Case Study: Subcutaneous Allergen Immunotherapy for Severe Atopic Dermatitis

Anil Nanda, MD

The following case study was presented at the American College of Asthma, Allergy and Immunology (ACAAI) annual meeting in Seattle, Washington.

Introduction: Atopic dermatitis has a wide variety of therapies, including topical moisturizers, topical corticosteroids, and biologics. However, there is still a debate regarding the efficacy of allergen immunotherapy in the treatment of atopic dermatitis. We report atopic dermatitis treated successfully with allergen immunotherapy.

Case Description: A patient was referred to our practice for the treatment of severe atopic dermatitis. A 48-year old man presented with a history of severe atopic dermatitis since childhood. Previous therapies, including mid and high potency topical corticosteroids, as well as the calcineurin inhibitors, pimecrolimus and tacrolimus, were ineffective. He had also required multiple doses of systemic corticosteroids for exacerbations. Biologic therapy was not available. He had positive specific IgE and allergy skin testing to multiple inhaled allergens, including dust mite, weeds, trees, grasses, mold, cat, and dog. The IgE level was 10,000 IU/mL. His initial Scoring Atopic Dermatitis Index (SCORAD) was 79.4. He was started on subcutaneous allergen immunotherapy to these inhaled allergens, while his topical therapies remained the same. In one year, at maintenance therapy at 1:1 dilution (0.5 cc injections), patient reported significant benefit in symptoms, and SCORAD index decreased to 48.5. He did not require systemic systemic steroid therapy once he reached maintenance dose of immunotherapy.

Discussion: Subcutaneous allergen immunotherapy can be an effective therapy for atopic dermatitis. This therapy can be used in conjunction with other treatments, including topical ones. Larger studies are required to further evaluate this therapy in atopic dermatitis.

“The man had suffered with severe eczema since childhood,” said lead author Anil Nanda, MD, of Texas Health Presbyterian in Flower Mound, Texas. “He had tried many previous therapies for years including mild and high strength topical corticosteroid cream, as well as other topical anti-inflammatory creams and topical moisturizer creams. Biologic therapy has been available to treat eczema for about a year and-a-half but was not yet a treatment option at the time we saw this man. We thought allergy shots might be beneficial because he also had multiple allergies.”

Atopic dermatitis is an allergic disease, and patients who have it often also have other types of allergies. Symptoms of eczema include severe itching along with excessive dryness or scaling, red or inflamed skin, sleep disturbance and skin pain.

"We conducted skin testing and found the man was allergic to dust mites, weeds, trees, grasses, mold, cats and dogs," said Anita Wasan, MD, ACAAI member and co-author of the paper. "Because his allergies could all be treated with allergy shots, we thought treating his allergies might also benefit his eczema. After one year, he reported significant benefit to his symptoms, which was great news. And once he reached a maintenance dose of allergy shots, he no longer needed high dose steroid therapy for his eczema."