Dupilumab in the management of topical corticosteroid withdrawal in atopic dermatitis: A retrospective case series

Abstract

Topical corticosteroid (TCS) withdrawal, or steroid addiction, is a poorly understood, distinct adverse effect of inappropriate TCS use. It occurs most commonly in adult women applying mid- or high-potency TCS to the face or genital region and is associated with increased frequency and duration of treatment.1, 2, 3 TCS withdrawal should be suspected when confluent erythema appears within days to weeks of discontinuing therapy, stinging and burning are prominent symptoms, and history is consistent with the at-risk population described above. This condition can be divided into 2 subtypes with distinct clinical presentations. The erythematoedematous variant is characterized by erythema, scaling, papules and nodules, desquamation, and edema, with symptoms including burning, pruritus, pain, and decreased tolerance for emollients. The papulopustular type is distinguished by the prominence of pustules, papules, and nodules and the less common presence of edema and burning.4 Although the mechanism of this phenomenon is not well understood, it is theorized to be caused by the effects of TCS on the local immune system and cutaneous blood vessels.5 TCSs decrease production of nitric oxide (NO), thereby inhibiting its vasodilatory action and depleting mast cells, which are regulated by NO.6, 7, 8 In the absence of TCS use, a rebound effect may occur in which NO levels increase, leading to exaggerated vasodilation.5 Similarly, sparse data exist to guide definitive diagnosis or therapy. In most reported cases, the first step in treatment is to discontinue TCS use. Other reported therapeutic modalities include medications such as tetracycline antibiotics, antihistamines, and calcineurin inhibitors. Ultraviolet therapy was described in 1 case report.4 Because rebound of underlying disease may occur and may be indistinguishable from TCS withdrawal when steroid therapy is halted, some investigators suggest initiation of oral corticosteroids or a TCS taper in an effort to circumvent flares.9 However, evidence to support the use of systemic immunosuppressants in the management of this condition is lacking. We performed a retrospective chart review of adult patients with suspected TCS withdrawal treated with dupilumab for atopic dermatitis at a single center from March 2017 to March 2018. Effectiveness was measured by decrease in body surface area (BSA) involved and decrease in Investigator's Global Assessment (IGA) score. Case summaries are presented in Table I. Table I Characteristics of patients with TCS withdrawal treated with dupilumab