In Germany, around 3.5 million people have neurodermatitis, including around 1.3 million children. In most of them, the disease, which is presumably a genetic cause, shows up in infancy and toddlerhood, but it improves in the majority of patients later in life. The fact that the chronic inflammatory skin disease breaks out at all can be promoted by a number of trigger factors.
The climate, for example, plays a role: in cooler regions with little sunshine, significantly more people are affected than in warmer climes, and the symptoms can also be more pronounced in winter than in summer. In both cases, a lower level of humidity promotes the drying out of the skin – this is exactly what those affected should avoid at all costs.
Because with neurodermatitis, the self-protection of the skin is limited and the immune system is out of balance. As a result, the skin loses moisture due to the impaired barrier function, becomes dry, itches and reacts sensitively. If it is scratched open, bacteria, viruses and fungi can penetrate more easily.
Finally, there may be a sensitization. In response, the immune system produces more antibodies – also against actually harmless allergens such as pollen, cosmetic products or animal hair. The antibodies in turn fuel the inflammatory process by stimulating other immune cells to release inflammatory substances.
“The result is a vicious circle of itching and scratching, which is based on the one hand on a disruption of the skin barrier and on the other hand on an immune disorder”, summarizes Peter Elsner, Director of the Clinic for Skin Diseases at Jena University Hospital.
According to Elsner, also spokesman for the German Dermatological Society (DDG), the predisposition to neurodermatitis is widespread in Germany: “About a third of people in this country have such an atopic disposition,” he explains. Initially, however, this only means that you have to learn to deal with this predisposition by taking trigger factors into account. In addition to the climate aspects already mentioned, this included airborne allergens such as pollen, grass and animal hair, but also frequent hot bathing or showering.
If “atopic dermatitis” or “atopic eczema”, as the disease is actually correctly called, does break out, it manifests itself in very different degrees of severity and courses. While in some people the typical areas in the elbows and hollows of the knees as well as the hands are affected, other people experience neurodermatitis all over their body. Symptoms can range from reddening of the skin to fine tears and thickening of the skin to inflamed, oozing and bleeding areas.
“Mild neurodermatitis with itching and dryness can usually be treated well in a basic therapy with a simple skin-care cream that contains urea or glycerine, or also with UV light,” says Elsner. In contrast, more severe cases require systemic, i.e. internally effective, therapy.
Until two to three years ago there were only two options, says Elsner: “On the one hand, the use of internal cortisone, on the other hand, treatment with the immunosuppressant cyclosporine, which actually comes from transplant medicine.” Both drugs would achieve good results against the disease , are associated with sometimes severe side effects.
“We had always hoped for agents that had a direct effect on the inflammatory processes,” says the dermatologist.
This is exactly what two new therapies now offer in the form of specific antibodies and so-called small molecules. Antibody-based therapies, also known as “biologics”, include dupilumab, which has been approved for treatment in adults since September 2017 and since November 2020 also for children aged six and over with moderate to severe atopic dermatitis. The active ingredient blocks two central proteins of the immune response and thus neutralizes their pro-inflammatory effects.
Tralokinumab, which was approved as a medicinal product in the EU in June this year, and other biologics that are currently in clinical development are based on this principle. “The advantage of dupilumab is that we now have an option for seriously ill patients that works very well for 60 to 70 percent of patients,” explains Michael Hertl, DDG President and Director of the Clinic for Dermatology and Allergology at University Hospital Marburg in a communication.
In addition, the previously approved biologics are very well tolerated, adds Peter Elsner: “About a fifth of patients report burning eyes or eye infections as annoying but harmless side effects that many accept because the agonizing itching is finally gone.”
In fact, the consequences of severe atopic dermatitis are serious for some people affected. “If the symptoms are severe, they can massively reduce the quality of life of those affected. At night, itching and pain disturb sleep and the visible skin changes are perceived by some in the social environment as “repulsive”, which can lead to stigmatization, “says Ralph von Kiedrowski, President of the Professional Association of German Dermatologists (BVDD) and resident dermatologist in Selters .
Studies from Denmark and the USA also suggest that atopic dermatitis in children is associated with learning disorders and poor academic success. “This shows that neurodermatitis is a disease that extends far beyond the skin,” says Peter Elsner. All the more gratifying are new treatment options such as biologics, which, however, have to be injected. This is not an option for all patients: “Here we have another new therapy option with the Janus kinase inhibitors.”
These JAK inhibitors are small molecules that inhibit signal transmission in the cell, with the effect that the inflammation can subside. “The JAK inhibitors show a very specific effect with few side effects,” explains Elsner. In addition, the active ingredients that are approved for adults can be taken in tablet form.
Both forms of therapy – biologics and the small molecules – are particularly suitable for severe atopic dermatitis cases, but in some cases they achieve quick results. “Some patients report drastically reduced itching after just a few days and can sleep through the night for the first time in a long time,” said DDG spokesman Elsner. For him, the new therapies are not least the result of an increasingly better understanding of the inflammatory mechanisms underlying the skin disease: “This better understanding allows us to intervene in a more targeted manner.”
In addition, studies nowadays are no longer carried out over a few weeks, but in the form of long-term studies, some of which run over three to five years – a procedure that is absolutely necessary in the case of an illness that often runs in phases.
And finally, the disease is now viewed and treated more holistically, from which patients with mild or moderate symptoms also benefit: “In therapy, it is now a matter of course to consider psychosocial factors more closely, such as the patient’s quality of life and his overall feeling”, describes Elsner.
This aspect is also part of the atopic dermatitis training courses that are recommended in the DDG guidelines and in which those affected learn how to deal with the previously incurable disease. “This is especially important for the long-term management of the disease,” says Elsner. In addition, a balanced lifestyle, an appropriate diet, and strategies for coping with stress would also be helpful.
The dermatologist, however, thinks little of alternative medical or homeopathic promises of healing without scientific proof of effectiveness, or of “neurodermatitis diets”, in which, for example, people are asked to do without eggs or milk. “Of course there are patients who react to certain foods with a surge – but they should then have an allergy test done to clarify.” In general, the disease has a very broad spectrum and requires individual therapy: “No neurodermatitis is like the other. That is why it is all the more important that we have different therapy options. “