month, his next 200 mg injection was performed at the 3-week mark instead of the 2-week mark. His atopic dermatitis flared during this time with pruritus. Dupilumab frequency was reinstated at every 2 weeks. The atopic dermatitis flare resolved, and post-inflammatory hyperpigmentation improved (Figure 4).
Dupilumab is a monoclonal antibody that blocks the IL-4 al-pha receptor and therefore inhibits IL-4 and IL-13 signaling, preventing the release of type 2 cytokines that promote inflammation in atopic dermatitis.11 A randomized control trial of 54 patients treated with dupilumab resulted in reduced cellular infiltrates and significant clinical improvement.11 After 16 weeks of treatment, researchers observed reversal of lesional atopic dermatitis phenotype.11
In this case, the post-inflammatory hyperpigmentation was quite severe. After initiation of dupilumab, clinical improvement of the post-inflammatory hyperpigmentation, and lightening of overall skin tone was noted. Suarez et al. compared chronic atopic dermatitis lesional skin, non-lesional skin, and normal skin biopsies and found that non-lesional skin has cutaneous T-cell expansion.6 Non-lesional and lesional skin differ from normal skin in regards to keratinocyte terminal differentiation and inflammatory pathways.6 The abnormalities seen in lesional atopic dermatitis skin are also seen in non-lesional skin, which suggests that the total body surface area of skin in patients with atopic dermatitis is abnormal, even if it appears normal clinically.6 This is especially important in skin of color patients who are more prone to residual effects of atopic dermatitis such as post-inflammatory hyperpigmentation.
Systemically treating moderate-severe atopic dermatitis with dupilumab in skin of color patients with significant, distressing hyperpigmentation should be considered. Reducing hyperpigmentation in non-clinically apparent areas of atopic dermatitis and evident post-inflammatory hyperpigmentation areas may contribute positively to quality of life. For skin of color patients, aggressive treatment with duplimab may accelerate the return of the patient’s overall normal skin tone.
Post-inflammatory hyperpigmentation often comes with psychosocial impairments. A study assessing quality of life found that patients with atopic dermatitis reported significantly more mood and sleep disorders compared to controls.5 These patients had significantly reduced health related quality of life on physical and mental domains.5 In a study of 419 patients, those with post-inflammatory hyperpigmentation had higher scores on the Dermatology Life Quality Index (DLQI) survey, which indicates poorer quality of life, when compared to patients with other disorders of hyperpigmentation.12 Additionally, the study demonstrated that DLQI scores were higher in women and those younger than 35 years of age. Having a graduate level education was associated with significantly lower DLQI scores, showing that patients with lower education level had a more negative impact on quality of life.12 Atopic dermatitis is a systemic disease. Dupilumab’s impact on post-inflammatory hyperpigmentation and apparent hyperpigmentation in non-lesional skin emphasizes the scientific data of atopic dermatitis activity in lesional and non-lesional skin. When considering whether to treat atopic dermatitis aggressively, it is essential to consider the overall