The Successful Treatment of COVID-19-Induced Bullous Pemphigoid With Dupilumab

Abstract

Bullous pemphigoid (BP) is a rare autoimmune blistering condition that predominantly affects the elderly population. Typical treatment regimens target the immune system and inflammatory response. We present a case of BP in a 78-year-old male patient that occurred following the coronavirus disease 2019 (COVID-19) vaccination. This case was refractory to topical steroids and immunosuppressants. However, it responded to treatment with dupilumab, a monoclonal antibody therapy. Dupilumab is classically indicated for the treatment of asthma, eosinophilic esophagitis, atopic dermatitis, and chronic rhinosinusitis with nasal polyposis. We highlight the importance of considering the off-label use of dupilumab and its success in treating BP.

Dupilumab in Inflammatory Skin Diseases: A Systematic Review

“…This included one pediatric patient [ 117 ]. Efficient dupilumab mono-therapy inducing clinical remission was reported in 3 cases [ 118 , 119 , 120 ]. However, some reports showed only partial or no response [ 114 ].…”

“…In addition, 4 cases of checkpoint inhibitor-induced BP were treated efficiently with dupilumab, a favorable medication as strong immunosuppression needs to be avoided due to the underlying malignancy [ 121 , 122 , 123 , 124 ]. Two patients with BP presumably triggered by COVID-19 vaccinations were also treated efficiently with dupilumab [ 120 , 125 ]. Most noticeably, two retrospective cohort studies compared co-therapy of dupilumab with conventional therapy against conventional therapy alone (comprised of systemic high-dose steroids and immunosuppressants) and found shorter median time to disease control, more rapid decline of itch measured by NRS and disease activity (measured by the BP disease activity index, BPDAI), higher quality of life (measured by the dermatology life quality index, DLQI) as well as lower cumulative doses of steroids and immunosuppressants in a total of 28 patients [ 126 , 127 ].…”

New Onset and Exacerbation of Autoimmune Bullous Dermatosis Following COVID-19 Vaccination: A Systematic Review

“…In the flare group, 92% of cases were classified as 'possible', and 8% as 'probable'. Notably, all cases deemed 'probable' in causality had experienced a disease flare following both doses of COVID-19 vaccines, contributing to the overall score for these cases [6,13,25,37,38,[40][41][42]49,50,53,54,68,71,75,86,91].…”

“…In the new onset group, BP patients with limited involvement were treated with topical corticosteroids, while those with more extensive involvements received a variety of systemic immunomodulators, including corticosteroids, doxycycline, nicotinamide, methotrexate, azathioprine, cyclosporine, mycophenolate mofetil, cyclophosphamide, dapsone, colchicine, or hydroxychloroquine [5,6,14,15,28,31,32,35,38,39,[42][43][44][45]49,51,53,56,[70][71][72][73]75,77,82,86,87,92,93]. DPP-4 inhibitors were suspended in patients using these medications [34,44,45,48].…”

“…DPP-4 inhibitors were suspended in patients using these medications [34,44,45,48]. Intravenous immunoglobulin G (IVIG) was administered in selected cases, and biologics, such as dupilumab and omalizumab, were utilized [26,34,49,55,56]. Rituximab was introduced in three cases, leading to significant improvement [51,56,63].…”