Dupliumab therapy for alopecia areata: a case series and review of the literature

Figures & data

Table 1. Characteristics of alopecia areata patients treated with dupilumab.

NO	Age (years)/Sex (M/F)	Height(cm)	weight(kg)	Age at Diagnosis with AA, y	type of AA at initial	duration of the current AA episode (months)	Atopic comorbidities	AD Duration and severity	Prior treatment for AA	Dosage / Duration of treatment (Month)	Combination treatment for AA	initial SALT score (%)	SALT Scores at Follow-up visits After Dupilumab	Percent change in SALT score(%) at month 3	Percent change in SALT score(%) at the end of follow-up	EBA(0 − 3)	ELA(0 − 3)	Dupilumab withdrawal,reason	P -Sat	IgE (IU/ml)	Eosinophil Cell Count (10^9/L)
1	21(F)	160	45	21	Not specified	0.5	AD	3 months;EASI (4),NRS(7)	Minoxidil	After an initial loading dose of 600 mg,300 mg q2w × 4.5 months; then 300 mg q4w ×2 months; then 300 mg q6w ×3 months; then 300 mg q8w ×2 months, ongoing	Topical corticosteroids, Minoxidil	45	3 months: 5 6 months: 0 9 months: 0 12 months: 0	89	100	baseline: 2 3 months: 2 6 months: 1	baseline: 0 3 months: 0 6 months: 0	No	Very satisfied	23.1	0.86
2	6(F)	110	20	5	Universalis	5	AD, allergic rhinitis	Since infancy; EASI (3),NRS(6)	Minoxidil	After an initial loading dose of 600 mg, 300 mg q4w × 5 months.	Topical corticosteroids	75	3 months: 95 5 months: 100	0	0	baseline: 3 3 months: 3	baseline: 3 3 months: 3	Yes, loss of efficacy	Very dissatisfied	17.7	1.48
3	10(M)	149	48	9	Universalis	4	AD;allergic rhinitis	1 years; EASI (2),NRS(1)	Minoxidil, oral corticosteroids	After an initial loading dose of 600 mg, 300 mg q3w × 9months, ongoing	Topical corticosteroids, tacrolimus	100	3 months: 10 6 months: 5 9 months: 5	90	95	baseline: 2 3 months: 2 6 months: 1	baseline: 2 3 months: 1 6 months: 0	No	Moderately satisfied	418	3.38
4	6(F)	117	15	4	Not specified	12	food allergies	N	Topical and oral corticosteroids	200 mg q4w × 4months; then 300 mg q4w ×6 months, ongoing.	Topical corticosteroids, Minoxidil	35	3 months: 25 6 months: 45 9 months: 20 10 months: 10	29	71	baseline: 0 3 months: 0 6 months: 0	baseline: 0 3 months: 0 6 months: 0	No	Very satisfied	905.47	0.21
5	17(F)	158	41	15	Universalis	4	N	N	oral corticosteroids, tofacitinib(Discontinued treatment due to liver function abnormality)	After an initial loading dose of 600 mg, 300 mg q2w × 7 months, ongoing	N	95	3 months: 50 6 months: 45 7 months: 30	47	68	baseline: 1 3 months: 1 6 months: 0	baseline: 0 3 months: 0 6 months: 0	No	Moderately satisfied	18	0.12
6	8(F)	135	27	7	Universalis	5	AD	Since infancy	Topical and oral corticosteroids	After an initial loading dose of 600 mg, 300 mg q3w × 10 months, ongoing	N	85	1 months: 70 3 months: 5 6 months: 0 9 months: 0 10 months: 0	18	100	baseline: 2 3 months: 2 6 months: 3	baseline: 0 3 months: 0 6 months: 0	No	Very satisfied	500	NA
7	10(F)	146	36	3	Totalis	12	AD	8 years; EASI (4.6),NRS(5)	Minoxidil, oral corticosteroids	After an initial loading dose of 600 mg, 300 mg q3w × 14.25 months; then 300 mg q4w ×1 months, ongoing	Topical corticosteroids	100	3 months: 40 6 months: 35 9 months: 15 12 months: 0 15 months: 0	60	100	baseline: 0 3 months: 0 6 months: 0	baseline: 0 3 months: 0 6 months: 0	No	Very satisfied	57.1	0.32
8	1 year, 4 months (F)	90	11	1	Totalis	4	food allergies	N	Topical corticosteroids	200 mg q4w × 3months.	N	100	3 months: 100	0	0	baseline: 2 3 months: 3	baseline: 2 3 months: 2	Yes, loss of efficacy	Very dissatisfied	124	NA
9	10(F)	141	36	9	Universalis	6	AD	Since infancy	oral corticosteroids	After an initial loading dose of 600 mg, 300 mg q3w × 3 months.	N	100	3 months: 100	0	0	baseline: 3 3 months: 3	baseline: 3 3 months: 3	Yes, loss of efficacy	Very dissatisfied	29.4	0.06
10	10(M)	147	39	9	Not specified	9	AD	9 months;EASI (18),NRS(10)	Topical corticosteroids, Minoxidil	After an initial loading dose of 600 mg, 300 mg q3w × 6 months.	N	55	3 months: 20 6 months: 35	63	57	baseline: 0 3 months: 0 6 months: 0	baseline: 0 3 months: 0 6 months: 0	Yes, delayed onset of effect	Moderately dissatisfied	203.2	0.25

N:None; M: male; F: female; AA: alopecia areata; AD: atopic dermatitis; SALT: Severity of Alopecia Tool; EASI: Eczema Area and Severity Index; NRS: Worst Pruritus Numerical Rating Scale; Q2/3/4/6W: treatment every two/three/four/six weeks; EBA: Eyebrow Assessment score; ELA: Eyelash Assessment score; P -Sat: Patient Satisfaction with Hair Growth.

Figure 1. SALT score for each patient at baseline, months 3,6,9 and 12.

Figure 2. Scalp pictures of two patients. A-C show scalp hair at baseline, month 6, and month 9 visits in patient 1 on dupilumab. D-F show scalp hair at baseline, month 3, and month 9 visits in patient 7 on dupilumab.

Table 2. Summary of the literature on dupilumab treatment of alopecia areata.

Study number	Author	Year	Age (years)/Sex (M/F)	Time	Prior treatment	Atopic comorbidities	AD Duration and severity	Non-atopic comorbidities	Initial SALT, Median	Treatment duration, months	Therapeutic regimen	SALT	IgE (IU/ml)
				from AA								improvement
				diagnosis								Median
1	Darrigade AS, et al (25)	2018	28/M	1 year	CsA, MTX	AD, asthma	Since childhood; EASI (14.9)	NA	87.4	6	300 mg every 15 days after a loading dose of 600 mg	92.00%	11987
2	Penzi LR, et al (26)	2018	13/F	11 years	CIT, SS, MTX	AD	12 years; NA	NA	100	11	300mg every two weeks	>60.0%	NA
3	Uchida H, et al (27)	2019	44/M	8 years	TS, SS	AD	Since childhood; EASI (46.7)	NA	61.6	3	300 mg every two weeks after a loading dose of 600 mg	87.00%	44300
4	Smogorzewski J, et al (28)	2019	35/F	8 years	TS, SS, CsA, omalizumab	AD, chronic urticaria	Since childhood; NA	NA	100	12	300 mg every two weeks	100%	NA
5	Alniemi DT, et al (29)	2019	49/M	6 years	NA	AD	Since childhood; NA	NA	100	8	300 mg every two weeks after a loading dose of 600 mg	100%	NA
6	Patruno C, et al (30)	2019	21/M	2 years	CsA	AD	Since childhood; EASI (52.8)	NA	49.2	4	300 mg every two weeks after a loading dose of 600 mg	83.30%	2.129
7	Ludriksone L, et al (31)		38/M	5 years	CsA	AD, allergic rhinoconjunctivitis, asthma	35 years; SCORAD (27)	NA	100	5.5	300 mg every two weeks after a loading dose of 600 mg	>50%	NA
		2019	32/M	2 years	NA	AD, allergic rhinoconjunctivitis, asthma	30 years; SCORAD (41)	NA	NA	5.25		100%	NA
8	Call JE, et al (32)	2019	34/F	27 years	SS	AD, asthma	Since childhood; NA	NA	100	10	300 mg every two weeks after a loading dose of 600 mg	100%	NA
9	Ushida M, et al (33)	2020	33/F	6 months	NA	AD	NA; EASI (46)	Trichotillomania	NA	4.75	NA	100%	NA
10	Magdaleno-Tapial J, et al (34)	2020	49/M	4 years	TS, MTX	AD	20 years; NA	NA	NA	3	300 mg every two weeks after a loading dose of 600 mg	100%	NA
11	Harada K, et al (35)	2020	33/F	3 years	TS, SS, CIT	AD	NA; EASI (35.2)	NA	73	13.5	300 mg every two weeks after a loading dose of 600 mg	89.30%	NA
			34/M	5 years	CIT	AD	NA; EASI (31.8)	NA	100	6		89.30%	NA
			34/M	2 years	TS, UV	AD	NA; EASI (59.4)	NA	27.3	9		100%	3290
			42/M	1 year	SS	AD	NA; EASI (19.7)	NA	98.5	5.5		73%	20800
			42/M	7 years	TS, SS, CIT	AD	NA; EASI (46.7)	NA	56	5		68.20%	9075
			43/M	7 years	TS, SS, CIT	AD	NA; EASI (41.6)	NA	100	6		63.60%	20375
			52/F	3 years	TS, SS, UV, CIT	AD	NA; EASI (5.2)	NA	100	6		0%	433.3
12	Zhu GA, et al (36)	2020	49/F	7 years	TS, CIT, tofacitinib	AD	NA	NA	NA	10	NA	0%	NA
			52/F	50 years	SS, tofacitinib	AD	NA	NA	NA	8		0%	NA
			27/F	9 years	TS, SS, hydroxychloroquine, CsA	AD	NA	NA	100	20		100%	NA
13	Babino G, et al (37)	2020	61/F	28 years	TS, SS, CsA, CIT, photodynamic therapy with 5-aminolaevulinic acid	None	–	Autoimmune thyroid disease	100	3	300 mg every two weeks after a loading dose of 600 mg	100%	NA
14	Gruenstein D, et al (38)	2020	4/M	1.5 years	TS	AD	Since infancy; NA	None	>50%	4	200mg every two weeks	100%	NA
15	Szekely S, et al (39)	2021	30/M	2 years	TS, SS	AD	Since childhood; EASI (36)	NA	NA	3	300 mg every two weeks after a loading dose of 600 mg	100%	NA
16	Muto J, et al (40)	2021	44/F	4 years	TS, SS	AD	Since childhood; EASI (21)	NA	100	10	300 mg every two weeks after a loading dose of 600 mg	100%	7050
17	McKenzie PL, et al (41)	2021	13/F	9 years	TS, SS	AD	9 years; IGA (3)	None	25	12	300 mg every 2 weeks	100%	NA
			8/M	3 years	TS, SS, CIT, MTX	AD	4 years; IGA (4)	None	35	7		77.10%	NA
			10/F	7 years	TS, SS, CIT, topical tofacitinib	AD	6 years; IGA (3)	hypothyroidism	100	3		0%	NA
			13/M	1 year	TS, CIT, topical tofacitinib	AD	1 year; IGA (3)	None	100	14		0%	NA
			16/F	5 year	TS, minoxidil	AD, asthma	6 years; IGA (2)	None	23	4		0%	NA
			17/F	4 years	TS, SS, MTX, tofacitinib	AD	14 years; IGA (3)	hypothyroidism	18	2		0%	NA
			15/M	3 years	TS, SS, MTX	AD, asthma	1 year; IGA (2)	None	100	12		2%	NA
			13/F	2 years	TS, SS, CIT, MTX, topical tofacitinib	AD	1 year; IGA (4)	None	45	2		0%	NA
			12/F	3 years	TS, SS, CIT, MTX	AD	2 years; IGA (3)	hypothyroidism	100	11		50%	NA
			16/M	3 years	TS, SS, MTX	AD	4 years; IGA (4)	celiac disease	25	12		100%	NA
18	Abercrombie M, et al (42)	2021	34/F	21 years	TS, CsA, topical tofacitinib	AD	NA	NA	NA	10	300 mg every 2 weeks	>90%	NA
19	Choe S, et al (43)	2021	33/F	14 years	TS, SS, CIT, minoxidil, topical tofacitinib, platelet-rich plasma injections, topical tacrolimus	None	–	None	81.5	12	300 mg every two weeks after a loading dose of 600 mg	90.20%	NA
20	Alotaibi L, et al (44)	2021	21/F	9 years	tofacitinib	AD	Since childhood; NA	NA	100	9	300 mg every 2 weeks	>80%	NA
21	McKenzie PL, et al (45)	2021	12/M	The median age of onset	TS, minoxidil	AD, asthma, food	Since infancy; IGA (4)	NA	75	24	NA	66.70%	NA
				of AA was 5.5 years (standard deviation, 2.9 years)		allergies
			7/M		TS	AD, Asthma	Since infancy; IGA (3)	NA	25	6		100%
			7/F		TS	AD, food	Since infancy; IGA (4)	NA	90	16		100%
						allergies
			8/F		SS, TS, CIT, minoxidil, topical tofacitinib	AD	Since infancy; IGA (2)	NA	25	6		100%
			7/F		TS, minoxidil, topical tofacitinib	AD	Since infancy; IGA (2)	NA	50	6		100%
			12/F		TS, SS	AD, food	Since infancy; IGA (3)	NA	100	16		0%
						allergies
22	Romagnuolo M, et al (46)	2022	49/F	>8 years	SS	AD, allergic rhinitis, asthma	Early-onset; NA	NA	100	23	300 mg every two weeks after a loading dose of 600 mg	90%	NA
23	Napolitano M, et al (47)	2022	6 (F)/4 (M); mean age	mean AA	TS (10), CsA (7), CIT (7)	NA	In all the patients, AD started before the age of 18 years, with a mean disease duration of 28.03 ± 6.81 years; the mean value of EASI was 26.22 ± 1.77	NA	mean SALT 91.63 ± 12.43	13	300 mg every two weeks after a loading dose of 600 mg	An increasing but not significant trend was observed for SALT (95.66 ± 8.51)	NA
			43.71 ± 8.22 years	Duration 8.22 ± 5.64 years
24	McFeely O, et al (48)	2022	45/F	42 years	TS, UV, MTX	AD	NA	NA	100	6	NA	100%	NA
25	Visconti MJ, et al (49)	2022	65/M	6 years	NA	AD, asthma	Since childhood; NA	Hyperlipidemia; herpes simplex virus infection	100	10	300 mg every two weeks after a loading dose of 600 mg	NA*	NA
26	Seo T, et al (50)	2022	62/M	6 years	SS, PUVA,CIT	AD	Since childhood; EASI (25.9)	NA	100	15	NA	0%	7321.3
27	Kulkarni M, et al (51)	2022	16/M	>8 months	None	AD, asthma	Since childhood; IGA (3)	None	100	36	300 mg every two weeks after a loading dose of 600 mg	100%	NA
28	Yan X, et al (52)	2023	9/F	1 year	TS	AD, allergic rhinitis, asthma	Since infancy; EASI (25.9)	None	20	7	300 mg every 4 weeks, after a loading dose of 600 mg	100%	999.6
29	Cai L, et al (53)	2023	4/M	3 years	TS, baricitinib	Allergic rhinitis	–	None	100	10	200 mg every	85%	Normal
											4 weeks, after a loading dose of 400 mg

* Experienced regrowth of the eyelashes, terminal hairs of the beard area, and vellus hairs of the eyebrows.

NA: not available; M: male; F: female; AA: alopecia areata; AD: atopic dermatitis; SALT: Severity of Alopecia Tool; EASI: Eczema Area and Severity Index; SCORAD: Corresponding Atopic Dermatitis Score; IGA: Investigator’s Global Assessment; TS: topical corticosteroids (include intralesional steroids); SS: systemic corticosteroids; UV: ultraviolet irradiation CsA, cyclosporine; MTX: methotrexate; CIT: contact immunotherapy; PUVA: topical psoralen plus ultraviolet A photochemotherapy.

Table 3. New-onset or worsening alopecia with dupilumab.

Study Number	Author	Year	Age (years)/Sex (M/F)	Previous history of alopecia areata	Atopic comorbidities	AD Duration	Time-lapse between starting dupilumab and alopecia onset/worsening (week)	Scalp biopsy/ Diagnosis*	Dupilumab withdrawal	Alopecia treatment and prognosis
1	Mitchell K, et al (54)	2018	29/M	No	AD	3 years	5	No; AA	No	Intralesional triamcinolone; slow improvement
2	Flanagan K, et al (55)	2018	27/M	No	AD	NA	18	Yes; AA-like	Yes	Intralesional and topical triamcinolone, topical tacrolimus; recovery of hair regrowth after 8 weeks
3	Barroso-García B, et al (56)	2018	31/M	No	AD	7 years	6	Yes; AA-like	No	Intralesional triamcinolone; NA
4	Kanda N, et al (57)	2019	35/M	No	AD	NA	6	No; AA	No	Systemic methylprednisolone; improved in 16 weeks
5	Yazdanyar S, et al (58)	2019	24/M	No	AD	NA	1	No; AA	NA	None; Gradual improvement in 3 weeks
6	Patruno C, et al (30)	2019	25/M	No	AD	20 years	4	No; AA	No	Topical mometasone; improvement in 8 weeks
7	Salgüero-Fernández I, et al (59)	2019	33/M	No	AD	Since childhood	7	Yes; AA-like	No	Topical mometasone; improvement in 12 weeks
8	Chung J, et al (60)	2019	51/F	No	AD, Allergic rhinitis, asthma	50 years	112	No; AA	No-discontinued but reintroduced after 6 months	Topical minoxidil and betamethasone solution was useless, then resumed dupilumab at monthly dosing; 90% scalp regrowth in 10 months
			25/M	Yes	AD, Asthma, Seasonal allergies	Since childhood	6-8	No; AA	No	CsA and tofacitinib; improvement in 6 weeks
9	Barbarin C, et al (61)	2019	23/F	No	AD, asthma, allergic conjunctivitis	Since childhood	1	No; AA	Yes	None; improvement in 24 weeks
10	Carnicle JM, et al (62)	2019	42/F	Yes	AD	Since childhood	16	No; AA	No	Systemic triamcinolone; Almost complete hair regrowth in 8 weeks
11	Gallo R, et al (63)	2020	24/M	No	AD	5 years	8	No; AA-like	Yes	CsA (3 mg/kg/day); after 3 months, hair regrowth was complete.
12	Zhu GA, et al (36)	2020	31/M	No	AD	NA	40	Yes; AA-like	Yes	Topical calcineurin inhibitors; Partial improvement
			37/M	No	AD	NA	9	No; AA	No	Topical calcineurin inhibitors; NA
			37/F	Yes	AD	NA	NA	No; AA	No	TS; Stable
13	Ständer S, et al (64)	2020	53/M	No	AD	3 years	52	No; AA	Yes	CsA; improvement in 4 months
14	McKenzie PL, et al (41)	2021	19/F	Yes	AD	3 years	8	No; AA	No	NA
			15/M	Yes	AD, asthma	1 year	8	No; AA	No	NA
15	Maiolini VM, et al (65)	2021	22/M	No	AD	Since childhood	40	Yes; AA-like	NA	Topical betamethasone dipropionate and calcipotriol; complete hair regrowth in 9 months
16	Beaziz J, et al (66)	2021	45/F	No	AD, asthma, allergic rhinitis	Since childhood	52	No; AA	No	topical application of clobetasol propionate 0.05%; complete hair regrowth in 2 months
17	Yamane S, et al (67)	2022	31/M	No	AD	Since childhood	8	No; AA-like	No	Topical clobetasol propionate; hair regrowth was observed two months later
18	Kulkarni M, et al (68)	2022	22/M	No	AD	Since infancy	28	Yes; AA	Yes	intralesional triamcinolone, topical clobetasol ointment, short course (10 days) of oral prednisone, and 500-mg mycophenolic acid mofetil twice daily for 3 months; Within 6 months, the patient’s scalp hair slowly returned.
19	Jin P, et al (69)	2022	63/F	No	Asthma	–	2	No; AA	Yes	Minoxidil; complete hair regrowth in 6 months

* AA-like is defined as atypical clinical/histological findings of AA.

NA: not available; M: male; F: female; AA: alopecia areata; AD: atopic dermatitis; CsA: cyclosporine.

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Data availability statement

The data that support the findings of this study are available on request from the corresponding author, [WS].