Cyclosporine and Extracorporeal Photopheresis are Equipotent in Treating Severe Atopic Dermatitis: A Randomized Cross-Over Study Comparing Two Efficient Treatment Modalities

Abstract

Background: Severe atopic dermatitis (AD) is a recurrent and debilitating disease often requiring systemic immunosuppressive treatment. The efficacy of cyclosporine A (CsA) is well proven but potential side effects are concerning. Several reports point at extracorporeal photopheresis (ECP) as an alternative treatment modality with few and mild side effects. However, no direct comparison between CsA and ECP in the treatment of AD has been performed so far.Objectives: To compare the efficacy of CsA (3 mg/kg/day) and ECP (administered two consecutive days twice a month) in a cohort of patients with severe AD.Methods: A randomized cross-over study involving twenty patients with severe AD (SCORAD index 41-89) refractory to other treatments. The patients were allocated to a 4-month course of either of the two treatment modalities. Individual relapse periods (2–8 weeks) were interspersed before cross-over to the other treatment modality. Treatment efficacy was evaluated by SCORAD, PRURITUS (VAS-index 0–10), “overall global assessment” and serological biomarkers; sIL-2Rα, sE-selectin, eosinophilocytes, basophilocytes, and sIgE.Results: 15 patients completed treatment. Both treatments lead to a marked and significant decrease in SCORAD and pruritus index. The average reduction of the SCORAD and pruritus index, respectively was a little higher for ECP treatment compared to CsA treatment; however, the differences did not reach statistical significance. The “overall global assessment” was significantly better in patients who underwent ECP therapy as compared to CsA treatment. None of the biomarkers showed significant changes after either treatment when compared to the initial values.Conclusion: ECP administered on two consecutive days twice a month to patients with severe AD has similar potency as CsA administered daily in a moderate dose. ECP is a treatment alternative in patients with severe AD that do not tolerate or are refractory to conventional immunosuppressants.

Systematic review about 10 interventions in dermatitis. A document from the Latin American Society of Allergy, Asthma, and Immunology

“…107,108,109,110,111 Once the drug is stopped the symptoms reappear quickly, eventually reaching pretreatment values approximately after 8 weeks from the end of treatment. 109,110,111 CSA has been shown to be effective and relatively safe in adults who received up to 1 year of continuous treatment, 112,113,114,115,116 but some of these studies had high dropout rates. 116 The staff recommended choosing the regimen on an individual basis; it could be reasonable to start with a dose of 2.5 mg/kg/day, 114,117 unless a rapid improvement is considered necessary, when a dose of up to 5 mg/kg/day may be used.…”

European dermatology forum: Updated guidelines on the use of extracorporeal photopheresis 2020 – Part 2

“…The effect of ECP (administered on two consecutive days a month) was compared to oral cyclosporine A (3 mg/kg/day) in a randomized crossover study including twenty patients with severe AD (SCORAD index 41–89) refractory to other therapies 119 . Patients were allocated to a 4‐month course of either of the two treatment modalities, and fifteen patients completed crossover treatment.…”

“…It is intriguing to note that ECP has also been shown to be effective in erythrodermas of another non‐atopic origin, such as red man syndrome, erythrodermic pityriasis rubra pilaris or photoaccentuated erythroderma associated with CD4 + T‐lymphocytopenia 120–123 . Together, no serious side effects have been reported so far in AD and other diseases treated with ECP 112,119 …”

Extracorporeal photopheresis as a non-specific immune therapy of autoimmune diseases and skin T-cell lymphoma (a review of the literature and own studies)

“…(2014) при проведении рандомизированного сравнительного исследования эффективности ЭКФ и циклоспорина А (CsA) у больных АтД пришли к заключению, что «общая глобальная оценка» была значительно лучше у пациентов, которым проводили ЭКФ по сравнению с лечением только CsA. Таким образом, авторы делают вывод о том, что ЭКФ можно признать альтернативой лечения у пациентов с тяжелым АтД, не переносящих или рефрактерных к обычным иммунодепрессантам [45].…”