Dupilumab in Atopic Dermatitis

Indications and Patient Selection

The American Academy of Dermatology recommends dupilumab as the first-line systemic therapy for adults with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies, with all guideline workgroup members favoring it over other systemic agents 1, 2
Patients with disease affecting multiple body areas, particularly sensitive locations, and those with inadequate response to optimized topical therapy, are key candidates for dupilumab 1, 3
Substantial impairment in quality of life despite topical management is also a key characteristic of patients who may benefit from dupilumab 4

Dupilumab is a fully human IgG4 monoclonal antibody targeting the IL-4 receptor α subunit, blocking signaling from both IL-4 and IL-13 5
The standard dosing of dupilumab is 600 mg subcutaneously at initiation, then 300 mg every 2 weeks, achieving EASI 75 in 63-64% of patients at 16 weeks when combined with topical corticosteroids 1, 5, 6
Dupilumab significantly improves signs, symptoms, quality of life, itch, and sleep compared to placebo, with a pooled EASI 75 of 59% at 16 weeks across 908 patients 5

The overall safety profile of dupilumab is excellent, with few major emergent safety concerns after more than 5 years in clinical practice 1, 2, 3
Ocular complications, such as conjunctivitis, are the most prevalent adverse events, occurring in 6-15% of patients in clinical trials and up to 26.1% in real-world data 5, 7
Only 4.2% of patients discontinue dupilumab due to ocular complications 5

The British Journal of Dermatology recommends advising patients to report new onset or worsening eye symptoms and regular follow-up to assess for ocular symptoms 3, 5, 7
A treatment algorithm for dupilumab-related ocular surface disorders includes preservative-free ocular lubricants and topical antihistamine eyedrops for mild symptoms, and referral to ophthalmology for severe symptoms 3, 7
Indications for dupilumab withdrawal include progressive loss of visual acuity, progressive conjunctival cicatrization, significant quality of life loss, and requirement for prolonged ocular topical corticosteroid therapy 7

The American Academy of Dermatology recommends using dupilumab concomitantly with topical agents for maintenance, rescue, or flare treatment, and counseling patients about ocular adverse events before initiation 1, 2, 5, 7
Common pitfalls to avoid include failing to establish an ophthalmology referral pathway for DROSD management and discontinuing therapy prematurely for mild ocular symptoms 7
Patients with pre-existing severe ocular surface disease, those requiring faster onset of action, and those with DROSD refractory to ophthalmologic management should be considered for alternative therapies 1, 7, 8

In patients receiving dupilumab, conjunctivitis was reported in 6–15 % of participants in clinical trials and in up to 26.1 % in real‑world practice. This reflects a notable risk of ocular adverse events associated with the drug. [9][10]
Discontinuation due to ocular complications was relatively low, occurring in approximately 4.2 % of treated individuals. [9][10]

Prophylactic use of preservative‑free ocular lubricants is recommended for patients who have pre‑existing corneal or conjunctival disease before starting dupilumab, to mitigate the risk of ocular irritation. [9][10]
Urgent ophthalmology referral (within 24 hours) should be arranged for any patient who develops the “RAPID” symptom cluster—Redness plus visual acuity loss, Acute pain, Photophobia (intolerance to light), or Evident corneal damage—to ensure prompt evaluation and management. [9][10]