Improvement of alopecia areata with Dupilumab in a patient with severe atopic dermatitis and review the literature

Abstract

Dupilumab, a biologic drug approved for the treatment of moderate-to-severe atopic dermatitis, has been associated with resolution or improvement in pre-existing alopecia areata. We report a case of significant improvement of AA after Dupilumab-onset treatment for atopic dermatitis and review the literature.

Remission of Alopecia Universalis after 1 Year of Treatment with Dupilumab in a Patient with Severe Atopic Dermatitis

“…Considering that AA has been classified as T helper 1-driven disease, whereas AD is the prototypical T helper 2 (Th2)-driven skin disorder, recent studies suggest that these forms may underlie a different chemokine expression resulting in a Th2 skewing as a key pathomechanism that could explain this association [3]. Several reports showed that dupilumab, a fully human monoclonal antibody targeting the interleukin (IL)-4α and IL-13 receptors and thus downregulating Th2 response, led to an improvement of AA associated with AD: the first report by Penzi et al [4] observed a full hair regrowth in a 13-yearold girl affected by AT and severe AD after 11 months of treatment with dupilumab; subsequently, several authors described an improvement of AA in their patients treated with dupilumab [5][6][7][8][9][10]. Although cases of AA induced by dupilumab have been described [11][12][13], it is possible that sex difference, AD duration, and immunological profile of the patients play a crucial role in the treatment's response; in fact as outlined by Marks et al [14], most of the patients in which dupilumab improved AA were females with AT or AU, early-onset AD, and atopic comorbidities, suggesting a predominant role of Th2 skewing in this subset of patients.…”

Dupilumab: A Review of Present Indications and Off-Label Uses

“…Renert-Yuval et al [131] provided an overview of activated immune pathways in alopecia areata, in which they analyzed overexpression of IL-4 and IL-13 and possible therapeutic modalities, including dupilumab. Recently, cases of alopecia areata [132][133][134][135][136][137][138][139][140] and alopecia universalis [135,[140][141][142][143][144][145][146][147] have been reported to heal during treatment with dupilumab for AD. Therefore, this dual efficacy of dupilumab for AD and alopecia areata/alopecia universalis may be explained by their shared immunopathogenic mechanisms.…”

Dupilumab: Advances in the off‐label usage ofIL4/IL13antagonist in dermatoses

“…54 Histopathologic studies of PN lesion have revealed abnormalities in various types of skin cells infiltration in the dermis of PN lesion especially T lymphocytes, mast cells, and eosinophils. 43,44 A multicenter adult cohort study contained 16 PN patients who receive dupilumab treatment for 3 months, 93.8% of them got at least partial responses of skin lesions and 87.6% of them got improvement of pruritus. 36 As for teenager PN patients, dupilumab administration (initial dose of 8 mg/kg, followed by 4 mg/kg every 2 weeks) was described to eliminate the severity of lesions and pruritus of a 9-year-old girl after 3 months.…”

“…Both Th1 and Th2 immunity participated in its pathogenesis: the infiltration of CD8(+) T cells and Th1 cytokines like IFN‐γ could induce the apoptosis of hair follicles, 42 however, some AA complicated with AD patients showed an overexpressed Th2 cytokines in the skin lesions and an elevated serum IL‐4, IL‐5, and IgE levels 42–44 . An article reviewed seven adult patients with AA and AD who got improvement after application of dupilumab, the average improvement duration is 3.67 months 43 . Another study summarized six children with AA and AD received dupilumab treatment for 12.3 months in average, only one patient did not have any improvement at endpoint 45 .…”

“…Although the exact pathogenesis is still unclear, the immune and neural dysfunction are implicated in the itch‐scrab cycle of PN patients 54 . Histopathologic studies of PN lesion have revealed abnormalities in various types of skin cells infiltration in the dermis of PN lesion especially T lymphocytes, mast cells, and eosinophils 43,44 . A multicenter adult cohort study contained 16 PN patients who receive dupilumab treatment for 3 months, 93.8% of them got at least partial responses of skin lesions and 87.6% of them got improvement of pruritus 36 .…”