Cyclosporine in the treatment of atopic dermatitis

Cyclosporine is an immunosuppressive drug. Since 1983 is used as prophylaxis in patients after transplantation what increases the post-transplantation survival rate and improves patient’s quality of life. Although the drug was discovered in 1970 and 1973 was used to treat psoriasis, it is more commonly associated with transplantology. (1) Cyclosporine inhibits humoral and cellular components of inflammatory response. That is why it is also used not only in the treatment of chronic inflammatory and autoimmune diseases such as rheumatoid arthritis or psoriasis, but also in severe atopic eczema which is resistant to other treatment.

Atopic dermatitis is a common hypersensitivity reaction of an organism to different factors, which are usually well tolerated and completely neutral for people with no allergy. The disorder affects people who are especially prone to atopic diseases (it is very often familial predisposition). Most often it appears in the childhood as a reaction to food allergens, as well as to respiratory and contact allergens. Nowadays, the allergies are more and more common in the society. They are recognized as an epidemic of the 21st century. However, the statistics concerning the number of people affected by allergies are not precise. It is estimated that about 14% of Polish society suffer from it. The statistics and most common allergens are different depending on a country. (2)

The turning point in the therapy of atopic diseases, including atopic dermatitis, was the implementation of immunotherapy: subcutaneous (SCIT), local, sublingual, which means administration of allergens solution in increasing but small doses in a given period of time. It helps to stimulate tolerance to the specific allergen thus reducing symptoms of allergy after the end of the treatment. However, the severe atopic eczema is rather inadvisable for immunotherapy. (3) That is why it was necessary to find another way of atopic dermatitis treatment, especially in the case when the daily care, local corticosteroids, calcineurin inhibitor drugs and oral antihistaminic do not help.

Recently, the use of the oral cyclosporine was introduced to the treatment of severe atopic eczema. It is rather controversial therapy because of common and severe side effects of the drug which are nephro-, gastrointensticial- and hepatotoxicity, and suppressive influence on the bone marrow. That’ s why it is advised to control the condition of that organs and verify the dosage if needed. That treatment is currently reserved only for the most severe cases and is used only under strict control, preferably hospital care. In children the treatment begins with a small dose of 2,5 mg/kg of body weight/ 24 hours. Then the doses are increased to up to 5 mg/kg/24h. In adults the first dose is 100 mg a day and then it is increased up to 200 mg/24h. If it is necessary, the doctor may modify the dosage at any time.

According to the recent research the therapy seems to lead to significant improvement. In the randomized research of 8 patients after one year of the treatment (with cyclosporine and SCIT) the scientists noted the improvement on the SCORAD scale (by 39,6% to 88,8% after 6 months and by 37,3% to 86,1% after 12 months).(4) According to meta-analysis of 15 publications , in which 602 severe atopic dermatitis patients were treated, it was proved that cyclosporine consistently improved the condition of the patients. (5) The effectiveness of the therapy seems to depend on dosage and duration of the treatment. After 2 weeks of small dose therapy (3mg/kg) the severity of the eczema was decreased by about 22% (8%-36%). Bigger dose therapy (4 mg/kg) has resulted in the decrease by about 40% (29%-51%). In the case of the 6-8 weeks-long therapy the improvement was by ca. 55% (no less than 48%, maximal up to 62%). The severity of the skin disorder was assessed according to the SCORAD scale.

Even though the treatment with cyclosporine seems to be the excellent solution for the severe form of atopic eczema, the patients cannot be subjected too easy to such therapy. The cyclosporine as a treatment of atopic dermatitis is registered in Germany and in the USA. In Poland it is still of label use and that’s why it is only used in special cases. Because of its side effects it would be advisable to look at the long-term effects. The efficacy of the cyclosporine therapy seems to be the same in children and in adults, however, it is better tolerated in children. Although increasing morbidity rate of atopic diseases and more common severe forms of that disorders, it is encouraging that we have something to fight them.

Written by: Magdalena Chorążka

2.The term Efficacy and Safety of Long Oral Cyclosporine Treatment for Patients with Atopic Dermatitis, Sik Haw, M.D., Min-Kyung Shin, M.D., and Choong-Rim Haw, M.D; Ann Dermatol. 2010 February; 22(1): 9-15
4.Treatment of Severe Atopic Dermatitis with a Combination of Subcutaneous Allergen Immunotherapy and Cyclosporin; Dong-Ho Nahm and Myoung-Eun Kim, Yonsei Med J. 2012 January 1; 53(1): 158–163
5. Cyclosporin in the treatment of patients with atopic eczema – a systematic review and meta-analysis; J. Schmitt, N. Schmitt, M Meurer, Journal of the European Academy of Dermatology and Venereology,Volume 21, Issue 5, pages 606–619, May 2007

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