Dupilumab Improves Atopic Dermatitis and Post-Inflammatory Hyperpigmentation in Patient With Skin of Color

July 2020 | Volume 19 | Issue 7 | Case Reports | 776 | Copyright © July 2020


Published online June 24, 2020

Ciara Grayson MSa, Candice R. Heath MDb,c

aFlorida State University College of Medicine, Tallahassee, FL bLewis Katz School of Medicine, Temple University, Department of Dermatology, Philadelphia, PA

Abstract
Atopic dermatitis, a chronic inflammatory condition, accounts for numerous dermatology visits for patients with skin of color. The inflammatory process often leads to post-inflammatory hyperpigmentation, especially in patients with skin of color, which may negatively impact quality of life. We present a case that demonstrates clinical improvement of atopic dermatitis, post inflammatory hyperpigmentation, and lightening of pigmentation in clinically non-lesional areas after initiation of dupilumab. Lightening of the patient’s skin even in areas that previously appeared clinically normal supports the scientific evidence that non-lesional skin in those with atopic dermatitis is often subclinically involved. For skin of color patients, aggressive treatment with duplimab may accelerate the return of the patient’s overall normal skin tone.

J Drugs Dermatol. 2020;19(7): doi:10.36849/JDD.2020.4937

INTRODUCTION

Atopic dermatitis is a chronic inflammatory skin condition that affects up to one fifth of the population in developed countries.1 It is characterized by relapsing pruritic patches and plaques with exudation, crusting, scaling, fissures, and lichenification in later stages.2 Atopic dermatitis lesions may be intensely itchy and elicit discomfort. African Americans are disproportionately affected by atopic dermatitis compared to their Caucasian counterparts, 19.3% and 16.1%, respectively.3 Additionally, atopic dermatitis may be more severe in patients with skin of color and for non-Hispanic black and Hispanic children, is more likely to persist into adulthood.4 Atopic dermatitis in skin of color patients may be particularly distressing due to post-inflammatory hyperpigmentation, which often leads to psychosocial effects and negative impacts on quality of life and productivity.5 In vivo, atopic dermatitis is active in both lesional and non-lesional skin.6 We highlight a case in which treating atopic dermatitis aggressively in a patient of African descent not only leads to clinically improved areas of atopic dermatitis and post-inflammatory hyperpigmentation, but also improves hyperpigmentation in non-lesional skin.

CASE PRESENTATION

A 53-year-old male of African-descent presented with a 1-year history of worsening pruritic rash. He was applying petroleum jelly without relief. Past medical history was significant for deafness and iron deficiency. On physical exam, there were multiple hyperpigmented plaques, hyperpigmented lichenified plaques, and hyperpigmented patches on the trunk, extremities, buttocks, neck, and face. The patient was diagnosed with moderate-severe atopic dermatitis. Triamcinolone ointment 0.1%, tacrolimus 1% and cetirizine 20 mg po daily were prescribed. Gentle skin care and soak and smear technique were reviewed. Two months later, the patient received 600 mg loading dose of dupilumab. Two weeks later, the patient’s atopic dermatitis and pruritus were improved (Figure 1). The patient continued 200 mg subcutaneous every 2 weeks resulting in continued improvement of atopic dermatitis, post-inflammatory hyperpigmentation, and apparent hyperpigmentation in non-lesional areas (Figures 2 and 3). Gentle skin care routine emphasized with intermittent use of topical triamcinolone 0.1% ointment or tacrolimus 1% ointment as needed for pruritus. After completion of the fifth