DUPILUMAB ASSOCIATED DERMATITIS: AN EMERGING ADVERSE EFFECT

Abstract

<h3>Introduction</h3> Dupilumab associated head and neck dermatitis (DAHND) refers to persistence or de novo head and neck dermatitis in patients receiving dupilumab for atopic dermatitis. Although not reported in initial clinical trials, it can occur in up to 10% of patients. As shown in this case, the etiology of the dermatitis can be multifactorial and challenging to diagnose and manage. <h3>Case Description</h3> A twelve-year-old boy with a history of severe atopic dermatitis involving 40% TBSA refractory to high potency topical steroids and topical calcineurin inhibitors was started on dupilumab. After two months he had significant improvement of his atopic dermatitis. Two weeks later he developed a new erythematous rash over the face, neck, and upper trunk with overlying scale. Dupilumab was discontinued and he was treated empirically with oral fluconazole with significant but incomplete improvement in symptoms. He then underwent patch testing with clinically relevant reactivity to propylene glycol, MCI/MI, and imidazolidinyl urea. After avoidance of implicated personal care products, his head and neck dermatitis resolved, although the atopic dermatitis flared over the antecubital fossae and flexural surfaces. <h3>Discussion</h3> Th2 blockade by dupilumab can lead to a Th1 or Th17-skewed inflammatory response that unmasks allergic contact dermatitis or <i>Malassezia</i> dermatitis. Initial management involves antifungal therapy and patients with refractory disease should undergo patch testing or evaluation for psoriasis and rosacea. Recognition of DAHND will only become more important as dupilumab becomes widely accessible for patients with atopic dermatitis.