Findings from a retrospective review of pediatric patients add to existing evidence suggesting that dupilumab (Dupixent; Sanofi/Regeneron Pharmaceuticals, Inc) may have a role as a systemic treatment for severe and refractory alopecia areata (AA).
In a letter published in the Journal of the American Academy of Dermatology, Leslie Castelo-Soccio, MD, PhD, reported on 16 children with coexisting atopic dermatitis (AD) and AA who received 300 mg dupilumab subcutaneously every 2 weeks.1 Four children also had concurrent asthma.
Dupilumab was well tolerated and appeared safe in this small series of patients. The only side effects were mild injection site reactions.
The responses of patients with AA after starting dupilumab varied. Improvement occurred in 4 of 6 patients with flare/active AA, and hair growth was seen in one additional patient. Six patients maintained hair growth. Of the patients who experienced benefit, the Severity of Alopecia Tool (SALT) score improved by an average of 33.3 at 12 months.
“A trial in one center [NCT03359356] at the Icahn School of Medicine at Mount Sinai led by Emma Guttman-Yassky, MD, PhD research on dupilumab for the treatment of AA in adults with and without concomitant AD has been completed and results should be available soon,” 2 Castelo -Soccio, an assistant professor of pediatrics and dermatology at the Perelman School of Medicine at the University of Pennsylvania and dermatologist at the Children’s Hospital Of Philadelphia in Philadelphia, Pennsylvania, told Dermatology Times®. “I will continue to use dupilumab to treat children with AA if it is comorbid with atopic disease for which the benefits of dupilumab are clear, but a clinical trial is needed to investigate its use to treat AA in children.”
Interest in dupilumab as a treatment for AA and an explanation for its potential benefit is supported by genome-wide association studies investigating susceptibility loci for AA, which showed an interleukin (IL)-13 signature in some patients.3
“Dupilumab could control the inflammatory response in AA and aid in AA flare-ups because it blocks the IL-13 signaling pathway by binding to the IL-4Rα subunit shared by the IL-4 and IL-13 receptor complexes” , explains Castelo-Soccio.
Castelo-Soccio said she cares for many pediatric patients with AA in her patient population, and many of these patients who have concurrent atopic conditions report experiencing AA attacks when their eczema or atopic rhinitis flares up.
“Dupilumab was more widely used in our center to treat children with severe AD, and anecdotally I had noticed hair growth and reduction in flare-ups in patients who also had AA,” noted Castelo-Soccio. “I conducted this retrospective review to get a clearer picture of how AA responded.”
Of the 16 patients included in the review, the duration of AA prior to initiation of dupilumab ranged from less than 1 year to 11 years. The median number of prior therapies for AA was 4 and 8 children received 1 or more additional therapies while being treated with dupilumab.
Types of AA among the 16 children included universalis (n = 7), ophiasis (n = 5), and patchy (n = 4). The AA was active in 6 patients. The SALT scores at the start of dupilumab ranged from 0 to 100. The 2 patients with active disease who did not respond to dupilumab had a SALT score of 100 at the start of dupilumab.
In 4 patients, AA worsened during the first 1 to 2 months after starting dupilumab, but it improved over time in the 2 patients who had further follow-up – and both patients had a SALT score of 0 12 months after the start. start dupilumab. Two patients with a SALT score of 0 when starting dupilumab were already receiving tofacitinib and were able to undergo a dose reduction of the Janus kinase inhibitor without increased hair loss.
In examining possible features associated with better response, Castelo-Soccio found that all patients who improved had moderate to severe AD when they started dupilumab. Compared to the non-responders, the responders had a lower median age at diagnosis of AD (6 years versus 13 years) and a longer median duration of AD (6 years versus 1 year).
“A previous report also found that patients whose AA responded to dupilumab had a more severe and longer-lasting history of AD,” Castelo-Soccio said.
AA is the most common autoimmune disease, and comorbidity between atopic disease and AA is not uncommon.4 An analysis limited to children with AA found that 26.6% had atopy.5
Castelo-Soccio said the standard therapy for AA in children includes topical steroids and topical sensitizers, along with the selected use of intralesional triamcinolone. Systemic therapy is considered for children with extensive hair loss (>30% to 50%) or for children with a smaller area of involvement but who experience a significant reduction in quality of life due to the disease.
“Ultimately, the decision to use systemic medications in children is made with the family and child after a thorough discussion of the benefits and risks,” Castelo-Soccio said. “I always remind families that we are treating the child and not the parents or guardians. In addition, I emphasize that AA is a medical disease and should be treated as a disease, but the visibility of the disease carries a huge psychological burden, and therefore care is also needed to address this part of the medical disease.
“Systemic therapy options include steroids, methotrexate, Janus kinase inhibitors or dupilumab. However, I don’t think dupilumab is effective in children without an atopic component.”
Castelo-Soccio has no material financial interests to disclose.
1. McKenzie PL, Castelo-Soccio L. Dupilumab therapy for alopecia areata in pediatric patients with concomitant atopic dermatitis. J Am Acad Dermatol. 2021;84(6):1691-1694. doi:10.1016/j.jaad.2021.01.046
2. Treatment of alopecia areata (AA) with dupilumab in patients with and without atopic dermatitis (AD). ClinicalTrials.gov. Updated January 7, 2021. Accessed June 9, 2021. https://clinicaltrials.gov/ct2/show/NCT03359356
3. Jagielska D, Redler S, Brockschmidt FF, et al. Follow-up study of the first genome-wide association scan in alopecia areata: IL13 and KIAA0350 as susceptibility loci supported with genome-wide significance. J Invest Dermatol. 2012;132(9):2192–2197. doi:10.1038/jid.2012.129
4. Marks DH, Mesinkovska N, Senna MM. Cause or cure? assessment of dupilumab and alopecia areata. J Am Acad Dermatol. Published online June 13, 2019. doi:10.1016/j.jaad.2019.06.010
5. Villasante Fricke AC, Miteva M. Epidemiology and burden of alopecia areata: a systematic review. Clin Cosmet Investig Dermatol. 2015;8:397-403. doi:10.2147/CCID.S53985