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Psoriasis onset under dupilumab treatment in two patients affected by atopic dermatitis and one patient affected by alopecia areata: Clinical and dermoscopic patterns

Dear Editor While dupilumab has emerged as an effective treatment for moderate-to-severe atopic dermatitis (AD) since its approval, interleukin (IL)-4 and 13 blockade has also demonstrated efficacy in off-label chronic dermatologic conditions, such as alopecia areata (AA). Recently, cases of dupilumab-induced phenotype switching from AD to psoriasis have been reported. Here, we present three cases of new psoriasis onset under dupilumab treatment: two patients affected by AD and one patient affected by AA. A 61-year-old woman presented with lifelong atopic dermatitis (AD) since childhood. Previous treatments for her AD included topical corticosteroids, topical tacrolimus, narrow-band ultraviolet B, and oral prednisone. Dupilumab was administered at the recommended dose for AD (600 mg on day 1, 300 mg every other week onwards) with an initial improvement in her AD. Nevertheless, after 1 month of treatment (four doses) she presented an acute onset of small, scaly, erythematous papules concentrated on the trunk and extremities, with dotted vessels and white scales on a reddish background seen at dermoscopy (Figure 1A,D). A diagnosis of guttate psoriasis was made and a clobetasol propionate cream was administered twice daily for 4 weeks, leading to a psoriasis remission. A 56-year-old woman presented with lifelong AD that started in her childhood and significantly worsened in her early 18th. Previous treatments included topical corticosteroids, intramuscular corticosteroids injections and methotrexate. Dupilumab was administered and improved significantly her AD, but after 2 months of treatment (seven