The edition · Dermatology
Stopping omalizumab is usually good news
Median drug survival in chronic urticaria is 3.1 years, and most early discontinuation happens because the urticaria has settled rather than because the drug failed. Plus carbon dioxide against erbium for atrophic acne scars, what CD1a T cells are sensing in eczema, and five-year survival from a melanoma trial that missed its endpoint.
The edition in brief
Today's dermatology desk opens on laser choice for atrophic acne scars. Pooling five comparative studies and 130 analysed participants, erbium-based fractional lasers were less likely than fractional carbon dioxide to achieve more than 50% clinical improvement (RR 0.69, 95% CI 0.49-0.97), though the randomised-only sensitivity analysis crossed the null at RR 0.76 (0.54-1.08). Carbon dioxide cost more pain (mean difference 1.86) and 3.67 more days of downtime, with no significant difference in post-inflammatory hyperpigmentation. A mechanistic study in atopic dermatitis identifies a persistent population of activated CD1a-positive dendritic cells as the dominant source of CCL17 and CCL22 in lesional skin, and shows they express neutral sphingomyelinase that processes inhibitory long-chain sphingomyelin and drives Th2 CD1a-autoreactivity - a route by which T cells appear to sense chronic barrier compromise. A review of psoriasis argues that immune-targeted therapy alone leaves keratinocyte amplification untouched, and proposes dual immune-epidermal targeting as a framework rather than a treatment. Extended follow-up of COMBI-I, which missed its primary progression-free survival endpoint, reports median overall survival of 61.5 months with spartalizumab added to dabrafenib and trametinib against 41.6 months without (HR 0.760, 95% CI 0.598-0.966), at the cost of grade 3 or worse treatment-related events in 57.3% against 36.7%. The edition closes on omalizumab in chronic urticaria: across 4,516 patients, median drug survival was 3.1 years, seven-year survival was higher in chronic inducible urticaria (43-49%) than chronic spontaneous urticaria (30%), autoimmune comorbidity doubled the risk of stopping for lack of efficacy (HR 2.03), and adverse events were an uncommon reason to stop.
Carbon dioxide outperformed erbium on acne scars, and the patient pays for it in downtime
Fractional carbon dioxide clears atrophic acne scars more often than erbium but costs more pain and about four more days of downtime - make that the conversation rather than the default.
What the T cells in eczematous skin are actually detecting
No change to prescribing, but a mechanistic reason to treat barrier repair as part of the inflammatory treatment rather than an adjunct to it.
Why IL-23 and IL-17 blockade leaves some psoriasis behind
Nothing to prescribe differently, but a clearer explanation for why psoriasis so often returns quickly after an effective biologic is stopped.
COMBI-I missed its endpoint and then reported a survival difference
Not a practice change - an overall survival signal in a trial that had already missed its primary endpoint, bought with considerably more severe toxicity.
In skin of colour, the settings conversation comes before the device conversation
Test spot and settings decide pigmentary outcome in darker skin far more than the choice between carbon dioxide and erbium.
Omalizumab in chronic urticaria: three years, and most stopping is success
Tell a patient starting omalizumab that about three years is typical, that most people stop because the urticaria has gone, and that thyroid autoimmunity makes an inadequate response more likely.
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