Dupilumab is highly effective.
Some patients of severe AD got remarkable reliefs even within two weeks after they started only the first subcutaneous injection.
Most patients are achieving marvelous clearance of their skin eczema,
and especially, tremendous itch of their skin has also gone.

So far, it is a safe medicine, too.
The most conspicuous adverse effect is conjunctivitis, which is controllable by eye drops.
Severe allergic reactions to the ingredients, or critical infections of microbes due to the immunosuppression have not been noted.

Many AD patients may wish for it, hoping if it doesn’t cost so high.
Frequent (once two weeks) injections mean more bothersome tasks than topical/oral agents, but up to now, patients are allowed to inject by themselves.
Just injecting secretly at home enables them to become free from all the physical, mental and social burdens from AD.
Dupilumab might bring an ideal cure to AD ones.

But monoclonal antibodies focusing to one specific target in this complex human immune system, made by an expert technology of the genetic modification, can not be obtained cheap and easy.
AD is not beyond an eczema, although sometimes patients suffer so much. We should think deeply whether it is reasonable to use such an expensive drug to only an eczema or not.

So the indications of such drugs should originally be restricted.
Each and every antibody medicine is commented in its instruction to use only for poorly improving cases by no means.
In cases of cancers and sarcomas, the indications are progressed, recurrent or metastatic stages, which can not be removed by operations, and/or exacerbate even after a chemotherapy.

As for dupilumab, its indication for AD is limited to adult AD with severe inflamed exanthema extended, which has not been relieved nevertheless adequate treatments of topical steroids or tacrolimus were done.
And patients have to understand it’s not a curable therapy.
Their daily tasks of applying emollients also remain.
Non-responders should cease the drug within 16 weeks as though few will fall in such unhappy cases.

All these restrictions eloquently tell how strong the power of the drug is.
It will impact immunologically and economically.
The former can affect human lives. The latter menaces both personal and social moneys.

Wise physicians always have the ability to assume such immunological risk.
While antibody drugs suppress some part of human immunity, which should be a protecting wall against external threats, microbes can break into our bodies and produce a fatal infectious disease.
All immunosuppressants for AD, like previous oral corticosteroids or an oral cyclosporin, often involve such adverse effects; that’s why they should be regulated within short-time use.

However, while a drug responses good and achieve somewhat reliefs, clinicians tend to overlook future risks instead.
Many patients suffering from severe eczema are often continuously/intermittently managed with low-dose oral corticosteroids for months or years.
In addition to the compromised immunity problems, corticosteroids also change fat tissue distribution and make a round, characteristic moon face.
Patients’ skin, soft tissue and blood vessels, many structures of bodies will gradually be thin and fragile.

In October, 2008, another immunosuppressant, cyclosporin capsules, were added AD in indication, just for the severest cases.
Though the results were not so satisfactory as initially expected, it has been the drug of last resort for difficult AD patients in whom any standard remedies like topical ointments, oral tablets and immuno-modulating ultraviolet radiations did not accomplish sufficient outcomes. There was no other means.
The prescription must be minimum; in no-response cases, dermatologists ought to give up within 8 weeks and even in effective cases, a continuation over 12 weeks is banned.
However, we can find some dermatologists who intend to break this rule.

Among adverse effects of it, over 5% patients experience reversible/irreversible renal disturbance.
And their blood pressure rises.
If it was easily used for long, then comes renal dysfunction, hypertension and immunosuppression.
A severe infections like acute pneumonia might be life-threatning.
Cyclosporin imposes life-and-death ills on AD patients instead of small reliefs.

Then, how about dupilumab and other antibody agents in preparation?
Can they be miraculous drugs, suppressing only limited points of AD patient so as to any adverse serious infection won’t occur in many years?
Or, may continuous medication totally change patients’ IL-4 immunity to normal, then after some years, he/she can finally quit dupilumab without certain aggravation?
It also can happen because originally, AD has a natural tendency to relieve.
Human bodies always adapt really well with any circumstances.

On the contrary, in other AD patients, antibody agents may be neutralized or sensitized and should be switched to another ones someday soon.
Or he/she might fall behind in the drug payment even the national medical financial help assists him/her.
Most of all, infectious attacks or other unknown adverse events will happen to them.

Nobody knows the total prognosis of AD with dupilumab yet.
We still have only three years’ experiences.
When an AD patient asks the doctor when he/she can stop it, there is no correct answer, but a plan.
If you don’t like an empty promise, you’d better not to start those medicines.

The philosophy of modern western medicines is, basically, allopathy.
They resist symptoms, they treat symptoms, then achieve an asymptomatic state, which means cure.
The supreme order is to suppress the condition how effectively, efficiently and safely all the time.
But, sometimes it leads to a true cure.

So, this dupilumab might be a perfect product.
It has done a pinpoint suppression to the abnormal AD immunity.
It also revealed unexpectedly the profile of this grave illness of AD.
All catastrophes of AD, body-wide eczema, severe itches and skin barrier disturbances due to filaggrin etc., are deeply related to IL-4.
As long as those invalidation of IL-4 does not raise another big problem.

Year, I say again, it is really sighing.

Then we have to rely on unnaturally rich immune-breaking medicines when we get sick.
Now a days, these brand-new antibody immunosuppressants are prevalent among each and every difficult diseases like SLE, colitis, cancers, etc.
Though they are originally life-threatening illnesses, but AD was just a skin eczema in childhood.
I had never expected such future, even I was in bed all day with whole-body AD eczema, that medical treatments should be done at the risk of one’s life and money.

Of course, antibody agents are for the severest patients.
Most AD patients are controlled by conventional therapies of emollients and corticosteroid ointments in local general hospitals and clinics.

However, in the first-line medical facilities like university hospitals and medical centers, antibody drugs are already in daily use.
Any dermatological meetings also feature them first.
What I want to sigh most is that today’s young dermatologists all undergo training there.
Antibody therapies would be quite usual regimens for them.
Then after a few decades, they will grow up into ordinary dermatological physicians seeing AD patients in hospitals and clinics.
I suppose they may recommend dupilumab etc. easily even to slight severe or moderate AD, and then, if the patients refuse to obey them, they will no longer have neither pity nor measures to manage their patients’ AD instead.
I am afraid of such dark horrible future just around the corner.

Now I shall talk about another horrible medicine.
It is a clobetasol propionate shampoo drug, sold as Comclo shampoo in Japan.
Clobetasol propionate is a popular corticosteroids of the strongest level.
These steroids has long been used in the name of Dermovate or many other generics, in the styles of ointments, creams or scalp lotions, but there never has been a shampoo drug.

Comclo shampoo is on sale from Jury, 2017 in Japan, but at that time the indication was only for psoriasis vulgaris.
In this February (in 2021), its indication was widened containing eczema and dermatitis.
Eczema and dermatitis make a pile of populations in dermatological area.
AD, we are focusing, is definitely included in this category, too.

How to use it? That’s very horrible.
Eczematous patients put the shampoo widely on their heads and wait 15 minutes before they wash and rinse it.
Due to abundant blood streams, head skin is well known to absorb contacted substances quite well, 3.5 times as much as the standard forearm skin, but this drug says to fill head exanthemas with the strongest corticosteroids without thinking carefully.
What an awful direction!

They say this is a short-time contact therapy, which enables more effectiveness and less absorption.
I doubt if their story is true.
Shampoo drug cannot help touch and soak the head skin widely, beyond affected areas.
Damaged skin barrier allows much more substances to penetrate than usual on the lesions.
Moreover, some of it inevitably drop onto the face skin while waiting for 15 minutes.
The face and neck skin absorb the drops vigorously, with 6 to 13 times rates as the forearm skin.
Especially, absorptions around eyes lead to heavy eye disorders like glaucoma.

Actually, the strongest corticosteroids do go into our body up to a dangerous level, because we can find both Cushing syndrome and an adrenal suppression in the drug instruction as toxic phenomenons.
As you know, Cushing syndrome means excess corticosteroids exist in a body. An adrenal suppression occurs responding to external oversupplies of corticosteroids.
Comclo shampoo will produce critical iatrogenic disturbances to our important organs, eye or adrenal, to peoples who had only somewhat skin diseases, psoriasis or eczema.

I think this medicine is stepping into a taboo.
Even if medical developers should always search more powerful drugs, this case would not be granted.
Why do they limit the usage within four weeks? Because they know it may be poisoning.
But patients will not think they have to stop the quite effective shampoo soon.
I wonder why they do not pay much attention to such likeliness, with quite brilliant brains enough to get the licenses of pharmacologists or medical doctors?
They may not have any choice not to sell the products they made.

Illnesses are obstacles on our way to live.
Medicines should be proper dodging measures.
I expect doctors as a patient, to help me as naturally as possible.
However, future doctors may be too busy to carry it out, by learning and administering lots of dangerous drugs without fail.
They may not afford to compassionate towards patients, think about their whole life and seek more natural measures for them.

Even with diseases, I want to live as independently as I can.
I just afraid of the future I will not be able to do so.

2021.4