Dear Editor,
Atopic dermatitis (AD) and psoriasis are chronic inflammatory dermatoses, considered to be extreme phenotypes of the immune mechanism modulated by T cells.11 Bircher AJ. Psoriasis-like Dermatitis Developing in a Patient with Atopic Dermatitis Treated with Dupilumab. Dermatitis. 2019;30:376-8. Dupilumab inhibits the signaling of IL-4 and IL-13, cytokines that mediate the skin barrier inflammation and dysfunction in AD, through Th2. There is no direct interference on the Th1 pathway.22 Tracey EH, Elston CE, Fease P, Piliang M, Michael M, Vij M. Erythrodermic presentation of psoriasis in a patient treated with dupilumab. JAAD Case Rep. 2018;4:708-10.
The present report describes a rare manifestation of alopecia areata-like psoriasis, associated with skin lesions after dupilumab use.
A 22-year-old male patient was diagnosed with AD since childhood and submitted to several previous treatments, such as topical and systemic steroids, azathioprine and methotrexate, which were withdrawn due to therapeutic failure. Additionally, he had been prescribed cyclosporine, with a reduction in SCORAD (Severity Scoring of Atopic Dermatitis) from 58 to 18, but with dose reduction due to an increase in liver transaminases (3-fold the reference value). In this context, dupilumab was started at the dose recommended in the leaflet, subcutaneously. After five months, he developed a scaling, erythematous alopecia plaque, with pruritus, on the vertex region, measuring 5 cm in diameter (Fig. 1), with erythema and follicular and interfollicular desquamation, suggesting an eczema pattern on dermoscopy. Scaling erythematous plaques were observed on the left wrist and toes, as well as onychodystrophy on the right hallux and nail pitting in the fingers (Fig. 2). The direct mycological test and cultures of the alopecia plaque were negative. The histopathological analysis showed psoriasiform dermatitis with confluent parakeratosis, spongiosis, exocytosis of lymphocytes and extravasated red blood cells. PAS and Grocott staining were negative. Due to the probable diagnosis of psoriasis, topical betamethasone dipropionate and calcipotriol were initiated. After one month, the patient returned with areas of hair regrowth on dermoscopy and improvement of the skin lesions. After about nine months (SCORAD = 10.6), he showed complete hair regrowth and regression of the lesions (Fig. 3).
AD and psoriasis are T-cell-mediated dermatoses.11 Bircher AJ. Psoriasis-like Dermatitis Developing in a Patient with Atopic Dermatitis Treated with Dupilumab. Dermatitis. 2019;30:376-8. Th2 cytokines, such as interleukins IL-4, IL-13, IL-22, and IL-31 are implicated in the pathogenesis of AD.33 Aoki V, Lorenzini D, Orfali RL, Zaniboni MC, de Oliveira ZNP, Rivitti-Machado MC, et al. Consensus on the therapeutic management of atopic dermatitis - Brazilian Society of Dermatology. An Bras Dermatol. 2019;94 2 Supl 1:67-75. Th1 cytokines, such as IL-17 and IL-23 are implicated in psoriasis.11 Bircher AJ. Psoriasis-like Dermatitis Developing in a Patient with Atopic Dermatitis Treated with Dupilumab. Dermatitis. 2019;30:376-8.
Dupilumab, a fully human monoclonal antibody, blocks the α-subunit of the IL-4 receptor, which leads to the blocking of Th2 cytokine signaling (IL-4 and IL-13). There is a hypothesis that the antagonism of the Th2 pathway with dupilumab would lead to the opposite activation of the Th1 pathway. On the other hand, patients with psoriasis or another Th1-mediated disease could develop AD after treatment with immunobiologicals.22 Tracey EH, Elston CE, Fease P, Piliang M, Michael M, Vij M. Erythrodermic presentation of psoriasis in a patient treated with dupilumab. JAAD Case Rep. 2018;4:708-10.
There have been reports of alopecia areata associated with dupilumab use, as well as resolution or significant improvement of the pre-existing condition after dupilumab use.44 Oua Z, Chena C, Chena A, Yanga Y, Zhoub W. Adverse events of Dupilumab in adults with moderate-to-severe atopic dermatitis: A meta-analysis. Int Immunopharmacol. 2018;54:303-10. In the described case, there was an erythematous alopecia plaque, with interfollicular and perifollicular scaling on dermoscopy, suggestive of psoriasis, eczema, or tinea capitis.
Erythrodermic, plaque, acral, and scalp psoriasis have been described, but there is no description of psoriatic alopecia plaques (alopecia areata-like) associated with the use of dupilumab.11 Bircher AJ. Psoriasis-like Dermatitis Developing in a Patient with Atopic Dermatitis Treated with Dupilumab. Dermatitis. 2019;30:376-8.,44 Oua Z, Chena C, Chena A, Yanga Y, Zhoub W. Adverse events of Dupilumab in adults with moderate-to-severe atopic dermatitis: A meta-analysis. Int Immunopharmacol. 2018;54:303-10. Alopecia is rarely directly related to psoriasis, with telogen effluvium being its most common form. In most cases, hair regrowth occurs, rarely progressing to the cicatricial form.55 George SMC, Taylor MR, Farrant PBJ. Psoriatic alopecia. Clin Exp Dermatol. 2015;40:717-21.
There have been reports of psoriasis as an adverse effect of dupilumab, but it has not been included as an adverse event in clinical trials.11 Bircher AJ. Psoriasis-like Dermatitis Developing in a Patient with Atopic Dermatitis Treated with Dupilumab. Dermatitis. 2019;30:376-8.,44 Oua Z, Chena C, Chena A, Yanga Y, Zhoub W. Adverse events of Dupilumab in adults with moderate-to-severe atopic dermatitis: A meta-analysis. Int Immunopharmacol. 2018;54:303-10. This case describes an unprecedented event associated with the use of dupilumab, which is important for the understanding and management of this drug.
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Financial supportNone declared.
References
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1Bircher AJ. Psoriasis-like Dermatitis Developing in a Patient with Atopic Dermatitis Treated with Dupilumab. Dermatitis. 2019;30:376-8.
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2Tracey EH, Elston CE, Fease P, Piliang M, Michael M, Vij M. Erythrodermic presentation of psoriasis in a patient treated with dupilumab. JAAD Case Rep. 2018;4:708-10.
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3Aoki V, Lorenzini D, Orfali RL, Zaniboni MC, de Oliveira ZNP, Rivitti-Machado MC, et al. Consensus on the therapeutic management of atopic dermatitis - Brazilian Society of Dermatology. An Bras Dermatol. 2019;94 2 Supl 1:67-75.
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4Oua Z, Chena C, Chena A, Yanga Y, Zhoub W. Adverse events of Dupilumab in adults with moderate-to-severe atopic dermatitis: A meta-analysis. Int Immunopharmacol. 2018;54:303-10.
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5George SMC, Taylor MR, Farrant PBJ. Psoriatic alopecia. Clin Exp Dermatol. 2015;40:717-21.
Publication Dates
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Publication in this collection
18 Oct 2021 -
Date of issue
2021
History
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Received
26 Jan 2021 -
Accepted
24 Mar 2021 -
Published
14 July 2021