CASE REPORT
Dupilumab treatment for atopic dermatitis
leading to unexpected treatment for
alopecia universalis
Dema T. Alniemi, MD, and Laura McGevna, MD
Burlington, Vermont
Key words: alopecia universalis; atopic dermatitis; drug reaction; dupilumab; immunomodulatory drug;
systemic drug.
INTRODUCTION
Abbreviations used:
Atopic diseases, including atopic dermatitis and
alopecia areata, are disease entities with much active BSA: body surface area
IL: interleukin
research, as new biologic medications are emerging
targeting each of these diseases. We report a case of a
single biologic medication used to treat atopic
dermatitis, leading to unexpected treatment for con-
current alopecia areata.
CASE REPORT
A 49-year-old woman with a long-standing history
of atopic dermatitis since childhood presented with
refractory atopic dermatitis. Past treatments included
topical steroids, topical calcineurin inhibitors, photo-
therapy, and oral methotrexate, 20 mg/wk, all with
mild to moderate control of disease. She necessitated
intermittent oral prednisone bursts for severe flares.
Her atopic dermatitis would often exceed 50% of
body surface area (BSA) during flares, which she
Fig 1. Patient with atopic dermatitis and alopecia univer-
experienced monthly on average. At best with salis before therapy with dupilumab.
treatments, her atopic dermatitis covered 15% to
20% BSA. Complementary and alternative medicine
methods were also pursued without improvement, every other week after a loading dose of 600 mg
including acupuncture and herbal supplements. subcutaneously, with significant improvement of
Other significant comorbidities included a 6-year cutaneous disease and quality of life. She currently
history of unrelated, sudden, adult-onset scalp alo- only requires minimal topical treatments to control
pecia areata that quickly progressed to alopecia minor flares, with a BSA of less than 5% at all times.
universalis (Fig 1). She had cyclic sparse and patchy After starting dupilumab for refractory atopic
hair regrowth and loss over the course of the disease, dermatitis, she noted immediate hair regrowth on
without permanent hair regrowth or growth the scalp. After 8 months of dupilumab use, she had
involving more than 5% of the scalp. Her eczema full scalp hair regrowth, which she had lacked for the
rarely involved the scalp, however. previous 6 years (Fig 2). Her eyebrows have also
For the refractory atopic dermatitis, the patient shown some regrowth, although the eyelashes and
was started on dupilumab, 300 mg subcutaneously, remainder of the body hair have yet to regrow. No
From the University of Vermont Medical Center. 2352-5126
Funding sources: None. Ó 2018 by the American Academy of Dermatology, Inc. Published
Conflicts of interest: None disclosed. by Elsevier, Inc. This is an open access article under the CC BY-
Correspondence to: Dema T. Alniemi, MD, University of Vermont, NC-ND license (http://creativecommons.org/licenses/by-nc-nd/
111 Colchester Ave, Division of Dermatology, EP3, Burlington, 4.0/).
VT 05401. E-mail: dema.alniemi@uvmhealth.org. https://doi.org/10.1016/j.jdcr.2018.11.006
JAAD Case Reports 2019;5:111-2.
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112 Alniemi and McGevna JAAD CASE REPORTS
FEBRUARY 2019
Fig 2. Patient with alopecia universalis shows full scalp hair regrowth and the start of eyebrow
regrowth after 8 months of dupilumab therapy for concurrent atopic dermatitis.
adverse clinical symptoms or abnormal laboratory Although our patient’s hair regrowth could have
tests were observed with use of dupilumab in this occurred spontaneously and without relation to
patient. dupilumab, our report of dupilumab being used
for atopic dermatitis with striking hair regrowth in a
DISCUSSION patient with alopecia universalis is the second
As many diseases have cytokine production reported case, to the best of our knowledge, which
pathways in common, it fits that one drug may be may indicate the promising result of dupilumab in
used to target multiple disease courses. Case reports treating alopecia universalis, totalis, and areata,
and studies are beginning to emerge regarding the along with the already known positive effect on
use of biologics for one disease that have concur- atopic dermatitis. However, further and larger
rent effects on other diseases. For example, tofaci- studies are needed to fully assess the effects of
tinib, a JAK 1/3 inhibitor, was originally approved dupilumab on diseases shared by the helper T cell 2
for rheumatoid arthritis but has shown promising pathway, as a recent case emerged of alopecia
effects for patients with alopecia universalis.1 areata onset after treatment of atopic dermatitis
Although the pathophysiology of both atopic with dupilumab.5 Further and continued use of
dermatitis and alopecia areata are still under biologics will elucidate their effects on disease, as
research and debate, because atopic dermatitis more patients continue to use systemic medications
and alopecia areata have similar robust helper T for myriad dermatologic conditions.
cell 2emediated cytokine pathways with down-
stream effects manifesting in the skin, it is under-
REFERENCES
standable that dupilumab, an interleukin (IL)-4 and 1. Morris GM, Nahmias ZP, Kim BS. Simultaneous improvement
IL-13 monoclonal antibody, would have effects on of alopecia universalis and atopic dermatitis in a patient
both diseases.2 Studies describe the association treated with a JAK inhibitor. JAAD Case Rep. 2018;4(6):515-517.
between these 2 diseases, indicating that IL-4 leads 2. Kilic, Arzu. New modalities in the treatment of refractory
alopecia areata, hair, and scalp disorders. IntechOpen. DOI:
to production of inflammatory mediators such as
10.5772/66591.
IgE, mast cells, and eosinophils and that this 3. Barahmani N, Schabath MB, Duvic M, et al. History of atopy or
inflammation is a main factor in disease manifesta- autoimmunity increases risk of alopecia areata. JAAD. 2009;
tion. Blocking IL-4, in addition to inflammatory 61(4):581-591.
mediator IL-13, therefore, inhibits the downstream 4. Darrigade AS, Legrand A, Andreu N, et al. Dual efficacy of
dupilumab in a patient with concomitant atopic dermatitis
effects of inflammation that leads to these 2 patho-
and alopecia areata. Br J Dermatol. 2018. https:
logic diseases.3 In fact, dupilumab was recently //doi.org/10.1111/bjd.16711 [Epub ahead of print].
reported to be effective in a patient with atopic 5. Mitchell K, Levitt J. Alopecia areata after dupilumab for atopic
dermatitis and concomitant alopecia areata.4 dermatitis. JAAD Case Rep. 2018;4(2):143-144.
