Case Letter
Alopecia areata-like and psoriasis after dupilumab use for atopic dermatitis
Viviane Maria Maiolini
, Nathalie Andrade Sousa, Paula Figueiredo de Marsillac, Aline Lopes Bressan
Corresponding author
Service of Dermatology, Faculty of Medical Sciences, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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There is no direct interference on the Th1 pathway.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The present report describes a rare manifestation of alopecia areata-like psoriasis, associated with skin lesions after dupilumab use.</p><p id="par0015" class="elsevierStylePara elsevierViewall">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to several previous treatments, such as topical and systemic steroids, azathioprine and methotrexate, which were withdrawn due to therapeutic failure.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 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), 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 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). 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 (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">AD and psoriasis are T-cell-mediated dermatoses.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Th2 cytokines, such as interleukins IL-4, IL-13, IL-22, and IL-31 are implicated in the pathogenesis of AD.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Th1 cytokines, such as IL-17 and IL-23 are implicated in psoriasis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">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.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">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.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In the described case, there was an erythematous alopecia plaque, with interfollicular and perifollicular scaling on dermoscopy, suggestive of psoriasis, eczema, or <span class="elsevierStyleItalic">tinea capitis</span>.</p><p id="par0035" class="elsevierStylePara elsevierViewall">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.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4</span></a> 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.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">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.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4</span></a> This case describes an unprecedented event associated with the use of dupilumab, which is important for the understanding and management of this drug.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors' contributions</span><p id="par0050" class="elsevierStylePara elsevierViewall">Viviane Maria Maiolini: Drafting and editing of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; approval of the final version of the manuscript; critical review of the manuscript.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Nathalie Andrade Sousa: Drafting and editing of the manuscript; intellectual participation in the propaedeutics and/or therapeutic conduct of the studied cases; critical review of the literature; approval of the final version of the manuscript; critical review of the manuscript.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Paula Figueiredo de Marsillac: Drafting and editing of the manuscript; intellectual participation in the propaedeutics and/or therapeutic conduct of the studied cases; critical review of the literature; approval of the final version of the manuscript; critical review of the manuscript.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Aline Lopes Bressan: Design and planning of the study; writing and editing of the manuscript; intellectual participation in the propaedeutics and/or therapeutic conduct of the studied cases; critical review of the literature; approval of the final version of the manuscript; critical review of the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors' contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-01-26" "fechaAceptado" => "2021-03-24" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Maiolini VM, Sousa NA, Marsillac PF, Bressan AL. Alopecia areata-like and psoriasis after dupilumab use for atopic dermatitis. 2021;96:634–6.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1335 "Ancho" => 2508 "Tamanyo" => 579904 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythematous-scaling alopecia plaque on the vertex region, measuring approximately 5 cm in its largest diameter. Dermoscopy showed erythema and follicular and interfollicular desquamation, suggesting an eczema pattern.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1252 "Ancho" => 2508 "Tamanyo" => 210059 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Erythematous scaling plaques on toes and onychodystrophy on the right hallux.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1142 "Ancho" => 3008 "Tamanyo" => 372257 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ten months after the onset of the condition, with complete hair regrowth and remission of erythematous-scaling lesions on toes and onychodystrophy undergoing resolution on the right hallux.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Psoriasis-like Dermatitis Developing in a Patient with Atopic Dermatitis Treated with Dupilumab" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 5 | 12 |
| 2024 October | 136 | 84 | 220 |
| 2024 September | 163 | 90 | 253 |
| 2024 August | 167 | 142 | 309 |
| 2024 July | 171 | 103 | 274 |
| 2024 June | 135 | 70 | 205 |
| 2024 May | 129 | 61 | 190 |
| 2024 April | 125 | 88 | 213 |
| 2024 March | 163 | 76 | 239 |
| 2024 February | 185 | 93 | 278 |
| 2024 January | 134 | 52 | 186 |
| 2023 December | 116 | 79 | 195 |
| 2023 November | 111 | 85 | 196 |
| 2023 October | 99 | 92 | 191 |
| 2023 September | 115 | 89 | 204 |
| 2023 August | 103 | 31 | 134 |
| 2023 July | 88 | 74 | 162 |
| 2023 June | 75 | 61 | 136 |
| 2023 May | 75 | 24 | 99 |
| 2023 April | 65 | 26 | 91 |
| 2023 March | 64 | 44 | 108 |
| 2023 February | 66 | 44 | 110 |
| 2023 January | 54 | 49 | 103 |
| 2022 December | 68 | 37 | 105 |
| 2022 November | 77 | 71 | 148 |
| 2022 October | 92 | 63 | 155 |
| 2022 September | 60 | 70 | 130 |
| 2022 August | 36 | 59 | 95 |
| 2022 July | 55 | 66 | 121 |
| 2022 June | 54 | 54 | 108 |
| 2022 May | 51 | 55 | 106 |
| 2022 April | 74 | 53 | 127 |
| 2022 March | 62 | 67 | 129 |
| 2022 February | 82 | 36 | 118 |
| 2022 January | 78 | 98 | 176 |
| 2021 December | 66 | 62 | 128 |
| 2021 November | 89 | 58 | 147 |
| 2021 October | 132 | 112 | 244 |
| 2021 September | 326 | 113 | 439 |
| 2021 August | 42 | 44 | 86 |
| 2021 July | 5 | 5 | 10 |
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