Case report: Challenges in the management of atopic dermatitis after dupilumab therapy
Hongwei Ren, Li Zhang, Ruiqun Qi, Song Zhen, Yuxiao Hong, Xinghua Gao
Department of Dermatology, The First Hospital of China Medical University
The objective of this clinical case report is to highlight this unusual presentation to avoid incorrect diagnosis and treatment about dupilumab for Atopic dermatitis (AD). AD is a common, chronic type 2 inflammatory skin disease, mostly since their infancy, having a much higher prevalence. The pathophysiology of AD is a complex combination of involving a strong genetic predisposition, disrupted epidermal barrier and T-cell driven inflammation. AD was initially characterized by defects in the congenital immune system and a vigorous skewed adaptive Th2. Although type-2 mechanisms are dominant, there are compelling evidences that the disorder involves multiple immune pathways. Dupilumab is the first biologic therapy that is Food and Drug Administration-approved human monoclonal antibody blocking interleukin 4 and interleukin 13 for moderate-to-severe AD. The safety and efficacy results of dupilumab was supported as consistent long-term treatment for adults with moderate-to-severe AD . Adverse effects associated with dupilumab have been reported, such as conjunctivitis, headache, injection site reaction, exacerbation of atopic dermatitis, alopecia areata, and psoriasis, psoriasiform eruption. Psoriasis is a chronic skin condition with an underlying perpetuation of cytokine production and T-helper 1/17 - driven autoimmune and inflammatory processes.There have been a few cases of psoriasis appearing to be induced by dupilumab. Here, we present two interesting cases of mimicking psoriasiform lesions after dupilumab therapy with a long history of AD. A 37-year-old woman presented at our Dermatology department with 10-year history of atopic dermatitis and a 18-year-old man with an 11-year history of atopic dermatitis. No personal or familial history of psoriasis were reported. Interestingly, both patients continued to take dupilumab while being treated with topical 0.05% halometasone cream twice daily. Six weeks and four weeks later respectively, their psoriasiform lesions resolved, and their atopic dermatitis resulted in significant improvement (NRS 1,SCORAD16.5, ADCT<7; NRS 2,SCORAD21, ADCT<7). No recurrence of AD was noted and the patients are both currently doing well. Atopic dermatitis (AD) and Psoriasis (PSO) are common inflammatory skin diseases with distinct clinical manifestations. Psoriasis and atopic dermatitis are both T-cell mediated inflflammatory diseases in which T-cell derived cytokines signal keratinocytes to alter growth and differentiation. Clinicians should be concerned these potential adverse events of dupilumab that are often mild and can occur a several months after treatment initiation. To date, the mechanism of the dupilumab reaction is no clear explanation to elucidate the association between dupilumab’s Th2 inhibition and its implication on psoriasis pathogenesis.This Paradoxical response is also postulated to be a consequence of skewing the Th1/Th2 balance. PSO and AD may be regarded as a spectrum of disease, rather than as a dichotomy. Further studies are needed to identify factors predictive of a shift toward Th1-response when blocking Th2 immune response. Furthermore, given the fact that dupilumab can induce psoriasis, physicians should carefully correlata the right diagnosis with manage by means of thorough examination of the clinical findings, medical history, confirmation of histopathology and conventional topical management.