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Dupilumab side effect in a patient with atopic

dermatitis: a case report study
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Biologics: Targets and Therapy

Sakhar S Albader 1 Abstract: Atopic dermatitis (eczema) is a common chronic disease that is described as severe
Abdulmajeed A Alharbi 2 itching associated with recurrent eczematous lesions. In 2017 the US Food and Drug
Rakan F Alenezi 1 Administration approved dupilumab for treatment of adults with moderate to severe atopic derma-
Fahad M Alsaif 3 titis not well controlled with topical therapies or when other therapies are inadvisable. Dupilumab is
1
a monoclonal antibody that inhibits interleukin-4 (IL-4) and IL-13 signaling by specifically binding
College of Medicine, King Saud
University, Riyadh, Saudi Arabia; 2College
to the IL-4R-alpha subunit shared by the IL-4 and IL-13 receptor complexes. There are many
For personal use only.

of Medicine, Alqassim University, Qassim, adverse effects reported after dupilumab therapy; commonly reported adverse effects include local
Saudi Arabia; 3Division of Dermatology, injection site reactions, conjunctivitis, headache, and nasopharyngitis. Some adverse effects are
College of Medicine, King Saud
University, Riyadh, Saudi Arabia rare, eg, alopecia areata and cicatricial extropion. We report a new case of a 28-year-old female who
experienced face and neck rash after dupilumab injection.
Keywords: atopic dermatitis, dupilumab, eczema, adverse effect

Introduction
Dupixent (dupilumab; Regeneron Pharmaceuticals, Inc., Eastview, NY, USA)is
a monoclonal antibody that inhibits interleukin-4 (IL-4) and IL-13 signaling by specifi-
cally binding to the IL-4R-alpha subunit shared by the IL-4 and IL-13 receptor
complexes.1,2 Dupilumab treatment has led to significant improvements in treating skin
lesions and in patients’ health-related quality of life (HRQoL).2 Multiple clinical trials and
meta-analyses have shown satisfactory outcomes after dupilumab therapy.
A new case study reported in October 2018 showed hair regrowth in
a patient with long-standing alopecia totalis after using dupilumab.3,4
Adverse effects after treating patients with dupilumab have been reported.
Commonly observed adverse events include local injection site reactions,
conjunctivitis, headache, and nasopharyngitis.5 Extremely rare reported side
effects include alopecia areata and cicatricial extropion.3,6 Overall, dupilumab
has clinical advantages over other immunotherapeutic agents, such as omali-
zumab foratopic dermatitis (AD) patients.7,8 A recently published case report
presents a case with moderate to severe AD who developed a facial rash after
treatment with dupilumab which was not observed before in the literature.9
We present a similar rash presentation in a patient treated with dupilumab
for AD in dermatology clinic at King Khaled University Hospital.
Correspondence: Sakhar S Albader
College of Medicine, King Saud University,
P. Box 145111, Alrabwah, Riyadh 4545, Case presentation
Saudi Arabia
Tel +966 55 466 7745
A 28-year-old married lady who had AD since childhood came to the dermatology clinic
Email Sakalbader@gmail.com at King Khaled University Hospital complaining of severe itchy erythematous patches

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that started on the limbs and progressed to the trunk since Discussion
childhood but which had got worse over the past 8–10 years. The US Food and Drug Administration has approved
She was initially started on cyclosporine 20 mg BID 2 dupilumab injection to treat adults with moderate-to-
months previously, but the patient reported worsening in the severe eczema (AD) not well controlled with topical thera-
symptoms and no improvement. After that, we started her on pies or when other therapies are inadvisable.
cyclosporine 100 mg BID (200 mg/day) with methotrexate Dupilumab is safe and effective as was established in
reaching a maximum dose of 20 mg q1wk where she reported three placebo-controlled clinical trials with a total of 2,119
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60% improvement since the previous visit. After that, she adult participants with moderate-to-severe AD not ade-
reported a flare up again and thus we started her on dupilumab. quately controlled by topical medications. Overall, parti-
The patient was started on dupilumab for 4 months cipants who received dupilumab achieved greater
duration 300 mg q2wk as she noticed redness in the face response, defined as clear or almost clear skin, and experi-
(Figure 1) and neck (Figure 2) 4 h after the injection and enced a reduction in itch after 16 weeks of treatment.
resolving spontaneously after 2 days. She noted that the A meta-analysis was done in January 2018 among
redness developed after every single injection simulta- eight randomized controlled trials (RCTs) which showed
neously with no appearing and fading episodes; however, that patients treated with dupilumab experienced
the rash became scaly in appearance before resolving. a higher risk of injection-site infection (13.2%) than
It was not related to sun exposure as it occurred when the the patients treated with placebo (6.5%), and they
patient was at home. She also gave the history of pain and found that conjunctivitis occurred more frequently in
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warmth over the area of redness which was rated as 7/10 in patients treated with dupilumab than the placebo
severity. There was no fever, itching, or swollen lips or eyelids. group, unlike previous studies which showed an equal
She was applying hydroxyzine and mometasone furoate frequency in dupilumab group and placebo-treated
cream BID for 3 days whenever she had the episode over the patients with asthma and chronic sinusitis, which could
affected areas and it faded after 2 days. On examination there indicate that dupilumab exerts a different mechanistic
was a non-pruritic skin rash over the cheeks and neck, no outcomes in asthma and chronic sinusitis than AD.10–12
palpable lymph nodes or hepatosplenomegaly. There was also a higher incidence of headache in dupi-
The laboratory workup was unremarkable which lumab-treated patients than placebo-treated patients but
showed negative antinuclear antibody (ANA), and normal unfortunately the mechanism is not clear and require
erythrocyte sedimentation rete which was 21 mm/h. further research.13,14

A B

Figure 1 Erythematous slightly edematous patch over the cheek (A) and chin (B).

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 Dovepress Albader et al

Ethics
Written informed consent has been provided by the patient
to have the case details and any accompanying images
published. No institutional approval was required to pub-
lish the case details.

Disclosure
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The authors report no conflicts of interest in this work.

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jdcr.2017.11.020
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Figure 2 Multiple erythematous patches over the neck without scales.
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AD, atopic dermatitis. 6736(17)31191-1

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