Dupilumab
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Atopic keratoconjunctivitis, new-onset periocular dermatitis and worsening of underlying periocular dermatitis: 2 case reports In a case series, a 66-year-old woman and a 28-year-old woman were described, who developed atopic keratoconjunctivitis (AKC), worsening of underlying periocular dermatitis or new-onset periocular dermatitis during treatment with dupilumab for atopic dermatitis (AD). Case 1: The 66-year-old woman had underlying chronic AD and periocular dermatitis. Her baseline AD presentation was remarkable for localisation to the flexor surfaces of her elbows, tops of her feet, hands, and mouth. Periocular involvement comprised mild skin thickening and eyelid fissures, for which she was receiving hydrocortisone and unspecified moisturisers. Her medical history consisted of bilateral upper and lower lid blepharoplasty and allergy to benzalkonium chloride. For the AD, SC dupilumab 600mg injection was started. However, 7 days after her first and only dupilumab injection, she exhibited exacerbation of her underlying periocular dermatitis was noted. The woman was treated with neomycin/polymixin B/dexamethasone and azithromycin. However, no improvement was noted. Subsequent examination demonstrated visual acuity of 20/20–3 in the right eye and 20/20 in the left eye. An external examination showed severe periocular erythema with skin thickening, peeling, and secondary ectropion. A slit-lamp examination displayed trace inferior injection and rare superficial punctate keratitis bilaterally (OU). Thereafter, all ocular drops and periocular ointments were discontinued. She was advised to use preservative free artificial tears and dexpanthenol/ levomenol/mineral oil/petrolatum/sodium dichloroacetate/ wool alcohols [Aquaphor] ointment. With this intervention, an improvement was observed. However, her dermatitis worsened following use of an over the counter eye cleansing agent [specific drug not stated]. Three weeks later, an examination revealed that her periocular dermatitis had extended to the lateral temples and was nearly confluent over the bridge of her nose. Anterior segment examination revealed diffuse 1+ chemosis and 2+ conjunctival injection (AKC) on both the eyes. Thereafter, she was treated with methylprednisolone, tacrolimus, hydrocortisone, loratadine and cetirizine. Subsequently, her periocular and perioral dermatitis returned to baseline. Both conjunctival chemosis and injection resolved. The AKC and worsening of underlying periocular dermatitis was considered to have developed secondary to dupilumab. Case 2: The 28-year-old woman, who had hand and upper extremity AD, started receiving SC dupilumab injection. The dupilumab was administered at an initial loading dose of 600mg, followed by 300mg every other week thereafter. However, five and a half months after initiation of dupilumab therapy (after receiving total 11 injections), she exhibited eye redness, excess tearing and a rash around her eyes. She also developed an flare of underlying AD in the hands and arms [aetiology not stated]. Subsequently,
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