be severe , especially if used for long periods of time . Some commonly seen side effects include increased risk of infection , hypertension , diabetes , osteoporosis , nausea , vomiting , and ( for those taking cyclosporine ) nephrotoxicity . 6 , 8 , 13 Given the inconsistent efficacy and significant side-effect profile of systemic immunosuppressive therapy for AD , there is an unmet need for long-term , efficacious treatments for AD that have minimal side effects .
In March 2017 , the novel treatment for AD , Dupilumab , became the first biologic agent approved by the FDA for treatment of moderate to severe AD . 6 Dupilumab is a fully human monoclonal IgG4 antibody that inhibits interleukin-4 and interleukin-13 signal transduction by blocking the shared alpha subunit of the interleukin-4 and interleukin-13 receptors . 1 , 12 This treatment results in changes in gene expression such as down regulation of markers of epidermal proliferation and inflammatory mediators , and up regulation of structural proteins , lipid metabolism proteins , and epidermal barrier proteins . These changes normalize the skin and relieve symptoms of AD . 12
Patient presented in 2011 with long history of atopic dermatitis ( AD ) and recurrent herpes simplex virus ( HSV ) infections . Note the background lichenification , excoriations and erythema consistent with AD . Note the acute vesicles in the glabellar area consistent with HSV .
In clinical trials , Dupilumab has shown promising results for successful treatment of AD . In one randomized , controlled trial of adults with AD who lived in North America , Europe , and Asia , a group receiving Dupilumab injections demonstrated improvement across multiple outcome measures compared to a group receiving placebo treatment . These outcome measures included objective signs of AD , subjective symptoms such as pruritus , mental health , and overall quality of life . 2 Dupilumab has a favorable side effect profile with common adverse events including injection site reactions , exacerbations of AD , nasopharyngitis , and conjunctivitis . When comparing the risks of long-term usage of immunosuppressants versus risks of long-term usage of Dupilumab , it is clear that Dupilumab is likely the safer and more effective long-term option . 6 This case emphasizes the safety and efficacy of Dupilumab treatment in a patient with severe AD . Clinicians should be aware of this treatment and the potential benefit it has to the large number of patients suffering from severe , treatment-resistant AD .
Same patient in May 2016 , after two years of dupilumab treatment . Note the improvement of background erythema , lichenification , and excoriations . Note no active HSV lesions or scarring from prior lesions . Note the improvement even of periorbital erythema and edema .
often require treatment with systemic immunosuppressants , which are variably effective and result in multiple safety concerns . 5 , 8 Current immunosuppressive treatment options include agents such as oral corticosteroids , cyclosporine , azathioprine , methotrexate , and mycophenolate modafonil . 6 , 8 The side effects of these agents can
References :
1 . Beck , L . A ., Thaçi , D ., Hamilton , J . D ., Graham , N . M ., Bieber , T ., Rocklin , R ., … Radin , A . R . ( 2014 ). Dupilumab Treatment in Adults with Moderate-to-Severe Atopic Dermatitis . New England Journal of Medicine , 371 ( 2 ), 130 – 139 . https :// doi . org / 10.1056 / NEJ- Moa1314768 .
2 . Simpson , E . L ., Bieber , T ., Guttman-Yassky , E ., Beck , L . A ., Blauvelt , A ., Cork , M . J ., ... & Kingo , K . ( 2016 ). Two phase 3 trials of dupilumab versus placebo in atopic dermatitis . New England Journal of Medicine , 375 ( 24 ), 2335-2348 .
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