in AD clinical trials of any region, which was consistent with research findings on an association between severity of AD and heat.⁶ With a warmer climate correlating with an increased incidence of AD, it is possible that more people are willing to participate in clinical trials in the South.

The Midwest was the only region in which region-specific clinical trials were not conducted. Recent studies have shown that individuals with AD who live in the Midwest have comparatively less access to health care associated with AD treatment and are more likely to visit an emergency department because of AD than individuals in any other US region.⁷ This discrepancy highlights the need for increased access to resources and clinical trials focused on the treatment of AD in the Midwest.

In 1993, the National Institutes of Health Revitalization Act established a federal legislative mandate to encourage inclusion of women and people of color in clinical trials.⁸ During the last 2 decades, there have been improvements in ethnoracial reporting. A 2020 global study found that 81.1% of randomized controlled trials (phases 2 and 3) of AD treatments reported ethnoracial data.³

Equal representation in clinical trials allows for further investigation of the connection between race, AD severity, and treatment efficacy. Clinical trials need to have equal representation of ethnoracial categories across all regions of the United States. If one group is notably overrepresented, ethnoracial associations related to the treatment of AD might go undetected.⁹ Similarly, if representation is unequal, relationships of treatment efficacy within ethnoracial groups also might go undetected. None of the clinical trials that we analyzed investigated treatment efficacy by race, suggesting that there is a need for future research in this area.

It also is important to note that broad classifications of race and ethnicity are limiting and therefore overlook differences within ethnoracial categories. Although representation of minority patients in clinical trials for AD treatments is improving, we conclude that there remains a need for greater and equal representation of minority groups in clinical trials of AD treatments in the United States.

Dupilumab is a subcutaneous injection therapy that inhibits the interleukin 4 receptor alpha subunit. It has been approved in the United States for the treatment of adults with moderate-to-severe AD since 2017 and has since been approved for children and adolescents older than 6 years. Many real-world studies of the effectiveness of dupilumab have been published over the past few years. Kojanova and colleagues reported findings from a retrospective, multicenter study of 360 adults with severe AD who received dupilumab. They found that a high proportion of patients achieved a 75% improvement in the Eczema Area and Severity Index (EASI-75) at week 16 (66.6%), 1 year (89.5%), and 2 years (95.8%). Drug persistence rates were very high (> 90%) throughout the 2 years of therapy, suggesting that dupilumab was effective and well-tolerated.

Dupilumab was previously found to be associated with increased conjunctivitis in clinical trials and real-world studies. Schneeweiss and colleagues conducted a population-based longitudinal study of 5,004,117 patients with AD who newly initiated dupilumab, methotrexate, mycophenolate, and cyclosporine. They found that the risk of developing conjunctivitis diagnosed in clinical practice within 6 months of treatment initiation was approximately double with dupilumab compared with methotrexate, mycophenolate, or cyclosporine. Interestingly, comorbid asthma was found to be a risk factor for conjunctivitis in dupilumab initiators. This study provides insight into how commonly clinically significant conjunctivitis occurs with dupilumab treatment. Of note, the study results may underestimate the incidence of conjunctivitis because milder cases may go undetected.

Upadacitinib is an oral selective Janus kinase (JAK) 1 inhibitor that was approved in the United States in 2022 for the treatment of moderate-to-severe AD. Simpson and colleagues reported on the long-term efficacy and safety of oral upadacitinib from the phase 3 double-blind, randomized controlled trials Measure Up 1 and Measure Up 2 in adolescents and adults with moderate-to-severe atopic dermatitis ho had an inadequate response to topical therapy. The initial phase of the Measure Up 1 and Measure Up 2 studies was 16 weeks in duration, with a placebo control group. At week 16, patients who received 15 or 30 mg upadacitinib in the initial 16 weeks of the study continued to receive that dose. Patients who received placebo in the initial 16 weeks were randomly assigned to receive oral 15 mg or 30 mg upadacitinib daily. So, in the long run, all patients received upadacitinib in the second phase of the study but were blinded to the dose they were receiving. The results from the first 16 weeks of treatment were previously published. Simpson and colleagues reported on the results up to week 52 from the second phase of the study. They showed that at week 52, 82.0% and 79.1% of patients in Measure Up 1 and Measure Up 2 achieved a 75% improvement in EASI-75 when continuing on 15 mg upadacitinib and 84.9% and 84.3% in patients continuing 30 mg upadacitinib, respectively. More than 80% of patients who switched from placebo to upadacitinib at week 16 achieved EASI-75 at week 52. No safety signals were observed in this phase of the study that were not previously observed in other studies of upadacitinib for atopic dermatitis and other indications (rheumatoid arthritis and psoriatic arthritis). These results indicate that upadacitinib has durable efficacy with long-term treatment in moderate-to-severe AD. These studies are ongoing, and I look forward to future results reporting for even longer-term treatment.

It is an exciting time in dermatology with the arrival of multiple novel therapies for atopic dermatitis. The field has already benefited so much by the tremendous interest and research effort into understanding how to best manage this disease. With so many more treatments in the pipeline, perhaps the best is yet to come.

Dupilumab is a subcutaneous injection therapy that inhibits the interleukin 4 receptor alpha subunit. It has been approved in the United States for the treatment of adults with moderate-to-severe AD since 2017 and has since been approved for children and adolescents older than 6 years. Many real-world studies of the effectiveness of dupilumab have been published over the past few years. Kojanova and colleagues reported findings from a retrospective, multicenter study of 360 adults with severe AD who received dupilumab. They found that a high proportion of patients achieved a 75% improvement in the Eczema Area and Severity Index (EASI-75) at week 16 (66.6%), 1 year (89.5%), and 2 years (95.8%). Drug persistence rates were very high (> 90%) throughout the 2 years of therapy, suggesting that dupilumab was effective and well-tolerated.

Dupilumab was previously found to be associated with increased conjunctivitis in clinical trials and real-world studies. Schneeweiss and colleagues conducted a population-based longitudinal study of 5,004,117 patients with AD who newly initiated dupilumab, methotrexate, mycophenolate, and cyclosporine. They found that the risk of developing conjunctivitis diagnosed in clinical practice within 6 months of treatment initiation was approximately double with dupilumab compared with methotrexate, mycophenolate, or cyclosporine. Interestingly, comorbid asthma was found to be a risk factor for conjunctivitis in dupilumab initiators. This study provides insight into how commonly clinically significant conjunctivitis occurs with dupilumab treatment. Of note, the study results may underestimate the incidence of conjunctivitis because milder cases may go undetected.

Upadacitinib is an oral selective Janus kinase (JAK) 1 inhibitor that was approved in the United States in 2022 for the treatment of moderate-to-severe AD. Simpson and colleagues reported on the long-term efficacy and safety of oral upadacitinib from the phase 3 double-blind, randomized controlled trials Measure Up 1 and Measure Up 2 in adolescents and adults with moderate-to-severe atopic dermatitis ho had an inadequate response to topical therapy. The initial phase of the Measure Up 1 and Measure Up 2 studies was 16 weeks in duration, with a placebo control group. At week 16, patients who received 15 or 30 mg upadacitinib in the initial 16 weeks of the study continued to receive that dose. Patients who received placebo in the initial 16 weeks were randomly assigned to receive oral 15 mg or 30 mg upadacitinib daily. So, in the long run, all patients received upadacitinib in the second phase of the study but were blinded to the dose they were receiving. The results from the first 16 weeks of treatment were previously published. Simpson and colleagues reported on the results up to week 52 from the second phase of the study. They showed that at week 52, 82.0% and 79.1% of patients in Measure Up 1 and Measure Up 2 achieved a 75% improvement in EASI-75 when continuing on 15 mg upadacitinib and 84.9% and 84.3% in patients continuing 30 mg upadacitinib, respectively. More than 80% of patients who switched from placebo to upadacitinib at week 16 achieved EASI-75 at week 52. No safety signals were observed in this phase of the study that were not previously observed in other studies of upadacitinib for atopic dermatitis and other indications (rheumatoid arthritis and psoriatic arthritis). These results indicate that upadacitinib has durable efficacy with long-term treatment in moderate-to-severe AD. These studies are ongoing, and I look forward to future results reporting for even longer-term treatment.

It is an exciting time in dermatology with the arrival of multiple novel therapies for atopic dermatitis. The field has already benefited so much by the tremendous interest and research effort into understanding how to best manage this disease. With so many more treatments in the pipeline, perhaps the best is yet to come.

Dupilumab is a subcutaneous injection therapy that inhibits the interleukin 4 receptor alpha subunit. It has been approved in the United States for the treatment of adults with moderate-to-severe AD since 2017 and has since been approved for children and adolescents older than 6 years. Many real-world studies of the effectiveness of dupilumab have been published over the past few years. Kojanova and colleagues reported findings from a retrospective, multicenter study of 360 adults with severe AD who received dupilumab. They found that a high proportion of patients achieved a 75% improvement in the Eczema Area and Severity Index (EASI-75) at week 16 (66.6%), 1 year (89.5%), and 2 years (95.8%). Drug persistence rates were very high (> 90%) throughout the 2 years of therapy, suggesting that dupilumab was effective and well-tolerated.

Dupilumab was previously found to be associated with increased conjunctivitis in clinical trials and real-world studies. Schneeweiss and colleagues conducted a population-based longitudinal study of 5,004,117 patients with AD who newly initiated dupilumab, methotrexate, mycophenolate, and cyclosporine. They found that the risk of developing conjunctivitis diagnosed in clinical practice within 6 months of treatment initiation was approximately double with dupilumab compared with methotrexate, mycophenolate, or cyclosporine. Interestingly, comorbid asthma was found to be a risk factor for conjunctivitis in dupilumab initiators. This study provides insight into how commonly clinically significant conjunctivitis occurs with dupilumab treatment. Of note, the study results may underestimate the incidence of conjunctivitis because milder cases may go undetected.

Upadacitinib is an oral selective Janus kinase (JAK) 1 inhibitor that was approved in the United States in 2022 for the treatment of moderate-to-severe AD. Simpson and colleagues reported on the long-term efficacy and safety of oral upadacitinib from the phase 3 double-blind, randomized controlled trials Measure Up 1 and Measure Up 2 in adolescents and adults with moderate-to-severe atopic dermatitis ho had an inadequate response to topical therapy. The initial phase of the Measure Up 1 and Measure Up 2 studies was 16 weeks in duration, with a placebo control group. At week 16, patients who received 15 or 30 mg upadacitinib in the initial 16 weeks of the study continued to receive that dose. Patients who received placebo in the initial 16 weeks were randomly assigned to receive oral 15 mg or 30 mg upadacitinib daily. So, in the long run, all patients received upadacitinib in the second phase of the study but were blinded to the dose they were receiving. The results from the first 16 weeks of treatment were previously published. Simpson and colleagues reported on the results up to week 52 from the second phase of the study. They showed that at week 52, 82.0% and 79.1% of patients in Measure Up 1 and Measure Up 2 achieved a 75% improvement in EASI-75 when continuing on 15 mg upadacitinib and 84.9% and 84.3% in patients continuing 30 mg upadacitinib, respectively. More than 80% of patients who switched from placebo to upadacitinib at week 16 achieved EASI-75 at week 52. No safety signals were observed in this phase of the study that were not previously observed in other studies of upadacitinib for atopic dermatitis and other indications (rheumatoid arthritis and psoriatic arthritis). These results indicate that upadacitinib has durable efficacy with long-term treatment in moderate-to-severe AD. These studies are ongoing, and I look forward to future results reporting for even longer-term treatment.

It is an exciting time in dermatology with the arrival of multiple novel therapies for atopic dermatitis. The field has already benefited so much by the tremendous interest and research effort into understanding how to best manage this disease. With so many more treatments in the pipeline, perhaps the best is yet to come.

BOSTON – Among atopic dermatitis (AD) patients infected with COVID-19, those who received topical treatments were nearly five times more likely to be hospitalized compared with those on dupilumab monotherapy, results from a global registry demonstrated.

Moreover, combination systemic treatment, especially those that included systemic corticosteroids, was associated with the highest risk of COVID-19–related hospitalization.

“Patients with inflammatory skin diseases such as AD may be at higher risk of COVID-19,” Annelie H. Musters, MD, said during a late-breaking abstract session at the annual meeting of the American Academy of Dermatology. “Another factor to consider is that AD patients are often treated with systemic immunomodulatory therapy, including systemic corticosteroids and nonsteroidal immunosuppressants such as methotrexate, cyclosporin, biologics, and Janus kinase inhibitors. Different mechanisms of action and levels of immunosuppression may impart variable risks of serious infections.”

On the other hand, some degree of immunomodulation may have beneficial effects on the course of COVID-19 in AD patients, said Dr. Musters, of the department of dermatology at Academic Medical Center, University of Amsterdam. Targeting of specific immune pathways could reduce the development of a hyperinflammatory state in severe COVID-19. Dual blockade of interleukin (IL)-4 and IL-13 with dupilumab may have a protective effect in the context of COVID-19 infection, because expression of Th2 cytokines, including IL-4 and IL-13, may be increased during COVID-19.

“At the start of the pandemic, many of us were faced with important questions, like do systemic immunomodulatory treatments influence outcomes of COVID-19 in patients with AD?” she said. “Do patients on dupilumab or other novel systemics fare better than those on conventional systemic treatment?”

To answer these questions, she and her colleagues launched a web-based registry in April 2020 to investigate COVID-19 outcomes in patients with AD treated with or without systemic immunomodulatory treatments. For the registry, known as Surveillance Epidemiology of Coronavirus Under Research Exclusion for Atopic Dermatitis (SECURE-AD), clinicians in 27 countries used a web-based form to enter anonymized data after patients had fully recovered from COVID-19. Eligibility criteria included having proven or highly suspected COVID-19, and there were no restrictions on age nor the type of AD treatment they were receiving.

Dr. Musters reported results from 442 patients who were recruited between April 2, 2020, and Oct. 31, 2021. Their mean age was 35.6 years, their median body mass index was 23.7 kg/m², and there was an even sex distribution. Most patients were White and were recruited from Italy. Of the 442 patients, 216 (48.8%) received dupilumab monotherapy, 131 (29.6%) received topical treatments, and 14 (3.16%) received combination systemic treatments, including systemic corticosteroids. About 12% presented to the emergency department and 6% were hospitalized. Of those hospitalized, 2% required intensive care and/or ventilation, and no deaths have occurred in the registry to date.

By treatment group, hospitalization rates were highest among those on combination treatments (35.7%), followed by systemic corticosteroids (14.3%), topical treatments only (9.9%), other conventional systemics (3.6%), methotrexate (3.3%), and dupilumab (2.3%).

To further explore the differences between hospitalization rates in treatment groups, the researchers performed a multivariable logistic regression analysis, adjusted for age, sex, ethnicity, and comorbidity score. Compared with those who received dupilumab, the adjusted odds ratios (ORs) for hospitalization were highest among those who received topical treatments (OR, 4.95), followed by those who received systemic corticosteroids (OR, 2.81), and those who received other conventional systemic treatments (OR, 2.36).

Dr. Musters and colleagues also found that compared with patients on nonsteroidal immunosuppressive therapy, patients on combination systemic therapy had a significantly higher odds of hospitalization, specifically an OR of 45.75 for those on combination treatment including corticosteroids, an OR of 37.57 for those on combination treatment not including steroids, and an OR of 1.87 for those on systemic corticosteroids as monotherapy.

“Overall, the risk of COVID-19 complications appears to be low in patients with AD, even when treated with systemic immunomodulatory agents,” Dr. Musters concluded. “Dupilumab monotherapy was associated with lower odds of hospitalizations compared with other therapies. Moreover, combination systemic treatment, especially combinations including systemic corticosteroids, was associated with the highest risk of severe COVID-19.”

She added that other population-based study designs are more suitable to answer other important questions, such as whether the overall risk of COVID-19 in patients with AD is higher or lower compared to healthy controls.

Amy S. Paller, MD, professor and chair of the department of dermatology at Northwestern University, Chicago, who was asked to comment on the study, characterized the results as reassuring. In this patient population, “we expected that dupilumab would not cause any problems,” she said. “We wouldn’t necessarily expect it to [confer] a benefit, but I think it’s because the patients who need a systemic medication are going on something that’s very targeted (dupilumab) rather than something that has a broader immunosuppressing function. It was interesting but not surprising that those on systemic steroids had more of a problem. Get them on something that’s very targeted if you can and don’t suppress the immune systems that might be handling COVID-19.”

Dr. Musters reported having no disclosures. Dr. Paller disclosed that she is consultant to and/or an investigator for many pharmaceutical companies.

BOSTON – Among atopic dermatitis (AD) patients infected with COVID-19, those who received topical treatments were nearly five times more likely to be hospitalized compared with those on dupilumab monotherapy, results from a global registry demonstrated.

Moreover, combination systemic treatment, especially those that included systemic corticosteroids, was associated with the highest risk of COVID-19–related hospitalization.

“Patients with inflammatory skin diseases such as AD may be at higher risk of COVID-19,” Annelie H. Musters, MD, said during a late-breaking abstract session at the annual meeting of the American Academy of Dermatology. “Another factor to consider is that AD patients are often treated with systemic immunomodulatory therapy, including systemic corticosteroids and nonsteroidal immunosuppressants such as methotrexate, cyclosporin, biologics, and Janus kinase inhibitors. Different mechanisms of action and levels of immunosuppression may impart variable risks of serious infections.”

On the other hand, some degree of immunomodulation may have beneficial effects on the course of COVID-19 in AD patients, said Dr. Musters, of the department of dermatology at Academic Medical Center, University of Amsterdam. Targeting of specific immune pathways could reduce the development of a hyperinflammatory state in severe COVID-19. Dual blockade of interleukin (IL)-4 and IL-13 with dupilumab may have a protective effect in the context of COVID-19 infection, because expression of Th2 cytokines, including IL-4 and IL-13, may be increased during COVID-19.

“At the start of the pandemic, many of us were faced with important questions, like do systemic immunomodulatory treatments influence outcomes of COVID-19 in patients with AD?” she said. “Do patients on dupilumab or other novel systemics fare better than those on conventional systemic treatment?”

To answer these questions, she and her colleagues launched a web-based registry in April 2020 to investigate COVID-19 outcomes in patients with AD treated with or without systemic immunomodulatory treatments. For the registry, known as Surveillance Epidemiology of Coronavirus Under Research Exclusion for Atopic Dermatitis (SECURE-AD), clinicians in 27 countries used a web-based form to enter anonymized data after patients had fully recovered from COVID-19. Eligibility criteria included having proven or highly suspected COVID-19, and there were no restrictions on age nor the type of AD treatment they were receiving.

Dr. Musters reported results from 442 patients who were recruited between April 2, 2020, and Oct. 31, 2021. Their mean age was 35.6 years, their median body mass index was 23.7 kg/m², and there was an even sex distribution. Most patients were White and were recruited from Italy. Of the 442 patients, 216 (48.8%) received dupilumab monotherapy, 131 (29.6%) received topical treatments, and 14 (3.16%) received combination systemic treatments, including systemic corticosteroids. About 12% presented to the emergency department and 6% were hospitalized. Of those hospitalized, 2% required intensive care and/or ventilation, and no deaths have occurred in the registry to date.

By treatment group, hospitalization rates were highest among those on combination treatments (35.7%), followed by systemic corticosteroids (14.3%), topical treatments only (9.9%), other conventional systemics (3.6%), methotrexate (3.3%), and dupilumab (2.3%).

To further explore the differences between hospitalization rates in treatment groups, the researchers performed a multivariable logistic regression analysis, adjusted for age, sex, ethnicity, and comorbidity score. Compared with those who received dupilumab, the adjusted odds ratios (ORs) for hospitalization were highest among those who received topical treatments (OR, 4.95), followed by those who received systemic corticosteroids (OR, 2.81), and those who received other conventional systemic treatments (OR, 2.36).

Dr. Musters and colleagues also found that compared with patients on nonsteroidal immunosuppressive therapy, patients on combination systemic therapy had a significantly higher odds of hospitalization, specifically an OR of 45.75 for those on combination treatment including corticosteroids, an OR of 37.57 for those on combination treatment not including steroids, and an OR of 1.87 for those on systemic corticosteroids as monotherapy.

“Overall, the risk of COVID-19 complications appears to be low in patients with AD, even when treated with systemic immunomodulatory agents,” Dr. Musters concluded. “Dupilumab monotherapy was associated with lower odds of hospitalizations compared with other therapies. Moreover, combination systemic treatment, especially combinations including systemic corticosteroids, was associated with the highest risk of severe COVID-19.”

She added that other population-based study designs are more suitable to answer other important questions, such as whether the overall risk of COVID-19 in patients with AD is higher or lower compared to healthy controls.

Amy S. Paller, MD, professor and chair of the department of dermatology at Northwestern University, Chicago, who was asked to comment on the study, characterized the results as reassuring. In this patient population, “we expected that dupilumab would not cause any problems,” she said. “We wouldn’t necessarily expect it to [confer] a benefit, but I think it’s because the patients who need a systemic medication are going on something that’s very targeted (dupilumab) rather than something that has a broader immunosuppressing function. It was interesting but not surprising that those on systemic steroids had more of a problem. Get them on something that’s very targeted if you can and don’t suppress the immune systems that might be handling COVID-19.”

Dr. Musters reported having no disclosures. Dr. Paller disclosed that she is consultant to and/or an investigator for many pharmaceutical companies.

BOSTON – Among atopic dermatitis (AD) patients infected with COVID-19, those who received topical treatments were nearly five times more likely to be hospitalized compared with those on dupilumab monotherapy, results from a global registry demonstrated.

Moreover, combination systemic treatment, especially those that included systemic corticosteroids, was associated with the highest risk of COVID-19–related hospitalization.

“Patients with inflammatory skin diseases such as AD may be at higher risk of COVID-19,” Annelie H. Musters, MD, said during a late-breaking abstract session at the annual meeting of the American Academy of Dermatology. “Another factor to consider is that AD patients are often treated with systemic immunomodulatory therapy, including systemic corticosteroids and nonsteroidal immunosuppressants such as methotrexate, cyclosporin, biologics, and Janus kinase inhibitors. Different mechanisms of action and levels of immunosuppression may impart variable risks of serious infections.”

On the other hand, some degree of immunomodulation may have beneficial effects on the course of COVID-19 in AD patients, said Dr. Musters, of the department of dermatology at Academic Medical Center, University of Amsterdam. Targeting of specific immune pathways could reduce the development of a hyperinflammatory state in severe COVID-19. Dual blockade of interleukin (IL)-4 and IL-13 with dupilumab may have a protective effect in the context of COVID-19 infection, because expression of Th2 cytokines, including IL-4 and IL-13, may be increased during COVID-19.

“At the start of the pandemic, many of us were faced with important questions, like do systemic immunomodulatory treatments influence outcomes of COVID-19 in patients with AD?” she said. “Do patients on dupilumab or other novel systemics fare better than those on conventional systemic treatment?”

To answer these questions, she and her colleagues launched a web-based registry in April 2020 to investigate COVID-19 outcomes in patients with AD treated with or without systemic immunomodulatory treatments. For the registry, known as Surveillance Epidemiology of Coronavirus Under Research Exclusion for Atopic Dermatitis (SECURE-AD), clinicians in 27 countries used a web-based form to enter anonymized data after patients had fully recovered from COVID-19. Eligibility criteria included having proven or highly suspected COVID-19, and there were no restrictions on age nor the type of AD treatment they were receiving.

Dr. Musters reported results from 442 patients who were recruited between April 2, 2020, and Oct. 31, 2021. Their mean age was 35.6 years, their median body mass index was 23.7 kg/m², and there was an even sex distribution. Most patients were White and were recruited from Italy. Of the 442 patients, 216 (48.8%) received dupilumab monotherapy, 131 (29.6%) received topical treatments, and 14 (3.16%) received combination systemic treatments, including systemic corticosteroids. About 12% presented to the emergency department and 6% were hospitalized. Of those hospitalized, 2% required intensive care and/or ventilation, and no deaths have occurred in the registry to date.

By treatment group, hospitalization rates were highest among those on combination treatments (35.7%), followed by systemic corticosteroids (14.3%), topical treatments only (9.9%), other conventional systemics (3.6%), methotrexate (3.3%), and dupilumab (2.3%).

To further explore the differences between hospitalization rates in treatment groups, the researchers performed a multivariable logistic regression analysis, adjusted for age, sex, ethnicity, and comorbidity score. Compared with those who received dupilumab, the adjusted odds ratios (ORs) for hospitalization were highest among those who received topical treatments (OR, 4.95), followed by those who received systemic corticosteroids (OR, 2.81), and those who received other conventional systemic treatments (OR, 2.36).

Dr. Musters and colleagues also found that compared with patients on nonsteroidal immunosuppressive therapy, patients on combination systemic therapy had a significantly higher odds of hospitalization, specifically an OR of 45.75 for those on combination treatment including corticosteroids, an OR of 37.57 for those on combination treatment not including steroids, and an OR of 1.87 for those on systemic corticosteroids as monotherapy.

“Overall, the risk of COVID-19 complications appears to be low in patients with AD, even when treated with systemic immunomodulatory agents,” Dr. Musters concluded. “Dupilumab monotherapy was associated with lower odds of hospitalizations compared with other therapies. Moreover, combination systemic treatment, especially combinations including systemic corticosteroids, was associated with the highest risk of severe COVID-19.”

She added that other population-based study designs are more suitable to answer other important questions, such as whether the overall risk of COVID-19 in patients with AD is higher or lower compared to healthy controls.

Amy S. Paller, MD, professor and chair of the department of dermatology at Northwestern University, Chicago, who was asked to comment on the study, characterized the results as reassuring. In this patient population, “we expected that dupilumab would not cause any problems,” she said. “We wouldn’t necessarily expect it to [confer] a benefit, but I think it’s because the patients who need a systemic medication are going on something that’s very targeted (dupilumab) rather than something that has a broader immunosuppressing function. It was interesting but not surprising that those on systemic steroids had more of a problem. Get them on something that’s very targeted if you can and don’t suppress the immune systems that might be handling COVID-19.”

Dr. Musters reported having no disclosures. Dr. Paller disclosed that she is consultant to and/or an investigator for many pharmaceutical companies.

Key clinical point: Patients with atopic dermatitis (AD) vs. healthy controls had significantly lower levels of serum 25-hydroxyvitamin D (25[OH]D), with the levels even lower in patients with severe vs. mild/moderate AD. Supplementation with vitamin D helped improve AD symptoms.

Major finding: The mean serum 25(OH)D level was significantly lower by 7.42 ng/mL in patients with AD vs. healthy controls and by an average of 7.99 ng/mL and 2.95 ng/mL in patients with severe vs. mild and moderate AD, respectively (all P < .001). Over a weighted mean of 2.88 months, patients receiving vitamin D supplementation at a weighted mean dose of 1,721 IU/day reported improvement in AD symptoms (P < .001).

Study details: Findings are from a meta-analysis of 20 studies with 1,882 cases of AD.

Disclosures: This study did not receive any funding. The authors declared no conflict of interests.

Source: Ng JC and Yew YW. Effect of vitamin D serum levels and supplementation on atopic dermatitis: A systematic review and meta-analysis. Am J Clin Dermatol. 2022 (Mar 5). Doi: 10.1007/s40257-022-00677-0

Key clinical point: Patients with atopic dermatitis (AD) vs. healthy controls had significantly lower levels of serum 25-hydroxyvitamin D (25[OH]D), with the levels even lower in patients with severe vs. mild/moderate AD. Supplementation with vitamin D helped improve AD symptoms.

Major finding: The mean serum 25(OH)D level was significantly lower by 7.42 ng/mL in patients with AD vs. healthy controls and by an average of 7.99 ng/mL and 2.95 ng/mL in patients with severe vs. mild and moderate AD, respectively (all P < .001). Over a weighted mean of 2.88 months, patients receiving vitamin D supplementation at a weighted mean dose of 1,721 IU/day reported improvement in AD symptoms (P < .001).

Study details: Findings are from a meta-analysis of 20 studies with 1,882 cases of AD.

Disclosures: This study did not receive any funding. The authors declared no conflict of interests.

Source: Ng JC and Yew YW. Effect of vitamin D serum levels and supplementation on atopic dermatitis: A systematic review and meta-analysis. Am J Clin Dermatol. 2022 (Mar 5). Doi: 10.1007/s40257-022-00677-0

Key clinical point: Patients with atopic dermatitis (AD) vs. healthy controls had significantly lower levels of serum 25-hydroxyvitamin D (25[OH]D), with the levels even lower in patients with severe vs. mild/moderate AD. Supplementation with vitamin D helped improve AD symptoms.

Major finding: The mean serum 25(OH)D level was significantly lower by 7.42 ng/mL in patients with AD vs. healthy controls and by an average of 7.99 ng/mL and 2.95 ng/mL in patients with severe vs. mild and moderate AD, respectively (all P < .001). Over a weighted mean of 2.88 months, patients receiving vitamin D supplementation at a weighted mean dose of 1,721 IU/day reported improvement in AD symptoms (P < .001).

Study details: Findings are from a meta-analysis of 20 studies with 1,882 cases of AD.

Disclosures: This study did not receive any funding. The authors declared no conflict of interests.

Source: Ng JC and Yew YW. Effect of vitamin D serum levels and supplementation on atopic dermatitis: A systematic review and meta-analysis. Am J Clin Dermatol. 2022 (Mar 5). Doi: 10.1007/s40257-022-00677-0

Key clinical point: Cimetidine at a dose of 25-40 mg/kg along with standard treatment reduced severity of acute extrinsic atopic dermatitis (AD) without any serious adverse events.

Major finding: The SCORing Atopic Dermatitis (SCORAD) and objective SCORAD scores improved significantly in the cimetidine vs. placebo group at week 2 (both P = .004) and continued to improve further at weeks 4 (both P = .001), 6 (both P < .001), and 8 (both P < .001) after treatment. At week 2, gastric discomfort was reported by 1 patient receiving cimetidine, which improved after treatment discontinuation.

Study details: Findings are from a phase 3 study including 26 patients aged 12-60 years with AD who had acute lesions and were randomly assigned to receive 25-40 mg/kg cimetidine daily or placebo, both in conjunction with standard AD treatment.

Disclosures: This study did not receive any funding. The authors declared no conflict of interests.

Source: Novianto E et al. Effectiveness of cimetidine as adjuvant therapy in the treatment of acute-extrinsic atopic dermatitis: A double-blind randomized controlled trial. Dermatol Ther (Heidelb). 2022 (Feb 17). Doi: 10.1007/s13555-022-00688-z

Key clinical point: Cimetidine at a dose of 25-40 mg/kg along with standard treatment reduced severity of acute extrinsic atopic dermatitis (AD) without any serious adverse events.

Major finding: The SCORing Atopic Dermatitis (SCORAD) and objective SCORAD scores improved significantly in the cimetidine vs. placebo group at week 2 (both P = .004) and continued to improve further at weeks 4 (both P = .001), 6 (both P < .001), and 8 (both P < .001) after treatment. At week 2, gastric discomfort was reported by 1 patient receiving cimetidine, which improved after treatment discontinuation.

Study details: Findings are from a phase 3 study including 26 patients aged 12-60 years with AD who had acute lesions and were randomly assigned to receive 25-40 mg/kg cimetidine daily or placebo, both in conjunction with standard AD treatment.

Disclosures: This study did not receive any funding. The authors declared no conflict of interests.

Source: Novianto E et al. Effectiveness of cimetidine as adjuvant therapy in the treatment of acute-extrinsic atopic dermatitis: A double-blind randomized controlled trial. Dermatol Ther (Heidelb). 2022 (Feb 17). Doi: 10.1007/s13555-022-00688-z

Key clinical point: Cimetidine at a dose of 25-40 mg/kg along with standard treatment reduced severity of acute extrinsic atopic dermatitis (AD) without any serious adverse events.

Major finding: The SCORing Atopic Dermatitis (SCORAD) and objective SCORAD scores improved significantly in the cimetidine vs. placebo group at week 2 (both P = .004) and continued to improve further at weeks 4 (both P = .001), 6 (both P < .001), and 8 (both P < .001) after treatment. At week 2, gastric discomfort was reported by 1 patient receiving cimetidine, which improved after treatment discontinuation.

Study details: Findings are from a phase 3 study including 26 patients aged 12-60 years with AD who had acute lesions and were randomly assigned to receive 25-40 mg/kg cimetidine daily or placebo, both in conjunction with standard AD treatment.

Disclosures: This study did not receive any funding. The authors declared no conflict of interests.

Source: Novianto E et al. Effectiveness of cimetidine as adjuvant therapy in the treatment of acute-extrinsic atopic dermatitis: A double-blind randomized controlled trial. Dermatol Ther (Heidelb). 2022 (Feb 17). Doi: 10.1007/s13555-022-00688-z