Oral and Topical Antifungals Beneficial for Dupilumab Facial Redness in Atopic Dermatitis

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Woman applying skin face cream.
A novel study reports the positive response to oral and topical antifungals for patients with atopic dermatitis (AD) treated with dupilumab who developed facial redness.

Oral and topical antifungals are effective for patients with atopic dermatitis (AD) who develop dupilumab facial redness (DFR) after receiving dupilumab treatment, researchers reported in a study published in Dermatologic Therapy.

The investigators reviewed data from 101 patients with AD who were treated with dupilumab. Eligible participants were diagnosed with DFR after beginning dupilumab therapy since March 2020. DFR was defined as a paradoxical eruption (macules, papules, or plaques, with or without pustules) occurring after initiation of dupilumab therapy, in a head-neck distribution (seborrheic), which was different from their usual AD lesions, was not associated with another disease, and did not respond to topical corticosteroids or calcineurin inhibitors.

A total of 13 patients (12.9%) with DFR were included (median age 29.5 ± 8.06 years; 69.2% men; median disease duration 22.3 ± 9.7 years). All participants were Latino, 84.6% had Fitzpatrick skin type 3, 69.2% had a history of AD since childhood, and all participants had received systemic treatment before dupilumab. Atopic and nonatopic comorbidities occurred in 92.3% of the patients. Dupilumab ocular surface disease was reported in 69.2% of patients, urticaria in 15.4%, and alopecia areata in 7.7%.

Owing to the seborrheic distribution of DFR in the participants, the study authors considered that the etiology was a hypersensitivity reaction to Malassezia.

Among the patients, 84.6% had DFR after 2 to 6 months, and 46.1% described their condition as mild and 46.1% as moderate. Severity AD scores ranged from mild to moderate when DFR was diagnosed.

All patients were treated with topical or systemic antifungals. Oral fluconazole 200 mg weekly for 4 weeks and topical clotrimazole cream 1% twice per day or 4 times per day for 2 weeks were proposed as first-line treatment. Itraconazole 100 mg once per day for 4 weeks was proposed as second-line treatment. A response of 68% was observed with first-line treatment, and 1 patient required second-line treatment, with a final improvement rate of 80%. A total of 7 patients (53.8%) had a relapse, with a median time of 2.7 months.

“In this case series, we report for the first time in the literature in a cohort, the positive response to oral or topical antifungals for AD patients treated with dupilumab who developed DFR, supporting the Malassezia hypersensitivity theory,” concluded the study authors.


Ordóñez-Rubiano MF, Casas M, Balaguera-Orjuela V, et al. Dupilumab facial redness: Clinical characteristics and proposed treatment in a cohort. Dermatol Ther. Published online September 21, 2021. doi:10.1111/dth.15140