Refractory Atopic Dermatitis Research Articles

Adjunctive treatment of atopic dermatitis with novel at-home handheld narrow-band UVB phototherapy.

While conventional in-office phototherapy has long been utilized as a successful treatment for atopic dermatitis (AD), it is associated with potential barriers including inconvenience, poor adherence, time and financial expense. In this retrospective study, we examine the efficacy, adherence, and patient-satisfaction of using adjunctive at-home, self-administered phototherapy utilizing a novel handheld narrow-band ultraviolet B (NB-UVB) device for the treatment of refractory mild to severe AD. Included AD patients were initially trained on proper use of the device. These patients treated involved areas three times per week for a period of 12weeks. Phototherapy dosing protocol was based on skin type. The cohort included 52 patients, who were aged 20-69 and represented all skin types. They were initially categorized by disease involvement as mild, moderate, and severe. Patients were also queried to self-score their disease severity and level of satisfaction. Compared to baseline, at 12weeks, 48% percent of patients indicated that at least one site was Clear/Almost Clear, 38% stated that more than 50% of body locations were Clear/Almost Clear, and 28% reported that 100% (all) treated sites were Clear/Almost Clear. After using at-home hand-held NB-UVB for the study duration, 67% (35/52) of patients experienced disease improvement. Mean overall satisfaction was extremely high at 4.43 on a 5-point scale. Skin type, age, gender, and disease severity at inception did not significantly affect patient satisfaction scores. Overall adherence rate among participants across all groups was 73%. In this small retrospective study, at-home handheld NB-UVB phototherapy was found to be an effective, well-tolerated, adjunctive treatment method for patients with refractory AD, which was associated with a high level of patient satisfaction and adherence.

Pearls for practice from the 2023 allergy immunology joint task force on practice parameters GRADE and institute of medicine based atopic dermatitis guidelines.

To review the updated 2023 Allergy Immunology Joint Task Force on Practice Parameters (JTFPP) GRADE and Institute of Medicine (IOM) Based Guidelines for the management of atopic dermatitis. Topical corticosteroids and/or calcineurin inhibitors are recommended in individuals with atopic dermatitis refractory to moisturizer alone and may be used to maintain remission after acute flare control is achieved. Calcineurin inhibitors are a class of immunosuppressants used to effectively manage different autoimmune disorders. Bleach baths and allergen immunotherapy may be beneficial for individuals with moderate-to-severe disease, while elimination diets, azathioprine, methotrexate, mycophenolate, and systemic corticosteroids are not recommended. Dupilumab is strongly recommended for refractory atopic dermatitis. Oral Janus kinase (JAK) inhibitors carry significant risks; however, this class of medicines may be considered in cases of severe or refractory atopic dermatitis with intolerance to dupilumab. Patient preferences regarding cost, availability, feasibility, and tolerability should be integrated into all treatment plans using a shared decision-making approach. The 2023 JTFPP Atopic Dermatitis Guidelines offer up-to-date guidance for the management of atopic dermatitis of varying severity in infants, children, and adults.

Treatment and referral patterns of patients with atopic dermatitis from the Danish primary care system to the tertiary care system

AbstractBackgroundPatients with atopic dermatitis (AD) are mostly managed by general practitioners (GPs) and practicing dermatologists (PDs) in Denmark. In cases of severe and refractory AD, the primary physician can refer the patient to a specialised dermatology department.ObjectivesAim of the study was to investigate treatment at the time of referral to a specialised dermatology department and the cause stated by the GP in a Danish cohort of AD patients referred to the Department of Dermatology, Aarhus University Hospital from 2019 to 2021.MethodsOne hundred and thirty cases were randomly selected via diagnosis codes for AD. Information regarding the cause for referral and treatment given at time of referral was obtained from medical records. 18 cases were excluded due to missing referral in the patients' medical records, other diagnosis than AD or treatment initiation before 2019. The final cohort consisted of 112 cases. Differences between patients referred from GP and PD were analysed with Fisher's exact test.ResultsMost cases were referred by PDs (45.5%) and GPs (24.1%). GPs primarily referred due to acute flare‐ups in need of treatment (40.7%), and PDs due to lacking disease control (64.7%), (p‐values < 0.0018). GPs generally included more descriptive information in their referrals than PDs, however, only the difference in mentioning sleep disturbance was significant (p‐value = 0.0144). Topical corticosteroids were the preferred treatments before referral regardless of the referring doctor, with no statistical differences. Topical calcineurin inhibitors were significantly more used among PD‐referred patients compared to GP‐referred patients (p‐value = 0.0018). Systemic therapy was initiated in 45 patients (40.2%) at the tertiary hospital with no differences between referral from either GPs or PDs.ConclusionsThe study identified few differences in the referral pattern of AD to a tertiary treatment center from GPs and PDs. No major deviations from Danish guidelines were found.

Real-World Efficacy and Safety of Oral Tofacitinib in Patients with Refractory Moderate to Severe Atopic Dermatitis: A Multicenter Retrospective Study.

Atopic dermatitis (AD) has a complex etiology that includes Th2 polarization, which is accompanied by the cytokines IL4, IL-5, IL-13, and IL-31, as well as Th17 and Th22, and in chronic lesions, Th1 cells. Tofacitinib inhibits Th1-, Th2-, and Th17-associated cytokines by selectively blocking JAK1 and JAK3 receptors. We conducted a multicentric, retrospective chart analysis to study the efficacy and safety of tofacitinib in patients with moderate to severe refractory AD. We included 16 adult patients (aged >18 years) with moderate to severe AD who had previously undergone systemic therapy with inadequate response. In the baseline, demographic data, previous treatment history, severity scores (eczema area and severity index [EASI] and SCORing Atopic Dermatitis [SCORAD]), and quality of life score (Dermatology Life Quality Index [DLQI]) were noted. Baseline blood investigations, including complete blood count, liver function test, renal function test, lipid profile, and interferon gamma release assay for tuberculosis, were done. Patients were followed up every month for 6 months that included documentation of severity scores, blood investigations, and DLQI. Any adverse events, if reported, were noted. All 16 patients completed the 6-month trial. Our patients were previously treated with cyclosporine (n = 10), methotrexate (n = 3), or both (n = 3). The mean EASI scores improved from 23.38 ± 9.56 at baseline to 8.50 ± 7.57 at the end of 6 months. The mean SCORAD score improved from 41.25 ± 8.69 at baseline to 14.93 ± 7.82 at the end of 6 months. Quality of life also improved as the mean DLQI improved from 15.18 ± 2.73 at baseline to 5.31 ± 4.11 at the end of the study period. No severe adverse reactions were noted, but 3 patients experienced dyslipidemia and 2 patients had altered bleeding time. Tofacitinib is a safe and effective treatment option for recalcitrant moderate to severe adult AD.

Systemic anti-inflammatory treatment of atopic dermatitis during conception, pregnancy and breastfeeding: Interdisciplinary expert consensus in Northern Europe.

Treating atopic dermatitis (AD) in pregnant or breastfeeding women, and in women and men with AD aspiring to be parents is difficult and characterized by uncertainty, as evidence to inform decision-making on systemic anti-inflammatory treatment is limited. This project mapped consensus across dermatologists, obstetricians and patients in Northwestern Europe to build practical advice for managing AD with systemic anti-inflammatory treatment in men and women of reproductive age. Twenty-one individuals (sixteen dermatologists, two obstetricians and three patients) participated in a two-round Delphi process. Full consensus was reached on 32 statements, partial consensus on four statements and no consensus on four statements. Cyclosporine A was the first-choice long-term systemic AD treatment for women preconception, during pregnancy and when breastfeeding, with short-course prednisolone for flare management. No consensus was reached on second-choice systemics preconception or during pregnancy, although during breastfeeding dupilumab and azathioprine were deemed suitable. It may be appropriate to discuss continuing an existing systemic AD medication with a woman if it provides good disease control and its benefits in pregnancy outweigh its risks. Janus kinase (JAK) inhibitors, methotrexate and mycophenolate mofetil should be avoided by women during preconception, pregnancy and breastfeeding, with medication-specific washout periods advised. For men preconception: cyclosporine A, azathioprine, dupilumab and corticosteroids are appropriate; a 3-month washout prior to conception is desirable for methotrexate and mycophenolate mofetil; there was no consensus on JAK inhibitors. Patient and clinician education on appropriate (and inappropriate) AD treatments for use in pregnancy is vital. A shared-care framework for interdisciplinary management of AD patients is advocated and outlined. This consensus provides interdisciplinary clinical guidance to clinicians who care for patients with AD before, during and after pregnancy. While systemic AD medications are used uncommonly in this patient group, considerations in this article may help patients with severe refractory AD.

Systemic Immunosuppressive Therapies for Children with Refractory Atopic Dermatitis: A Large Real-Life Cohort Study.

Systemic immunosuppressants are used off-label to treat paediatric patients with moderate-to severe atopic dermatitis (AD) for whom topical treatment has failed. A large real-life cohort of paediatric patients with AD treated with systemic immunosuppressive treatments is described in order to guide dermatologists’ prescribing practices when faced with a moderate to-severe AD paediatric patient who has failed or has a contraindication to topical treatment, phototherapy, biological agents or Janus kinase inhibitors.

Justification of the efficacy of combined therapy with dupilumab and cyclosporine in children with severe dermato-respiratory syndrome

BACKGROUND: Atopic dermatitis is characterized by a clear upward trend in the prevalence and development of severe forms of dermatosis, which represents an important medical and social problem.
 AIM: Pathogenetic justification and study of clinical efficacy of combined use of dupilumab and cyclosporine in children with severe refractory atopic dermatitis.
 MATERIALS AND METHODS: The study included 30 children and adolescents over 6 years of age, with a diagnosis of atopic dermatitis with severe disease severity. The control group consisted of 15 people. EASI, Pruritus VAS score, CDLQI index were used to assess the dynamics of disease symptoms. The content of interleukins in blood serum was determined by enzyme immunoassay. Children included in the study were divided into two groups of 15 patients by randomization. Group 1 patients received dupilumab monotherapy, Group 2 patients were treated with a combination of dupilumab and cyclosporine.
 RESULTS: Positive dynamics in the course of the cutaneous pathological process was observed in all patients. A more pronounced and persistent tendency to further decrease of EASI values was preserved in patients receiving combined therapy. During dupilumab monotherapy and combined treatment there was a significant reduction in nasal obstruction, a decrease in the number of bronchial obstruction/cough attacks. In the course of therapy in all patients it was possible to achieve a significant reduction in the negative impact of atopic dermatitis on the quality of life of children and adolescents. Dupilumab therapy contributed to normalization of cytokine status, eosinophil levels and total immunoglobulin E. However, after 12 weeks of dupilumab monotherapy, signs of Th1-response activation were revealed.
 CONCLUSION: Combined therapy reduces the duration of treatment with dupilumab to 12 weeks, avoids side effects and complications, and significantly increases clinical efficacy of therapeutic measures in children and adolescents with severe atopic dermatitis.

Treatment of Severe Recalcitrant Atopic Dermatitis with Dupilumab in a Kidney Transplant Patient

This case report highlights the successful treatment of refractory atopic dermatitis (AD) in an immunosuppressed patient using dupilumab, a biologic agent that selectively targets cytokines crucial in the pathogenesis of AD. The patient had a history of failed treatment with numerous topical and systemic immunomodulating agents, including corticosteroids and immunosuppressive drugs for organ transplant. Dupilumab treatment resulted in significant improvement of symptoms, including reduced pruritus, and ultimately achieved disease control. Importantly, the patient experienced no adverse effects apart from one COVID-19 infection over three years of co-administration of dupilumab with immunosuppressive transplant rejection treatment. The safety of dupilumab in immunocompromised and transplant patients has been a concern, but studies have shown its safety and efficacy in these patient populations. This case highlights the potential for dupilumab as a safe and effective treatment option for patients with severe AD who are immunocompromised or have undergone solid organ transplantation.

Health technology management: the experience of a managed access approach to the reimbursement of dupilumab in Ireland

BackgroundDupilumab was the first biological medicine to receive marketing authorisation, in Ireland, for the treatment of atopic dermatitis (AD). In 2019, Ireland’s National Centre for Pharmacoeconomics recommended that dupilumab not be reimbursed at the submitted price; it was not cost effective. Following confidential price negotiations, the Health Service Executive (HSE) reimbursed dupilumab subject to a HSE-Managed Access Protocol (MAP). Patients with refractory, moderate-to-severe AD were deemed eligible to receive treatment under the MAP; the cohort for which dupilumab is expected to be most effective and most cost effective (versus standard of care). Approval, for treatment, is granted on an individual patient basis by the HSE-Medicines Management Programme.AimsApplications for approval of treatment with dupilumab were analysed to determine the percentage of patients deemed eligible. Key characteristics of this population were investigated.MethodsData from individual patient applications were analysed. Key characteristics of the approved population were investigated using IBM SPSS Statistics® version 27.Data were derived from the HSE-Primary Care Reimbursement Service pharmacy claims database. The number of patients who received dupilumab over the study period was determined.ResultsIn total, 96% of submitted applications were deemed eligible. Of these, 65% were male and 87% were adults. In the main, the approved patient population had severe refractory AD; the mean Eczema Area Severity Index score was 28.72.ConclusionThe majority of applications submitted were approved. This work highlights how a MAP can facilitate access to treatment in patients who are deemed eligible whilst containing overall expenditure.

Targeting Interleukin 13 for the Treatment of Atopic Dermatitis.

Atopic dermatitis (AD) is a common chronic inflammatory skin condition that has a significant impact on a patient's quality of life and requires ongoing management. Conventional topical and systemic therapies do not target specific components of AD pathogenesis and, therefore, have limited efficacy and may be associated with long-term toxicity. Thus, AD management is challenging, with a significant proportion of patients not achieving clear skin or a reduction in pruritus. There remains a large unmet need for effective therapeutic strategies with favorable safety profiles that can be used long-term in patients with refractory AD. The emergence of targeted biological and small molecule therapies has effectively broadened available treatment options for moderate-to-severe AD. Most recently, interleukin 13 (IL-13) inhibitors were shown to be efficacious and well-tolerated, with tralokinumab already approved for use in this patient population. It is important for dermatologists to be aware of the evidence behind this emerging class of biologic agents to guide treatment choices and improve outcomes in patients with AD. The main objective of this paper is to review the current literature regarding the efficacy and safety of current and emerging anti-IL-13 monoclonal antibodies, including tralokinumab, lebrikizumab, cendakimab, and eblasakimab, for the treatment of moderate-to-severe AD.

Etiology and Treatment of Refractory Atopic Dermatitis with Alopecia and Growth Impairment

Etiology and Treatment of Refractory Atopic Dermatitis with Alopecia and Growth Impairment

Infectious dermatitis associated with HTLV-I: uncommon case in southern Brazil simulating refractory atopic dermatitis

Infectious dermatitis associated with HTLV-I: uncommon case in southern Brazil simulating refractory atopic dermatitis

Off-label use of omalizumab in a 6-year-old child with severe atopic dermatitis.

Background: Atopic dermatitis (AD) is a common chronic inflammatory skin disorder that affects up to 3% of adults and 15%-20% of children across the world. Although the mainstay of treatment is topical corticosteroids and/or calcineurin inhibitors, a majority of patients will not achieve a control of their condition and will need systemic treatment with steroids and immunosuppressants (1). Omalizumab is a humanized anti-IgE antibody licensed by the European Medical Agency for treatment of severe allergic asthma and spontaneous chronic urticaria in children older than 6 and 12 years, respectively; and a promising efficacy of omalizumab in the treatment of severe refractory AD has been shown by the ADAPT randomized clinical trial (2).Case report: A 6-year-old male patient being treated and followed at a pediatric dermatology clinic for a diagnosis of AD since the age of 3 years, showed unresponsive disease to different topical treatment options and non-pharmacological measures. The patient was referred to our clinic for systemic treatment when his SCORAD index was 70/103. At our immunology clinic, we did an extensive workup to unveil a comorbid or underlying disease. His labs showed high IgE levels at 2500 IU/mL, hypereosinophilia, and normal IgA, IgM, and lymphocyte subsets. We started him on different lines of immunosuppressants, including cyclosporine, prednisolone, tacrolimus, and intensive topical treatment; however, the patient did not show any noticeable response for 2 years. We then started him on omalizumab 300 mg twice weekly, and the SCORAD index dropped to 57 at 12 weeks and 55 at 18 weeks. The drug is still well tolerated, and we were able to stop systemic steroids at 15 weeks of treatment.Conclusion: Off-label use of omalizumab in a 6-year-old child with refractory severe AD was effective and safe in controlling the disease even though conventional systemic immunosuppressants proved ineffective.

Refractory Pediatric Psoriasis and Atopic Dermatitis: The Importance of Therapeutical Adherence and Biological Management.

The rates of refractory pediatric psoriasis and atopic dermatitis (AD) have steadily risen over the last few decades, demanding newer and more effective therapies. This review aims to explore the reasons for resistant disease, as well as its management; this includes the indications for, efficacy of, and safety of current therapies for refractory pediatric dermatologic disease. A PubMed search for key phrases was performed. Poor medication adherence is the most common cause of resistant disease and may be managed with techniques such as simplified treatment regimens, more follow-ups and educational workshops, as well as framing and tailoring. Once problems with adherence are ruled out, escalating treatment to stronger biologic therapy may be indicated. Development of anti-drug antibodies (ADAs) can cause patients’ disease to be refractory in the presence of potent biologics, which may be addressed with regular medication use or concomitant methotrexate. If patients with AD fail to respond to biologic therapy, a biopsy to rule out mycosis fungoides, or patch testing to rule out allergic contact dermatitis, may be indicated. A limitation of this study is the absence of more techniques for the management of poor medication adherence. Managing medication adherence, escalating treatment when appropriate, and addressing possible anti-drug antibodies will help assure control and relief for patients with resistant disease.

Effects of dupilumab in type 1 neurofibromatosis coexisting with severe atopic dermatitis

Neurofibromatosis type 1 still lacks established treatment options aimed at controlling the progression of neurofibromas as well as effective therapy for the neurogenic itch associated with the disease. We report the case of a 30-year-old Caucasian woman with type 1 neurofibromatosis coexisting with severe refractory atopic dermatitis. Dupilumab, a novel anti-IL-4 receptor alpha monoclonal antibody, the first biologic agent approved for atopic dermatitis, was the drug of choice in this case. We observed remission of atopic dermatitis and a remarkable reduction in the size and swelling of neurofibromas and in the related pruritus, that became evident after one month of treatment. After 18 months of therapy, no new neurofibromas were detected and preexistent lesions showed no increase in size. These findings are consistent with the hypothesis that dupilumab, a potent anti-inflammatory drug, may have a positive effect on type 1 neurofibromatosis by stopping the progression of preexisting neurofibromas and the onset of new lesions.

New Biologics for the Treatment of Atopic Dermatitis: Analysis of Efficacy, Safety, and Paradoxical Atopic Dermatitis Acceleration.

Atopic dermatitis (AD) is a chronic, inflammatory skin disease with an eczematous rash and itching. Due to undesired adverse effects of traditional systemic treatment, there is still an unmet need for safe and effective long-term therapy for refractory AD. As our understanding of the pathogenesis underlying AD grows, novel treatments targeting specific molecules have been developed. Here, we discuss the efficacy and safety profiles of these drugs in recent clinical trials. Among their adverse effects, of particular note is AD acceleration. Although there is still debate about whether certain adverse reactions can be said to be paradoxical adverse events (PAEs), a wide range of PAEs have been reported during biological treatment for chronic immune-mediated diseases. Close surveillance of novel biologics is crucial to detect new undescribed paradoxical reactions and to shed light on the convoluted pathogenesis of AD.

Anti-IL-4Ralpha monoclonal antibody dupilumab mimics ulcerative colitis: a case report

BackgroundVarious molecular-targeted therapeutic agents that inhibit cytokines and immune checkpoints are used in clinical practice. Some of these biologics that control immunity, such as anti-interleukin-17, anti-programmed cell death protein-1, and anti-cytotoxic T-lymphocyte-associated protein antibodies, affect intestinal immune homeostasis and cause intestinal inflammation. Development of enteritis due to dupilumab (an anti-IL-4Ralpha monoclonal antibody) therapy is not yet reported in the literature.Case presentationA 17-year-old man was administered an injection of dupilumab and continued to receive it for refractory atopic dermatitis. After 3 months of initiating dupilumab therapy, he developed intermittent abdominal pain, tenesmus, and had diarrhea. Colonoscopy examination showed decreased vascularity, mild friability, and erythema in the cecum, part of the ascending colon, sigmoid colon, and rectum without any pathogenic bacteria. Histological examination revealed moderate mixed inflammatory cell infiltration, cryptitis, destruction of the crypt, decreased goblet cells, mucosal erosions, and edema. He was diagnosed with UC and was prescribed oral mesalazine (4800 mg/day) treatment. Within a month of the treatment, his diarrhea improved and the frequency of defecation decreased.ConclusionsThis is a first report that dupilumab mimicked ulcerative colitis. Careful monitoring for adverse effects with the onset of an intestinal inflammation will be recommended after dupilumab administration.

Successful Treatment of Refractory Atopic Dermatitis With the Use of High-Peak Power 1064 nm Nd:YAG Laser Therapy

Atopic dermatitis is a chronic inflammatory skin disease involving the complex association of genetic, immunologic, and environmental causes. Until recently, the treatment of eczematous processes was limited to the use of topical corticosteroids, systemic immunosuppressants, and controlling environmental triggers. Photobiotherapy offers a promising approach to the management of atopic dermatitis. Photobiotherapy is the clinical application of light for healing superficial wounds. We present 2 cases of patients with biopsy-proven, long-standing, poorly controlled atopic dermatitis successfully treated with a high-peak power 1064-nm neodynium:yttrium aluminum garnet (Nd:YAG) laser. Over the course of 9 years, each patient continued to undergo periodic laser treatments to maintain control over their disease. Both patients underwent a series of laser using high-peak power treatments with long-pulsed 1064-nm Nd:YAG laser (Cool Glide, Cutera, Brisbane, California) in “photorejuvenation/Genesis mode” over the course of 9 years. Case 1 received 29 treatments over a 9-year period. When financially able to, the patient had 1 treatment a month for 2 to 6 treatments a year. At the very least, she had a treatment during her worst flares. Case 2 received 19 treatments over 9 years with the timing being monthly when possible but with longer intervals between treatments if her disease was not flaring. One patient that was on systemic immunotherapy to control her atopic dermatitis was able to successfully come off this medication early in her treatment, and both patients experienced long-lasting improvement in their symptoms. The dramatic improvement in the skin eruption, symptoms, and quality of life in these patients further supports addition of the 300-µs 1064-nm Nd:YAG laser for the treatment of refractory atopic dermatitis. The authors are using this modality for less severe eczema that is refractory to topical therapies. However, a greater number of patients are needed as well as larger studies to further elucidate the mechanisms of lasers for eczematous processes. If further studies support this modality, it would be a safe alternative to systemic immunotherapies.

Effective remission of an elderly patient with refractory atopic dermatitis and foot ulcers following infusion with human umbilical cord‑derived mesenchymal stem cells: A case report

Mesenchymal stem cells (MSCs) are excellent sources for use in the treatment of refractory and relapsing disorders mainly due to their hematopoietic‑supporting and immunoregulatory capacities. However, their safety and effectiveness for the treatment of refractory atopic dermatitis (AD) and multiple complications in elder patients are largely unknown. Therewith, the present study describes the case of a 65‑year‑old female patient with AD accompanied by foot ulcers and refractory urinary tract infection. Briefly, 5x10⁷ human umbilical cord‑derived MSCs (hUC‑MSCs) were intravenously infused into the body of the patient after obtaining the approval of the relevant ethics committee and the consent of the patient. The clinical and biochemical outcomes, including general symptoms, hemogram and blood constituents, medical images, together with tumour biomarkers, were observed and recorded. By conducting only one single intravenous infusion of hUC‑MSCs, the AD‑associated pathophysiological manifestations of the elderly patient, including an unbearable itch, diffuse erythema and eczema, and in particular, inflammatory foot ulcers and refractory urinary infection were completely attenuated. Simultaneously, the outcomes of the accompanied complications were effectively improved, whereas no recrudesce or adverse reactions were observed in the 14‑month follow‑up visit. The findings of the present study suggested that the administration of hUC‑MSCs was safe and effective for restricting the symptoms and of the patient preventing associated complications. Thus, the use of hUC‑MSCs may prove to be a promising treatment option for AD and foot ulcer management, even for elderly patients with multiple underlying conditions or complications.

Vitamin B12 and Atopic Dermatitis: Any Therapeutic Relevance For Oral Supplementation?

In vitro experimental studies have demonstrated the anti-inflammatory and immune-regulatory potential of vitamin B 12. Nevertheless, few studies have explored so far the relevance of topical products containing vitamin B12 as a treatment option for atopic dermatitis, and the association between blood levels of Vitamin B12 and the severity of atopic dermatitis has never been investigated. Thus the effect of Vitamin B12 oral supplementation in atopic dermatitis is unknown. We describe the case of a 18 years old boy affected by severe refractory atopic dermatitis requiring continuous topical steroid therapy and 5-6 oral steroid trials per year to achieve satisfactory control. During a three years follow-up, an association between Vitamin B12 blood levels and atopic dermatitis severity was detected, as well as a clinically significant SCORAD improvement following Vitamin B12 oral supplementation. Although the cause-effect relationship between Vitamin B12 deficiency and AD severity or relapse needs to be confirmed in larger studies, our case report suggests that Vitamin B12 levels deserve to be assessed in patients with difficult to control atopic dermatitis and points out the potential therapeutic relevance of Vitamin B12 oral supplementation.