Abstract
The efficacy of dupilumab in pediatric patients with severe eczema presenting in the setting of elevated immunoglobulin E (IgE) levels and recurrent bacterial skin infections is not well-understood. Here we present the case of a child with elevated IgE levels in whom dupilumab treatment led to remarkable control of his eczema and recurrent skin infections. We also review the use of dupilumab in other patients with molecularly proven cases of hyper IgE (HIGE) syndrome. Our case supports the notion that dupilumab may have a seminal application in treating severe eczema that occurs in the setting of elevated IgE levels and recurrent bacterial skin infections.
Highlights
Management of severe atopic dermatitis presenting in the context of elevated immunoglobulin E (IgE) levels and recurrent bacterial skin infections is challenging
Dupilumab is a monoclonal antibody that inhibits IL-4 signaling via the Type I receptor and both IL-4 and IL-13 signaling through the Type II receptor resulting in decreased IL-4 and IL-13 cytokine-induced responses, including the release of proinflammatory cytokines, chemokines, and IgE
Dupilumab down-regulates many genes salient for epidermal hyperplasia and dendritic and T cell activity, while up-regulating genes important for enforcing epithelial integrity [6]. It is currently approved by the Food and Drug Administration (FDA) for the treatment of moderate to severe atopic dermatitis and asthma [7]
Summary
Management of severe atopic dermatitis presenting in the context of elevated immunoglobulin E (IgE) levels and recurrent bacterial skin infections is challenging. There is a paucity of clinical knowledge regarding the effectiveness of dupilumab in treating severe eczema that presents in the setting of elevated IgE levels and recurrent bacterial skin infections. We report the case of a patient with severe eczema, elevated IgE levels, and recurrent bacterial skin infections who experienced significant improvement of his atopic dermatitis, recurrent skin infections, and quality of life following treatment with dupilumab. Despite excellent skincare, including wet wraps, topical steroids, and antibiotics, the patient developed multiple Staphylococcus aureus skin infections, requiring both topical and systemic antibiotics in addition to systemic steroids His scoring atopic dermatitis (SCORAD) score upon initial evaluation was 91.7/103. At age 8, he was started on cyclosporine 2–3 mg/kg and oral trimethoprim/sulfamethoxazole in an attempt to control his eczema He continued to develop severe eczematous flares, leading to recurrent superimposed bacterial infections requiring hospitalizations and intravenous antimicrobial agents. Nineteen months after starting treatment, he continues to tolerate dupilumab, with no side effects reported
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