What to do when Dupilumab Triggers Alopecia Areata in Atopic Dermatitis

Is Dupilumab Ever An Option Again if it Triggers Alopecia?

Dupilumab is a monoclonal antibody that interferes with IL-4 and IL-13 signaling. It was approved by the Food and Drug Administration for use in moderate-to-severe atopic dermatitis in 2017.

Several studies have suggested that dupilumab can be used to both treat alopecia areata but in other situations it can trigger alopecia areata too. Little is known about what to do in situations where dupilumab triggers AA. Should dupilumab be stopped? Can it be used at lower doses?

Kulkarni et al, 2022

Kulkarni et al presented the case of a 22-year old African American man with long standing atopic dermatitis. In the past, he has been treated with topical corticosteroids, a JAK inhibitor and mycophenolate mofetil. Unfortunately, these treatments did nothelp his eczema.

He was then started on dupilumab. He was given a subcutaneous injection of 600-mg as the loading dose, followed by 300-mg subcutaneous injections every 2 weeks. The patient noted significant clinical improvement of his AD within 4 months of starting dupilumab. Unfortunately, the patient also experienced alopecia areata.

His alopecia areata was treated with intralesional triamcinolone topical clobetasol ointment, as well as a short course (10 days) of oral prednisone. Hair did not regrow. He was then given another intralesional steroid injection to the area. Dupilumab was discontinued, and the patient was started on 500-mg mycophenolic acid mofetil twice daily for 3 months.

Within 6 months, the patient’s scalp hair slowly returned . During this time, the patient received approximately 1 more month of treatment with mycophenolate mofetil.

His atopic dermatitis was worsening and the patient requested to be restarted on dupilumab. Following a discussion of risks of AA recurrence, he was put on a lower dose of 300 mg monthly. Four months after starting this new regimen, the patient showed significant improvement of his eczema and did not experience any additional hair loss with the new regimen, and his scalp hair returned to baseline One year after restarting the lower dosage of dupilumab, he has had no recurrence of AA

Conclusion

This is a helpful article. It’s difficult to know what to do when patients develop alopecia areata while on Dupilumab. Do we stop the drug? Do we continue at a lower dose? This study does not have all the answers for what to do in all scenarios but does suggest that stopping dupilumab for a period of time and treating the alopecia areata and then restarting dupilumab at a lower dose (like 300 mg monthly) might be a good answer.

REFERENCE

Kulkarni et al. Resolution of dupilumab-associated alopecia areata with dosage modification. JAAD Case Rep. 2022 Feb 17;22:85-88.