Allergen immunotherapy for atopic dermatitis: Systematic review and meta-analysis of benefits and harms - 04/01/23
Abstract |
Background |
Atopic dermatitis (AD, eczema) is driven by a combination of skin barrier defects, immune dysregulation, and extrinsic stimuli such as allergens, irritants, and microbes. The role of environmental allergens (aeroallergens) in triggering AD remains unclear.
Objective |
We systematically synthesized evidence regarding the benefits and harms of allergen immunotherapy (AIT) for AD.
Methods |
As part of the 2022 American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters AD Guideline update, we searched the MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, Global Resource for Eczema Trials, and Web of Science databases from inception to December 2021 for randomized controlled trials comparing subcutaneous immunotherapy (SCIT), sublingual immunotherapy (SLIT), and/or no AIT (placebo or standard care) for guideline panel–defined patient-important outcomes: AD severity, itch, AD-related quality of life (QoL), flares, and adverse events. Raters independently screened, extracted data, and assessed risk of bias in duplicate. We synthesized intervention effects using frequentist and Bayesian random-effects models. The GRADE approach determined the quality of evidence.
Results |
Twenty-three randomized controlled trials including 1957 adult and pediatric patients sensitized primarily to house dust mite showed that add-on SCIT and SLIT have similar relative and absolute effects and likely result in important improvements in AD severity, defined as a 50% reduction in SCORing Atopic Dermatitis (risk ratio [95% confidence interval] 1.53 [1.31-1.78]; 26% vs 40%, absolute difference 14%) and QoL, defined as an improvement in Dermatology Life Quality Index by 4 points or more (risk ratio [95% confidence interval] 1.44 [1.03-2.01]; 39% vs 56%, absolute difference 17%; both outcomes moderate certainty). Both routes of AIT increased adverse events (risk ratio [95% confidence interval] 1.61 [1.44-1.79]; 66% with SCIT vs 41% with placebo; 13% with SLIT vs 8% with placebo; high certainty). AIT’s effect on sleep disturbance and eczema flares was very uncertain. Subgroup and sensitivity analyses were consistent with the main findings.
Conclusions |
SCIT and SLIT to aeroallergens, particularly house dust mite, can similarly and importantly improve AD severity and QoL. SCIT increases adverse effects more than SLIT. These findings support a multidisciplinary and shared decision-making approach to optimally managing AD.
Le texte complet de cet article est disponible en PDF.Graphical abstract |
Key words : Atopic dermatitis (atopic eczema), allergy, allergen immunotherapy (AIT), aeroallergen, house dust mite, subcutaneous immunotherapy (SCIT), sublingual immunotherapy (SLIT), systematic review, meta-analysis, GRADE approach, multidisciplinary, evidence-based medicine, SCORAD, DLQI, quality of life, itch (pruritus), sleep disturbance, adverse events
Abbreviations used : AAAAI, ACAAI, AD, AIT, CI, Der f, Der p, DLQI, GRADE, HDM, QoL, RCT, RoM, RR, SCIT, SCORAD, SLIT
Plan
| The authors, editors, and journal take a neutral position with respect to territorial claims in published maps and institutional affiliations. |
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| The first and last authors contributed equally to this article, and both should be considered first author. |
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| This work was commissioned by the American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma and Immunology through the Joint Task Force on Practice Parameters to inform upcoming guidance on management of atopic dermatitis. The funder contributed to defining the scope of the review but otherwise had no role in study design and data collection. Data were interpreted and the report drafted and submitted without funder input. The funder was provided a copy of the report at time of submission. The review team had the ability, but not obligation, to consider the funder’s feedback. The corresponding author had full access to all data in the study and had final responsibility for the decision to submit for publication. |
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| Disclosure of potential conflict of interest: T. Winders has no direct conflicts of interest regarding this work; however, her institution has received funding for unbranded disease awareness and education from the following: AbbVie, ALK, Amgen, AstraZeneca, Incyte, Lilly, GSK, Novartis, Pfizer, Sanofi/Regeneron, and TEVA. J. Wang reports data safety and monitoring board membership for ALK and Abello; and receipt of research grants to her institution from Aimmune, DBV, Regeneron, and NIH. The other authors declare that they have no relevant conflicts of interest. |
Vol 151 - N° 1
P. 147-158 - janvier 2023 Retour au numéro
Article précédent
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