Psoriasis onset under dupilumab treatment in two patients affected by atopic dermatitis and one patient affected by alopecia areata: Clinical and dermoscopic patterns

Abstract

While dupilumab has emerged as an effective treatment for moderate-to-severe atopic dermatitis (AD) since its approval, interleukin (IL)-4 and 13 blockade has also demonstrated efficacy in off-label chronic dermatologic conditions, such as alopecia areata (AA). 1,2 Recently, cases of dupilumab-induced phenotype switching from AD to psoriasis have been reported. 3,4 Here, we present three cases of new psoriasis onset under dupilumab treatment: two patients affected by AD and one patient affected by AA. I. D'Ambra and G. Babino have contributed equally to this article

Tumor Necrosis Factor Inhibitor-Induced Eczematous Eruption: A Report of Two Cases and Review of the Literature

“…Interestingly, a contrasting phenomenon has been reported where patients with atopic dermatitis developed psoriasiform eruptions after treatment with dupilumab, a monoclonal antibody against Th2 cytokines IL-4 and IL-13 [14][15][16][17]. In these cases, it is postulated that the inhibition of the Th2 pathway by dupilumab leads to an activation of the opposing Th1 axis, manifesting as psoriasis.…”

Practical Management of Patients with Atopic Dermatitis on Dupilumab

“…Paradoxical psoriasiform eruption has been described in a small number of cases of patients taking dupilumab for AD in adults [ 87 – 92 , 114 – 118 ]. Localization was typically limited to extremities, although other locations were described.…”

“…In patients who do not respond to the above, those with significant effect on QoL, or for those with severe recalcitrant face and neck involvement, addition of MTX or CsA or a temporary/permanent discontinuation of dupilumab has been reported and can be considered [110]. Paradoxical psoriasiform eruption has been described in a small number of cases of patients taking dupilumab for AD in adults [87][88][89][90][91][92][114][115][116][117][118]. Localization was typically limited to extremities, although other locations were described.…”

“…With the limited number of reports available, the prevalence of this phenomenon remains in question. The case reports to date also have limited information on patient characteristics at baseline; only a few cases document patients meeting the Hanifin and Rajka diagnostic criteria [87][88][89][90][91][92][114][115][116][117][118]. Although most cases of AD and PsO are easily distinguished clinically, phenotypes can overlap or mimic each other, and both eczematoid psoriasis and psoriasiform dermatitis can be found on histology [119,120].…”

New Biologics for the Treatment of Atopic Dermatitis: Analysis of Efficacy, Safety, and Paradoxical Atopic Dermatitis Acceleration

“…Representative examples of PAEs are palmoplantar pustular reactions, psoriasiform reactions, and hidradenitis suppurativa (HS) in patients under treatment for rheumatoid arthritis (RA) or inflammatory bowel disease (IBD) [15]. A few reviews and case reports have described PAEs: de novo psoriasis in atopic dermatitis patients treated with dupilumab [16][17][18][19][20][21][22][23], paradoxical head and neck erythema in patients with atopic dermatitis treated with dupilumab [24][25][26], mepolizumabinduced alopecia in severe eosinophilic asthma [27], and secukinumab-induced exacerbation of previously diagnosed psoriasis [15]. Regarding atopic dermatitis acceleration, two cases reported the exacerbation of atopic dermatitis symptoms by ustekinumab in psoriatic patients [28].…”