New study of Pediatric Alopecia Areata: Dupilumab Helps Some

Dupilumab (DUPIXENT) May be an Option for Children with Alopecia Areata Who have Severe Early Onset Atopic Dermatitis

The exact cause of alopecia areata has not yet been worked out.  It is known that many parts of the immune system are activated in those with alopecia areata - and the underlying activations and degree of activation may not be the same in all patients with alopecia areata. Both Th1 and Th2 immune responses have a role. Recently, the drug dupilumab (DUPIXENT), an interleukin (IL)-4 receptor antagonist that downregulates Th2 response, has been suggested to help some patients with alopecia areata.  The drug is FDA approved for treating atopic dermatitis as well as some types of asthma and some forms of sinusitis. Paradoxically, the drug also appears to trigger the development of alopecia areata in some patients as well. To date, there have been a handful of patients reported in the medical journals who have  developed alopecia areata-like hair loss with use of dupilumab and continued reports of patients with alopecia areata who regrew hair back with use of dupilumab. 

SEE: Dupilumab for Alopecia Areata: Does it Help AA or Trigger AA?

New Study Examines Dupilumab Use in Pediatric Alopecia Areata

One of the largest studies to date of dupilumab use in pediatric patients with alopecia areata was a 2021 study by McKenzie and colleagues. The study was a retrospective review of 16 patients with alopecia areata. 7 had alopecia universalis, 5 had ophiasis type alopecia areata and 4 had patchy alopecia areata. All patients had atopic dermatitis (eczema) and 4 had asthma. 12 patients had failed to regrow hair in the past with prednisone, and 9 had failed methotrexate. 

In the study, treatment was initiated with dupilumab 300 mg every 2 weeks. Follow up was for varying lengths of time although a majority had follow up of 4 months or more. Of the 8 patients in the study with longer follow up (4 or more months) and who had measurable hair loss prior to receiving dupilumab (ie SALT score > 0), about one-half of patients had no significant response (4/8, 50 %). Another 1 patient had some response (12.5%) and 3 of the 8 patients 37.5% had significant improvement with use of dupilumab. 

Of 4 patients with alopecia totalis and universalis prior to starting dupilumab (SALT score 85-100) who had at least 4 months of follow up, 3 had no response to treatment (75%), and 1 (25%) had partial response. There were no complete responders in those with AT or AU prior to starting dupilumab injections.   

Summary and Comment

This is a small study but quite interesting and nicely detailed. What was particularly interesting in this study is that all patients with improvement had moderate-to-severe atopic dermatitis at the start of treatment, and dupilumab “responders” were more likely to be diagnosed with atopic dermatitis at much younger ages and had lived with eczema longer.  These findings lend support to the concept that degree of activation of the Th2 axis may influence the chances of success with dupilumab. 

What does this study mean to me ?

This study is important because it keeps Dupilumab on the list of treatments for alopecia areata. It’s quite a miraculous thing that this eczema treatment is a potential treatment for alopecia areata. This was a very nicely described study. The data is important to look at carefully as conclusions can be spun so many different ways in this particular study (and all studies).

However, we need to see in mind a few things:

1) Dupilumab is new. If alopecia areata is going to need to be treated for decades, we need to keep in mind always that we don’t yet really understand the long term side effects. Maybe there are no long term serious ones. Maybe there are. General side effects are quite well known.

2) Dupilumab does not help everyone. It helps a small proportion with alopecia totalis and universalis. In the present study above, it did not help a lot of those with advanced alopecia areata forms. Dupilumab does not appear was effective as tofacitinib and may not even be as effective as steroid injections or topical steroids for localized patchy AA. Before we rush to this treatment, wee need to remember the past 60 years and where we have been. The safety of dupilumab is encouraging and it may in fact be safer long term than Tofacitinib. Those long term studies need to be done.

3) With the possibility that dupilumab can trigger alopecia areata we need to have respect for this treatment. While it makes sense to consider in those patients with alopecia areata who have moderate to severe underlying atopic dermatitis, we don’t really understand the risks of using it in other groups. Does using it in a patient “without” atopic dermatitis alter the long term natural course of the AA? We just don’t know and a healthy respect is needed. Those studies are underway.

4) The safety so far for dupilumab seems encouraging. We don’t need blood tests before starting dupilumab or after starting it. Kids hate blood tests. Adults hate blood tests. I hate blood tests. This is a nice feature of dupilumab.

5) One must keep in mind too that dupilumab is not FDA approved for alopecia areata. Unless the child has atopic dermatitis (or one of the other FDA approved reasons), the drug is not going to be approved by a lot of insurers. The drugs costs $ 18,000 CAD per year so this drug will not be option for many.

I do know with great great certainty that we are now going to see dupilumab used a lot for treating alopecia areata . Doctors like new thing especially when the old things don’t always reliably help. We need to keep in mind that this treatment is new and the best evidence exists for use in those alopecia areata patients with eczema. Clinical trials are underway for those without eczema - I’ll be interested to see that data when it comes out.

REFERENCE

McKenzie P. Dupilumab Therapy for Alopecia Areata in Pediatric Patients with Concomitant Atopic Dermatitis. Journal of the American Academy of Dermatology 2021.