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May 2023 Volume 7 Issue 3

BRIEF ARTICLE

Treatment of Severe Recalcitrant Atopic Dermatitis with
Dupilumab in a Kidney Transplant Patient

Vivian Li, MMS1, Sophie Guenin, MSc2 3, Mark Lebwohl, MD3

1Lake Erie College of Osteopathic Medicine, Erie, PA
2New York Medical College, Valhalla, NY
3Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY

Atopic dermatitis (AD) is a chronic
inflammatory skin condition that affects both
children and adults. Clinical symptoms of AD
include severe itching, redness, and dry skin.
AD relapse is driven by genetic
predisposition and includes altered skin
barrier function associated with filaggrin gene
mutation and filaggrin deficiency.1 Type 2
cytokines such as interleukin (IL)-4 and IL-13
play a significant role in the pathogenesis of
AD. IL-4 has been shown to initiate the Th2
response while IL-13 maintains the
response.1 Although topical corticosteroids
are the first line treatment for AD, systemic

immunomodulating agents such as
mycophenolate mofetil or prednisone may be
used in patients who do not respond well to
topical therapy or have severe refractory AD.2

These systemic agents aim to reduce
cutaneous inflammation and achieve long-
term disease control by disrupting disease
pathways, leading to reduced lymphocyte
proliferation; however, these treatments are
related to notable adverse effects, such as an
increased risk of infections and the
occurrence of rebound flares.3,4 This case
report highlights the unique specificity and
safety of dupilumab, a biologic agent that
selectively targets cytokines (IL-4 and IL-13)
that are crucial in the pathogenesis of AD, in

ABSTRACT

This case report highlights the successful treatment of refractory atopic dermatitis (AD) in an
immunosuppressed patient using dupilumab, a biologic agent that selectively targets
cytokines crucial in the pathogenesis of AD. The patient had a history of failed treatment with
numerous topical and systemic immunomodulating agents, including corticosteroids and
immunosuppressive drugs for organ transplant. Dupilumab treatment resulted in significant
improvement of symptoms, including reduced pruritus, and ultimately achieved disease
control. Importantly, the patient experienced no adverse effects apart from one COVID-19
infection over three years of co-administration of dupilumab with immunosuppressive
transplant rejection treatment. The safety of dupilumab in immunocompromised and
transplant patients has been a concern, but studies have shown its safety and efficacy in
these patient populations. This case highlights the potential for dupilumab as a safe and
effective treatment option for patients with severe AD who are immunocompromised or have
undergone solid organ transplantation.

INTRODUCTION

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successfully treating an immunosuppressed
patient with refractory AD.

A 30-year-old male first presented to us with
severe atopic dermatitis in the context of an
atopic triad. His past medical history included
congenital kidney dysplasia and end-stage
renal disease for which he received three
kidney transplantations. Of note, he was on
oral tacrolimus 1.5 mg twice daily,
mycophenolate mofetil 1000 mg twice daily,
and prednisone 5 mg daily for transplant
immunosuppression. His atopic dermatitis
was inadequately controlled with fluocinonide
cream and clobetasol, evidenced by the
presence of pigmented patches, xerosis,
excoriations, and mild to moderate,
generalized pruritus throughout the body.
Over the next year, the patient was treated
with phototherapy and various topicals, such
as pimecrolimus, tacrolimus, mometasone,
and methylprednisolone. Notably, his oral
transplant anti-rejection medications did not
adequately treat his AD symptoms.

The following year, the patient presented with
exacerbation of his AD, asthma, and
allergies. At this time, his Eczema
Assessment Severity Index (EASI) score was
37 and he was initiated on dupilumab
therapy. The dupilumab treatment consisted
of an initial 600 mg dose, followed by 300 mg
dose every two weeks thereafter. Within two
weeks of his initial treatment, the patient
reported that his skin had improved
considerably, and the general level of pruritus
had reduced significantly.

Physical examination during the patient’s
follow-up appointment three months later
showed that his skin was clear, and the
symptoms of AD had largely disappeared.
His use of topical treatments for AD is

minimal, with rare flares controlled with
topical ruxolitinib. The patient’s EASI score
was reduced to 0, and he reports a dramatic
increase in quality of life. Importantly, the
patient experienced no adverse effects apart
from one COVID-19 infection over three
years of co-administration of dupilumab with
immunosuppressive transplant rejection
treatment.

Dupilumab is a monoclonal antibody that
selectively inhibits the signaling of both IL-4
and IL-13, key drivers of the inflammatory
response in atopic dermatitis, by binding to
their shared receptor alpha subunit.5 This
blocks downstream signaling and ultimately
decreases the Th2-driven inflammatory
response to help reduce skin inflammation
and improve skin barrier function.5
Dupilumab is approved for the treatment of
moderate to severe atopic dermatitis.5
Patients in the dupilumab clinical trials
reported 75% or greater improvement from
their baseline EASI score over the course of
sixteen weeks, relief from pruritus, and
enhanced quality of life.5

Although our patient was on an
immunosuppressive organ transplant
regimen, his AD remained uncontrolled.
Mycophenolate mofetil inhibits the
proliferation of T and B cells thereby,
reducing the production of cytokines that
contribute to inflammatory pathways.6
Similarly, oral tacrolimus functions by forming
a complex with FKBP-12 to inhibit the
downstream effects of calcineurin, a key
enzyme responsible for T-cell activation.7
Prednisone, a corticosteroid, broadly
suppresses the immune system.8 However,
despite a robust combination of
immunosuppressive therapies, our patient’s
AD failed to respond.

CASE REPORT

DISCUSSION

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The safety of dupilumab in
immunocompromised and transplant patients
has been a concern due to the potential risk
of infections and impaired immune function.
However, Lukac et al. conducted a study
which demonstrated the safety of dupilumab
in these patient populations.9 Other studies
have also reported successful use of
dupilumab in patients with AD and underlying
primary immunodeficiency disorders, such as
X-linked agammaglobulinemia and hyper IgE
syndrome.10,11 The risk of infections with
dupilumab appears to be similar to that of
placebo, and there have been no reports of
opportunistic infections or reactivation of
latent infections.12 Demonstrated by our
patient, dupilumab can be considered as a
safe and effective treatment option for
patients with severe AD who are
immunocompromised or have undergone
solid organ transplantation.

Conflict of Interest Disclosures: Vivian Li and
Sophie Guenin have no conflicts of interest. Mark
Lebwohl is an employee of Mount Sinai and receives
research funds from: Abbvie, Amgen, Arcutis,
Avotres, Boehringer Ingelheim, Cara Therapeutics,
Dermavant Sciences, Eli Lilly, Incyte, Inozyme,
Janssen Research & Development, LLC, Novartis,
Ortho Dermatologics, Regeneron, and UCB, Inc.
Dr. Lebwohl is also a consultant for AnaptysBio,
Arcutis, Inc., Arena Pharmaceuticals, Aristea
Therapeutics, Avotres Therapeutics, BioMX,
Boehringer-Ingelheim, Brickell Biotech, Castle
Biosciences, Corevitas, Dermavant Sciences,
Evommune, Inc., Facilitatation of International
Dermatology Education, Forte Biosciences,
Foundation for Research and Education in
Dermatology, Hexima Ltd., Meiji Seika
Pharma, Mindera, National Society of Cutaneous
Medicine, New York College of Podiatric Medicine,
Pfizer, Seanergy, SUN Pharma, Verrica, and Vial.

Funding: None

Corresponding Author:
Vivian Li, MMS
Lake Erie College of Osteopathic Medicine
Erie, PA
Email: livivian23@gmail.com

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11. Wang HJ, Yang TT, Lan CE. Dupilumab
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immunoglobulin E syndrome. J Eur Acad
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