Successful Treatment of Keloids and Hypertrophic Scars With Systemic and Intralesional Dupilumab

December 2023 | Volume 22 | Issue 12 | 1220 | Copyright © December 2023


Published online November 29, 2023

Michelle S. Min MD MSa,b, Daniel R. Mazori MDa, Michelle S. Lee BAb, Joseph F. Merola MD MMSca,c, Ruth Ann Vleugels MD MPH MBAa, Gabriela Cobos MDa, Avery H. LaChance MD MPHa

aDepartment of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
bDepartment of Dermatology, University of California Irvine School of Medicine, Irvine, CA
cDivision of Rheumatology, Immunology, and Allergy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

Abstract
Keloids and hypertrophic scars negatively impact the quality of life for millions of people in the world. Unfortunately, though many thera-peutic approaches are used to treat scars, they are often limited in efficacy with high rates of recurrence. Lately, a better understanding of the immune dysregulation of several dermatologic conditions has led to the emergence of multiple cytokine-targeted therapies for numerous conditions. Several studies have implicated T helper 2 (Th2) immune dysregulation in the development of scars and keloids, with interleukins (IL)-4 and -13 identified as pro-fibrotic mediators. Dupilumab is an IL-4 receptor alpha antagonist that inhibits the ex-pression of both IL-4 and -13. Herein, we describe a 44-year-old woman who developed numerous disfiguring hypertrophic scars and keloids after suffering from a severe herpes zoster infection. Given the number of scars, intralesional corticosteroid injections were not feasible. Therefore, treatment with systemic dupilumab was initiated. Many scars flattened, several even developing a cigarette-paper-like texture due to rapid involution. The largest and most recalcitrant keloid was further treated with intralesional dupliumab injec-tions every 2 weeks with an even more dramatic improvement noted in 2 months. To our knowledge, this is the first report of treating multiple keloids and hypertrophic scars with both systemic and intralesional dupilumab. Dermatologists may want to consider treating keloids that cover a large area with systemic dupilumab, a therapy with an established, reassuring safety profile. The most recalcitrant areas may further benefit from concentrating dupilumab by intralesional delivery.

J Drugs Dermatol. 2023;22(12):1220-1222.  doi:10.36849/JDD.6385

INTRODUCTION

Keloids and hypertrophic scars negatively impact millions of people in the world each year. In addition to cosmesis, functional impact and symptomatic complaints (pruritus and pain) contribute to poor quality of life.1 Intralesional corticosteroid injections remain the mainstay of therapy; however, several other treatment strategies (ie, scar revision, laser therapy, cryotherapy, 5-fluorouracil, and bleomycin) are utilized. Unfortunately, they are all limited in efficacy with high rates of recurrence.1 

A better understanding of the pathogenesis of scars has raised the possibility of targeted treatment.2,3 Herein, we report the benefits of treating keloids and hypertrophic scars with both systemic and intralesional dupilumab, a monoclonal antibody that inhibits the expression of interleukin (IL)-4 and IL-13.

CASE REPORT

A 44-year-old woman with history of keloid scarring presented with firm nodules and plaques on her right flank and abdomen. A few months prior, she had developed numerous painful vesicles on her right lower trunk. Due to the coronavirus disease 2019 pandemic, she had not sought medical care, but it was suspected that she had suffered from herpes zoster. Vesicles resolved but were replaced with multiple firm lesions. These lesions became progressively indurated, large, and painful, with focal ulcerations, consistent with hypertrophic scars and keloids (Figure 1a). A biopsy confirmed the diagnosis.

Given the number of scars, monthly intralesional triamcinolone injections were not feasible. Dupilumab 600 mg followed by 300 mg subcutaneous injections every 2 weeks was initiated. Five months later, the patient noted significant improvement with 
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