Spezifische Immuntherapie

SCIT (subcutaneous immunotherapy) and SLIT (sublingual immunotherapy) are the only routinely available therapies, which modify allergic diseases sustainably. The ongoing reduction of symptoms and the lower need of symptomatic medication are able to improve the quality of life over a long period of time. However, allergic patients are underprovided due to low use of SIT (specific immunotherapy). After thorough diagnostic workup, the indication has to be checked carefully especially in patients with allergic rhinitis and allergic asthma, to insure that SIT is standard therapy. Allergen extracts are manufacturer-specific preparations, therefore their effects cannot be compared directly, just as SCIT and SLIT efficacy cannot be compared directly. In general, preparations with proven efficacy and safety profile should be preferred. Allergens listed in the TAV (Therapeutic Allergen Regulation) fulfill these requirements. However, it is important to ensure adherence for 3 years of therapy, independent of the route of application. SIT has proven socioeconomic benefit already after a short time of therapy.     

Spezifische Immuntherapie

Successful allergen-specific immunotherapy (SIT) induces complex immunologic changes resulting in reduced allergic inflammatory reactions. SIT has long-term effects in mild forms of inhalant allergies and is effective even when standard pharmacotherapy fails. Moreover, the risk to develop additional allergic sensitizations and the development of asthma is significantly reduced in children with allergic rhinitis. SIT is the treatment of choice in patients with systemic reactions to hymenoptera venoms. Although the exact effector mechanisms of SIT still have to be clarified, the most probable effect is a modulation of regulatory T cells associated with a switch of allergen-specific B-cells towards IgG4 production. The critical point to insure efficacy and safety is the selection of patients and allergens, task best performed by a specialist trained in allergology. Further details are available in the position papers of the German allergy societies—DGAI (Deutsche Gesellschaft für Allergologie und Klinische Immunologie) and ÄDA (Ärzteverband Deutscher Allergologen)—which can be found at www.dgaki.de.     

Spezifische Immuntherapie und atopische Dermatitis

Although allergen-specific immunotherapy, which celebrates its 100-year anniversary this year, represents the only potentially corrective or curative therapy available in the field of allergy, this therapeutic option is rarely employed in patients with atopic dermatitis (AD), one of the most common chronic inflammatory skin diseases. The reason is the relatively low number of controlled studies and a high number of uncontrolled studies or case reports with quite heterogenous study designs focusing on the value of SIT in AD in the literature. However, since allergens clearly impact on the initiation and impairment of AD as well as flare-up of eczematous skin lesions in a subgroup of patients, selected patients might benefit from SIT as an additional therapeutic option. In this overview, we summarize the current data and provide a state-of-the-art view on the value of SIT in AD.     

Spezifische Immuntherapie bei der Behandlung der atopischen Dermatitis

Atopic dermatitis (AD) is a common chronic inflammatory skin disease that is part of the atopic syndrome and is frequently associated with asthma and allergic rhinoconjunctilitis. Acute eczematous lesions are characterized by erythema, cozing and crusting, whereas chronic lesions show thickened skin and papules. In addition to local and systemic therapy adjusted to the stage of the disease, the search for relevant trigger factors and consecutively their avoidance plays a crucial role in disease management. Aeroallergens like house-dust-mites, pollen and animal epithelia represent important trigger factors in sensitized patients. While allergen-specific immunotherapy (SIT) is widely and most effective used in allergy to insect venoms and allergic rhinitis, its use in AD is still controversial. Double-blind, placebo-controlled clinical trials show that SIT is effective in patients with AD and clinically relevant sensitization to house dust mites and grass pollen and leads to clinical improvement of eczema. Despite these encouraging data, the use of SIT as a routine therapeutic approach in AD requires further evaluation.     

Spezifische Immuntherapie (SIT) bei atopischer Dermatitis und Nahrungsmittelallergie

Atopic dermatitis (AD) is one of the most frequent chronic inflammatory skin diseases with an increasing prevalence. About 80% of adult AD patients are sensitized against seasonal or perennial aeroallergens and/or food allergens which may play a pivotal role in triggering or maintaining eczema. In addition to local and systemic therapy adjusted to the stage of the disease, the search for relevant trigger factors and then their avoidance plays a crucial role in managing AD. While the effectiveness of SIT is best established in allergic rhinitis, bronchial asthma and insect venom allergy, its use in AD is still controversial. Double-blind, placebo-controlled clinical studies are now available showing good efficacy of SIT in patients with AD. For food allergies there are clues from case reports and small clinical studies suggesting effectiveness of SIT both for food allergies and associated aeroallergens. Double-blind, placebo-controlled studies involving larger numbers of patients are needed to establish the clinical effectiveness and immunologic mechanisms of SIT in food allergies.     

Sublinguale Immuntherapie

Allergic diseases represent a global health problem. They affect 20% to 30% of the German population, but more than 40% of the group between 20 and 40 years of age. The symptoms have a considerable influence on social life and cause an impairment of sleep and performance at work/school, leading to a high but avoidable economic impact. For over 100 years specific immunotherapy (SIT) has been used to treat IgE-mediated allergic diseases. Numerous well-controlled studies have provided evidence of its efficacy, safety and tolerability. Today SIT represents a well-established treatment of allergic rhinitis, rhinoconjunctivitis and allergic asthma with a positive health economic impact. Initially, SIT was administered subcutaneously (SCIT), but other routes of application have been developed. In particular the sublingual-swallow method (SLIT) has been proven to be effective and well-tolerated in large studies on grass pollen allergies and represents an additional effective route of administration in adults and children.     

Spezifische Schwangerschaftsdermatosen

The specific dermatoses of pregnancy represent a heterogeneous group of inflammatory skin diseases related to pregnancy and/or the postpartum period. The most recent classification includes pemphigoid gestationis, polymorphic eruption of pregnancy, intrahepatic cholestasis of pregnancy, and atopic eruption of pregnancy. The hallmark of all four entities is severe pruritus that is accompanied by characteristic skin changes. While some of these dermatoses are distressing only to the mother because of pruritus, others may be associated with significant fetal risks. Early diagnosis and prompt treatment are therefore essential. In this review, we will discuss the various pregnancy dermatoses in detail and present an algorithm for diagnosis and management of pruritus in pregnancy.     

Immuntherapie des Melanoms

Even early clinical studies showed that adjuvant chemotherapy achieved no therapeutic benefit for melanomas so that in the current guidelines its use is only recommended within the framework of clinical studies. For over 30 years interferons have been used in the adjuvant treatment of primary high risk melanomas as well as in the treatment of metastasized melanomas. They function in an antiviral, immune modulating and antitumor fashion. Direct and indirect effects on tumor cells could be demonstrated for interferons. In Europe low dosage interferon therapy is approved and has become widely established for stage II melanomas, whereas in the USA high dosage therapy for stage III and since March 2011 therapy with pegylated interferon in stage III are also approved. In this article the most important study results will be dealt with in detail. In summary, according to the current study situation therapy with interferon should be offered especially to patients with ulcerated primary melanoma and microscopic lymph node infiltration. Many attempts have been made in the last decades to positively influence the survival time of distant metastasized melanoma by systemic therapy. The recent development of the antibody ipilimumab against cytotoxic T-lymphocyte protein 4 (CTLA-4) could show for the first time a survival advantage in the therapy of melanoma patients in advance stage disease. The licensing of ipilimumab has meant that there is now a new standard available for the second line therapy of malignant melanoma which will be included in the guidelines on therapy of malignant melanoma. A further interesting option for adjuvant therapy is currently vaccination with the recombinant melanoma-associated protein 3 (MAGE-A3) protein in combination with the adjuvant AS015.     

Wirkmechanismen der spezifischen Immuntherapie

Specific immunotherapy (SIT) is a well-established and clinically effective treatment for allergic rhinitis and bronchial asthma. The immunological mechanisms of the subcutaneously applied immunotherapy have been partially elucidated over the past several years but are not completely understood. This report summarizes the immunological and immunoregulatory changes during SIT of wasp venom allergic patients. The induction of IL-10-producing regulatory T cells is described.     

Immunologische Verlaufsparameter unter spezifischer Immuntherapie

In vivo-methods used for clinical follow-up control during specific immunotherapy (SIT) are associated with the risk of potentially severe reactions. As a safe diagnostic alternative, several in vitro-methods are currently available permitting the evaluation of immunomodulatory SIT effects. The basophil activation test, the lymphocyte transformation test and fluorescence immunoassays detecting allergen-specific IgG- and IgG4-antibodies have been utilized for this purpose. However, a reliable correlation of an immunological follow-up parameter with clinical efficacy of SIT has not been established. Therefore, further controlled studies are needed to evaluate the clinical usefulness of the described in vitro-techniques. In the future, a combination of different diagnostic methods defining sequential immunological modifications could lead to the identification of an in vitro profile characteristic of a successful SIT.     

Spezifische und unspezifische Behandlung von Pyodermien

Ohne Zusammenfassung