Title : Dupilumab-Induced alopecia – A case of rapid-onset hair loss
Abstract:
Background: Dupilumab is a monoclonal antibody targeting IL-4 and IL-13 cytokines, used for moderate-to-severe atopic dermatitis. Despite well-documented efficacy, emerging reports highlight rare side effects, including drug-induced alopecia. We report a case of rapidly-evolving scalp alopecia following dupilumab initiation.
Case Report: A 30-year-old-female presented with erythroderma, secondary to generalised atopic dermatitis (EASI: 57.5, DLQI: 30, PGA: 5). Previous treatment included cyclosporin and oral glucocorticoid therapy. She avoided topical cortisone and calcineurin inhibitors due to steroid phobia and tachyphylaxis. Aside from a family history of thyroid disease, she had no personal or family history of autoimmune diseases. Baseline serology was unremarkable, and dupilumab was initiated. By her third dose of dupilumab 300mg, she reported improved eczematous symptoms, but new-onset scalp hair thinning and shedding. A scalp biopsy demonstrated miniaturisation, prominent sebaceous gland atrophy. There was no peribulbar inflammation in a “swarm of bees” pattern to suggest alopecia areata. Telogen count was greater than 50% with a majority of follicles shifted into catagen/telogen phase. Histology ruled out other differential diagnoses including psoriatic alopecia or cutaneous lupus. A diagnosis of dupilumab-induced alopecia was made, supported by similar case reports. Dupilumab was discontinued and at her six-week follow-up, hair shedding had ceased and visible regrowth of vellus hair identified on examination.
Discussion: While dupilimab is being trialled as an off-label treatment for alopecia areata, dupilumab-associated alopecia is uncommon. In such cases, hair loss was reported more often in males, occurring months after initiation of dupilumab. This case is notable for its rapid onset in a female patient after just three doses of dupilumab 300mg for atopic dermatitis.
Conclusion: Dermatologists should recognise the potential for dupilumab-induced alopecia, particularly in patients with severe atopic dermatitis. Early recognition can mitigate patient distress, enhance informed consent, and optimise clinical outcomes.
