To the Editor: Atopic dermatitis (AD) or eczema is often the first manifestation of atopy, with approximately 80% of children eventually developing food allergies, asthma, or allergic rhinitis (AR). Since the discovery of the IgE molecule, its role as a crucial immune mediator of allergic inflammation has come to light. Although its exact role in the pathogenesis of asthma is unclear, previous studies have shown a strong correlation between the severity of AD, serum IgE levels, and concomitant allergic rhinitis and/or bronchial asthma.1Stein R.T. Holberg C.J. Morgan W.J. Wright A.L. Lombardi E. Taussig L. et al.Peak flow variability, methacholine responsiveness and atopy as markers for detecting different wheezing phenotypes in childhood.Thorax. 1997; 52: 946-952Crossref PubMed Scopus (247) Google Scholar Even in the absence of known food allergies, eczema patients often have elevated specific and total serum IgE levels.2Johnson E.E. Irons J.S. Patterson R. Roberts M. Serum IgE concentration in atopic dermatitis. Relationship to severity of disease and presence of atopic respiratory disease.J Allergy Clin Immunol. 1974; 54: 94-99Abstract Full Text PDF PubMed Scopus (121) Google Scholar Factors that influence IgE production include cytokines (like interleukins-4 and -13) and inflammatory cells that are present in the milieu. When antigen cross-links the specific IgE bound to the FcεRI on mast cells and basophils, these cells initiate and amplify the inflammatory response in both the airways and atopic skin. In the skin, these events are responsible for the hallmark features that include erythema, papulation, lichenification, exudation, and crusting. Omalizumab is a chimeric monoclonal antibody that binds IgE at the same binding site as FcɛRI and FcɛRII, thereby inhibiting mast cell or basophil activation. Recent studies have demonstrated a significant benefit from anti-IgE in the treatment of both atopic asthma and allergic rhinitis by decreasing serum IgE levels, nasal symptoms,3Casale T.B. Condemi J. LaForce C. Nayak A. Rowe M. Watrous M. et al.Effect of omalizumab on symptoms of seasonal allergic rhinitis: a randomized controlled trial.JAMA. 2001; 286: 2956-2967Crossref PubMed Scopus (327) Google Scholar and bronchoconstriction during both the early and late-phase responses to inhaled allergen.4Milgrom H. Fick Jr., R.B. Su J.Q. Reimann J.D. Bush R.K. Watrous M.L. et al.Treatment of allergic asthma with monoclonal anti-IgE antibody. rhuMAb-E25 Study Group.N Engl J Med. 1999; 341: 1966-1973Crossref PubMed Scopus (688) Google Scholar These translate to a reduction of asthma-related symptoms, corticosteroid dose, and improvement in quality of life. Because of similarities in the immune mechanisms underlying asthma and AD, we decided to look at the effect of anti-IgE therapy on cutaneous symptoms of AD. We report on 7 AD patients (aged 7-58 yrs) who received anti-IgE treatment for their persistent asthma. All patients had history of asthma, AR, and eczema since early childhood (<3 yrs old) and a strong family history of atopy. They had positive skin tests or RAST for common aeroallergens and high IgE titers (226-2020 kU/L or IU/mL). Physician assessments at 3 and 7 months were used to generate eczema scores (ranked 0-5 in increasing order of severity) using the Global Assessment (IGA) scoring system.5Wahn U. Bos J.D. Goodfield M. Caputo R. Papp K. Manjra A. et al.Efficacy and safety of pimecrolimus cream in the long-term management of atopic dermatitis in children.Pediatrics. 2002; 110: e2Crossref PubMed Scopus (326) Google Scholar All patients received omalizumab calculated according to patient's mass and baseline IgE titers per manufacturer's nomogram. Those whose IgE levels were >700 kU/L were given the maximum dose (375 mg every 2 wks) (Table I). The Human Subjects Committee of the Washington University School of Medicine approved the study.Table IPatients' baseline characteristicsPt 1Pt 2Pt 3Pt 4Pt 5Pt 6Pt 7Age (yrs)/sex7/F13/F24/F38/M38/F43/F58/FAtopic conditionsPAR, ADPAR, ADPAR, ADPAR, ADPAR, ADPAR, ADPAR, ADAeroallergen sensitivityCat, dog, DM, trees, weeds, molds, and grassesCat, DM, trees, weeds, and grassesCat, dog, ragweed, and moldsCat, dog, DM, trees, molds, and grassesCat, dogDog, treesCat, dog, DMIgE titer (kU/L)137520207849675451484265Omalizumab dose375 mg SQ q2wk375 mg SQ q2wk375 mg SQ q2wk375 mg SQ q2wk375 mg SQ q2wk375 mg SQ q2wk300 mg SQ q2wkStart mo. of therapyNovemberDecemberNovemberOctoberOctoberSeptemberDecemberEczema severityModerateModerateModerateModerateSevereSevereMildIGA score3333442AD, Atopic dermatitis; DM, dust mite; IGA, Investigator Global Assessment; PAR, perennial allergic rhinitis; SAR, seasonal allergic rhinitis. Open table in a new tab AD, Atopic dermatitis; DM, dust mite; IGA, Investigator Global Assessment; PAR, perennial allergic rhinitis; SAR, seasonal allergic rhinitis. Before using omalizumab, their atopic symptoms were not controlled despite a sound, conventional regimen that included an oral, second-generation antihistamine, a cysteinyl leukotriene receptor antagonist, intranasal steroids, maximum dose of inhaled corticosteroids, and a long acting inhaled β-2 agonist. For their cutaneous symptoms, 7 patients were using high-potency topical corticosteroids, 4 received topical tacrolimus or pimecrolimus, while none was on doxepin. Additionally, elimination diet in 2 patients with identified food allergies failed to control the dermatitis. One patient had several sessions of narrowband ultraviolet B treatment, but improvement was minimal. None of the patients received immunotherapy in the past or had more than three short courses of oral steroids in the preceding 12 months before treatment was started. Eczema symptoms were scored at baseline, 3, and 7 months of treatment. Six of 7 patients had at least an IGA score of 3 (moderate disease) or more before starting omalizumab. Clinical improvement became evident after about 8 to 12 weeks of treatment. By the third month, all but 2 patients had an IGA score of 2 or lower, which is equivalent to mild clinical disease. IGA scores continued to improve, and significantly lower IGA scores were noted at the 7-month evaluation (Fig 1). Once a clinical improvement occurred while on omalizumab, none of the patients experienced worsening of their eczema symptoms. Frequent exacerbations and remissions are typical for AD, but were not seen in our study population. A coincidental improvement in all 7 subjects is unlikely. In fact, 2 of the patients were able to stop all of their eczema medications. Two patients had to discontinue omalizumab after only 3 months of treatment because their insurance companies refused to cover the cost of the treatment. Recently, Krathen et al6Krathen R.A. Hsu S. Failure of omalizumab for treatment of severe adult atopic dermatitis.J Am Acad Dermatol. 2005; 53: 338-340Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar published their experience with 3 patients with severe adult atopic dermatitis who did not improve with omalizumab. Their doses and treatment duration are comparable to our study (450 mg vs 375 mg every 2 weeks, 4 months compared to 3 months). However, their baseline IgE-levels (range 5440-24,400 IU/ml or kU/L; mean 17,600 IU/ml) are substantially higher from our patients (range 265-2020 kU/ml; mean 1063 kU/ml), which may explain the difference in treatment outcome. Possibly, in patients with such high IgE-levels as seen in their study, omalizumab cannot decrease IgE-levels below a certain necessary threshold (<90%)7Busse W. Corren J. Lanier B.Q. McAlary M. Fowler-Taylor A. Cioppa G.D. et al.Omalizumab, anti-IgE recombinant humanized monoclonal antibody, for the treatment of severe allergic asthma.J Allergy Clin Immunol. 2001; 108: 184-190Abstract Full Text Full Text PDF PubMed Scopus (1068) Google Scholar, rendering the therapy ineffective. The results from this series of 7 patients with severe AD provide preliminary evidence demonstrating the beneficial effect of anti-IgE treatment (omalizumab) in AD. These findings are encouraging and should be validated in a randomized, double-blinded, placebo-controlled, prospective manner.