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Patient: Male, 16-year-old Final Diagnosis: Alopecia areata Symptoms: Scalp hair loss Medication: — Clinical Procedure: — Specialty: Dermatology Objective: Unusual or unexpected effect of treatment Background: Dupilumab is a relatively new immune-modulating drug that has transformed the way clinicians treat common immunologic conditions, including atopic dermatitis, asthma, and chronic rhinosinusitis with nasal polyposis. Blocking signaling molecules involved within the Th2 immune response, dupilumab is a proven effective treatment for moderate to severe atopic dermatitis – a condition whose disease pathogenesis is heavily linked to the dysregulation of this immunologic pathway. Interestingly, dupilumab has found broader clinical utility, showing efficacy in treating other distinct dermatologic diseases, including alopecia areata. Case Report: A 16-year-old White male with a past medical history of moderate atopic dermatitis presented to our clinic with complete scalp hair, eyebrow, and eyelash loss. At this time, the patient was given a clinical diagnosis of alopecia totalis. Understanding that dupilumab has been previously used for treatment in adults of this specific autoimmune condition, we started this adolescent patient on dupilumab to concomitantly treat his atopic dermatitis and alopecia areata. The patient gradually experienced complete regrowth of his hair and almost complete resolution of his atopic dermatitis. Three years after starting dupilumab, the patient remains without signs of alopecia totalis. Conclusions: This case report demonstrates the long-term efficacy of dupilumab use in alopecia areata. More investigation is required to understand dupilumab’s broadening clinical indications. Additionally, this case highlights the complex relationship between dysregulation of the Th2 response and autoimmunity. Crosstalk between immune pathways within the disease spectrum of alopecia areata may explain why dupilumab has been reported to both treat and exacerbate alopecia areata.

The development of immune checkpoint inhibitors such as programmed cell-death receptor 1 (PD-1) antagonists has rapidly advanced chemotherapy within the last several decades. PD-1 targeted immunotherapy drugs like pembrolizumab, ipilimumab, nivolumab, and durvalumab have known associations with several immune-mediated dermatological reactions. We report a case in which an elderly male experienced segmental vitiligo after use of durvalumab therapy for small cell lung cancer. Distinct from non-segmental vitiligo, segmental vitiligo presents in a unilateral blaschkoid distribution and typically does not cross the midline. To our knowledge, checkpoint inhibitor-induced segmental vitiligo has yet to be documented.

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