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The use of biological drugs consisting of large molecules has in recent years expanded to new indications and new specialties. These drugs are most commonly proteins possessing the structure of an antibody or a receptor, and treatment with them is significantly more expensive than that carried out with conventional small molecule drugs. Determination of drug levels and emerging antibodies form the basis of individualization. They will enable better treatment results with simultaneous avoidance of unnecessary medications, excessive doses--and extra costs. We demonstrate the individualization of TNF-α blocker therapy through patient cases in various situations.

Summary Background Long-term follow-up studies on the prognosis and consequences of occupational hand eczema (OHE) and the prognostic risk factors for persistent OHE are sparse. Objectives To determine the medical and occupational outcome after a follow-up of 7–14 years in 605 patients diagnosed with OHE and to identify the prognostic risk factors for the continuation of hand eczema. Methods Patients examined at the Finnish Institute of Occupational Health in 1994–2001 completed a follow-up questionnaire 7–14 years after diagnosis. Results The hand eczema had healed (no eczema during the last year) in 40% of patients with OHE. The duration of hand eczema before diagnosis was strongly associated with the continuation of eczema. Age, sex and diagnosis (allergic or irritant contact dermatitis) were not associated with the prognosis, but skin atopy, and especially respiratory atopy, were correlated with the continuation of hand eczema. Contact allergies in general were not risk factors for persistent OHE, but the presence of a work-related chromate allergy was associated with poor healing. A total of 34% of patients had changed their occupation due to OHE, and their long-term prognosis was better than those who had not. The hand eczema of patients originally in food-related occupations continued on an unfavourable course. Conclusions In the logistic model, risk factors for the continuation of OHE were a long duration of hand eczema before diagnosis, respiratory atopy, skin atopy, and continuation in the same occupation. Those who ended up changing occupation due to their OHE had a better medical and economic prognosis.

Background: Occupational skin diseases (OSDs) often have considerable medical and occupational consequences. Previous data on prognostic factors have been derived from studies with fairly small sample sizes. Objectives: To determine the medical and occupational outcome in 1048 patients diagnosed with OSD at the Finnish Institute of Occupational Health and to identify the prognostic risk factors for the continuation of OSD. Methods: Patients examined in 1994–2001 filled out a follow-up questionnaire 6 months after the diagnosis. Data on atopy, contact allergies, and occupation were analysed. Results: Six months after the diagnosis the skin disease had healed in 27% of the patients. The OSD had cleared up in 17% of those with no changes at work, and in 34% of those who had changed their job/occupation. The best clearing had occurred in the patients with contact urticaria (35%), whereas the healing of allergic (27%) and irritant (23%) contact dermatitis was similar. The risk factors for continuing occupational contact dermatitis (OCD) were no changes in work, age > 45 years, food-related occupations, respiratory atopy, and male sex. Conclusions: The healing of OSD was associated with discontinuation of the causative exposure. A change in work and the presence of easily avoidable work-related allergies were associated with a good prognosis.

BACKGROUND Although the development of therapy-related skin reactions is common along with an increase in the number of adult patients receiving anti-TNFα, there are few studies on pediatric inflammatory bowel disease; hence, this prospective study focuses on skin reactions related to infliximab therapy. METHODS All pediatric patients with inflammatory bowel disease undergoing infliximab therapy were prospectively screened for the presence of skin manifestations at the time of each infusion between March 1, 2011 and March 31, 2011 at Children's Hospital, Helsinki, Finland. Blood inflammatory markers and fecal calprotectin levels were measured at the time of infusions. RESULTS During the study period, 84 children with inflammatory bowel disease (Crohn's n = 64) received infliximab infusions (the median duration of therapy 12.2 mo). Almost every other patient (n = 40; 47.6%) presented chronic skin reactions, 23% with lesions considered severe. Most commonly, the patient's ear lobes and scalp were affected with psoriasis-like manifestations, followed by their eyelids, perioral and pubic area, trunk, and the extremities. However, an HLA-Cw*0602 genotype associating with psoriasis was rare. Interestingly, most patients with skin reactions had a low degree of intestinal inflammation based on their fecal calprotectin levels (median level, 133 μg/g versus 589 in unaffected patients; P < 0.016). Seven patients (8.3% of all patients but 17% of those with skin lesions) discontinued the given therapy due to a skin reaction. CONCLUSIONS Skin reactions are common during maintenance therapy with infliximab in pediatric patients. For most patients, skin reactions seem to correlate with a low level of intestinal inflammation. Although potentially harsh, skin lesions mostly allow continuation of infliximab.

Psoriasis in the only skin disease for which biological drug treatments are in use. Three of these are TNFalpha inhibitors and one, ustekinumab, is an inhibitor of the interleukins (IL) 12 and 23. The new IL-17 inhibitors have proven to be highly efficient, and new low molecular weight drugs such as Janus kinase inhibitors and phosphodiesterase 4 inhibitors may provide a competitive oral alternative to monoclonal antibodies. No biological drugs are available for atopic eczema. The pathogenesis of atopic eczema has, however become more precise, providing several interesting therapeutic targets in the future.

The performance of the interferon gamma release assays (IGRAs) and tuberculin skin test (TST) was reviewed retrospectively in patients with psoriasis, inflammatory musculoskeletal diseases, or miscellaneous inflammatory conditions. The study was carried out over a 22-month period using 109 records of patients with psoriasis ( 𝑛 = 2 1 ), musculoskeletal disease ( 𝑛 = 7 4 ), or other inflammatory conditions ( 𝑛 = 1 4 ). Forty-four (48%) of 109 patients were on immunosuppressive therapy and 38/109 (35%) on systemic glucocorticoid therapy. The agreement between the IGRAs was substantial ( 𝜅 = 0 . 7 1 ) whilst that between the IGRAs and TST was low ( 𝜅 = 0 . 3 2 ). Logistic regression models revealed that IGRAs associated with risk factors for latent tuberculosis infection better than TST. TST was influenced by age, BCG vaccination, sex, and glucocorticoid therapy. We found that IGRAs performed equally well with low level of indeterminate results (1-2%). IGRAs were superior to TST because the latter was influenced by BCG-vaccination status and immunosuppressive therapy.