Intramuscular Injection of Autologous Serum in Adolescent and Adult Patients with Atopic Dermatitis: A Preliminary Randomized Clinical Trial

Purpose@#The favorable clinical efficacies of intramuscular injection of autologous blood in patients with atopic dermatitis (AD) and intramuscular injection of autologous serum in patients with chronic urticaria have been demonstrated by randomized clinical trials. In this study, we assessed the clinical effectiveness and safety of the intramuscular injection of autologous serum in patients with AD. @*Materials and Methods@#In this randomized, placebo-controlled, and double-blind trial, 23 adolescent and adult patients with moderate-to-severe AD were enrolled. The patients were randomized to receive eight intramuscular injections of 5 mL of autologous serum (n=11) or saline (n=12) over 4 weeks, and were followed up until week 8. Changes in the clinical severity scores of AD assessed by SCORing Atopic Dermatitis (SCORAD), patient-reported Dermatology Life Quality Index (DLQI) score, and incidence of adverse events were assessed from baseline to week 8. @*Results@#One patient in the treatment group and two patients in the placebo group were lost to follow-up before week 8. The intramuscular administration of autologous serum, compared with saline, decreased the SCORAD clinical severity score (-14.8% vs. 10.7%, p=0.006) and improved the DLQI score (-32.6% vs. 19.5%, p=0.01) from baseline to week 8. Serious adverse events were not observed. @*Conclusion@#Intramuscular injection of autologous serum may be effective in treating AD. Further studies are needed to evaluate the clinical usefulness of this intervention for AD (KCT0001969).

Clinical efficacy and compliance of dupilumab therapy in adolescent and adult patients with atopic dermatitis in real clinical practice: An analysis of data from a single allergy clinic in Korea

Purpose@#Dupilumab (a monoclonal antibody to interleukin-4 receptor alpha) is the first biological agent approved for the treatment of moderate-to-severe atopic dermatitis (AD). We evaluated the clinical efficacy and compliance of dupilumab therapy for AD in real clinical practice. @*Methods@#Medical records of 132 adolescent and adult patients with AD who received at least one dose of dupilumab were retrospectively analyzed. Clinical efficacy of dupilumab was assessed by either changes in eczema area and severity index (EASI) or changes in the requirement of medications from baseline to weeks 16 and 42. Clinical response was determined by the proportion of patients with decreased EASI scores of at least 75% from baseline at week 16 (EASI–75). Clinical remission was defined as a complete withdrawal of all the medications for AD except dupilumab. @*Results@#Dupilumab was administered for 16 weeks (77.3%) and 42 weeks (63.6%) in 132 patients with AD. In patients who received reimbursement from National Healthcare Insurance of Korea (NHIK) for dupilumab therapy, the compliance of dupilumab therapy was 90.2% and 87.8%, and EASI–75 response rate was 92.5% and 100% at weeks 16 and 42, respectively. In patients who received the dupilumab therapy without NHIK reimbursement (self-payment), the compliance of dupilumab therapy was 71.4% and 52.7%, the clinical remission rate was 44.0% and 64.6%, and the median interval of dupilumab therapy was 4 weeks (range, 2–13 weeks) and 5 weeks (2–15 weeks) at weeks 16 and 42, respectively. @*Conclusion@#Dupilumab therapy may be clinically useful in the aspects of efficacy and compliance in patients with AD.

Causes of food allergy according to age and severity: A recent 10-year retrospective study from a single tertiary hospital

Purpose@#Recent studies of food allergy (FA) at all ages are scanty in Korea. We performed this study to better understand severity-related and age-stratified causes of FA from infants to older adults in a single tertiary hospital in Korea. @*Methods@#A retrospective medical record review was performed on patients of all ages diagnosed with immediate-type FA between March 2008 and February 2018 in Ajou University Hospital. @*Results@#A total of 4,680 cases of FA among 2,733 patients were reported. The distribution of onset ages of the first FA symptom was as follows: 45.3% below 2 years, 16.2% at 2–6 years, 5.5% at 7–12 years, 4.0% at 13–18 years, 16.9% at 19–40 years, 10.4% at 41–65 years, and 1.8% above 65 years of age. The major 10 causative foods were hen’s eggs (17.2%), cow’s milk (16.7%), wheat (8.6%), crustaceans (8.5%), fish (4.6%), walnuts (4.4%), pork (3.2%), peanuts (3.2%), shellfish (3.0%), and peach (2.2%). The culprits ranked from the 11th to the 20th were as follows: soybean, apple, chicken, buckwheat, beef, kiwi, almonds, perilla seeds, tomato, and squid. The top 3 causative foods in children were hen’s eggs, cow’s milk, and wheat, while those in adults were crustaceans, wheat, and fish. Food-induced anaphylaxis was reported in 29.2% of all cases, with cow’s milk, hen’s eggs, wheat, crustaceans, fish, walnuts, pork, shellfish, buckwheat, and peanuts being the major 10 causes. @*Conclusion@#This study could provide a better understanding of the detailed ranks of the causes of FA according to severity and age in Korea.

Safety of Ultra-rush Schedule of Subcutaneous Allergen Immunotherapy With House Dust Mite Extract Conducted in an Outpatient Clinic in Patients With Atopic Dermatitis and Allergic Rhinitis

PURPOSE: Ultra-rush schedule of subcutaneous allergen immunotherapy (UR-SCIT) administering maximum maintenance dose of allergen extract within one day can save time and effort for allergen immunotherapy in patients with allergic disease. However, UR-SCIT is associated with an increased risk of systemic reaction (SR) and typically has been conducted in a hospital admission setting. To overcome disadvantages of UR-SCIT, we evaluated the safety of UR-SCIT conducted in an outpatient clinic in patients with atopic dermatitis (AD) and allergic rhinitis (AR). METHODS: UR-SCIT was performed in 538 patients with AD and/or AR sensitized to house dust mite (HDM). A maximum maintenance dose of tyrosine-adsorbed HDM extract (1 mL of maintenance concentration) was divided into 4 increasing doses (0.1, 0.2, 0.3, and 0.4 mL) and administered to the patients by subcutaneous injection at 2-hour intervals for 8 hours in an outpatient clinic. SRs associated with UR-SCIT were classified according to the World Allergy Organization grading system. RESULTS: SR was observed in 12 of 538 patients (2.2%) with AD and/or AR during UR-SCIT. The severity grades of the observed SRs were mild-to-moderate (grade 1 in 7 patients, grade 2 in 4 patients, and grade 3 in 1 patient). The scheduled 4 increasing doses of HDM extract could be administered in 535 of 538 patients (99.4%) except 3 patients who experienced SR before administration of the last scheduled dose. SR was observed within 2 hours in 11 patients after administration of the scheduled doses of HDM extract except one patient who experienced a grade 2 SR at 5.5 hours after administration of the last scheduled dose. CONCLUSIONS: UR-SCIT with tyrosine-adsorbed HDM extract conducted in an outpatient clinic was tolerable in patients with AD and AR. UR-SCIT can be a useful method to start a SCIT in patients with AD and AR.

Factors Associated with Adherence to Allergen Specific Subcutaneous Immunotherapy

PURPOSE: Allergen-specific immunotherapy (AIT) is known to be the only therapeutic modality to alter the natural course of allergic diseases. However, at least 3 years of treatment is recommended for achieving long-term disease modifying effect. This study aimed to investigate factors associated with immunotherapy non-adherence in real practice. MATERIALS AND METHODS: We retrospectively reviewed medical records of patients who were diagnosed with allergic rhinitis, asthma, or atopic dermatitis, and received AIT to common allergens such as house dust mite and/or pollens from January 2007 to August 2014. In this study, non-adherence was defined as not completing 3 years of AIT. RESULTS: Among 1162 patients enrolled, 228 (19.6%) failed to complete 3 years of AIT. In multivariate analysis, age less than 20 years [odds ratio (OR) 3.11, 95% confidence interval (CI) 1.70–5.69] and 20 to 40 years (OR 2.01, 95% CI 1.17–3.43), cluster build-up (OR 1.78, 95% CI 1.05–3.02) and ultra-rush build-up schedules (OR 5.46, 95% CI 2.40–12.43), and absence of visit to other departments in the same hospital (OR 1.87, 95% CI 1.05–3.32) were independently associated with immunotherapy non-adherence. Disease duration of 5–10 years was negatively associated with non-adherence compared to shorter disease duration of less than 5 years (OR 0.61, 95% CI 0.40–0.94). Although male sex and commercial product of AIT, Tyrosine S®, compared to Novo-Helisen® were non-adherent factors in univariate analysis, no statistical significances were identified in multivariate analysis. CONCLUSION: Various factors are associated with immunotherapy adherence affecting the utility of immunotherapy. Clinicians should be aware of factors associated with adherence to maximize the utility of allergen-specific subcutaneous immunotherapy.

A Retrospective Study of Clinical Response Predictors in Subcutaneous Allergen Immunotherapy With House Dust Mites for Allergic Rhinitis

PURPOSE: House dust mites (HDM) are major allergens that cause allergic rhinitis (AR). Allergen-specific subcutaneous immunotherapy (SCIT) has been shown to be clinically beneficial in many clinical trials. Such trials, however, are not reflective of all patient populations. The aim of this study was to describe the efficacy and safety of SCIT in routine clinical practice in Korean adults with AR sensitized to HDM. METHODS: We reviewed medical records of 304 patients with AR treated at an allergy clinic of a tertiary hospital using SCIT with aluminum hydroxide-adsorbed allergen extract targeting HDM alone or with pollens for at least 1 year from 2000 to 2012. Patients with asthma were excluded. Rates of remission, defined as no further requirement of maintenance medication, over time were determined by means of life tables and extension of survival analysis. Specific immunoglobulin E (IgE) levels to HDM were categorized into 6 classes. RESULTS: The mean time until achieving remission was 4.9±0.1 years, and the cumulative incidence of remission from AR was 76.6%. Severe AR (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.23-0.69; P=0.001), specific IgE levels to HDM ≥17.5 kU/L (OR, 1.85; 95% CI, 1.01-3.37; P=0.045), and duration of immunotherapy ≥3 years (OR, 7.37; 95% CI, 3.50-15.51; P<0.001) were identified as significant predictors of clinical remission during SCIT for patients with AR sensitized to HDM. Overall, 73 patients (24.0%) experienced adverse reactions to SCIT, and only 1 case of anaphylaxis (0.3%) developed. CONCLUSIONS: SCIT with HDM was found to be effective and safe for patients with AR. Specific IgE levels to HDM and a duration of SCIT ≥3 years may be predictors of clinical responses to SCIT in AR patients.

Therapeutic Effect of Omalizumab in Severe Asthma: A Real-World Study in Korea

PURPOSE: Omalizumab, an anti-immunoglobulin E (IgE) monoclonal antibody, has proved to be effective for the treatment of severe asthma. However, there is no direct evidence of effectiveness of omalizumab in Korean patients with severe asthma. We sought to evaluate the real-world effectiveness of omalizumab in Korean adult patients suffering from severe asthma and to identify predictors of favorable response. METHODS: A retrospective analysis of electrical medical records was performed on severe allergic asthmatic patients with omalizumab treatment group (OT group) for more than 6 months between March 2008 and February 2016. Propensity score matching was applied to define the standardized treatment control group (STC group) treated without omalizumab. Asthma-related outcomes were compared between the 2 groups, and analyzed before and after omalizumab use in the OT group. Responders to treatment were defined as patients showing >50% reduction in asthma exacerbations and/or systemic steroid requirement during the outcome period. RESULTS: One hundred twenty-four patients with severe asthma (62 in the OT group; 62 in the STC group) were enrolled in the study. Proportion of patients having the reduction of asthma exacerbation (53.2% vs 35.5%, P=0.015) and the rate of responders (67.7% vs 41.9%, P=0.007) were significantly higher in the OT group than in the STC group. Significant reductions were noted in asthma exacerbation (P=0.006), hospitalization (P=0.009), hospitalization days (P=0.006), systemic corticosteroid requirements (P=0.027), and sputum eosinophil count (P=0.031) in OT group compared with STC group. There were no significant differences in changes of forced expiratory volume in the 1 second (FEV1) levels between the 2 groups. No predictors of responders were found for omalizumab treatment. CONCLUSIONS: Omalizumab can reduce exacerbations/hospitalization/systemic steroid burst in Korean adult patients with severe asthma.

Linguistic adaptation of the rhinitis control assessment test in Korean

PURPOSE: Allergic rhinitis is one of the most common chronic diseases that affect in sleep, fatigue, headache, impaired cognition, and performances at work or school. Monitoring rhinitis control is important, because rhinitis is a life-long disease and affects patients' health-related quality of life. The rhinitis control assessment test (RCAT) completed its development and initial validation, following confirmation of its reliability, validity, and responsiveness in the United States. To apply the RCAT in Korean clinical practice, we conducted linguistic adaptation of the RCAT in Korean language. METHODS: The process of linguistic adaptation was composed of 10 steps: preparation, forward translation, reconciliation, back translation, back translation review, harmonization, cognitive debriefing, review of cognitive debriefing results and finalization, proofreading, and the final report. RESULTS: We completed a Korean version of the RCAT according to 10 steps. The Korean version of the RCAT was composed of 6 items, including nasal and ocular symptoms, sleep disturbances, limitation of casual activity, and symptom control. The score ranged from 5 to 30. Higher score indicated the well-controlled status of rhinitis. CONCLUSION: We conducted linguistic adaptation of the RCAT in Korean, which would be helpful in clinical practice to assess the status of rhinitis control and to adjust rhinitis medications.

Subcutaneous Immunotherapy for Allergic Asthma in a Single Center of Korea: Efficacy, Safety, and Clinical Response Predictors

Allergen-specific immunotherapy is the only causal treatment for allergic diseases. However, the efficacy of immunotherapy may vary around the world due to differences in climate, the nature of aero-allergens and their distribution. The aim of this study was to describe the effects of subcutaneous immunotherapy (SCIT) in Korean adults with allergic asthma (AA). As a retrospective cohort study, we reviewed medical records for 627 patients with AA in Korea who were sensitized to house dust mite (HDM) and/or pollens and who underwent SCIT with aluminum hydroxide adsorbed allergen extract from 2000 to 2012. Rates of remission, defined as no further requirement of maintenance medication, over time were determined by means of life tables and extension of survival analysis. Herein, 627 asthmatic patients achieved remission within a mean of 4.7 ± 0.2 years. The cumulative incidence rates of remission from AA were 86.9% upon treatment with SCIT. Baseline forced expiratory volume in the first second (FEV1) ≥ 80% (hazard ratio [HR], 3.10; 95% confidence interval [CI], 1.79–5.39; P < 0.001), and maintenance of immunotherapy for more than 3 years (HR, 1.82; 95% CI, 1.21–2.72; P = 0.004) were significant predictors of asthma remission during SCIT. In 284 patients on SCIT with HDM alone, initial specific immunoglobulin E (IgE) levels to Dermatophagoides pteronyssinus and Dermatophagoides farinae did not show significant difference between remission and non-remission group after adjusting demographic variables. In conclusion, SCIT was effective and safe treatment modality for patients with AA. Initial FEV1 ≥ 80% and immunotherapy more than 3 years were found to be associated with favorable clinical responses to SCIT.

Autologous Immunoglobulin Therapy in Patients With Severe Recalcitrant Atopic Dermatitis: Long-Term Changes of Clinical Severity and Laboratory Parameters

This report evaluated long-term changes in clinical severity and laboratory parameters in 3 adult patients with severe recalcitrant atopic dermatitis (AD) who were treated with intramuscular injections of 50 mg of autologous immunoglobulin G (IgG) twice a week for 4 weeks (autologous immunoglobulin therapy, AIGT) and followed up for more than 2 years after the treatment. We observed the following 4 major findings in these 3 patients during the long-term follow-up after AIGT. (1) Two of the 3 patients showed a long-term clinical improvement for more than 36 weeks after AIGT with a maximum decrease in clinical severity score greater than 80% from baseline. (2) These 2 patients also showed long-term decreases in serum total IgE concentrations and peripheral blood eosinophil count for more than 36 weeks after AIGT with a maximum decrease in the two laboratory parameters of allergic inflammatory greater than 70% from baseline. (3) No significant side effect was observed during the 2 years of follow-up period after the AIGT in all 3 patients. (4) Serum levels of IgG anti-idiotype antibodies to the F(ab')2 fragment of autologous IgG administered for the treatment were not significantly changed after AIGT in all 3 patients. These findings suggest that AIGT has long-term favorable effects on both clinical severity and laboratory parameters in selected patients with severe recalcitrant AD. Further studies are required to evaluate the clinical usefulness and therapeutic mechanism of AIGT for AD.

Multicenter questionnaires on the current management of atopic dermatitis in Korea

PURPOSE: The effective management of atopic dermatitis (AD) adjusted to individual clinical courses and demands can be challenging to both patients and physicians. Understanding of actual situations, experienced and perceived by patients with AD and their caregivers, is essential to improve clinical outcomes and satisfaction in real practice. METHODS: This multicenter survey was conducted in patients with AD or their caregivers from 9 centers with questionnaires on diagnosis and management of AD. RESULTS: A total of 324 patients and caregivers participated in the study. Most of the AD cases were initially diagnosed by physicians (80.6%), followed by self-diagnosis. Patients and caregivers thought that allergic substances, such as house dust mites, food, and pollutants, are responsible for AD development; moisturization, environmental control, and improvement of the body constitution are important for AD management. Allergy tests were performed in 194 patients (59.9%), but allergen avoidance strategy was instructed in only 81 subjects (41.8%). Major topical medications were steroids (81.8%) and topical immunomodulators (34.3%), while systemic medications were steroids (42.6%), antihistamines (36.4%), and cyclosporins (2.8%). One hundred eighty-one subjects (55.9%) had received complementary alternative medicine, including Oriental medicine. Many subjects desired to receive individualized management, use of specialized institutions for AD as well as evidence-based, effective, sustainable treatment. CONCLUSION: Our findings suggest that there may still be an unmet need for patients with AD in real practice. Personalized, evidencebased, and multidisciplinary approaches, including patient education, should be implemented for good outcomes.

Associations of Atopic Dermatitis With Obesity and Unmarried Status in Young Adults: Evidence for Atopic Dermatitis as a Life-Style Disorder With High Social Impact

No abstract available.

Clinical Efficacy of Subcutaneous Allergen Immunotherapy in Patients with Atopic Dermatitis

PURPOSE: The clinical usefulness of subcutaneous allergen immunotherapy (SCIT) in the treatment of atopic dermatitis (AD) is still controversial. We analyzed the clinical efficacy of SCIT in patients with AD and the clinical characteristics of patients showing a favorable clinical response to the treatment. MATERIALS AND METHODS: Two hundred and fifty one patients with AD sensitized to house dust mite (HDM) were treated by SCIT using HDM extract. The clinical severity of AD was measured using the standardized clinical severity scoring system for AD (SCORAD) at baseline and 12 months. A favorable clinical response to SCIT was defined as a decrease in SCORAD value at 12 months greater than 50% compared to baseline value. Severe AD was defined as a baseline SCORAD value above 50. RESULTS: A favorable clinical response to SCIT was observed in 73.6% of patients. The proportion of patients showing a favorable clinical response to SCIT was significantly higher in patients with severe AD (90.6%) than patients with mild to moderated AD (63.7%) (p<0.001). Patients with severe AD showing a favorable clinical response had a significantly shorter duration of AD (12.3±8.5 years; mean±SD) than patients with severe AD showing no significant clinical response (20.6±10.9 years) (p<0.05) at baseline. CONCLUSION: SCIT could be a clinically useful therapeutic option for patients with severe AD sensitized to HDM. Early initiation of SCIT might provide a favorable clinical outcome in patients with severe AD sensitized to HDM.

Clinical Efficacy of Subcutaneous Allergen Immunotherapy in Patients with Atopic Dermatitis

PURPOSE: The clinical usefulness of subcutaneous allergen immunotherapy (SCIT) in the treatment of atopic dermatitis (AD) is still controversial. We analyzed the clinical efficacy of SCIT in patients with AD and the clinical characteristics of patients showing a favorable clinical response to the treatment. MATERIALS AND METHODS: Two hundred and fifty one patients with AD sensitized to house dust mite (HDM) were treated by SCIT using HDM extract. The clinical severity of AD was measured using the standardized clinical severity scoring system for AD (SCORAD) at baseline and 12 months. A favorable clinical response to SCIT was defined as a decrease in SCORAD value at 12 months greater than 50% compared to baseline value. Severe AD was defined as a baseline SCORAD value above 50. RESULTS: A favorable clinical response to SCIT was observed in 73.6% of patients. The proportion of patients showing a favorable clinical response to SCIT was significantly higher in patients with severe AD (90.6%) than patients with mild to moderated AD (63.7%) (p<0.001). Patients with severe AD showing a favorable clinical response had a significantly shorter duration of AD (12.3±8.5 years; mean±SD) than patients with severe AD showing no significant clinical response (20.6±10.9 years) (p<0.05) at baseline. CONCLUSION: SCIT could be a clinically useful therapeutic option for patients with severe AD sensitized to HDM. Early initiation of SCIT might provide a favorable clinical outcome in patients with severe AD sensitized to HDM.

Favorable outcome of omalizumab treatment in a patient with idiopathic anaphylaxis

Anaphylaxis is a severe and life-threatening systemic reaction. Despite the extensive evaluation to determine the cause, 30%-60% of cases of anaphylaxis in adults remain idiopathic. Recently, omalizumab treatment has been postulated to treat refractory idiopathic anaphylaxis. We report a case of idiopathic anaphylaxis treated with omalizumab and investigated its pharmacological mechanism. A 66-year-old female presented to our clinic with recurrent anaphylaxis. She suffered from anaphylaxis 2-3 times a month for 6 months. She had past medical history of nonallergic bronchial asthma. History was carefully undertaken and anaphylaxis was not related to any specific foods, drugs, exercise, and insect bites. Serum specific IgE antibodies to common food allergens showed negative results. Oral provocation tests to food additives revealed to be negative. To screen systemic mastocytosis and mast cell activating syndrome, baseline tryptase level was checked, and it was within normal range. From comprehensive evaluation, she was diagnosed as having idiopathic anaphylaxis. She could not tolerate oral medications due to gastrointestinal discomfort, therefore, omalizumab treatment (150 mg, monthly) was started. After 6 months of treatment, anaphylaxis did not occur with complete remission status. To evaluate the pharmacological mechanism of omalizumab treatment, basophil histamine releasability test was performed. Histamine releasability induced by anti-IgE did not change after 6 months of treatment, while that induced by calcium inophore decreased. Omalizumab treatment can induce remission or favorable effects on idiopathic anaphylaxis, which may be derived from increased threshold of mast cell degranulation. Long-term studies in a larger cohort will be needed to confirm its efficacy.

Immunologic Evaluation of Patients with Cefotetan-Induced Anaphylaxis

Cefotetan is a commonly prescribed second-generation cephalosporin that acts against a wide range of bacteria. However, cefotetan-induced hypersensitivity has rarely been reported. We report 2 cases of cefotetan-induced anaphylaxis with immunologic evaluation. The first case was a 70-year-old asthmatic woman who had dyspnea and hypotension during administration of cefotetan, in which high serum-specific IgE to cefotetan-human serum albumin (HSA) conjugate was detected by enzyme-linked immunosorbent assay. The second case was a 63-year-old asthmatic woman who complained of chest tightness and dyspnea during cefotetan infusion, in which high serum-specific IgG1 and IgG4 with no serum specific IgE to cefotetan-HSA conjugate was detected. The basophil activation test using basophils from the patient showed a significant up-regulation of CD63 with the addition of anti-IgG4 antibody compared with that in non-atopic healthy controls. In conclusion, cefotetan can induce anaphylaxis, which may involve both IgE- and IgG4-mediated responses in the pathogenic mechanism.

Personalized Immunomodulatory Therapy for Atopic Dermatitis: An Allergist's View

The current standard medical therapy for atopic dermatitis (AD) mainly focuses on symptomatic relief by controlling skin inflammation with topical corticosteroids and/or topical calcineurin inhibitors. However, the clinical efficacy of pharmacological therapy is often disappointing to both patients and physicians. The terminology of AD contains a historical meaning of eczematous dermatitis caused by hypersensitivity reaction to environmental inhalant or food allergen. Complex interrelationships among genetic abnormalities, environmental triggers, skin barrier defects, and immune dysfunction resulting in a vicious domino-circle seem to be involved in the development and maintenance of AD. In the viewpoint of AD as an allergic disease, complete avoidance of clinically relevant allergen or induction of specific immune tolerance through administrations of allergen (allergen immunotherapy) can provide clinical remission by breaking the vicious domino-circle maintaining a chronic disease state. In recent clinical studies, monoclonal antibodies including the anti-interleukin-4 receptor antibody and anti-B cell antibody induced significant clinical improvements in patients with AD. The detailed characteristics of immune dysfunction are heterogeneous among patients with AD. Therefore, a personalized combination of immunomodulatory therapies to reduce hypersensitivity (allergen immunotherapy) and correct immune dysfunction (monoclonal antibody therapy) could be a reasonable therapeutic approach for patients with AD. Future immunomodulatory therapies for AD should be developed to achieve long-term treatment-free clinical remission by induction of immune tolerance.

Present and future of allergen immunotherapy for allergic diseases

Current pharmacological therapies for allergic diseases can improve clinical symptoms but cannot change their long-term clinical course. There is an unmet need for a curative treatment for allergic diseases. Allergen immunotherapy (AIT) is the practice of administering increasing doses of clinically relevant allergens to an allergic subject to reduce the clinical symptoms associated with subsequent exposure to the allergen. AIT is clinically effective for allergic asthma, allergic rhinitis, venom-induced anaphylaxis, and atopic dermatitis. AIT can change the natural course of allergic diseases and induce allergen-specific immune tolerance. In current clinical practice, AIT is delivered either subcutaneously or sublingually. Both subcutaneous and sublingual AIT have long-term therapeutic efficacy after of 3-5 years of treatment. The development of safer and more effective AIT strategies is needed. Conclusion: AIT is a disease-modifying therapy for allergic diseases. Future development of AIT should be directed toward achieving long-term clinical remission in patients with allergic diseases by the safe and effective induction of immune tolerance.

Autologous Immunoglobulin Therapy in Patients With Severe Recalcitrant Atopic Dermatitis: A Preliminary Report

The management of severe recalcitrant atopic dermatitis (AD) is a challenging issue for clinicians and patients. We hypothesized that repeated intramuscular injections of autologous immunoglobulin (autologous immunoglobulin therapy: AIGT) might induce clinical improvements in patients with AD by stimulation of the active immune response to antigen-binding-site of pathogenic antibodies. We tried AIGT in 3 adult patients with severe recalcitrant AD whose clinical conditions could not be effectively controlled by medical treatments (including oral cyclosporine) for more than 2 years. Autologous immunoglobulin was purified from the autologous plasma by affinity chromatography using Protein A. The patients were treated by an intramuscular injection of 50 mg of autologous immunoglobulin twice a week for 4 weeks. A clinical severity score of AD (SCORAD value) showed a decrease greater than 30% at 8 weeks after the initiation of AIGT compared with the baseline before the initiation of AIGT in all 3 patients with severe recalcitrant AD. No significant side effects from treatment were observed. Further studies with larger numbers of patients are required to evaluate the clinical usefulness of AIGT for AD.

A Case of Codeine Induced Anaphylaxis via Oral Route

Codeine is widely prescribed in clinical settings for the relief of pain and non-productive coughs. Common adverse drug reactions to codeine include constipation, euphoria, nausea, and drowsiness. However, there have been few reports of serious adverse reactions after codeine ingestion in adults. Here, we present a case of severe anaphylaxis after oral ingestion of a therapeutic dose of codeine. A 30-year-old Korean woman complained of the sudden onset of dyspnea, urticaria, chest tightness, and dizziness 10 minutes after taking a 10-mg dose of codeine to treat a chronic cough following a viral infection. She had previously experienced episodes of asthma exacerbation following upper respiratory infections, and had non-atopic rhinitis and a food allergy to seafood. A skin prick test showed a positive response to 1-10 mg/mL of codeine extract, with a mean wheal size of 3.5 mm, while negative results were obtained in 3 healthy adult controls. A basophil histamine release test showed a notable dose-dependent increase in histamine following serial incubations with codeine phosphate, while there were minimal changes in the healthy controls. Following a CYP2D6 genotype analysis, the patient was found to have the CYP2D6*1/*10 allele, indicating she was an intermediate metabolizer. An open label oral challenge test was positive. To the best of our knowledge, this is the first report of a patient presenting with severe anaphylaxis after the ingestion of a therapeutic dose of codeine, which may be mediated by the direct release of histamine by basophils following exposure to codeine.