Introduction: After the introduction of dupilumab as systemic treatment for atopic dermatitis, an increasing number of patients have been successfully treated. However, reports of patients developing psoriasis as a secondary skin condition have been accumulating. The most likely reason is assumed to be an immune shift from Th2- to Th1-mediated auto-inflammatory processes. Case Presentation: Our patient is a 38-year-old male suffering from head-neck type atopic dermatitis since childhood. As one of the first patients in Switzerland, he received dupilumab in 2018 leading to a significant improvement of his skin lesions. One year later he developed progressing circular erythematous-squamous plaques which correlated histologically with psoriasis. In 2021, 3 years after initiating dupilumab, we switched systemic therapy to baricitinib. Three months after initiation, his psoriatic lesions were completely healed, while the atopic lesions remained stable with low inflammatory activity. Conclusion: In patients treated with dupilumab for atopic dermatitis immune shift needs to be considered in case of newly appearing skin lesions. With a growing number of described cases, we conclude that baricitinib is a good alternative treatment for atopic dermatitis in patients suffering from biologic-induced psoriasis.

Dupilumab, a dual inhibitor of the IL-4 and IL-13 pathways that suppresses Th2 expression, has rapidly become the treatment of choice for atopic dermatitis [1, 2]. However, there have been increasing reports of patients developing psoriasis as a secondary skin condition [3, 4]. Psoriatic lesions mostly appeared 1–18 months after initiation of dupilumab [3]. The most likely reason might be an immune shift from Th2- to Th1- and/or Th17-mediated auto-inflammatory processes [5‒7]. At the molecular level, a decrease in IL-4 and an increase in IL-23A and IL-17A have been demonstrated [8, 9].

It is believed that drugs that do not target IL-4 would not lead to psoriatic-like dermatitis [4]. Within this, Janus kinase (JAK) inhibitors have become the subject of further investigation for the treatment of patients with psoriasis and atopic dermatitis [10]. Baricitinib has been officially introduced as treatment for atopic dermatitis and an increasing number of publications illustrate its efficacy in the treatment of psoriasis [11, 12]. Our publication demonstrates its successful use in treating atopic dermatitis and dupilumab-induced psoriasis.

Our patient is a 38-year-old male suffering from atopic dermatitis since childhood. He was first referred to our department in 2014 with severe eczematous lesions predominantly on the face, scalp and neck, and further manifestations on his extremities and trunk. His condition had worsened during his early working years. Combined topical and narrow-band ultraviolet B (UVBnb) therapy produced unsatisfactory results. Systemic therapy with cyclosporine had to be discontinued twice due to side effects.

As one of the first patients in Switzerland, he received dupilumab in 2018, which led to a significant improvement of his skin lesions with an improvement of his SCORAD score from 62,9 to 5,9 points and EASI score from 15,8 to 1,3 points. Initially, besides chronic conjunctivitis, no major side effects occurred. However, 1 year later, the patient gradually developed circular erythemato-squamous plaques on his trunk and lower extremities. In his family, no skin diseases were known. Clinically, no nail changes were visible. There were no plantar or palmar changes. No joint pain was reported. On his scalp, seborrheic scaling was present and persistent in the context of the atopic dermatitis. No new psoriasiform scalp changes were seen. Auspitz sign was positive, and dermoscopy showed sharply demarcated lesions with white scales and dotted vessels. The diagnosis was confirmed by skin biopsy, which showed psoriasiform acanthosis with papillomatosis, hypogranulosis and abundant neutrophils in the stratum corneum. No spongiotic reaction pattern or eosinophils were seen. Periodic acid Schiff (PAS) staining revealed no fungal elements (Fig. 1). Clinical manifestations correlated with a PASI score of 10,4 points.

Fig. 1.

Histology showed psoriasiform acanthosis with papillomatosis, hypogranulosis (a) (HE, ×100), and abundant neutrophils in the stratum corneum (b) (HE, ×200). c Periodic acid Schiff (PAS) staining revealed no fungal elements (×200).

Fig. 1.

Histology showed psoriasiform acanthosis with papillomatosis, hypogranulosis (a) (HE, ×100), and abundant neutrophils in the stratum corneum (b) (HE, ×200). c Periodic acid Schiff (PAS) staining revealed no fungal elements (×200).

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Due to the excellent response of the atopic lesions to dupilumab, treatment was continued, topical treatment of the psoriatic lesions was initiated, and combined with UVBnb therapy. Despite this, the patient reported progression of his newly diagnosed psoriasis.

In 2021, 3 years after starting dupilumab, we switched his systemic therapy to baricitinib 4 mg daily. Discontinuation of systemic therapy was not considered due to improved but persistent manifestations of atopic lesions in the head and neck region. Three months after initiation, his psoriasis lesions were completely cleared, leaving areas of postinflammatory hyperpigmentation (Fig. 2). Meanwhile, the head and neck accentuated atopic lesions remained stable with mainly lichenoid changes but low inflammatory activity. Systemic therapy was interrupted for 3 weeks due to a surgical procedure. This resulted in a marked worsening of his atopic lesions. After reintroduction of baricitinib postoperatively, his skin recovered very quickly. The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000539124).

Fig. 2.

VECTRA® overview images of the front (1) and back (2) before (a1, a2) and 8 months after (b1, b2) treatment switch to baricitinib.

Fig. 2.

VECTRA® overview images of the front (1) and back (2) before (a1, a2) and 8 months after (b1, b2) treatment switch to baricitinib.

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In patients treated with dupilumab for atopic dermatitis, immune shift should be considered in cases of new skin lesions. With a growing number of reported cases, describing almost all psoriasis subtypes, including manifestations on the scalp, nails, erythrodermic, guttate and pustular type manifestations, we conclude from our experience that baricitinib is a good alternative treatment for atopic dermatitis in patients with biologic-induced psoriasis. Our findings are consistent with a similar case reports published recently [13, 14].

So far, most of the reported cases of dupilumab-induced psoriasis were treated topically, with or without discontinuation of dupilumab. In some cases, systemic therapy was switched to methotrexate or cyclosporine [5, 13, 14]. There are a few case reports in which systemic therapy was switched to other biologic agents (omalizumab, apremilast, ustekinumab, anakinra, upadacitinib) [10, 13, 14].

In general, further careful research is needed to better understand these biologic-induced dermatologic adverse events. There are initial reports of cases illustrating a transition from atopic dermatitis to psoriasis with upadacitinib [15]. This suggests a superiority of tyrosine kinase (TYK) 1 and 2 inhibition compared to singular TYK2 inhibition. Therefore, cautious follow-up with biologic therapy is warranted.

Dupilumab, while effective for atopic dermatitis, can induce psoriasis as a secondary skin condition, likely due to an immune shift. Baricitinib emerges as a promising alternative for treating both atopic dermatitis and dupilumab-induced psoriasis. Careful monitoring and consideration of alternative therapies, such as JAK inhibitors, are essential for managing biologic-induced dermatologic adverse events effectively. Further research is needed to understand and optimize treatment approaches in these cases.

Ethical approval is not required for this study in accordance with local or national guidelines. Written informed consent was obtained from the patient for publication of the details of their medical case and any accompanying images.

Prof. A. Navarini declares being a consultant and advisor, receiving speaker’s fees and/or grants and/or served as an investigator in clinical trials for AbbVie, Almirall, Amgen, Biomed, BMS, Boehringer Ingelheim, Celgene, Eli Lilly, Galderma, GSK, Janssen-Cilag, LEO Pharma, MSD, Novartis, Pfizer, Pierre Fabre Pharma, Regeneron, Sandoz, Sanofi, and UCB.

No funding received to be declared.

Dr. Lina Weiss and Corinne Marbet contributed equally to compiling this case report. Dr. Mühleisen provided information on histology and compiled the histologic images and description. Dr. Branca and Professor Navarini aided in finding relevant references and writing the manuscript.

Additional Information

Lina Weiss and Corinne Punsap Marbet contributed equally to this work.

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author. The authors declare that the information of this case report has been presented and published as a poster contribution at the Annual Conference of Swiss Dermatologists 2022 and as such been published in the member publication “Dermatologica Helvetica”.

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