Two Cases of Recalcitrant Dyshidrotic Eczema Treated With Dupilumab

after cessation. Patch testing with the North American Standard Series failed to identify potential contact allergens. The patient was treated with apremilast for approximately 1 month without significant improvement, and treatment was curtailed due to development of depressed mood. He was started on dupilumab 600mg SQ, followed by 300mg SQ every other week. He concurrently began treatment with narrow-band UVB 2-3 times per week and topical clobetasol under occlusion as needed at this time. At follow up 6 weeks later, he reported an 80–90% improvement with complete resolution of symptoms on his soles. Physical exam showed complete clearing of the bilateral feet with some fine scale on the bilateral palms. Narrow-band UVB was discontinued and the improvements persisted at 3 months.

In this article, we report two cases of recalcitrant dyshidrotic eczema, which were successfully treated with dupilumab. Dupilumab is an interleukin 4 receptor-α antagonist that inhibits the action of both IL-4 and IL-13, thus blocking two important cytokines responsible for Th2-mediated inflammation.¹² Dupilumab has been FDA approved for atopic dermatitis in adults not controlled by topical therapy. Additional ongoing studies on the efficacy of dupilumab include treatment of eosinophilic esophagitis, pediatric peanut allergies, alopecia areata, and chronic urticaria.¹³

Dyshidrotic eczema is a distinct entity thought to be on the clinical spectrum with atopic dermatitis. It is often difficult to control, and relapses are common after cessation of therapy. To date, there have been few randomized control trials for the treatment of dyshidrotic eczema and no FDA approved treatment exists. Current treatment options for refractory cases are limited by poor efficacy and significant side effects. Systemic corticosteroids are often effective but are generally not a viable long-term option. Immunosuppressants are limited by their significant side effect profile and relapse typically occurs after discontinuation.^14,15 Dupilumab is typically very well tolerated with a low side effect profile, with the most common adverse effects being conjunctivitis, injection site reaction, and localized herpes simplex.¹²

These two cases add to the newly emerging evidence that dupilumab can be used as a highly effective treatment for patients with unmanageable dyshidrotic eczema on the palms or soles. To date, four other total cases of the successful treatment of dyshidrotic eczema with dupilumab have been reported in the literature, all of which have been associated with profound and sustained responses.^16-18 This case series adds to the growing literature supporting the use of dupilumab in the treatment of patients with recalcitrant dyshidrotic eczema, both with and without diagnosed contact allergens.

The authors of this publication have no disclosures, relevant financial relationships, patents, or conflicts of interest to report. Disclaimer: The views expressed in this article are those of the authors and do not reflect the official position of the institution, the Department of the Navy, the Department of Defense, or the US Government.

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Ryan A. Gall MD ryan.gall.md@gmail.com