The Journal of Allergy and Clinical Immunology
Volume 121, Issue 1 , Pages 122-128, January 2008

Anti-CD20 (rituximab) treatment improves atopic eczema

  • Dagmar Simon, MD

      Affiliations

    • Department of Dermatology, Inselspital, University of Bern, Bern, Switzerland
    • ,
  • Susanne Hösli, MD

      Affiliations

    • Department of Pharmacology, University of Bern, Bern, Switzerland
    • ,
  • Ganna Kostylina, PhD

      Affiliations

    • Department of Pharmacology, University of Bern, Bern, Switzerland
    • ,
  • Nikhil Yawalkar, MD

      Affiliations

    • Department of Dermatology, Inselspital, University of Bern, Bern, Switzerland
    • ,
  • Hans-Uwe Simon, MD, PhD

      Affiliations

    • Department of Pharmacology, University of Bern, Bern, Switzerland
    • Corresponding Author InformationReprint requests: Hans-Uwe Simon, MD, PhD, Department of Pharmacology, University of Bern, Friedbühlstrasse 49, CH-3010 Bern, Switzerland.

Received 2 October 2007; received in revised form 14 November 2007; accepted 14 November 2007.

Article Outline

Background

Atopic eczema (AE) is a chronic inflammatory skin disorder characterized by eczematous skin lesions, pruritus, and typical histopathologic features.

Objective

We asked whether depletion of B cells by monoclonal anti-CD20 antibody therapy (rituximab) would improve severe AE.

Methods

Six patients (4 women and 2 men) with severe AE received 2 intravenous applications of rituximab, each 1000 mg, 2 weeks apart. To evaluate the efficacy of rituximab, we monitored clinical parameters (eczema area and severity index, pruritus), total and allergen-specific IgE levels, skin histology, and inflammatory cells and cytokine expression in the skin and peripheral blood before and after therapy (ClinicalTrials.gov Identifier: NCT00267826).

Results

All patients showed an improvement of their skin symptoms within 4 to 8 weeks. The eczema area and severity index significantly decreased (before therapy, 29.4 ± 4.3; week 8, 8.4 ± 3.6; P < .001). Histologic alterations such as spongiosis, acanthosis, and dermal infiltrate, including T and B cell numbers, also dramatically improved. However, whereas blood B cells were below detectable levels as a consequence of rituximab administration, skin B cells were reduced by approximately 50% only. Expression of IL-5 and IL-13 was reduced after therapy. Moreover, whereas allergen-specific IgE levels were not altered, we observed a slight reduction in total IgE concentrations in blood.

Conclusions

B cells play a major role in AE pathogenesis. Treatment with an anti-CD20 antibody leads to an impressive improvement of AE in patients with severe disease.

Key words: Atopic dermatitis, B cells, biologics, cytokines, inflammation, rituximab, T cells

Abbreviations used: AE, Atopic eczema, EASI, Eczema area and severity index, ECP, Eosinophil cationic protein

 

Atopic eczema (AE) is a chronic inflammatory skin disorder based on a genetic predisposition and triggered by environmental factors presenting with erythematous, oozing or scaling lesions, and severe pruritus.1 The typical histopathologic findings are acanthosis and spongiosis of the epidermis, as well as a perivascular infiltrate in the dermis, consisting predominantly of T cells,2 but variable numbers of B cells, mast cells, and eosinophils are also present.3, 4, 5 In about 80% of patients with AE, elevated levels of total IgE and/or specific IgE to environmental allergens are found.6 Furthermore, Langerhans cells of AE skin bear the high-affinity IgE receptor on their surface, thus providing the link between environmental allergen exposure and T-cell activation.7 These observations point to the possibility that B cells play a role in AE pathogenesis.

Rituximab is a chimeric monoclonal anti-CD20 antibody, originally developed for the therapy of B-cell malignancies, that eliminates B cells8 by inducing antibody-dependent cell-mediated cytotoxicity, complement-dependent toxicity, or apoptosis.9 CD20 is expressed by pre-B cells and mature B cells, but not plasma cells.10 Recent studies reported the efficacy of rituximab in the treatment of autoimmune diseases, such as rheumatoid arthritis,11, 12, 13 SLE,14, 15 and pemphigus vulgaris.16, 17, 18, 19, 20 The efficacy of rituximab in these clinical studies could not simply be explained by a reduction in autoantibody titers, because this was often not the case. Instead, it was suggested that the loss of the antigen-presenting and immunomodulatory functions of B cells might be responsible for the beneficial clinical effects.21

Because it was likely that, besides T cells, B cells play a role in AE pathogenesis, we initiated a pilot study to investigate the clinical efficacy and immunopharmacologic effects of rituximab in AE. In addition to clinical parameters, we monitored inflammatory cells and cytokines in peripheral blood and skin lesions.

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Methods 

Patients 

In this investigator-initiated, open-label pilot study, 6 patients with severe AE according to the criteria of Hanifin and Rajka22 (4 women, 2 men; age, 19-63 years; average, 39 ± 7 years) were enrolled between October 2005 and April 2006. All patients had not adequately responded to topical corticosteroid and/or calcineurin inhibitor therapy and were candidates for, or had previously received, systemic treatment. Patient characteristics are given in Table I. The study was approved by the ethics committee of the Canton Bern. Written informed consent was obtained from all patients before participation in the study. All patients had a 2-week washout of all topical therapy except corticosteroids and a 4-week washout of systemic treatment except antihistamines. Two weeks before rituximab administration and during the study period, the treatment was restricted to moderately potent topical corticosteroids (mometasone, halometasone) and antihistamines (hydroxycine, cetericine) as needed. Complement deficiency, immunoglobulin deficiencies, and severe infections had been ruled out before rituximab treatment. The study design is shown in Fig 1. Rituximab (MabThera; Roche Pharma [Schweiz] AG, Reinach, Switzerland) was administered twice, each 1000 mg intravenous, 2 weeks apart. To avoid intolerance reactions, 1000 mg paracetamol and 2 mg clemastinum were given before each infusion. Punch biopsies were taken from lesional skin before and from the same or symmetrical areas 6 weeks after therapy. All 6 patients finished the study including the 22-week observation period after therapy.

Table I. Patient characteristics
Patient no.Sex, age (y)Duration of AEGrading of AE∗EASI at baselineTotal IgE (kU/L)Specific IgE to inhalative allergens† (kU/L)Specific IgE‡Skin prick test‡
1Male, 4820938.0475089.9B,G,C, HDMB,G,C, HDM
2Female, 2713832.0187493.1G,C, HDMG,C, HDM
3Female, 4947927.0301078.4G,CG,C
4Female, 197817.047126.9B,GB,G
5Male, 2622943.52275>100B,G,C, HDMNot done
6Female, 6320818.049416.8HDMHDM

∗Grading of long-term severity according to Langeland and Rajka (1-3 = mild AE; 7-9 = severe AE).

†Screening test of 8 common inhalative allergens (house dust mite [Dermatophagoides pteronyssinus], cat and dog danders, mold [Cladosporium herbarum], and pollens of birch, grass, mugwort, and rye).

‡Test for pollens of birch (B) and grass (G), cat dander (C), and house dust mites Dermatophagoides pteronyssinus and Dermatophagoides farinae (HDM).

Clinical parameters 

To evaluate the clinical efficacy of rituximab therapy, the eczema area and severity index (EASI),23 a pruritus score (0, no; 1, mild; 2, moderate; 3, severe), the use of concomitant therapy for AE such as topical corticosteroids and antihistamines, and adverse events were monitored at each visit.

Peripheral blood analysis 

To monitor platelet, leukocyte, and differential counts, an automatic blood count analysis system (Sysmex KX-21, Sysmex Corp, Kobe, Japan; Digitana SA, Yverdon-les-Bains, Switzerland) was used. To determine lymphocyte subsets, blood was analyzed by standard flow-cytometric techniques using a FACS Calibur (BD Biosciences, Basel, Switzerland).24, 25 Total and specific IgE levels were measured with the UniCAP system (Phadia, Uppsala, Sweden).

PBMCs were separated from peripheral blood by Ficoll-Hypaque density gradient centrifugation.26, 27 The cells were suspended at 1 × 106/mL in complete culture medium (RPMI 1640 supplemented with 2 mmol/L L-glutamine, 200 IU/mL penicillin, 100 μg/mL streptomycin, and 10% FBS; all from Life Technologies, Basel, Switzerland) and cultured in the presence and absence of phytohemagglutinin for 24 hours. The supernatants were harvested and frozen at –80°C until cytokine analysis. IL-2, IL-4, IL-5, and TNF-α were measured using a Cytometric Bead Array assay (BD Biosciences). IL-13 levels were determined with the Quantikine ELISA kit (R&D Systems, Abingdon, United Kingdom).

Skin histology 

Sections of 6 μm of the paraformaldehyde-fixed, paraffin-embedded skin biopsies were stained with hematoxylin and eosin and examined by light microscopy in a blind fashion (Axiovert 35; Carl Zeiss, Heidelberg, Germany). To assess the extent of hyperkeratosis, acanthosis, spongiosis, and dermal infiltrate, a semiquantitative score (0, none; 1, mild; 2, moderate; 3, severe) was applied.4

Immunohistologic examination 

Immunofluorescence staining was undertaken on 4-μm sections of paraformaldehyde-fixed and paraffin-embedded skin biopsies. To identify the inflammatory cell pattern in the dermis, sections were treated with monoclonal antibodies against CD4 (TH cells) and CD8 (T effector cells) purchased from Serotec (Düsseldorf, Germany), against CD20 and CD21 (B cells) from Biogenesis (Poole, United Kingdom [UK]), against eosinophil cationic protein (ECP; eosinophils) from Pharmacia & Upjohn Diagnostics AB (Uppsala, Sweden), and against tryptase (mast cells), CD1a (epidermal dendritic cells), and CD138 (plasma cells; all from Dako, Baar, Switzerland) at 4°C overnight. To analyze cytokine expression by T cells, in addition to the CD4 or CD8 antibodies, antibodies recognizing human IL-5 and IL-13 (both from Santa Cruz Biotechnology, Santa Cruz, Calif) as well as against IL-10 and IFN-γ (both from R&D Systems) were used. Antibody binding was detected with appropriate Alexa Fluor 488–conjugated (Invitrogen, Paisley, United Kingdom) and/or indocarbocyanine (Cy3)–conjugated (Jackson ImmunoResearch, Suffolk, United Kingdom) secondary antibodies. Mouse IgG1 and rabbit IgG negative control antibodies (both from Dako) and normal goat IgG (R&D Systems) served as negative controls. Immunofluorescence staining was evaluated by 2 independent investigators using a confocal laser scanning microscope (LSM 510; Carl Zeiss) equipped with argon and helium-neon lasers. Positive cells were counted in 10 consecutive fields, which were 0.1 mm2, at a magnification of ×1000.

Real-time PCR 

Total RNA was extracted from fifty 10-μm sections by using the RNeasy Fibrous Tissue Kit (Qiagen, Basel, Switzerland). Contaminating DNA was removed with DNase (Qiagen). Total RNA yield and quality were determined by the NanoDrop spectrophotometer (NanoDrop Technologies, Wilmington, De) and Agilent 2100 bioanalyzer (Agilent Technologies, Palo Alto, Calif). cDNA was prepared with Powerscript RT (BD Biosiences) and random primers (Promega, Madison, Wis) according to the manufacturer's instructions. PCR was performed by using TaqMan Gene Expression Assays (Applied Biosystems, Foster City, Calif). PCR primers and probes were purchased as premade assays on demand spanning exon-exon borders for IFN-γ, IL-5, IL-10, IL-13, and 4 control genes (ribosomal 18S RNA, hypoxanthine phosphoribosyltransferase 1, β2 microglobulin, glyceraldehyde-3-phosphate dehydrogenase). By using geNorm software (PrimerDesign Ltd, Southampton, UK), hypoxanthine phosphoribosyltransferase 1 was determined as the most stable expressed control gene and further used as an endogenous reference gene.28 Amplification reactions were performed in a final volume of 20 μL with 1 μL cDNA, 1 set each of TaqMan Universal PCR Master Mix and Assay-on-Demand Gene Expression Assay Mix using the 7300 Real Time PCR System (both Applied Biosystems). Cycle conditions were as follows: after a 10-minute hold at 95°C, the samples were cycled 40 times at 95°C for 15 seconds and 60°C for 1 minute.

Statistical analysis 

Data are presented as means ± SEMs. To compare the data before and after therapy, the t test or t test on ranks was applied. In cases of repeated measurements, the 1-way ANOVA or 1-way ANOVA on ranks was used. A P value <.05 was considered statistically significant. The P values of significant differences are indicated in Fig 2, Fig 3, Fig 4, Fig 5 and Table II. Analysis of relative gene expression was performed with the 2-ΔΔCT method as described previously.29

  • View full-size image.
  • Fig 2. 

    Rituximab improves AE symptoms in association with B-cell depletion in blood. A, Clinical response within 4 weeks, after 2 rituximab infusions, in patient 5. B, Time-dependent EASI reduction after rituximab treatment. P values of significant differences are indicated. C, Effect of rituximab on circulating B-cell (CD20+) numbers in each of the 6 patients (P 1-6).

  • View full-size image.
  • Fig 3. 

    Histologic features of patients with AE before and after rituximab treatment (week 8). A, Hematoxylin and eosin–stained skin biopsy specimens (×200). B, Statistical analysis of hyperkeratosis, acanthosis, spongiosis, and dermal infiltrate. P values of significant differences are indicated.

  • View full-size image.
  • Fig 4. 

    Identification of dermal infiltrating cells by immunofluorescence analysis. A, Statistical analysis on the numbers of inflammatory cells in skin lesions of patients with AE before and after rituximab treatment (week 8). P values of significant differences are indicated. B, Representative original results of the identification of dermal infiltrating cells (×1000).

  • View full-size image.
  • Fig 5. 

    Expression of cytokines in skin biopsy specimens before and after rituximab treatment (week 8) as determined by double immunofluorescence analysis. A, Statistical analysis on the numbers of cytokine-producing CD4+ and CD8+ cells in skin lesions of patients with AE. P values of significant differences are indicated. B, Representative original results of the data presented in A (CD4+; ×1000).

Table II. Immunophenotyping of PBMCs
After therapy
Cell population Surface markerBefore therapy Week 0Week 4Week 8Week 16Week 24
CD20+9.9 ± 2.90.0 ± 0.0∗0.0 ± 0.0∗0.0 ± 0.0∗0.4 ± 0.2∗
CD3+75.7 ± 2.581.5 ± 2.980.3 ± 2.784.2 ± 2.482.1 ± 2.4
CD3+CD4+52.2 ± 3.457.6 ± 3.054.9 ± 2.561.0 ± 1.356.9 ± 3.0
CD3+CD8+22.0 ± 1.422.9 ± 1.524.1 ± 1.620.8 ± 2.922.9 ± 1.9
CD4+HLA-DR+7.2 ± 1.88.6 ± 1.56.7 ± 2.26.1 ± 1.78.0 ± 1.8
CD4+CD25+44.6 ± 7.940.8 ± 6.236.5 ± 6.039.2 ± 5.440.8 ± 6.3
CD8+HLA-DR+13.4 ± 4.017.9 ± 4.315.0 ± 4.113.3 ± 3.816.8 ± 5.5
CD8+CD25+8.7 ± 1.94.9 ± 1.0∗4.2 ± 0.9∗3.9 ± 0.8∗4.0 ± 0.8∗
CD3-CD16+CD56+4.9 ± 1.67.9 ± 2.48.4 ± 1.96.7 ± 1.99.2 ± 3.0
CD14+HLA-DR+99.0 ± 0.598.4 ± 0.698.8 ± 0.699.1 ± 0.599.1 ± 0.4

∗Statistically significant difference from relative cell number before therapy (P < .05).

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Results 

Reduction of AE symptoms by rituximab 

To evaluate the clinical efficacy of the treatment with rituximab, the EASI was determined. Before treatment, the mean EASI was 29.4 ± 4.3 (Table I). All patients had a significant improvement of their AE lesions within 4 weeks of treatment (Fig 2, A and B). In 2 patients, we observed a rapid improvement within the first week of treatment. All patients further improved between weeks 4 and 8. One patient developed a moderate flare-up at week 12. At weeks 16 and 24, all patients had low EASI scores, suggesting a sustained effect of rituximab, in spite of the fact that B cells became detectable in blood in 50% of the patients at week 24 (Fig 2, C). The pruritus scores decreased in parallel with the EASI scores (data not shown). All patients reduced the application of topical corticosteroids. The average frequency of application was 6 times per week before therapy and declined to 3 times at week 8. Moreover, with the decrease of affected skin areas, the amount of applied corticosteroids markedly decreased.

The treatment with rituximab was well tolerated; no severe adverse events were observed. However, 1 patient reported pain in the leg starting 12 hours after the second infusion, resolving the next day after taking paracetamol and ibuprofen. During the 24-week study period, 1 patient reported an infection of the upper airways with fever, another patient had otitis media treated with antibiotics for 1 week, and a third patient had a 1-day episode of nausea and vomiting.

Depletion of B cells and reduced T-cell activation in blood 

Platelets and red and total white blood cell counts were monitored at each visit, revealing no significant differences. The immunophenotyping of lymphocytes revealed that the number of CD20+ cells dropped to 0 within 3 days (data not shown). CD20+ cells started to return in 3 patients at week 24 (Fig 2, C). In contrast with B cells, numbers of CD4+ and CD8+ T cells, CD3-CD16+CD56+ (natural killer) cells, and HLA-DR+ monocytes did not show any significant differences before and after therapy (Table II).

A significant reduction of CD8+CD25+ was observed, suggesting reduced activation of CD8+ T cells in association with rituximab treatment (Table II). The presence of reduced numbers of activated T cells in blood was also indicated by reduced spontaneous IL-13 production of PBMCs ex vivo (before, 25.7 ± 5.7 pg/mL; after, 5.5 ± 4.1 pg/mL; P = .018). The spontaneous production of IL-2, IL-4, IL-5, and TNF-α was also, but not significantly, reduced after therapy (data not shown). The proliferation rate and cytokine production of PBMCs on phytohemagglutinin stimulation in vitro was not affected by rituximab therapy (data not shown).

No reduction of total and allergen-specific IgE levels 

Before therapy, all patients had elevated levels of total IgE (2145 ± 662 kU/L), specific IgE to environmental allergens (67.5 ± 14.8 kU/L), and positive skin prick tests (Table I). Eight weeks after initiation of therapy, total IgE levels (1861 ± 612 kU/L; P = .067) but not allergen-specific IgE levels (73.4 ± 14.5 kU/L) were slightly reduced.

Reduced acanthosis, spongiosis, and inflammatory infiltrate 

The biopsy specimen from all patients taken from lesional AE skin before therapy revealed the typical features of eczematous skin. After treatment, the skin histology showed an impressive improvement (Fig 3, A). All assessed parameters, hyperkeratosis, acanthosis, spongiosis, and the infiltration by dermal inflammatory cells decreased significantly toward findings usually seen in nonlesional skin of AE4 (Fig 3, B).

Marked reduction of B and T cells in the skin 

To identify the inflammatory cells infiltrating the dermis of lesional skin, we stained cells with antibodies against lineage-associated markers. Before therapy, the dermal infiltrate largely consisted of CD4+ and CD8+ T cells and to a lesser extent B cells (CD20+), eosinophils (ECP+), and mast cells (tryptase+). We also quantified epidermal dendritic cells (CD1+). On therapy with rituximab, a marked decrease of T cells and B cells, but not eosinophils and mast cells, was observed (Fig 4, A). For the detection of B cells, we also used anti-CD21 antibodies to exclude the possibility that rituximab might have bound to B cells and therefore somehow prevented CD20 staining. However, this was not the case, because both anti-CD20 and anti-CD21 antibodies yielded same results (Fig 4, B). Therefore, the partial disappearance of skin B cells (approximately 50% of the original numbers) did indeed occur as a consequence of rituximab treatment. Plasma cells (CD138+) were observed only occasionally in specimens taken before and after therapy.

Decreased IL-5 and IL-13 expression in the skin 

By measuring mRNA of cytokines in the skin, we observed relative decreases in IL-5 (mean reduction, 53%; range, 20% to 73%) and IL-13 expression (mean reduction, 83%; range, 79% to 86%) after rituximab treatment. In contrast, only marginal changes were seen in IFN-γ and IL-10 mRNA expression (both were reduced by 16% only). We also determined the expression of these cytokines by immunofluorescence analysis. In agreement with the mRNA expression data, the numbers of cytokine-expressing CD4+ and CD8+ T cells were reduced after therapy (Fig 5). Therefore, the reduced IL-5 and IL-13 mRNA expression was likely a result of reduced infiltration of T cells expressing these cytokines. However, it remains unclear why the reduction in IL-10 and IFN-γ mRNA expression was less dramatic compared with IL-5 and IL-13. Clearly, mRNA and protein levels do not necessarily correlate. On the other hand, it is also possible that the remaining T cells express more IL-10/IFN-γ per cell and/or other cells start producing these cytokines on the initiation of rituximab treatment.

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Discussion 

The inflammatory reaction in AE is orchestrated by various immune cells. In contrast with T cells, little is known about the role of B cells in AE skin, which are also found among the dermal infiltrating cells, although in smaller numbers compared with T cells.3, 4, 5 Inspired by the excellent clinical effects obtained by selective B-cell depletion in autoimmune diseases,11, 12, 13, 14, 15, 16, 17, 18, 19, 20 we initiated this pilot study to evaluate the clinical and immunopharmacologic effects of rituximab in AE. We applied the same dosage regimen as previously used for the treatment of rheumatoid arthritis.13 As expected, treatment with rituximab completely abolished blood B cells for at least 4 months. In contrast with blood B cells, little is known about the effect of rituximab on B cells present at inflammatory sites. This study shows that rituximab reduced B cells in lesional skin of patients with AE by approximately 50%, suggesting that the mechanisms believed to be responsible for B-cell depletion in blood and bone marrow may not fully function in inflamed tissues.

Although skin B cells were not completely depleted, the reduction of their numbers was associated with an impressive improvement of AE symptoms, reduced skin inflammation, and normalization of skin architecture. All 6 patients with AE involved in this study demonstrated an improvement of skin symptoms and pruritus with a maximal reduction of the EASI by approximately 70% four weeks after initiating rituximab treatment. The clinical improvement was sustained for at least 24 weeks. However, it should be noted that a moderate AE exacerbation was observed in 1 patient at week 12 that was not related to an increase in blood B-cell numbers. This study suggests for the first time that rituximab is effective in severe AE recalcitrant to topical therapy with corticosteroids and calcineurin inhibitors.

How can we explain the effect of an anti–B-cell therapy in a disease that has been considered largely T-cell–driven? Physiologically, besides their role in antibody production, B cells function as antigen-presenting cells, activators of T cells and dendritic cells, and cytokine/chemokine-producing cells.21, 30, 31 In AE lesions, B and T cells may interact closely with each other. For instance, B cells may present allergenic peptides to CD4 cells, leading to their activation and cytokine production.32, 33, 34 This interaction requires direct contact between B and T cells via MHC class II/T-cell receptor and additional surface receptors, such as CD40 and CD80/CD86 on B cells and their ligands CD154 (CD40L) and CD28 on T cells.

The costimulatory molecule CD86 was reported to be highly expressed on B cells in AE.35 Moreover, costimulation of CD28 on T cells results in the production of large amounts of IL-5 and IL-13 in AE.27 Therefore, it is likely that the reduction of B cells in lesional skin of patients with AE results in reduced T-cell activation, explaining, at least in part, the clinical improvement as well as the reduced cytokine production by T cells that we observed in this study as a consequence of rituximab treatment. This assumption is supported by the observation that rituximab also reduced T-cell activation in patients with lupus nephritis, as indicated by a downregulation of the costimulatory molecule CD154 (CD40 ligand) and the activation markers CD69 and HLA-DR.36 Moreover, in a mouse model of rheumatoid arthritis, it has been demonstrated that B cells are required for the production of proinflammatory cytokines by CD4+ T cells, such as IFN-γ and IL-1β.37

B cells are also involved in chemoattraction of other immune cells. Activated B cells produce the chemokines CCL17 (thymus and activation-regulated chemokine) and CCL22 (macrophage-derived chemokine); both were found to be elevated in AE.38 Lowering the expression of these chemokines in the skin by reducing B-cell numbers would likely inhibit the recruitment of TH cells, which selectively express the matching receptor CCR4. IL-16 is another chemokine attracting CD4+ T cells that is highly expressed in AE39, 40 and also produced by B cells.41 In conclusion, the reduction of skin B cells in AE can result not only in reduced T-cell activation but also in less T-cell recruitment into AE lesions.

Because plasma cells do not express CD2042 and survive for months or even years,43 rituximab has no dramatic effect on total serum immunoglobin levels.44 In patients with SLE, a decrease was seen in the IgM and IgE classes, but not in the IgG fraction.45 The clinical effect of rituximab in patients with rheumatoid arthritis did not seem to be exclusively related to a decrease of disease relevant autoantibodies.46 Other studies in autoimmune diseases reported a clinical improvement despite constant disease antibody titers in some patients.18, 47 We did not observe a reduction in allergen-specific IgE antibodies at week 8 on initiation of rituximab treatment. Total IgE levels were only slightly decreased within this period. Therefore, the clinical effect of rituximab was unlikely the consequence of reduced allergen-specific IgE levels. Future studies should involve patients with AE with the intrinsic form6 to investigate whether rituximab is indeed effective in AE independent of any potential influence on IgE production.

This is the first report regarding the use of rituximab in an IgE-associated allergic disorder. The study was initiated to prove the concept that depletion of B cells may improve AE. Because the effect of rituximab in AE was not predictable, the study was performed open-label with the permission of concurrent use of topical corticosteroids and antihistamines. Our results clearly identify B cells as key players in the pathogenesis of AE and support the concept that B cells regulate the immune response beyond antibody production.48 However, which B-cell subpopulations are responsible for the drug response requires additional investigation.49 Rituximab appears to be promising in patients with severe AE recalcitrant to topical corticosteroid and/or calcineurin inhibitor therapy. Further placebo-controlled studies are necessary to define the efficacy and safety of rituximab in patients with AE.

Clinical implications

Rituximab is a drug that can be used in severe atopic eczema. Further clinical studies are recommended.

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We are indebted to the participating patients and to E. Kozlowski and E. Seger, who provided excellent technical support. Rituximab was provided by Roche Pharma AG, Reinach, Switzerland.

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 Supported by grants from the Swiss National Science Foundation (310000-107526) and Roche Pharma AG, Reinach.

 Disclosure of potential conflict of interest: The authors have declared that they have received research support from Roche Pharma AG.

PII: S0091-6749(07)02253-1

doi:10.1016/j.jaci.2007.11.016

The Journal of Allergy and Clinical Immunology
Volume 121, Issue 1 , Pages 122-128, January 2008

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