Use of Dupilumab for Adult-Onset Atopic Dermatitis: A Real-World Retrospective Study

To the Editor,

Atopic dermatitis (AD) is an inflammatory skin condition typified by severe pruritus with profound impacts on quality of life. ¹ Despite the emergence of adult-onset AD as an entity with unique pathogenetic and phenotypic features, there is limited information on its treatment. ⁴ Dupilumab, a monoclonal antibody for interleukin (IL)-4/13 has gained regulatory approval for moderate-to-severe AD in numerous countries.^2,3 In this study, we sought to investigate the outcomes of dupilumab therapy in patients with adult-onset AD.

We conducted a retrospective chart review of adult patients treated with dupilumab for AD (standard dosing) from two tertiary academic dermatology centres in Toronto, Canada. Data was collected from December 2017 to December 2022. Our group previously reported a 2-year efficacy, safety, and drug survival on these patients in 2021. ⁵

We identified 21 patients with adult-onset AD (new onset at age 18 or older) of which n = 20, n = 14, n = 13, n = 10, and n = 9 completed treatment at 16, 52, 104, 156, and 208 weeks, respectively (Supplementary Table 1). There were 8 males (38.1%) and 13 females (61.9%). Mean age was 56.5 (range: 34-88) years. We identified 9 (42.9%) and 5 (23.8%) patients with a personal or family history of atopy, respectively. Before initiating dupilumab, patients failed an average of 1.9 previous systemic therapies with prednisone (52.4%, 11/21) and methotrexate (52.4%, 11/21) being most common (Supplementary Table 2). Four patients used concomitant medications, including cyclosporine (4.8%, 1/21), prednisone (4.8%, 1/21), and methotrexate (9.5%, 2/21).

There were 13 (61.9%), 10 (52.6%), 12 (63.2%), 10 (58.8%), and 9 (60%) patients that met the primary endpoint of this study at 16-, 52-, 104-, 156-, and 208-week endpoints, respectively which reflected an Investigator Global Assessment (IGA) score of 0 (clear) or 1 (almost clear) (range: 0-5) (Supplementary Table 3). Five patients (23.8%) discontinued treatment from week 8 and beyond due to lack of efficacy. These patients were recorded as non-responders. Four patients (21%, 4/19) were lost-to-follow-up from weeks 104 to 208 (Supplementary Table 2). Additionally, three patients (16%) discontinued treatment due to insurance loss, non-treatment-related death, and self-discontinuation following disease clearance. Four patients (19%) experienced mild ocular surface disease (Supplementary Table 3).

Despite the paucity of literature on adult-onset AD, extant investigations have shown that adult-onset AD may entail a diminished impact of filaggrin and immunoglobulin E, alongside sustained induction of Th2-related cytokines, notably IL-4/13, in comparison with pediatric-onset AD. ⁴ Furthermore, several national guidelines have recommended dupilumab (IL-4/13 inhibition) as second-line therapy for refractory AD. ² Recently, a 4-year open-label extension trial for dupilumab demonstrated 53.8%, 58.2%, 74.6%, and 64.4% of patients achieving an IGA score of 0 or 1 from weeks 52, 100, 148, and 204 respectively. ³ These findings are commensurate with the positive therapeutic effects we observed following dupilumab implementation in our distinctive cohort of adult-onset patients.

Given its retrospective nature, this study may be limited by potential inclusion of heterogeneous diagnoses, possible bias due to lack of control, and small sample size. Nonetheless, our results support the long-term use of dupilumab for adult-onset AD in real-world practice.

Supplemental Material

sj-docx-1-cms-10.1177_12034754231220933 – Supplemental material for Use of Dupilumab for Adult-Onset Atopic Dermatitis: A Real-World Retrospective Study

Supplemental material, sj-docx-1-cms-10.1177_12034754231220933 for Use of Dupilumab for Adult-Onset Atopic Dermatitis: A Real-World Retrospective Study by Siddhartha Sood, Jorge R. Georgakopoulos, Khalad Maliyar, Muskaan Sachdeva, Asfandyar Mufti and Jensen Yeung in Journal of Cutaneous Medicine and Surgery

Supplemental Material

sj-docx-2-cms-10.1177_12034754231220933 – Supplemental material for Use of Dupilumab for Adult-Onset Atopic Dermatitis: A Real-World Retrospective Study

Supplemental material, sj-docx-2-cms-10.1177_12034754231220933 for Use of Dupilumab for Adult-Onset Atopic Dermatitis: A Real-World Retrospective Study by Siddhartha Sood, Jorge R. Georgakopoulos, Khalad Maliyar, Muskaan Sachdeva, Asfandyar Mufti and Jensen Yeung in Journal of Cutaneous Medicine and Surgery

Supplemental Material

sj-docx-3-cms-10.1177_12034754231220933 – Supplemental material for Use of Dupilumab for Adult-Onset Atopic Dermatitis: A Real-World Retrospective Study

Supplemental material, sj-docx-3-cms-10.1177_12034754231220933 for Use of Dupilumab for Adult-Onset Atopic Dermatitis: A Real-World Retrospective Study by Siddhartha Sood, Jorge R. Georgakopoulos, Khalad Maliyar, Muskaan Sachdeva, Asfandyar Mufti and Jensen Yeung in Journal of Cutaneous Medicine and Surgery