De novo case of lichenoid eruption following dupilumab treatment

Clinical Profile of Patients with Lichenoid Drug Eruption: A Observational Study

Background

Lichenoid drug eruption (LDE) is an uncommon cutaneous adverse drug reaction, where a variety of drugs used in day-to-day clinical practice have been implicated.

Objective

To describe the clinico-demographic characteristics of patients with LDE and to identify the most likely drugs involved.

Methods

In this prospective, observational study, consecutive patients with LDE presenting to the dermatology department of a tertiary teaching hospital were included. The clinico-demographic profile of patients with LDE and implicated drugs was noted. Treatment of drug reaction along with outcome was also documented. Naranjo adverse drug reaction probability scale was used for causality assessment of the drug reactions. A thorough literature review on LDE was also undertaken due to the paucity of existing literature.

Results

A total of 15 patients (11 males and 4 females) with LDE were evaluated. Their age ranged from 37 to 61 years, with a mean of 51.53 ± 7.59 years. Anti-hypertensive medications (40%) were the most common culprit agent, followed by antitubercular drugs (33.4%), anti-diabetic agents (13.3%), and others (13.3%). The latent period (time from drug initiation to the appearance of a cutaneous eruption) varied from 15 days to 6 months (mean 2.2 months). Cutaneous involvement was generalized in 73.4% and photo-distributed lesions in 26.6%. Drug provocation test was done to identify the culprit drug. According to the Naranjo adverse drug reaction probability scale, one-third of LDEs were "definite," whereas two-thirds were designated as "probable."

Conclusion

LDE is more common in the elderly population. The latent period is comparatively longer in LDE than in other common drug reactions. Prompt recognition and withdrawal of suspected drug are essential to minimize disease morbidity.

Perforating lichen nitidus in the setting of atopic dermatitis

Perforating lichen nitidus is a rare subtype of lichen nitidus, with approximately 11 cases reported worldwide. Lesions typically present in young male patients at sites prone to mechanical irritation, including the hands, feet, forearms, elbows, and knees. Classic histopathologic features of perforating lichen nitidus show a lymphohistiocytic infiltrate within the papillary dermis between hyperplastic rete ridges with transepidermal elimination of dermal contents. Very few cases are reported in the literature of lichen nitidus and its association with atopic dermatitis. This is the first case describing perforating lichen nitidus in a patient with a history of atopic dermatitis being treated with dupilumab injections. Lesions of perforating lichen nitidus worsened with successful treatment of atopic dermatitis. These findings suggest a unique pathophysiology of perforating lichen nitidus lesions.

A Review of Dupilumab-Induced Adverse Events to Dermatologists and the Potential Pathogenesis in the Treatment of Atopic Dermatitis

Dupilumab, a monoclonal antibody targeting interleukin-4 antibody, is approved for use in many type 2 inflammatory diseases, including atopic dermatitis. It is generally well tolerated with no need of routine laboratory monitoring. However, several adverse events have been reported during real-world practice and in pivotal trials. We conducted a systematic literature research of the PubMed, Medline, and Embase databases to identify articles recording the clinical manifestation and potential pathogenesis of these adverse events with interests (AEIs) to dermatologists. In total, 547 cases from 134 studies have developed 39 AEIs 1 day to 2.5 years after dupilumab treatment. The most common AEIs are facial and neck dermatitis (299 cases), psoriasis (70 cases), arthralgia (56 cases), alopecia (21 cases), cutaneous T cell lymphoma (19 cases), severe ocular diseases (19 cases), and drug eruption (6 cases). Most of the AEIs recorded in this review resolved or improved after dupilumab discontinuation or the addition of another treatment, whereas 3 of the cases died of severe AEI. The potential pathogenesis included T help type 1 (Th1)/T help type 2 (Th2) imbalance, Th2/T help type 17 (Th17) imbalance, immune reconstitution, hypersensitivity reaction, transient hypereosinophilia related, and Th1 suppression. Clinicians should be alert of these AEIs for timely diagnosis and appropriate treatment.

A Case Report and Literature Review of the Role of Dupilumab in the Management of Lichen Planus: Cause or Treatment?

Lichen planus (LP) is a chronic inflammatory skin condition characterized by the six Ps (ie. purple, planar, polygonal, pruritic, plaques, and papules) often causing physical, emotional, and psychological stress for the person affected. Drug-induced LP has been described after the administration of drugs like antihypertensives, non-steroidal anti-inflammatory drugs (NSAIDs), and biologics like adalimumab and etanercept. Currently, there is a dearth of studies discussing the association between LP and dupilumab. Here, we present the case of a young adult female who developed LP 24 months after treatment with dupilumab for severe atopic dermatitis. We also conducted a review of the literature discussing the association between LP and dupilumab.

Dupilumab-Induced Lichen Planus: A Case with Oral and Cutaneous Eruptions

Lichen planus is a chronic, inflammatory, immune-mediated dermatosis affecting the patient's skin, scalp, mucous membranes, and nails. Drug-induced lichen planus is described after the administration of antimalarials, ß-blockers, methyldopa, NSAIDs, penicillamines, and sodium aurothiomalate. The use of biologicals such as adalimumab, etanercept, and infliximab has also been linked with the appearance of lichenoid eruptions in the recent past. In this case, we report on a patient developing oral and cutaneous lichen planus after the administration of dupilumab. The lichenoid lesions occurred after 11 months of the drug's administration and involved the buccal walls, trunk, and extremities. Dupilumab had been administered in an effort to counter severe atopic dermatitis exacerbations. Dupilumab is associated with a downregulation of T-helper 2 cell activation by blocking the Interleukin-4/Interleukin-13 pathway, so leading to a TH1/TH2 imbalance. This imbalance may cause a shift toward a TH1-mediated immune response and be an explanation for the drug-induced lichen planus. Dupilumab was discontinued, and the patient was treated with oral corticosteroids and UVB phototherapy, leading to a significant improvement in the lichen planus lesions.

Development of systemic lupus erythematosus after dupilumab treatment in a case of atopic dermatitis

Dupilumab, a monoclonal antibody that specifically inhibits signal transductions by interleukin (IL)-4 and IL-13, has been used to treat T-helper (Th)2-type allergic disorders, including atopic dermatitis and asthma. We report a 21-year-old female patient with atopic dermatitis who developed systemic lupus erythematosus (SLE) unexpectedly after dupilumab treatment. Her skin lesions partially improved after dupilumab treatment; however, a part of her skin lesions on the face, nape, and upper extremities were refractory even after a 15-month period of dupilumab treatment. These dupilumab-refractory skin lesions were histopathologically diagnosed as cutaneous lupus erythematosus, moreover, subsequent phenomenons, diffuse alopecia, joint pain, lymphopaenia, hypocomplementemia, and positivities for anti-nuclear, anti-double-stranded DNA, anti-U1 ribonucleoprotein, anti-Smith, and anti-Sjögren's syndrome-related antigen A antibodies made a diagnosis of SLE. Our retrospective investigations on her serum samples indicted that these abnormalities of laboratory examinations had not appeared at the initiation of dupilumab treatment. Our case at least indicated that dupilumab was not effective in treating SLE. Moreover, inhibition of Th2-type immune responses by dupilumab may accelerate the pathogenesis of Th1-related inflammatory disorders, including SLE, as observed in our case. Our case also presented another possibility that dupilumab has no effect on the progression of underlying SLE. Because a significant relationship exists between atopic dermatitis/asthma and the risk of SLE, the utility of dupilumab should be carefully considered for each case.