A worldwide look at drug therapies for eczema

A market research company has just released a new report analyzing the market for eczema therapeutics and predicting how the field will change over the next six years.

The report, titled "Eczema Therapeutics - Pipeline Assessment and Market Forecasts to 2018", can be yours for only $3500.

This type of market research is carried out by independent companies that sell their work to other companies large and small. Because they're providing a commercial, fact-based service, you can expect that they've done a thorough job.

Decisions that companies make based on reports like this explain the gap between what eczema patients need and what actually makes it to market. No matter whether it's feasible to develop a drug, because the cost of taking a chemical compound from discovery to FDA approval is around $1 billion, no company is going to invest in developing a drug that doesn't promise to pay its way and then some.

I tried to get a copy of the report--when I tweeted about it, got a direct message inviting me to apply for my free sample--but when I did, I was asked to pay $3500 upfront. D'Oh! It was unreasonable to expect the market research company to give their product away for free, especially to someone who clearly intends to blab all over the internet.

So we're left trying to deconstruct the table of contents for whatever meaning we can squeeze out of it.

The authors have segmented the globe into the leading national markets: the US, France, Germany, Italy, Spain, the UK, and Japan. I wonder why this order was picked--you'd think that Japan would rank higher than Spain, just because of the population size.

Why have they done this? What's different about the national markets? No surprise that the US leads, nor that all of them are developed Western countries. I suspect, because eczema prevalence seems to track the level of a nation's economy, that the markets are not different because, say, people in France need different therapies than people in the US. But governments regulate drugs differently. French companies--like Sanofi--and their products may enjoy preferential tax treatment in France. Or perhaps European companies are privileged in Europe.

This matters to you, the patient or parent, because you can't assume that the country you live in necessarily has the best therapies available to you. Maybe you live in the UK, but the eczema you have is a variety that is prevalent in Japan, and the Japanese market features therapies that would work best for you. Maybe you should be lobbying your own government to approve those therapies at home. Regional differences in therapies is an area that I am now going to pay attention to.

The authors have also kindly identified the leading companies in the eczema therapeutics field. They are Almirall, Anacor Pharmaceuticals, BioCis Pharmaceuticals, MIKA Pharma GmbH, Novartis AG, GlaxoSmithKline, and Sanofi.

This is useful because, to average Joes like me, the pharmaceutical world seems an unknowable universe where every company makes every kind of drug. But that's not the case. (Where's Bayer in this list? J&J?) Even in big pharma, companies have their cash cows (e.g. Pfizer and, until recently, Lipitor) and their areas of technical expertise. From now on I am going to pay attention to which companies have what products coming down the pipeline. The results of clinical trials, if not published in the business section, are usually sent out in press releases that you can find online.

Interested to learn what, globally, the leading drug therapies for eczema are? I bet you haven't heard of some of them. Protopic (tacrolimus), Elidel (pimecrolimus), MimyX, Atopiclair, and, of course, the whole gamut of topical corticosteroids. I'm going to look more closely at MimyX and Atopiclair, to start. I wonder what they are, what they do, and where they're approved for use.

Common antibacterial also suppresses mast cells--maybe why it works for eczema

Triclosan is a well-known antibacterial found in soaps. I know I've seen it listed on every pump-container of liquid soap that claims to "kill 99% of bacteria," whatever that means. (99% of species? 99% of one species?) What I didn't know until recently about triclosan, which is found in a wide range of consumer products, is that it relieves symptoms of eczema. But scientists are not sure exactly how it works.

New research by scientists led by Julie Gosse at the University of Maine shows that at least one reason that triclosan helps reduce eczema symptoms is that it prevents mast cells in the skin from releasing histamine and other allergy-mediating molecules. Triclosan prevented the scientists' model cells from getting activated in general. In short, it's an immunosuppressant.

Mast cells have molecules on their surfaces that bind to IgE antibodies--the type responsible for allergic hypersensitivity. When mast cells encounter antigen, perhaps from food or pet dander, they release histamine and other molecules, which cause inflammation.

The scientists, working with a laboratory cell line that they claim is identical to mast cells, found that doses of triclosan significantly reduced the amount of one molecule, beta-hexosaminidase, released by the cells when they met antigen.

Activated mast cells change shape, ruffling around the edges. Triclosan also prevented this from happening.

The scientists claim their results show that reducing "degranulation"--the release of granules stored by mast cells--is the way that triclosan helps alleviate skin inflammation in eczema.

Through the paper, the authors refer to histamine--but reducing histamine probably isn't the main avenue by which triclosan acts. If you have eczema, you know that antihistamines don't help. I don't know why some doctors prescribe them. Relatively recent research (I wrote about it here) has identified a neural itch pathway independent of histamine.

So what good is this research?

It helps clarify the picture of what triclosan is doing. It's a contribution that could, in the end, help produce another topical anti-itch ointment that incorporates triclosan or some derivative, possibly together with a steroid. You'd think it'd be a no-brainer, because of its antibacterial properties. But, like any drug, triclosan comes with its own side effects.

[Edited Jan.13]

Controlling scratching and modeling how to behave for your kids

If you've got eczema, you scratch. And sometimes you scratch in front of others--either you're not aware that you're doing it, or you are but you're nervous, or you've just got that itch that needs dealing with. You can control it when you really need to--say you're on stage presenting a talk at a conference. As soon as you're out of the spotlight, you give in to the urge.

But sometimes you get called on it. "Hey, why are you scratching?" Or you can tell someone's noticed. And that's embarrassing. Because it's not socially acceptable to do it in public. Like picking your nose or masturbating, scratching is something that most people do privately if they want to keep their jobs and spouses.

So how do you explain to a child with eczema that they should try not to scratch in public? Given, of course, that some outbreaks are unbearably itchy and you can't help yourself. I'm talking about scratching that you could control if you wanted to.

This hasn't come up as an issue for us yet, but I've been thinking about it. You know that just telling your kids to do something is not enough.You have to model the behavior yourself. I know this well. Just this week (as a New Year's resolution) I started eating raw vegetables, instead of my usual chips or chocolate, in front of the kids during their dinnertime. Whaddya know? All of a sudden Voov wants a carrot stick. Shmoop can't get enough kohlrabi.

If Voov, currently two and three quarters years old, grows up with eczema, as she shows every sign of doing, I'd like her not to scratch unduly in public. They'll eat you alive in high school for that. So, as her eczema-afflicted dad, I need to try not to scratch in front of her.

I admit it. Around my kids, I usually behave as if they're not even there, when it comes to personal matters. When your kids like to barge into the bathroom and closely examine your butt as you're toweling off after a shower, it's hard to follow Miss Manners' code of conduct once you're fully dressed. So I often find myself vigorously scratching my feet, or picking at my scalp, in front of Voov.

Really, I need to smarten up and stop this; act as I would in front of my boss. Because the only way she's going to know how to control herself, to the extent it's possible with eczema, is if I show her that it can be done.

I'm hoping I can speak to a behavioral expert about this and learn some tips about controlling compulsive scratching--an issue that I wouldn't be surprised to learn is connected to OCD. If I do learn anything, I'll blog about it.

Three new eczema mutations discovered. Is this useful?

A large-scale genetic study recently identified three new locations in the human genome at which mutations are linked to eczema. Two of the locations are near genes thought to be important in dividing and developing skin cells; the third is near a cluster of genes involved in chemical signaling.

The study was published in Nature Genetics, a high-ranking journal. It is actually a meta-study, which re-analyzes data from 30 other studies, totaling more than 11,000 people affected with eczema and more than 40,000 unaffected controls. I don't know how meta-studies account for all the differences in methods and objectives, but I am impressed with the numbers. Generally when it comes to genetics bigger is better.

The question for a patient is: how is this information going to lead to a therapeutic (e.g. new drug)? At this point the researchers don't even know what the genes in the mutated regions do. (None of the mutations were actually IN genes; they were in regions BETWEEN genes.) To get to a therapeutic, you'd have to identify how the mutations affect proteins, what the proteins do, and find drug targets on those proteins, screen for drugs that work, and proceed through the whole billion-dollar death march to FDA approval.

Basically, we're not going to see something in our lifetime from this. Our kids might though.

The authors do at one point say "These observations...support the claim that atopic dermatitis encompasses distinct disease entities rather than being one illness, as is reflected by the current, relatively broad and inclusive concept of this condition." It is possible that within a decade or so we could see direct-to-consumer genetic tests that could tell you what subtype of eczema you suffer from, and you or your doctor could use this information to pick a treatment that might be more effective.

The Eeyore within me says that I'd most likely find that my type was the least treatable. Would I want to know this? Curiously, yes. I found out a few years ago that I carry one copy of the most common mutation for cystic fibrosis. Not good news, but it gave me a small sense of power to have the information.

Blog on hold

Have to take a break for a while to work out some NEW back problems. Isn't getting older fun? Best wishes to everyone.