Allergy Abstract Update: Intravenous immunoglobulin to treat severe atopic dermatitis in children

Intravenous immunoglobulin to treat severe atopic dermatitis in children: a case series.

Turner PJ, et al.

Pediatr Dermatol. 2012 Mar;29(2):177-81.

Severe cases of atopic dermatitis (AD) may require systemic immunosuppression to achieve disease control. Unfortunately, some cases continue to be refractory to management or develop unacceptable adverse effects. There are limited reports of the use of intravenous immunoglobulin (IVIg) in the treatment of severe AD, but results are inconsistent. In a retrospective study, we report 10 children with severe AD refractory to systemic immunosuppression and maximal topical therapy who were treated using IVIg. The children received monthly IVIg for an average of 24 months. This resulted in a significant improvement in symptoms, with fewer infection-related exacerbations and hospitalizations, allowing systemic immunosuppression to be tapered. The effect was associated with a significant decrease in serum immunoglobulin E and was sustained after cessation of IVIg in 50% of cases. No significant side effects attributable to the IVIg infusions were noted. In this cohort of children with severe AD and recurrent cutaneous infections, IVIg provided an effective treatment with minimal side effects and significant benefits in school attendance and quality of life.

Source: Department of Allergy and Immunology, Children’s Hospital at Westmead Discipline of Paediatrics and Child Health, School of Medicine, University of Sydney Department of Dermatology, Children’s Hospital at Westmead, Sydney, Australia.

Intravenous immunoglobulin treatment in a child with resistant atopic dermatitis.

Kwon HH, et al.

Ann Dermatol. 2012 Feb;24(1):66-9. Epub 2012 Feb 2.

Source: Department of Dermatology, Seoul National University College of Medicine, Seoul, Korea.

In a subgroup of patients suffering from atopic dermatitis (AD), treatment is quite difficult even after taking oral immunosuppressants. High-dose intravenous immunoglobulin (IVIG) treatment has been reported to be beneficial for them in a few uncontrolled trials. Herein we report a case of intractable AD in a 5-year-old girl who had significant clinical improvement after receiving 3 cycles of IVIG treatment (2 g/kg) without notable side effects. Since the first infusion of IVIG, the patient’s skin lesions improved steadily and the improvement persisted until the 8-month follow-up. The eczema area and severity index score decreased remarkably, while immunologic parameters did not correlate with clinical improvement. This case suggests that IVIG therapy can be quite effective and safe for children with resistant AD.


High dose intravenous immunoglobulin in atopic dermatitis and hyper-IgE syndrome.

Wakim M, et al.

Ann Allergy Asthma Immunol. 1998 Aug;81(2):153-8.

Source: Department of Pediatrics, UCLA School of Medicine, Los Angeles, California 90095-1752, USA.

BACKGROUND: High dose intravenous immunoglobulin (IVIG) has immunoregulatory and anti-inflammatory properties that might benefit illnesses with exaggerated IgE responses including atopic dermatitis and hyper-IgE immunodeficiency syndrome.

OBJECTIVE: To determine if high-dose IVIG would be of benefit to patients with severe atopic dermatitis and/or hyper-IgE syndrome using serial clinical, pulmonary, and laboratory studies for evaluation.

METHODS: This was an open label study in which we gave patients with hyper-IgE syndrome (n = 1) or severe atopic dermatitis (n = 9) IVIG as a 10% solution (Venoglobulin I-Alpha Therapeutic Corporation, Los Angeles, CA) at a dose of 2 g/kg every 30 days for seven infusions.

RESULTS: Therapy was completed in nine of the ten patients. Skin disease improved slightly in six patients, remained unchanged in two patients, and worsened slightly in one patient. The average daily prednisone dosage was 6.8 mg/day prior to treatment and 5.1 mg/day during IVIG therapy (P = .1250). The three patients with abnormal pulmonary function showed very mild improvement of pulmonary function during treatment, but returned to baseline during follow-up. Flow cytometric studies showed no consistent pattern of change. IgA and IgM levels were unchanged. The mean serum IgE levels went from 3221+/-2454 IU/mL (SD) before IVIG to 2944+/-2491 IU/mL (P = .4609) during IVIG and then to 2321+/-2229 IU/mL (P = .1484) during the 6-month follow-up period. In vitro IgE production of peripheral blood mononuclear cells (PBMC) following IL-4 and anti-CD40 stimulation before IVIG was 6.6+/-3.1 ng/mL (SD) and 4.3+/-3.1 ng/mL (P = .1641) after six IVIG treatments. There were no significant trends in lymphocyte proliferative responses to PHA (phytohemaglutinin), Candida, tetanus, and anti-CD3 monoclonal antibody. Radioallergosorbent (RAST) testing showed no clear changes from positivity to negativity.

CONCLUSION: We conclude that IVIG was of no clear clinical benefit in these nine patients and did not significantly decrease IgE levels, IgE synthesis, or other measures of immunologic function.

Changes of serum levels of interleukin-2, intercellular adhesion molecule-1, endothelial leukocyte adhesion molecule-1 and Th1 and Th2 cell in severe atopic dermatitis after intravenous immunoglobulin therapy.

Huang JL, et al.

Ann Allergy Asthma Immunol. 2000 Mar;84(3):345-52.

Source: Department of Pediatrics, Chang Gung Children’s Hospital and Chang Gung University, Taoyuan, Taiwan.

OBJECTIVE: To evaluate the effect of intravenous immunoglobulin (IVIG) in the treatment of severe intractable atopic dermatitis (AD) in children and to investigate the inflammatory markers used to measure their disease activity.

MATERIALS AND METHODS: Serum levels of interleukin-2 receptor (sIL-2R), intercellular adhesion molecule-1 (ICAM-1), endothelial leukocyte adhesion molecule (ELAM-1), and eosinophil cationic protein (ECP) were measured in five children with AD (group A) who had a mean age of 9.4 months (range 7 to 12 months) before and after IVIG therapy. Seven age-matched patients with similar severity of AD who only received topical corticosteroid therapy served as the control group (group B). Ten normal control serum samples were collected from well-baby clinic (group C). T helper 1 (Th1) was defined by IFN-gamma/CD4+ and Th2 by IL4/CD4+, using 3-colored flow cytometry. Clinical severity of AD was evaluated with the SCORAD index. Intravenous immunoglobulin (2 g/kg/dose) was administered monthly for a total of 3 doses.

RESULTS: The serum levels of ICAM-1, ELAM-1, and IL-2R in patients with AD were significantly higher than normal control infants. After IVIG therapy, the SCORAD index and the inflammatory markers (ICAM-1, ELAM-1, and ECP) in group A were significantly decreased (P = .01 for SCORAD index; .034, .043, and .03 for ICAM-1, ELAM-1 and ECP, respectively). The serum levels of ICAM-1, ELAM-1, ECP and IL-2R in group B did not show a significant reduction after 3 months of topical corticosteroid therapy. In comparison to normal healthy children, patients with AD had decreased Th2 cells (P = .009) and higher ratio of Th1/Th2 (P = .009) in peripheral blood mononuclear cells (PBMC). There was no significant difference of Th1, Th2 cells, and ratio of Th1/Th2 in PBMC before and after IVIG therapy in patients with AD.

CONCLUSION: Intravenous immunoglobulin can be safely and effectively given for the treatment of severe intractable AD. The determination of ICAM-1, ELAM-1, and ECP levels may be useful in monitoring disease activity of AD in childhood. The IVIG may play a role in treatment.

A randomized controlled evaluator-blinded trial of intravenous immunoglobulin in adults with severe atopic dermatitis.

Paul C, et al.

Br J Dermatol. 2002 Sep;147(3):518-22.

Source: Department of Dermatology, Saint Louis University Hospital, 1 avenue Claude Vellefaux, 75475 Paris, France.

Comment in
Br J Dermatol. 2003 Jun;148(6):1284-5; author reply 1285-6.
BACKGROUND: There is a need for alternative therapy in severe adult atopic dermatitis (AD). Intravenous immunoglobulin (IVIG) treatment has been shown to be beneficial in a few open observations, but evidence of effectiveness is still lacking.

OBJECTIVE: To investigate whether treatment with IVIG is effective in adults with severe AD.

METHODS: In a randomized evaluator-blinded trial, 10 patients with severe AD were randomized to immediate or delayed (by 1 month) treatment with IVIG 2 g kg-1. Patients received an 8-h infusion of 1 g kg-1 daily for two consecutive days. They were assessed clinically at days 15, 30, 60 and 90. The primary efficacy criterion was measurement of the severity scoring of AD (SCORAD) index at day 30.

RESULTS: The SCORAD values were not significantly different between the two groups at day 30. Similarly, global evaluation of disease severity by patients did not show any clinically significant change at day 30. In the cohort of 10 patients, the mean percentage decrease in SCORAD as compared with baseline was, respectively, 15%[95% confidence interval (CI) 6-24%] and 22% (95% CI 5-39%) at 30 and 60 days after IVIG infusion.

CONCLUSIONS: IVIG treatment was not associated with clinically significant improvement of AD signs and symptoms in this randomized study. Although this study may have been too small to detect a beneficial effect in a small subset of patients, the results do not support the common use of IVIG in refractory AD.

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One response to “Allergy Abstract Update: Intravenous immunoglobulin to treat severe atopic dermatitis in children

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