Features Associated With Quality of Life Impairment in Hidradenitis Suppurativa Patients.

Background: Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease with an adverse impact on patients' quality of life (QoL). Objectives: To quantify QoL impairment in patients in Germany suffering from HS and to identify the parameters associated with QoL impairment. Methods: A non-interventional, cross-sectional, mono-centric study with 500 HS patients. QoL data (measured using the Dermatology Life Quality Index; DLQI) and demographic, anamnestic, clinical, and blood parameters were collected. All patients were examined by dermatologists that documented the skin alterations. QoL data from 462 HS patients were available and evaluated. Results: The mean (± standard deviation) DLQI score of HS patients was 13.18 ± 7.99. Approximately 40% and 20% of HS patients declared very large and extremely large QoL impairment, respectively. The degree of QoL disturbance correlated with the severity of skin alterations, blood leucocyte count and, in particular, with anogenital localization and the presence of nodules and fistulas. Furthermore, QoL impairment was associated with specific comorbidities, such as adiposity and back pain, but not with HS family history. QoL impairment was not influenced by whether or not the patients had undergone resection surgery or antibiotic treatment but was more severe in HS patients that had undergone abscess lancing compared to patients without such treatment in the past. Limitations: It was a mono-centric study and most data were obtained from self-administered patient questionnaires. The association of QoL with type of treatment was analyzed for abscess lancing, resection surgery, and antibiotic treatment. Further therapeutic modalities recommended in the guidelines were not investigated. Conclusion: A profound impairment in QoL was present in patients with HS, and this was higher than that observed in other studied dermatoses. The degree of impairment correlated with the extent of cutaneous and some extra-cutaneous alterations. Surgical and conventional medicamentous therapies of HS were not associated with long-lasting reduction of QoL impairment. Our data support the implementation of patient-reported outcome measures for the assessment of therapy responses.

Predominant Api m 10 sensitization as risk factor for treatment failure in honey bee venom immunotherapy.

BACKGROUND: Component resolution recently identified distinct sensitization profiles in honey bee venom (HBV) allergy, some of which were dominated by specific IgE to Api m 3 and/or Api m 10, which have been reported to be underrepresented in therapeutic HBV preparations. OBJECTIVE: We performed a retrospective analysis of component-resolved sensitization profiles in HBV-allergic patients and association with treatment outcome. METHODS: HBV-allergic patients who had undergone controlled honey bee sting challenge after at least 6 months of HBV immunotherapy (n = 115) were included and classified as responder (n = 79) or treatment failure (n = 36) on the basis of absence or presence of systemic allergic reactions upon sting challenge. IgE reactivity to a panel of HBV allergens was analyzed in sera obtained before immunotherapy and before sting challenge. RESULTS: No differences were observed between responders and nonresponders regarding levels of IgE sensitization to Api m 1, Api m 2, Api m 3, and Api m 5. In contrast, Api m 10 specific IgE was moderately but significantly increased in nonresponders. Predominant Api m 10 sensitization (>50% of specific IgE to HBV) was the best discriminator (specificity, 95%; sensitivity, 25%) with an odds ratio of 8.444 (2.127-33.53; P = .0013) for treatment failure. Some but not all therapeutic HBV preparations displayed a lack of Api m 10, whereas Api m 1 and Api m 3 immunoreactivity was comparable to that of crude HBV. In line with this, significant Api m 10 sIgG4 induction was observed only in those patients who were treated with HBV in which Api m 10 was detectable. CONCLUSIONS: Component-resolved sensitization profiles in HBV allergy suggest predominant IgE sensitization to Api m 10 as a risk factor for treatment failure in HBV immunotherapy.

Comparison of molecular and extract-based allergy diagnostics with multiplex and singleplex analysis.

BACKGROUND: ImmunoCAP ISAC 112, is a commercially available molecular allergy IgE multiplex test. Data on the comparison of this rather novel test with extract-based as well as molecular ImmunoCAP singleplex IgE tests is missing. OBJECTIVE: To perform a comparison between the ISAC multiplex IgE assay and the ImmunoCAP singleplex test results. METHODS: Serum samples of 101 adults with grass pollen allergy were analysed for sIgE to 112 allergenic molecules represented on the ISAC test as well as to common atopy-related extract-based allergy tests with the ImmunoCAP System (house dust mite [d1], cat [e1], dog [e5], cow's milk [f2], hen's egg [f1], hazelnut [f17], celery [f85], Alternaria alternate [m6], as well as pollen from birch [t3], hazel [t4], mugwort [w6], and ragweed [w1]). Subsequently statistical analysis was performed with the Spearman rank correlation test and the Clopper-Pearson method in order to compare the ISAC multiplex results with the sIgE singleplex results. RESULTS: The positive percent agreements (PPA) and negative percent agreement (NPA) of corresponding allergens between the ISAC sIgE test and the extract-based singleplex ImmunoCAP results at cutoff 0.1 kUA/l varied between 60-100 % for PPA and 78-97 % for NPA. CONCLUSION: When taking into account corresponding allergens molecular testing with the ISAC multiplex test correlates well with ImmunoCAP singleplex results.

Sensitization pattern to inhalant and food allergens in symptomatic children at first evaluation.

BACKGROUND: Data on specific IgE sensitization prevalence in children with allergy-like symptoms seen in the primary care setting are rare. Early diagnosis of allergic diseases is important to prevent clinical manifestations, exacerbations or expansion of allergic diseases to other organ systems. The present study aims to assess the usefulness of early serological diagnosis in children with common allergic symptoms. METHODS: 532 children (<15 years of age), with at least one of ten allergy-like symptoms, from 21 primary care centers in two geographic areas of Italy and Spain were included in the study. Patients were tested with, either Phadiatop® Infant (0-5 years of age) or Phadiatop® and food mix (fx5e) (>5 years of age) to discriminate atopic from non-atopic subjects. A blood sample of atopic subjects was taken for additional 6-26 specific IgE antibody determinations from a predefined panel using the ImmunoCAP® System. RESULTS: 267 children (50.2 %) were positive in the initial test and were classified as atopic. 14 % were mono-sensitized, 37 % were sensitized to 2-3 allergens and 49 % to more than 3 allergens. The average number of symptoms in the atopic group was 3.3 vs 2.8 in the non-atopic group. The prevalence of sensitization to single allergens was highest for grass and ragweed pollen and house-dust mites (19-28 %). Sensitization to tree allergens was highest for olive tree (16.5 %). Cow's milk and egg white were the most sensitizing foods (~15 %). Food allergen sensitization predominated in younger children (OR = 2.8) whereas the inverse occurred with inhalant allergens (OR = 2.5 to 5.6). A significant positive correlation between patient age and the number of sensitizations was found. CONCLUSIONS: Specific IgE sensitization in children with allergy-like symptoms is common. Multiple sensitization is predominating. Number of clinical symptoms was higher in the atopic group compared to the non-atopic without a correlation with the number of positive allergens. Age seems to play a crucial role in the development of sensitization with a significant positive correlation between patient age and the number of sensitizations.

Spiking with recombinant allergens to improve allergen extracts: benefits and limitations for the use in routine diagnostics: Part 19 of the Series Molecular Allergology.

Essentially, allergen components offer three possibilities to improve in vitro IgE diagnostics: Allergen components can be used individually for IgE determination.Allergen components can be combined as a mix in one test.Individual allergen components can be specifically added to the extract. Option (a) is currently being used most extensively in practice, while (b) represents more of a theoretical possibility. The specific addition ("spiking") of allergen components to an allergy extract (c) has been performed in the past for the ImmunoCAP® tests for latex (09/2001), hazelnut (05/2006) and wasp venom (06/2012). Through this approach under-represented allergen components could be compensated and the analytical sensitivity of the test systems significantly increased. In combined use with molecular Singleplex tests, these modified tests allow for new diagnostic possibilities. Clear communication from the manufacturer regarding in which test and from what time point on, recombinant allergens were added - and where this was not done despite under-represented allergen components - is important for the interpretation of the test results in routine clinical practice.

Acupuncture for allergic disease therapy--the current state of evidence.

This review summarizes current evidence for acupuncture treatment of allergies. Several randomized controlled trials have demonstrated a specific effect of acupuncture for allergic rhinitis; while a few studies have shown positive effects for atopic dermatitis, asthma and itch. Specifically for allergic rhinitis and asthma, acupuncture may be cost-effective in terms of money spent per quality-of-life gained. Acupuncture plays an increasingly important role as an evidence-based therapy for allergy relief and can be recommended as adjunct therapy for allergic rhinitis. Future randomized controlled trials need to further explore acupuncture efficacy for the treatment of itch, atopic dermatitis and asthma. More experimental research is also needed to investigate mechanisms of action underlying acupuncture for allergy relief.

Component resolution reveals additional major allergens in patients with honeybee venom allergy.

BACKGROUND: Detection of IgE to recombinant Hymenoptera venom allergens has been suggested to improve the diagnostic precision in Hymenoptera venom allergy. However, the frequency of sensitization to the only available recombinant honeybee venom (HBV) allergen, rApi m 1, in patients with HBV allergy is limited, suggesting that additional HBV allergens might be of relevance. OBJECTIVE: We performed an analysis of sensitization profiles of patients with HBV allergy to a panel of HBV allergens. METHODS: Diagnosis of HBV allergy (n = 144) was based on history, skin test results, and allergen-specific IgE levels to HBV. IgE reactivity to 6 HBV allergens devoid of cross-reactive carbohydrate determinants (CCD) was analyzed by ImmunoCAP. RESULTS: IgE reactivity to rApi m 1, rApi m 2, rApi m 3, nApi m 4, rApi m 5, and rApi m 10 was detected in 72.2%, 47.9%, 50.0%, 22.9%, 58.3%, and 61.8% of the patients with HBV allergy, respectively. Positive results to at least 1 HBV allergen were detected in 94.4%. IgE reactivity to Api m 3, Api m 10, or both was detected in 68.0% and represented the only HBV allergen-specific IgE in 5% of the patients. Limited inhibition of IgE binding by therapeutic HBV and limited induction of Api m 3- and Api m 10-specific IgG4 in patients obtaining immunotherapy supports recent reports on the underrepresentation of these allergens in therapeutic HBV preparations. CONCLUSION: Analysis of a panel of CCD-free HBV allergens improved diagnostic sensitivity compared with use of rApi m 1 alone, identified additional major allergens, and revealed sensitizations to allergens that have been reported to be absent or underrepresented in therapeutic HBV preparations.

Influence of alpine mountain climate of Bavaria on patients with atopic diseases: studies at the Environmental Research Station Schneefernerhaus (UFS - Zugspitze) - a pilot study.

Mountain and maritime climate therapy takes advantage of specific climatic conditions to treat chronic allergic diseases. It was the aim of the study to investigate effects of a 5 day sojourn on atopic diseases at the highest German mountain. In this pilot study 18 patients with grass pollen-induced rhinoconjunctivitis, atopic ezcema or asthma and 11 non-allergic controls were included. Skin physiology parameters, changes of the respiratory and nasal functions, subjective symptoms and blood parameters were measured during a 5-day observation period in the Environmental Research Station Schneefernerhaus (UFS) at the moderate altitude mountain region (Zugspitze; 2650 m alt.) compared to a low altitude area (Munich; 519 m alt.). Several of the skin physiology parameters changed significantly during the observation period (decrease of skin hydration, increase of skin smoothness, skin roughness, skin scaliness and pH-value). In patients with atopic eczema, the SCORAD (Severity Scoring of Atopic Dermatitis) and the scores of the DIELH (Deutsches Instrument zur Erfassung der Lebensqualität bei Hauterkrankungen) did not change significantly. Histamine induced itch decreased significantly. Parameters of nasal function did not change significantly. Several lung parameters showed a slight, but statistically significant improvement (forced expiratory volume in one second/volume capacity [FEV1/VC], peak expiratory flow [PEF], maximum expiratory flow at 50% of vital capacity [MEF 50], maximal mid-expiratory flow between 25% and 75% of vital capacity [MMFEF 25/75]), whereas the vital capacity (VC) decreased significantly. ECP (eosinophil cationic protein) in the serum and parameters of blood count changed significantly. These results show that the benefit of a moderate altitude mountain climate sojourn over a period of 5 days differs in depending on the atopic disease. Especially asthma parameters and itching of the skin improved. It would be interesting to assess the parameters during longer observation periods in alpine climate.

Effect of acupuncture on allergen-induced basophil activation in patients with atopic eczema:a pilot trial.

OBJECTIVE AND METHODS: The crucial symptom of atopic eczema is itch. Acupuncture has been shown to exhibit a significant effect on experimental itch; however, studies focusing on clinical itch in atopic eczema and corresponding mechanisms are lacking. The study design was a unicenter, single-blinded (observer), prospective, randomized clinical pilot trial with an additional experimental part. In 10 patients with atopic eczema, we investigated the effect of acupuncture treatment (n = 5) compared to no treatment (n = 5) on itch intensity and in vitro basophil CD63 expression upon allergen stimulation (house dust mite and timothy grass pollen) in a pilot trial. RESULTS: Mean itch intensity in a visual analog scale was rated significantly lower in the acupuncture group (-25% ± 26% [day 15-day 0]; -24% ± 31% [day 33-day 0]) than in the control group (15% ± 6% [day 15-day 0]; 29% ± 9% [day 33-day 0]). From day 0 (before treatment) to day 15 (after 5 acupuncture treatments) as well as day 33 (after 10 acupuncture treatments), the acupuncture group showed less CD63 positive basophils than the control group regarding stimulation with house dust mite and grass pollen allergen at various concentrations (5 ng/mL, 1 ng/mL, 0.5 ng/mL, or 0.25 ng/mL). CONCLUSIONS: Our results show a reduction of itch intensity and of in vitro allergen-induced basophil activation in patients with atopic eczema after acupuncture treatment. Reducing basophil activation can be a further tool in investigating the mechanisms of action of acupuncture in immunoglobulin E-mediated allergy. Due to the limited number of patients included in our pilot trial, further studies are needed to strengthen the hypothesis.

Pruritus and atopic dermatitis.

Atopic eczema is one of the most pruritic skin diseases. Mediators of atopic eczema itch in the skin are still mostly unknown, but recent studies showed that the histamine 4 receptor plays an important role in itch pathophysiology; tryptase and interleukin-31 are also involved. Differences in itch perception and itch kinetics between healthy volunteers and eczema patients point towards an ongoing central nervous inhibitory activity in patients. Questionnaire studies reported comparatively higher loads in affective items chosen by patients with atopic eczema. In the concept of patient management, the therapy of clinical pruritus has to consider origin and perception of itch, namely the skin and the central nervous system, by combining topical and systemic treatment.

A review of treatment with mepolizumab, an anti-IL-5 mAb, in hypereosinophilic syndromes and asthma.

The hypereosinophilic syndromes (HESs) are a heterogeneous group of diseases characterized by peripheral blood eosinophilia with end-organ damage and varying in severity from nonspecific symptoms to life-threatening. Treatment objectives are a safe reduction of blood and tissue eosinophil levels and prevention of eosinophil-mediated tissue damage. Current treatment of patients with HESs, who lack the FIP-1-like 1-platelet-derived growth factor receptor alpha (FIP1L1-PDGFRA) fusion gene, is mainly systemic corticosteroid therapy. Eosinophil development from hematopoietic progenitor cells is regulated by IL-5, which influences maturation, differentiation, mobilization, activation, and survival. Consequently, inhibiting IL-5 is a logical therapeutic objective for patients with HESs or selected patients with asthma. Mepolizumab is a fully humanized anti-IL-5 monoclonal IgG(1) antibody that binds to free IL-5 with high affinity and specificity to prevent IL-5 from associating with the IL-5 receptor complex alpha-chain on the surface of eosinophils. In clinical trials with patients with HESs, mepolizumab reduced blood eosinophil counts and the maintenance corticosteroid dose and had no major safety concerns. Mepolizumab reduced airway and blood eosinophils and prevented asthma exacerbations. Thus, mepolizumab may be effective for long-term treatment of patients with selected eosinophilic disorders.

Comparative in situ topoproteome analysis reveals differences in patch test-induced eczema: cytotoxicity-dominated nickel versus pleiotrope pollen reaction.

A subgroup of patients with atopic eczema develops acute eczematous reactions to type I allergy-inducing agents such as pollen that clinically resemble type IV allergies induced by haptens like metal ions. To clarify the underlying immunologic mechanisms, this study was designed to map the inflammatory in situ topoproteome of eczematous responses to grass/birch pollen and nickel by using atopy patch test (APT) and nickel patch test (NPT) as an appropriate clinical model, respectively. Biopsies from NPT (n = 6) and APT (n = 6) with positive reactions at 72 h were analysed by multiple epitope ligand cartography (MELC), which enabled to investigate coexpression of 49 different epitopes immunohistochemically in a single given tissue section. Colocalisation of IgE and FcepsilonRI was investigated by confocal microscopy. Compared with APT responses, NPT reactions were dominated by cytotoxic TIA-1 + and CD8 + T cells. In contrast, the immune response in APT reactions appeared more pleiotrope - as detected by colocalisation analysis. Multiple combinatorial molecular phenotype (CMP) motifs containing naive, early maturation and memory T cell (CD45RA, CD7, CD44, CD45R0), and general activation markers (CLA, HLA-DR, CD13, CD29, CD58, CD71, CD138) were significantly higher expressed in APT when compared with NPT reactions. APT response was confirmed to be accompanied by IgE bound to FcepsilonRI. In summary, our results demonstrate that the NPT reaction is clearly dominated by cytotoxic events, while the APT reaction to pollen grains is more heterogeneous and elicits a combined humoral and cellular immune reaction.

Hypereosinophilic syndrome: a multicenter, retrospective analysis of clinical characteristics and response to therapy.

BACKGROUND: Hypereosinophilic syndrome (HES) is a heterogeneous group of rare disorders defined by persistent blood eosinophilia > or =1.5 x 10(9)/L, absence of a secondary cause, and evidence of eosinophil-associated pathology. With the exception of a recent multicenter trial of mepolizumab (anti-IL-5 mAb), published therapeutic experience has been restricted to case reports and small case series. OBJECTIVE: The purpose of the study was to collect and summarize baseline demographic, clinical, and laboratory characteristics in a large, diverse cohort of patients with HES and to review responses to treatment with conventional and novel therapies. METHODS: Clinical and laboratory data from 188 patients with HES, seen between January 2001 and December 2006 at 11 institutions in the United States and Europe, were collected retrospectively by chart review. RESULTS: Eighteen of 161 patients (11%) tested were Fip1-like 1-platelet-derived growth factor receptor alpha (FIP1L1-PDGFRA) mutation-positive, and 29 of 168 patients tested (17%) had a demonstrable aberrant or clonal T-cell population. Corticosteroid monotherapy induced complete or partial responses at 1 month in 85% (120/141) of patients with most remaining on maintenance doses (median, 10 mg prednisone equivalent daily for 2 months to 20 years). Hydroxyurea and IFN-alpha (used in 64 and 46 patients, respectively) were also effective, but their use was limited by toxicity. Imatinib (used in 68 patients) was more effective in patients with the FIP1L1-PDGFRA mutation (88%) than in those without (23%; P < .001). CONCLUSION: This study, the largest clinical analysis of patients with HES to date, not only provides useful information for clinicians but also should stimulate prospective trials to optimize treatment of HES.

Pollen grains induce a rapid and biphasic eczematous immune response in atopic eczema patients.

INTRODUCTION: Eczematous reactions to type I allergy-inducing antigens are documented in a subgroup of patients with atopic eczema. Yet, the underlying immunological mechanisms are not well understood. MATERIAL AND METHODS: To delineate the effect of native pollen grains on human skin of healthy and atopic individuals we performed patch tests (atopy patch test with native pollen grains, PPT). Nickel patch tests (NPT) served as an established model of contact dermatitis. Skin site biopsies were taken 6-96 h after allergen application and investigated immunohistochemically. RESULTS: Histology of positive patch tests showed an influx of mononuclear cells (predominantly CD4+, CD25+, CD45RO+). This influx was detected earlier in the PPT reaction than in the immune response to nickel. A biphasic cytokine response could be detected in the PPT: IL-5 dominated in the early, IFN-gamma in the late phase. The NPT was continuously dominated by IFN-gamma. Dendritic cell subpopulations imitated the earlier kinetics of the mononuclear infiltrate. DISCUSSION: Thus, pollen grains induce eczematous reactions in susceptible individuals. This reaction appears clinically and immunohistochemically similar to the contact hypersensitivity reaction to nickel but follows a faster kinetic and a biphasic course: Th2 and IgE in the early (24 h) and Th1 predominance in the late (96 h) phase.

Mast cell-derived proteases control allergic inflammation through cleavage of IgE.

BACKGROUND: Cross-linking of mast cell-bound IgE releases proinflammatory mediators, cytokines, and proteolytic enzymes and is a key event in allergic inflammation. OBJECTIVE: We sought to study the effect of proteases released on effector cell activation on receptor-bound IgE and their possible role in the regulation of allergic inflammation. METHODS: Using molar ratios of purified recombinant tryptase and human IgE, we studied whether tryptase can cleave IgE. Similar experiments were performed with mast cell lysates in the presence or absence of protease inhibitors. IgE cleavage products were detected in supernatants of allergen cross-linked, cultivated mast cells and in tissue fluids collected from patients' skin after IgE-mediated degranulation. The effects of protamine, an inhibitor of heparin-dependent proteases on IgE-mediated allergic in vivo skin inflammation in human subjects were studied. RESULTS: We show that beta-tryptase, a major protease released during mast cell activation, cleaves IgE. IgE degradation products were detected in tryptase-containing tissue fluids collected from sites of allergic inflammation. The biologic significance of this mechanism is demonstrated by in vivo experiments showing that protease inhibition enhances allergic skin inflammation. CONCLUSION: We suggest that IgE cleavage by effector cell proteases is a natural mechanism for controlling allergic inflammation.