Dupilumab in the real world
Some patients on dupilumab do not have a complete response with dosing every 2 weeks and may benefit from more frequent dosing, said Dr. Rosmarin.
“We know from the SOLO-1 and SOLO-2 studies that dupilumab weekly dosing was evaluated. It was only the every-other-week dosing that was approved, and we can see why – in terms of the changes in EASI [Eczema Area and Severity Index] score they’re close to overlapping,” he said.
In real life, however, “some patients benefit from different dosing. It’s important to realize that. I think we all have some patients who may dose more frequently and some who may dose less frequently,” Dr. Rosmarin said.
For a patient who “gets absolutely no response from dupilumab after 3-4 months, I’d switch them to something else. But for those who are partial responders, particularly those who tell me they’re getting itchy before their next dose, they’re the ones who benefit most from doubling the dose to dupilumab weekly,” he said.
For patients who experience dupilumab-associated head and neck dermatitis, itraconazole may help, Dr. Rosmarin added. “We’re using 200 mg daily for 2 weeks and weekly thereafter, and it helps some of our patients.” The average self-reported improvement was 52% for patients with dupilumab-associated facial redness treated with itraconazole in a retrospective medical record review that he and his colleagues published in 2022.
Dr. Rosmarin pointed to a multicenter prospective cohort study also published in 2022 showing that baseline/pretreatment levels of Malassezia-specific IgE were associated with the development of dupilumab-associated head and neck dermatitis. The median levels of Malassezia-specific IgE were 32 kUL–1 versus 2.3 kUL–1 in patients who experienced dupilumab-associated facial redness, compared with those who did not.
He said that, while there “may be multiple reasons” for dupilumab-associated head and neck dermatitis and that “plenty of patients” who don’t have Malassezia-specific IgE develop head and neck dermatitis, “this could be one cause.”
Itraconazole has been shown in his practice to be superior to fluconazole, likely because it has greater anti-inflammatory effects and provides better coverage of Malassezia because it is more lipophilic, said Dr. Rosmarin, who does not test for Malassezia-specific IgE before trying itraconazole.
Dr. Elaine Siegfried
For dupilumab-associated ocular surface disease, Elaine C. Siegfried, MD, offered her first-line suggestions: warm compresses (such as a microwaved bean bag), bland ocular lubricant (such as preservative-free artificial tears), oral hydration, and if needed and accessible, the prescription ophthalmic solution lifitegrast.
“It’s become an issue – what the dermatologist can do first line,” said Dr. Siegfried, professor of pediatrics and dermatology at Saint Louis University and director of the division of pediatric dermatology at Cardinal Glennon Children’s Hospital, St. Louis.
“If these don’t work, then I’ll identify an ophthalmologist who’s knowledgeable about Dupixent-related ocular surface disease,” she said. Selection is “important because they’re not all knowledgeable ... corneal specialists typically have the most knowledge.”