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I OFTEN begin a lecture on atopic dermatitis by reflecting what on our very limited (perhaps even naive) view of the pathogenesis of this challenging condition was 20 years ago, and how dramatically our understanding has improved over this same time. Many of us remember a time when ‘cytokine’ was a new and unfamiliar term, and the newest trend in therapy was cautious and prudent use of short-term oral glucocorticoids rather than long-acting injections. Fast-forward to today, where interfering with cytokine pathways is standard treatment, and research continues to elucidate pathways and provide new targets for drugs aimed at inflammatory skin diseases.
The authors of these reviews provide a comprehensive overview of ciclosporin and its uses in veterinary dermatology. The drug has become a mainstay for treatment of canine atopic dermatitis, and has, of course, recently been extended to use in cats. Since ciclosporin's original approval and registration, the field has continued to evolve. It has been a team sport, with research scientists, dermatology specialists, first-opinion practitioners, pets, and their owners engaged in a cooperative effort to understand more about using the drug optimally. What have we learned about veterinary use of ciclosporin in the past decade?
We know more about its various actions, and that it can provide therapeutic benefit for not only atopic dermatitis, but for other skin diseases as well.
We know ciclosporin has a long-term safety record as an immunomodulatory drug for chronic treatment of canine atopic dermatitis. Most adverse effects are manageable and/or without clinical significance, even over many years of treatment. For those adverse effects that do occur, we now have a better understanding of how they can be managed.
We know more about the nuances of optimal use, including tapering strategies to minimise cost, the possibility of speeding onset of relief via brief co-administration of other medications, and monitoring steps that are prudent (or of equal importance, unnecessary) with extended use.
Ciclosporin, as with all tools for treatment of canine atopic dermatitis, works best as part of a multimodal treatment effort. With increasing realisation of the complicated pathogenesis of atopic dermatitis, ‘multimodal therapy’ has become a vitally important concept for veterinarians to understand. With multimodal therapy, we recognise that any one single treatment is unlikely to provide optimal patient response. Rather, all treatments for atopic dermatitis are considered tools, which must be combined in accordance with individual patient needs, to achieve an overall management strategy that is effective, convenient, safe, affordable, and provides long-lasting relief over the patient's lifetime. Ciclosporin remains one of our most important tools within this strategy.⇓⇓
The information in this volume summarises our experience with ciclosporin over the past 10 years, but also points to questions we should investigate down the road. Recent advances in formulation chemistry raise the possibility of topical use in the future. We need more studies that will give us guidance on when and how best to combine ciclosporin with, for example, the azole antifungal drugs to optimise effectiveness while limiting cost. We need to know more about the relationship between ciclosporin and allergen-specific immunotherapy, another of our most valuable tools. These and other questions will give investigators plenty to ponder over the next 10 years. Meanwhile, ciclosporin will maintain its important role as a safe and effective treatment that improves quality of life, not only for many pets, but also for their human companions.
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