Facial erythema in patients with atopic dermatitis treated with Dupilumab – a descriptive study of morphology and Aetiology

Abstract

Background The development of dermatitis on face and neck, which was not described in phase 3 clinical trials, has been reported in the literature in patients treated with dupilumab. Little is known regarding the causes or defining features of the facial dermatitis. Objectives We conducted surveys of consecutive patients with AD on dupilumab to describe its clinical features, morphology and aetiology. Methods A multi‐centre prospective cohort study was conducted from 1 January 2020, to 31 December 31 2020. A total of 162 patients under dupilumab treatment were asked to complete a questionnaire and patients were evaluated by dermatologists. Results Of all 162 patients, 137 (84.6%) patients reported pre‐existing facial dermatitis prior to dupilumab therapy. One hundred and twenty‐one (88.3%) patients with pre‐existing facial dermatitis reported improvement of their facial dermatitis with dupilumab therapy, nine (6.6%) patients reported no change after the treatment and seven (4.3%) patients of them got worse after the treatment (exacerbation group). Of 25 patients who reported no pre‐existing active facial dermatitis, six (24%) patients reported new‐onset facial erythema after the starting dupilumab therapy (new‐onset group). A large proportion of the patients in both the exacerbation (86%) and new‐onset groups (67%) had a history of facial TCS use. Both groups showed similar clinical manifestations and distribution with few differences. Conclusions The vast majority of patients treated with dupilumab in academic institutions from Korea and the United States experienced improvement in their facial dermatitis with dupilumab therapy. A small proportion of patients had new onset and exacerbation. Although the mechanisms of this adverse event remain unclear, steroid withdrawal should be considered as a diagnosis of the erythema in some patients.

Head and neck dermatitis is exacerbated by Malassezia furfur colonization, skin barrier disruption, and immune dysregulation

“…AD is a chronic condition that severely affects patients' quality of life (30), and among its various clinical features, HND may be one of the most deleterious symptoms, as the facial skin is involved. Even after the emergence of biologics, including dupilumab, head and neck dermatitis is often encountered in patients with AD (31)(32)(33). Therefore, it is necessary to explore the influence of skin barrier and microbes on the occurrence of HND, in addition to the direct blocking of the Th2 response.…”

Progress in Dermatology and Venereology in 2023 as reflected in the Journal of the European Academy of Dermatology and Venereology

“…In studying the medications, the authors conclude that the development of facial erythema may be a result of topical steroid withdrawal. 12 New kinase inhibitors have shown tremendous effects in atopic dermatitis after oral application. A new substance already registered for vitiligo treatment namely ruxolitinib has been used topically in a double-blind placebo-controlled trial in atopic dermatitis.…”

“…This phenomenon was studied in 162 patients with severe atopic dermatitis under Dupilumab treatment; 137 had facial erythema before Dupi treatment, 121 improved, seven got worse and six out of 25 patients developed new facial erythema under Dupilumab. In studying the medications, the authors conclude that the development of facial erythema may be a result of topical steroid withdrawal 12 …”

Clinical trials of antibody drugs in the treatments of atopic dermatitis

“…Moreover, transient eosinophilia was also reported, which was evidenced by a significant increase in absolute eosinophil count ( 47 ). Surprisingly, while improvements of pre-existing facial dermatitis, which was suggested to be accociated with the evaluation of Malassezia-specific IgE ( 48 ), was seen after Dupilumab therapy, 24% patients reported new-onset facial erythema after the treatment ( 49 ). Similar pattern could be observed in the trial conducted by Jo et al, with totally 8 worsening cases within 101 patients, and another study carried out by de et al, which demonstrated that erythema, particularly in head and neck areas, was highly expressed after treated by Dupilumab ( 50 , 51 ).…”