Dupilumab Conjunctivitis

The patient is a 55 year-old woman who has been on dupilumab (Dupixent) for two months.  She had life-ling severe atopic dermatitis and states that her skin has never been this clear in her memory.  She has, however, developed a conjunctivitis of her lid and bulbar conjunctivae.  She is so happy that her skin is clear that she is not complaining, and her eyes are not uncomfortable.

There are no references to conjunctivitis on dupilumab, but the package insert indicates that 10% of patients have experienced this.  If you have any recommendations, I would appreciate hearing them.

Photos presented with patient permission

5/2/18.  Two months after starting Protopic ointment 0.03%, there has been no improvement of her conjunctivitis.  We have, therefore, prescribed fluoromethanlone 0.1% ophthalmic solution b.i.d.   The patient says that having the cojunctivitis is acceptable as long as her skin is doing well for the first time in > 50 years.  Photos taken before starting fluoromethalone ophthalmic.

Reference:

Conjunctivitis occurring in atopic dermatitis patients treated with dupilumab-clinical characteristics and treatment.

Wollenberg A J Allergy Clin Immunol Pract. 2018 Feb 9. pii: S2213-2198(18)30089-8.  Free Full Text.

Here, we report our experience with this clinically relevant complication of dupilumab treated AD seen in 25% and 50% of patients from our two centers from April 2016 to February 2017, and give treatment recommendations based on our personal experience with 13 moderate-to-severe dupilumab-treated AD patients developing conjunctivitis as adverse event. This conjunctivitis is reported in temporal association with dupilumab treatment, but a causal relation is not established.

However, in our limited experience, antihistamine eye drops and artificial tears did not confer any alleviation in this type of conjunctivitis. In 11 patients, dupilumab-related conjunctivitis was treated with topical tacrolimus or steroids, leading to clinically significant improvement or full recovery in all 11 patients treated.

Two treatment options were particularly effective.

In 5 patients conjunctivitis was treated with fluorometholone 0.1% eye drops, leading to significant improvement.

In four patients, conjunctivitis was treated with tacrolimus 0.03% eye ointment. Signs and clinical symptoms improved significantly in all patients, and in 2 patients, full recovery of conjunctivitis was achieved.