Q:

10/16/2012
I have a 3 year old little girl with atopic dermatitis which started at 18 months of age. She has been relatively healthy except for her skin problems. No asthma, very little rhinitis. Mom has eliminated foods and been careful to watch to see if foods are an issue and she doesn't feel that they are. Lately her eczema has worsened and she has required a few antibiotics to clear her skin. She has had no other infections. Her mom is convinced that outdoor allergens exacerbate her skin and wants to consider desensitization but through the sublinqual route. Her total IgE is 92736 and of course she has significantly elevated serum IgE to many airborne allergens especially pets. Her back was too inflamed to perform skin testing. My question is as follows: Would you consider SLIT in this young lady to airborne allergens? Thanks.

A:

Thank you for your inquiry.

Although there is some evidence that sublingual immunotherapy may be helpful in patients with atopic dermatitis (abstracts taken from examples of this literature are copied for you below), I would not recommend sublingual immunotherapy for this patient for two reasons:

1. This therapy is not yet approved for use in the United States. The vaccines that we have available have not been evaluated sufficiently for this use and are not available for SLIT use at this time. We have no definitive data regarding the dose that should be used for SLIT with our present vaccines.
2. Even though, as noted above, there are scattered studies implying there may be improvement in patients treated with sublingual immunotherapy, the data are not substantive enough, at least in my opinion, to warrant its use for this purpose at the present time.

Thank you again for your inquiry and we hope this response is helpful to you.

Allergol Immunopathol (Madr). 2000 Mar-Apr;28(2):54-62.
Specific sublingual immunotherapy in atopic dermatitis. Results of a 6-year follow-up of 35 consecutive patients.
Mastrandrea F, Serio G, Minelli M, Minardi A, Scarcia G, Coradduzza G, Parmiani S.
Source
Allergy and Clinical Immunology Operative Unit, A.O. S.S. Annunziata, Taranto, Italy.
Abstract
Background: allergen-specific immunotherapy has proved to be effective in selected patients with IgE-mediated respiratory allergic diseases, and alternative routes of administration are being studied. Atopic Dermatitis (AD) is currently regarded as an allergic inflammatory disease.
Methods: we conducted a cohort study to evaluate the safety and effectiveness of sublingual-swallow immunotherapy (SLIT) in selected patients with allergic (extrinsic) AD. Thirty-five patients, 16 suffering from AD without respiratory allergic symptoms (Group A) and 19 with AD associated to mild asthma and/or rhinitis (Group B), were enrolled in the study. The severity of the skin lesions (eczema) was scored on a 0 to 4 scale (and subsequently related to the more recent SCORAD Index), where 0 indicated complete healing of the eczema and 4 indicated maximal spread of the lesions. Only patients with an eczema score of 1 to 3 were started on allergen-specific SLIT for 36 months. Eczema scores, symptoms and side effects were recorded every two months during the first 2 years and then after 36 months. After SLIT was completed, all patients attended 3 yearly follow-up visits to evaluate the long-term effects of the treatment. All patients followed a set of rules designed to control for identified confounding variables. All patients received ketotifen during the first 3 months of SLIT.
Results: only the complete disappearance of skin lesions (score 0) was considered to indicate effectiveness. In Group A this was observed in 12.6% of the patients after 6 months of SLIT, in 31,2% after 12 months and 68.8% after 24 months. In Group B, eczema disappeared in 0% after 6 months, in 36.8% after 12 months and 73.7% after 24 months. No patients in Group A developed asthma during SLIT, and 1 patient developed asthma 3 years after immunotherapy had ended. Three focal reactions consisting of 2 cases of mild eczema and one case of diarrhoea were recorded. One case of urticaria, due to violation of the administration schedule was the only systemic reaction observed. No life-threatening reactions appeared at any time of the study.
Conclusions: the outcomes obtained, taken into account the limitations of the study design, suggest that sublingual allergen-specific immunotherapy for the treatment of the extrinsic form of Atopic Dermatitis is safe and well tolerated by patients, and may favourably affect the natural course of the disease.

Am J Clin Dermatol. 2004;5(5):281-94.
The potential role of allergen-specific sublingual immunotherapy in atopic dermatitis.
Mastrandrea F.
Source
Allergy and Clinical Immunology Operative Unit, AUSL TA1 SS Annunziata Hospital, Taranto, Italy.
Abstract
Atopic dermatitis is a chronic inflammatory skin disease associated with increasing prevalence, morbidity, and cost in developed Western countries. Frequently associated with respiratory allergy during adulthood, atopic dermatitis often represents the first phenotypic appearance of atopy in early childhood when the allergic 'march' starts and progressively moves toward food allergy, asthma, and rhinitis. At present, a consistent body of evidence supports the view that atopic dermatitis may represent the skin compartmentalization of a systemic allergic inflammation. Lymphocytes infiltrating early lesional skin express a T helper (Th) 2 pattern of cytokine secretion (increased levels of interleukin [IL]-4 and/or IL-13 and decreased levels of interferon-gamma) as well as the typical Th2-type chemokine receptor CCR4, specific to the thymus and activation-regulated chemokines. Keratinocytes from patients with atopic dermatitis produce thymic stromal lymphopoietin, a novel cytokine that supports the early lymphocyte development in mouse models, and activates dendritic cells involved in the pathogenesis of allergic diseases in humans. Increased levels of circulating hemopoietic precursor cells have been reported in atopic dermatitis, as in allergic asthma and rhinitis. Furthermore, the recognition of CD34+ hemopoietic precursor cells, and evidence for cellular differentiation/maturational events occurring within atopic dermatitis skin lesion infiltrates, are consistent with the recent reinterpretation of the Th2/Th1 paradigm, where Th2 cells appear to belong to the early stages and Th1 to the ultimate stages of a linear, rather than divergent, pattern of lymphoid differentiation. This more detailed understanding of the immunologic derangements contributing to the atopic dermatitis pathogenesis has led to growing interest in allergen-specific immunotherapy for the disease. Due to the complexity intrinsic to atopic dermatitis and the lack of consensus-based guidelines for standardized outcome measure, only eight studies are available in the literature for a qualitative evaluation of this treatment approach. Two of these studies were double blind and placebo controlled, and six were cohort studies. Immunotherapy was found to be effective in one controlled study and five observational reports. Uncertain results were provided by one low-powered, controlled study, and negative outcomes were raised by a unique study performed with oral immunotherapy, which is not an effective route of mucosal allergen administration. Thus, more efficacy studies are required before immunotherapy could be recommended for the routine treatment of atopic dermatitis. Allergen-specific sublingual immunotherapy, given its excellent safety profile and ability to interfere with the systemic aspects of allergic inflammation, appears a good potential candidate for the pathogenetic treatment of the disease.

Curr Med Res Opin. 2007 Oct;23(10):2503-6.
Sublingual immunotherapy efficacy in patients with atopic dermatitis and house dust mites sensitivity: a prospective pilot study.
Cadario G, Galluccio AG, Pezza M, Appino A, Milani M, Pecora S, Mastrandrea F.
Source
S. Giovanni Battista Hospital, Allergy Clinical Immunology, Turin, Italy.
Abstract
Background: Specific subcutaneous immunotherapy (SCIT) with house dust mite (HDM) preparation has recently been shown to improve eczema in patients with atopic dermatitis (AD). So far, there is less data regarding efficacy and safety of specific sublingual immunotherapy (SLIT) in patients with AD. Study aim: To evaluate in an open non-controlled, non-randomized pilot trial the effect of SLIT with HDM allergen extracts preparation (SLITone, ALK Abellò Italy) on SCORAD in adult patients with mild-moderate AD.
Patients and Methods: 86 Subjects (53 females and 33 males) between 3 and 60 years of age with AD and IgE-proved (Class > 2) HDM sensitization were enrolled after their informed consent in the trial. Exclusion criteria were severe asthma and treatment with systemic or high potent topical corticosteroids or immunosuppressant agents. Patients were treated with SLIT (Dermatophagoides pteronyssinus and Dermatophagoides farinae extracts: SLITone, ALK-Abellò) for at least 12 months. SCORAD was evaluated at baseline and after 12 months of treatment.
Results: Baseline SCORAD value, mean +/- SD, was 43.3 +/- 13.7 (range 15-84). After 1 year of SLIT, mean +/- SD, SCORAD value was reduced to 23.7 +/- 13.3 (range: 0-65) (p = 0.0001; unpaired t-test vs. baseline). This was a 46% reduction in SCORAD in comparison with baseline value. A significant improvement, defined as a SCORAD reduction of > 30%, was observed in 51 out of 86 patients (59%). In 5 patients (5.8%) SCORAD values did not change at the end of the observation period. In 30 patients (35%) the SCORAD reduction after SIT was <or= 30% in comparison with baseline. Total and specific IgE serum levels were significantly (p = 0.001) reduced after SLIT. No severe adverse events were observed during the trial.
Conclusion: In this open non-controlled trial SLIT with HDM extracts in patients with mild to moderate AD was effective in reducing the SCORAD after 1 year of SLIT treatment. In addition the treatment was very well tolerated. Treatment with SLIT, furthermore, has allowed a gradual and relevant reduction of concomitant therapies with topical corticosteroids or immunosuppressants. Present results require further controlled trials in order to confirm the potential clinical benefit of SLIT in this clinical setting.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology