Simultaneous effectiveness of dupilumab in atopic dermatitis and alopecia areata in two patients

Abstract

Alopecia areata (AA) is a fairly common, non-cicatricial type of hair loss with an estimated lifetime incidence of 2.1 % and an epidemiological association with atopy [1–3]. The clinical presentation can vary from small, well-circumscribed round or oval alopecic patches to a complete absence of scalp hair in alopecia totalis (AT) or of the entire scalp and body hair in alopecia universalis (AU). Despite the relatively high prevalence of AA, the therapeutic armamentarium of topical/intralesional corticosteroids, topical dithranol or diphenylcyclopropenone, systemic corticosteroids and photochemotherapy is often insufficient, especially in extensive or long-standing AA [4, 5]. We report two cases highlighting the dual effectiveness of dupilumab in AA and atopic dermatitis (AD). Case 1 is a 38-year-old male who presented to our dermatology department for management of his moderate to severe atopic dermatitis, which he had had since the age of three years. He also had associated allergic rhinoconjunctivitis (ARC) and asthma, currently treated with reproterol/cromoglycate and salbutamol. In addition, he had a history of alopecia universalis for five years. Previous treatments of AD included UVB 311 nm phototherapy followed by cyclosporine (max. 4.72 mg/kg body weight [bw]). However, due to generalized myalgia the cyclosporine dose was reduced to 2.0 mg/ kg body weight, which led to frequent AD exacerbations. Physical examination at presentation demonstrated multiple eczematous patches affecting the back, upper and lower extremities, as well as hyperkeratotic hand eczema. The corresponding atopic dermatitis score (SCORAD) was 27. He also had complete hair loss of the body and scalp, with only a few eyebrow hairs left (Figure 1a). Cyclosporine was stopped and the patient was then started on dupilumab at 600 mg subcutaneously on day 0, followed by 300 mg subcutaneously every two weeks. The patient noticed the first hair re-growth four weeks after initiation of dupilumab treatment. At week 22 of dupilumab treatment, a few eczematous patches on the back and upper extremities as well as the hyperkeratotic hand eczema persisted, while the corresponding SCORAD score had improved to 16. The scalp, eyelashes and eyebrows also showed significant hair re-growth (Figure 1b). Case 2 is a 32-year-old male with severe atopic dermatitis since the age of two, with concomitant ARC and asthma (which was treated with salbutamol on demand). He also had ophiasis-type AA for two years. Previous treatments of AD included repeated sessions of UVA1 phototherapy followed by cyclosporine (max. 2.3 mg/kg bw) and azathioprine (max. 2.5 mg/kg bw); the latter two were discontinued due to abdominal pain and recurrent infections, respectively. Physical examination four weeks after cessation of the UVA1 phototherapy demonstrated multiple eczematous Clinical Letter