Jan 23, 2026
Clinical and molecular changes after allergen immunotherapy in patients with atopic dermatitis. A proof-of-concept clinical trial.
- Jorge Sanchez1,
- Sara Garcia1,
- Claudia-Ximena Asela-Pinzón1
- 1Group of Clinical and Experimental Allergy, "Alma Mater de Antioquia" Hospital, University of Antioquia
- GACE
Protocol Citation: Jorge Sanchez, Sara Garcia, Claudia-Ximena Asela-Pinzón 2026. Clinical and molecular changes after allergen immunotherapy in patients with atopic dermatitis. A proof-of-concept clinical trial.. protocols.io https://dx.doi.org/10.17504/protocols.io.ewov1k9n2gr2/v1
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License: This is an open access protocol distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Protocol status: Working
We use this protocol and it's working
Created: January 22, 2026
Last Modified: January 23, 2026
Protocol Integer ID: 239145
Keywords: Atpic dermatitis, Immunotherapy, Allergy, Safety, Efficacy, Effectiveness, allergen immunotherapy, atopic dermatitis, patients with atopic dermatitis, molecular changes after allergen immunotherapy, immunotherapy, several systemic therapy, systemic therapy, appropriate selection of therapy, topical treatment, clinical response with these therapy, other therapies such as st, other therapy, clinical trial, allergen, personalized medicine, cyclosporine, concept clinical trial, therapy, principles of personalized medicine, inhibitor, clinical response
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Abstract
Rationality: Atopic dermatitis (AD) is a prevalent disease in
childhood (15% to 25%) but also affects 8% of the adult population. Currently,
several systemic therapies (STs) are often used when topical treatments are
insufficient, such as methotrexate, cyclosporine, dupilumab, and JAK
inhibitors. However, these therapies often carry a risk of serious adverse
effects and generate a high cost for the healthcare system. Allergen
immunotherapy (AIT) has shown to be effective in 30% to 50% of patients with
atopic dermatitis. This therapy could be positioned as an alternative to
systemic therapies due to its balance of safety, cost, and benefit. However, it
is necessary to identify those patients with a higher probability of clinical
response since there are no parameters that allow us to predict which patients
could benefit from AIT and which would not, so that they can be prioritized for
other therapies such as STs. Identifying molecular components that allow us to
predict the clinical response with these therapies helps to manage health
resources more efficiently through the appropriate selection of therapies and
also brings us closer to the principles of personalized medicine.
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Clinical and molecular changes after allergen immunotherapy in patients with atopic dermatitis. A proof-of-concept clinical trial.
Rationality: Atopic dermatitis (AD) is a prevalent disease in
childhood (15% to 25%) but also affects 8% of the adult population. Currently,
several systemic therapies (STs) are often used when topical treatments are
insufficient, such as methotrexate, cyclosporine, dupilumab, and JAK
inhibitors. However, these therapies often carry a risk of serious adverse
effects and generate a high cost for the healthcare system. Allergen
immunotherapy (AIT) has shown to be effective in 30% to 50% of patients with
atopic dermatitis. This therapy could be positioned as an alternative to
systemic therapies due to its balance of safety, cost, and benefit. However, it
is necessary to identify those patients with a higher probability of clinical
response since there are no parameters that allow us to predict which patients
could benefit from AIT and which would not, so that they can be prioritized for
other therapies such as STs. Identifying molecular components that allow us to
predict the clinical response with these therapies helps to manage health
resources more efficiently through the appropriate selection of therapies and
also brings us closer to the principles of personalized medicine.
GLOSSARY
EASI: Eczema Area and Severity Index.
DLQI: Dermatology Life Quality Index.
Itchy-NRS: Itchy Numerical Range Score.
Steroid MRP: Steroid maximum recommended potency.
IGA: Investigator Global
Assessment.
SCORAD: Scoring Atopic Dermatitis.
OBJECTIVES
General
objective: To evaluate the efficacy and explore the molecular and clinical
characteristics that may be related to the clinical response to AIT in AD.
Operational
objective: To evaluate the clinical response of immunotherapy according to the
composite outcome (EASI75 and NRS<2) by using allergen immunotherapy for
mites versus conventional treatment with topical steroid according to the
maximum recommended potency (MRP) for age.
Specific
objectives:
1. Evaluate the clinical
response to AIT according to the composite outcome (EASI75 and itchy-NRS<2)
and other clinical scales (SCORAD, DLQI, IGA itchy-INR, Mental health scale).
2. Explore skin and blood
molecular markers and their relationship to clinical response to AIT.
3. Propose potential
prognostic markers to predict clinical response to ITA.
4. Reduction in the need to
initiate biological therapy
Expected
results: Alternative hypothesis (H1): There are molecular markers associated with
the clinical response to ITA in patients with AD. Null hypothesis (H0):
There are no molecular markers associated with the clinical response to ITA in
patients with AD.
STUDY DESIGN
This is a phase IV blinded
randomized clinical trial. The objective of this project is divided into two
parts: 1) to evaluate the efficacy of AIT in AD, and 2) to explore the clinical
and molecular variables that could predict the clinical response to this
therapy.
We will follow the
recommendations of the PROGRESS (Prognosis Research Strategy) initiative for
the evaluation of prognostic factors in phase 2. This will allow us to conduct
an initial exploration of the hypothesis: "There are molecular markers
associated with the clinical response to immunotherapy in patients with atopic
dermatitis." The purpose of this proof-of-concept study is to evaluate the
feasibility of the hypothesis while avoiding high costs. Therefore, an initial
assessment of the feasibility of the idea will be performed to determine
whether subsequent studies with a confirmatory sample size and design warrant
it. AIT will be subminister for 18 months and patients will be followed for 24
months with evaluation periods (Baseline, 3, 6, 9, 12, 18, 24 months). Skin and
serum and samples will be recollected at baseline, 6, 12, 18, 24 months.
OUTCOMES TO BE EVALUATED
Principal outcome: The clinical response of immunotherapy will be evaluated according to the
composite outcome (EASI reduction of 75% from baseline and NRS under
<2points) by using allergen immunotherapy for mites versus conventional
treatment with topical steroid according to the maximum recommended potency
(MRP) for age.
The following secondary outcomes will be evaluated:
1. Clinical response of patients according to the
SCORAD scale.
2. Evaluation of clinical improvement in atopic
dermatitis according to a 50% reduction in the EASI score.
3. Changes in the T2 inflammation profile before and
after receiving the therapies.
4. Changes in the protein expression profile in the
skin and blood before, during, and after receiving the immunotherapy.
PROCEDURES
We will perform
clinical evaluations and collect biological samples to measure molecular
changes. The procedures to be performed are described below.
Clinical scales: The EASI, SCORAD, DLQI, itchy-INR, IGA, Mental health scale, will be assessed at all follow-up points.
Blood samples: These samples will be
used to analyze autoantibodies, specific IgE, the patients' serum proteome, and
eosinophil levels using ELISA, flow cytometry, and fluoroenzyme immunoassay
techniques (ImmunoCap System, Uppsala, Sweden). The measurement of T2 inflammatory
response proteins (e.g., IL4, IL5, IL13, IL21), chemokines (e.g., CCL17, T1,
IL1, IL6, IL2, interferon (IFN)-γ), and regulatory
response molecules (e.g., tumor necrosis factor (TNF)-α, IL10, Fas-L) will
be evaluated using a multi-assay kit for mRNA quantification and/or ELISA. Blood samples will be
recollected at baseline, 6, 12, 18, 24 months.
Skin samples: The natural
moisturizing factor (NMF) will be assessed using a non-invasive technique with
skin tape, known as “tape tripping”. Briefly, the technique involves applying
10 consecutive strips of adhesive tape to the same area of untreated skin.
The first four strips will be discarded to improve sample homogeneity and limit
contamination errors. For each patient, both injured and uninjured skin samples
will be assessed according to the treating clinician's criteria. Each strip
will be pressed against the skin with a roller for five seconds (approximately
200 g/cm³). After application and release of pressure, the strips will be
removed and immediately frozen in dry ice, then stored in a freezer at -70°C
until quantification. The NMF is defined as the sum of the concentrations of
the components histidine, pyrrolidone-5-carboxylic acid (PCA), and the cis and
trans isomers of urocanic acid (cis-UCA and trans-UCA). These components will
be measured in the laboratory using high-performance liquid chromatography (HPLC)
analysis. NMF concentrations will be expressed as nmol/L of protein. A water
vapor meter (Tewameter‱ Tmhex) measuring water vapor per cubic centimeter will
be used to assess transepidermal water loss.
Pharmacotherapy
administration: The permitted pharmacological medications will be:
Hydrocortisone 1% cream, Mometasone 1% cream, and Clobetasol 0.5% cream. The
choice among these treatments will be based on the use of topical treatment at
the maximum recommended potency (MRP) for the patient's age, extent of lesions,
and severity, according to international guidelines. Treatment will consist of
an active regimen (application to the affected area twice daily for a maximum
of 7 days) and a preventive regimen (application to areas with a high frequency
of recurrence once daily on Mondays, Wednesdays, and Fridays). In patients with
a history of steroid-induced reactions, the same regimen will be followed, but
the steroids will be replaced with tacrolimus 0.03% ointment and tacrolimus
0.1% ointment.
Immunotherapy
administration: Allergen immunotherapy is the intervention in this
study. It will be carried out by administering a Derf/Derp/Blot (33/33/34%)
allergen concentrate from Inmunotek Laboratories with an antigenic potency of
10,000 TU/ml. Administration will follow the standard rapid regimen: the
initial dose will be administered subcutaneously in two divided doses (0.2 ml
and 0.3 ml, 30 minutes apart) with a 30-minute interval between doses.
Subsequent doses will be administered as a single dose (0.5 ml) with 30 minutes
of follow-up monitoring. All patients will be instructed on warning signs and
the need to avoid strenuous physical activity for 24 hours. The medication will
be supplied according to the institution's protocol and provided by the
healthcare system. Patients will be contacted one week and 48 hours prior to
immunotherapy administration to ensure it is performed on the scheduled date
and to avoid delays. In the event that the patient loses their social security
coverage, the intervention and its costs will be covered by the study group, at
no cost to the patient. The maximum interval between applications is considered
to be 8 weeks (53); a longer period will be considered a deviation and will be
reported for further analysis of its impact on the results obtained.
Randomization: Before being
assigned to the randomized group, patients must discontinue all therapies that
may influence the clinical control of CRS four weeks prior to randomization
(washout period). Randomization between the active and control groups will be
performed using the Jamovi program with R modules, and the allocation will be
done using a 1:1 scheme.
Blinding of the
intervention: at a central pharmacy, each immunotherapy vial will
be blinded prior to delivery to the administration personnel. The personnel
administering the medication will be different from those preparing it at the
central pharmacy and will not have access to the patients' clinical or
demographic information.
SELECTION CRITERIA
Among
the patients who agree to participate, the following selection criteria will be
considered:
Inclusion criteria
●
Patients diagnosed according to William de Reason
criteria: Target population for study.
●
Having
a DA with EASI greater than 7 points, SCORAD greater than 25 points and
itchy-NRS greater than 4 points
●
AD
patients with IgE sensitization to mites. Reason: Dust mites are the main
allergenic source globally and specifically in Colombia, where the study will
be conducted.
●
Patient
between 6 and 12 years old. Reason: AD is a disease that predominates in
childhood.
Exclusion criteria
●
Patients
with contraindications for starting ITA. Reason: to avoid confounding factors,
since this is the baseline therapy for evaluation.
●
Patients
diagnosed with other serious skin diseases that may alter the skin composition
or the interpretation of the results. Reason: To avoid
confounding factors.
●
Patients
who are receiving a biological therapy at the start of the study.
Patients prior to
randomization will have a washout period where they will receive the study
topical therapies (one month); Hydrocortisone 1% cream, Mometasone 1% cream,
Clobetasol 0.5% Cream, adjusted to MRP.
As a rescue treatment, a cycle
of systemic steroids adjusted to the age will be prescribed. If the patient
receives any other therapy that may affect the interpretation of the results
(e.g., biological therapies or JAK inhibitors), follow-up will continue for
future sub-analyses but will not be included in the main analysis.
RECRUITMENT AND DATA COLLECTION SOURCES
Patients who meet the
selection criteria from at least three centers in two cities in Colombia
(Medellín and Bogotá) will be invited to participate in this study.
BIAS CONTROL
Selection bias: In clinical
trials, selection bias is infrequent, since the selection and recruitment of
the population occur before the outcome of interest, so it can be assumed that
participant selection is independent of the event. Referral bias may occur
because, since the participating centers specialize in AD, there is a potential
risk of including a high number of more severe cases compared to mild cases.
However, in the case of this study, this does not negatively affect the
evaluation, as it specifically focuses on AIT prescribed by an AD specialist;
therefore, the distribution found represents the distribution that the end
users will experience.
Control of
information bias (measurement bias): The clinical variables to be considered in the model are objective and
subject to little variability between evaluators. Due to the nature of the
disease and its characteristic symptoms, these variables can be objectively
assessed using photographic records. This allows for the control of potential
measurement biases, and the personnel administering the tests will be experts
trained in questionnaire administration.
Control of
confounding biases: For this study,
we are interested in identifying variables that can predict a clinical outcome,
regardless of whether the association is causal or not. Therefore,
multivariable analysis here is considered a tool to identify the variables that
best predict the outcome, not a means of controlling for confounding variables.
ETHICAL
CONSIDERATIONS
The study begins
after approval by the ethics committee. The treatment that will be administered
to all patients, both pharmacological and immunotherapy, follows international
guidelines and is part of the conventional management of AD. All patients, and
their parents will sign an informed consent form for the initiation of
immunotherapy, validated by the ethics committee of the University of
Antioquia, which also reviewed and granted permission for the evaluation of the
records, respecting patient anonymity.
SAMPLE SIZE AND POWER
The primary outcome is dichotomous (EASI75 Reduction
or no). For potential utility in real-world clinical practice, we define a
difference of at least 30% in favor of the intervention as clinically relevant.
Based on this assumption, a sample size with the following statistical
factors—a Type I error (α) of 0.05, a Type II error (β) of 0.1, statistical
power of 90%, a two-tailed test, and an effect size of at least 0.2—requires at
least 130 patients per group. According to the formula proposed by Yin-Yin (58)
useful for proof of concept studies, where, essentially, the probability of
reproducing the results in a future confirmatory study is calculated based on
the statistical factors described above, assuming a certain number of subjects
to be included; with 35 patients per group, there is a probability of at least
0.7 that the results of the point-of-care (POC) study will be reproduced in a
subsequent confirmatory study. With 99 patients per group, the probability is
0.8.
RANDOMIZATION AND MASKING
Patients will be randomly assigned (1:1) to AIT group
administrated each month, or placebo group, stratified by baseline disease
severity (moderate and severe EASI). Placebo
will be provided in identical syringes. The study remained blinded to all
individuals (including patients, investigators, and study personnel) until the
time of prespecified unblinding.
STATISTICAL ANALYSIS
The full analysis set
will include all randomized patients for efficacy and molecular evaluation
analyses at prespecified timepoints (3, 6, 12, 18 months). The safety
analysis set will include all randomized patients who received study drug,
based on dose regimen received.
Binary endpoints will
be analyzed using the Cochran-Mantel-Haenszel test adjusted by randomization
strata. Primary analyses of binary endpoints were by intention to treat;
patients were categorized as non-responders after rescue treatment initiation
or study withdrawal.
The distribution of
continuous variables will be assessed using the Shapiro-Wilk test, with a
p-value of 0.05 defining whether or not a distribution is normal: with p ≤
0.05, we reject the null hypothesis that the distribution is normal. In this
description, independent variables will be compared considering the presence or
absence of the outcome. For continuous variables, an unpaired t-test will be
used if the data distribution was normal, or the Mann-Whitney U test if this
criterion was not met.
Categorical variables
will be analyzed with the chi-square test of independence if, in all cases, the
expected frequencies were greater than 5; otherwise, Fisher's exact test will
be used (in both cases, a p-value < 0.05 will be considered significant).
For the evaluation of
predictive models, variables with a p-value < 0.20 in the initial
comparisons will be included (Hosmer-Lemeshow criterion). Those variables that
do not meet this criterion will not be excluded unless the biological
plausibility defined by clinical experts deemed it necessary.
ROLE OF THE FUNDING
SOURCE
This study was funded
by the GREAT (Global Research on Environmental, Allergy, and Autoimmunity in
the Tropics) initiative which is founded by public and private entities
(“Asociación Colombiana de Alergia Asma e Inmunología”, “Alma Mater de
Antioquia” Hospital, Sanofi, Novartis). The financial contribution from the
funders to the initiative is for the researchers' free use, and therefore they
do not intervene in the conception or design of the study, analysis or interpretation
of the data, drafting and critical revision of the report, and gave approval to
submit.