Dupilumab unmasking cutaneous T‐cell lymphoma; report of a fatal case

Dupilumab-associated lymphoproliferative disorders: a comprehensive review on clinicohistopathologic features and underlying mechanisms

Dupilumab, a monoclonal antibody targeting interleukin 4 receptor, has shown significant efficacy in treating atopic dermatitis (AD). However, emerging case reports indicate that it may unmask or cause cutaneous T cell lymphoma (CTCL). This review analyzes 29 studies involving 124 patients who developed lymphoproliferative disorders after dupilumab, including 13 cases of lymphoproliferative reactions not meeting lymphoma criteria. The median time from dupilumab initiation to biopsy-confirmed lymphoproliferative disorders was 5 months, with 39.05% of cases in advanced stages. Histopathological examination of dupilumab-induced CTCL reveals epidermotropism with spongiosis and increased superficial lymphoid infiltration. Notably, early lymphoproliferative reaction shows subtle lymphoma features, characterized by perivascular infiltration with sprinkled intraepidermal lymphocytes, CD30 expression, and absence of clonal TCR rearrangement and T-cell markers loss. Adult-onset AD patients, particularly those with atypical skin lesions, short-term exacerbation, or no atopy history, should be closely monitored during dupilumab treatment, and skin biopsy is essential if no clinical improvement occurs. Discontinuation is recommended when lymphoid infiltration increases, even without typical lymphoma features. The mechanisms underlying dupilumab-associated lymphoma remain speculative. Current hypotheses include upregulation of IL13RA2 signaling pathway, prolonged persistence of immune cell populations, and varying responses of different tumor cell subclusters. Additionally, the effects of dupilumab on various cell types are complex and multifaceted. Consequently, the distribution of type 2 inflammatory cytokine receptors and the patterns of cellular infiltration within the microenvironment may impact disease progression following dupilumab treatment. Further research is needed to clarify the mechanisms linking dupilumab to CTCL for better defining dupilumab's safety profile.

Exploring the Link Between Dupilumab and Cutaneous T-Cell Lymphomas: A Systematic Review

Dupilumab, an IL-4 and IL-13 antagonist, is a biological medication approved for treating moderate-to-severe atopic dermatitis (AD) and other inflammatory conditions. While dupilumab has been effective in managing AD, recent reports suggest a possible link between dupilumab and the unmasking or progression of cutaneous T-cell lymphomas (CTCL), including mycosis fungoides and Sézary syndrome. This systematic review examines 35 studies, including case reports, case series, and retrospective studies, to investigate the association between dupilumab and CTCL development or exacerbation. Findings reveal both cases of symptom relief and worsening pruritus or disease progression in patients treated with dupilumab. Mechanisms proposed include misdiagnosis of early-stage CTCL as AD and potential dupilumab-induced changes in immune signaling pathways that may promote malignant transformation. Key limitations of existing studies include small sample sizes, lack of standardized treatment duration, and limited long-term follow-up, making it challenging to establish causation. While dupilumab remains an important therapy for AD, these findings underscore the need for careful patient evaluation, particularly in those with persistent or atypical presentations. Further large-scale, longitudinal studies are essential to clarify the role of dupilumab in CTCL development and progression and to optimize patient safety in clinical practice.

Tumors in the setting of dupilumab use: A review of the literature

Dupilumab is the first monoclonal antibody approved for treating moderate-to-severe atopic dermatitis (AD) and has significantly improved the quality of life of AD patients. However, the safety of dupilumab is yet unclear in the context of cancer. Therefore, we aimed to investigate the safety of dupilumab and its relationship with the progression and occurrence of tumors. By reviewing relevant medical records of 90 patients who had pre-existing tumors before dupilumab treatment or presented new tumors after dupilumab treatment, we found that dupilumab probably had no significant negative effects on most tumors, but several patients with Cutaneous T-cell lymphomas (CTCLs) had relatively unfavorable outcomes during dupilumab treatment. Besides, CTCLs and lymphomas accounted for the majority of patients who presented new tumors after dupilumab treatment. Several patients were first diagnosed with presumed AD and probably were the presentations of CTCL at an early stage, and they developed typical CTCL symptoms after dupilumab treatment. Finally we came to the conclusion that dupilumab is safe for most patients with cancer. However, the effect of dupilumab on CTCLs is disputable. The use of dupilumab requires individual evaluation and closely monitored. When the efficacy is poor, re-evaluation of the diagnosis, especially of CTCLs and related diseases, is necessary.

Biologics and small molecules treatment for moderate-to-severe atopic dermatitis patients with comorbid conditions and special populations: an Italian perspective

This comprehensive review offers a detailed look at atopic dermatitis (AD) treatment in Italy, focusing primarily on the use of biologics and small molecules. In response to advancing knowledge of AD's causes and treatments, there's a global need for updated guidelines to provide physicians with a more comprehensive clinical perspective, facilitating personalized treatment strategies. Dupilumab, a groundbreaking biologic, gained approval as a significant milestone. Clinical trials demonstrated its ability to significantly reduce AD severity scores, with an impressive 37% of patients achieving clear or nearly clear skin within just 16 weeks of treatment. Real-world studies further support its efficacy across various age groups, including the elderly, with a safety profile akin to that of younger adults. Tralokinumab, a more recent approval, shows promise in clinical trials, particularly among younger populations. However, its real-world application, especially in older individuals, lacks comprehensive data. Janus Kinases inhibitors like Upadacitinib, Baricitinib, and Abrocitinib hold substantial potential for AD treatment. Nevertheless, data remains limited for patients over 75, with older adults perceived to carry a higher risk profile. Integrated safety analyses revealed individuals aged 60 and above experiencing major adverse cardiovascular events and malignancies, underscoring the need for cautious consideration. While these therapies offer promise, especially among younger patients, further research is essential to determine their safety and efficacy in various populations, including pediatric, geriatric, and those with comorbidities. Biologics and small molecules are improving AD treatment, as shown in this review.

A Review of Dupilumab-Induced Adverse Events to Dermatologists and the Potential Pathogenesis in the Treatment of Atopic Dermatitis

Dupilumab, a monoclonal antibody targeting interleukin-4 antibody, is approved for use in many type 2 inflammatory diseases, including atopic dermatitis. It is generally well tolerated with no need of routine laboratory monitoring. However, several adverse events have been reported during real-world practice and in pivotal trials. We conducted a systematic literature research of the PubMed, Medline, and Embase databases to identify articles recording the clinical manifestation and potential pathogenesis of these adverse events with interests (AEIs) to dermatologists. In total, 547 cases from 134 studies have developed 39 AEIs 1 day to 2.5 years after dupilumab treatment. The most common AEIs are facial and neck dermatitis (299 cases), psoriasis (70 cases), arthralgia (56 cases), alopecia (21 cases), cutaneous T cell lymphoma (19 cases), severe ocular diseases (19 cases), and drug eruption (6 cases). Most of the AEIs recorded in this review resolved or improved after dupilumab discontinuation or the addition of another treatment, whereas 3 of the cases died of severe AEI. The potential pathogenesis included T help type 1 (Th1)/T help type 2 (Th2) imbalance, Th2/T help type 17 (Th17) imbalance, immune reconstitution, hypersensitivity reaction, transient hypereosinophilia related, and Th1 suppression. Clinicians should be alert of these AEIs for timely diagnosis and appropriate treatment.

Malignant T cells induce skin barrier defects through cytokine-mediated JAK/STAT signaling in cutaneous T-cell lymphoma

Cutaneous T-cell lymphoma (CTCL) is a devastating lymphoid malignancy characterized by the accumulation of malignant T cells in the dermis and epidermis. Skin lesions cause serious symptoms that hamper quality of life and are entry sites for bacterial infection, a major cause of morbidity and mortality in advanced diseases. The mechanism driving the pathological processes that compromise the skin barrier remains unknown. Here, we report increased transepidermal water loss and compromised expression of the skin barrier proteins filaggrin and filaggrin-2 in areas adjacent to TOX-positive T cells in CTCL skin lesions. Malignant T cells secrete mediators (including cytokines such as interleukin 13 [IL-13], IL-22, and oncostatin M) that activate STAT3 signaling and downregulate filaggrin and filaggrin-2 expression in human keratinocytes and reconstructed human epithelium. Consequently, the repression of filaggrins can be counteracted by a cocktail of antibodies targeting these cytokines/receptors, small interfering RNA-mediated knockdown of JAK1/STAT3, and JAK1 inhibitors. Notably, we show that treatment with a clinically approved JAK inhibitor, tofacitinib, increases filaggrin expression in lesional skin from patients with mycosis fungoides. Taken together, these findings indicate that malignant T cells secrete cytokines that induce skin barrier defects via a JAK1/STAT3-dependent mechanism. As clinical grade JAK inhibitors largely abrogate the negative effect of malignant T cells on skin barrier proteins, our findings suggest that such inhibitors provide novel treatment options for patients with CTCL with advanced disease and a compromised skin barrier.

T cells in the skin: lymphoma and inflammatory skin disease

T cells are established contributors to the pathogenesis of atopic dermatitis (AD) and psoriasis, yet whether they are the key drivers or simply unwitting participants remains incompletely understood. Conversely, malignant T cells are the undisputed culprits of cutaneous T cell lymphoma (CTCL), a group of diseases that share key clinical, histopathological and molecular features with inflammatory skin disease (ISD). Here, we compare the pathogenesis of ISD and CTCL and discuss the resulting insights. Recurrent, skin-limited disease implicates skin-resident T cells (T_RM) in both ISD and CTCL. In CTCL, malignant T cells recruit benign T cells into inflammatory skin lesions, a disease-amplifying function also proposed for pathogenic T cells in ISD. Mechanistically, cytokines produced by malignant T cells in CTCL and by pathogenic T cells in ISD, respectively, are likely both necessary and sufficient to drive skin inflammation and pruritus, which in turn promotes skin barrier dysfunction and dysbiosis. Therapies for ISD target T cell effector functions but do not address the chronicity of disease while treatments for CTCL target malignant T cells but not primarily the symptoms of the disease. By integrating our understanding of ISD and CTCL, important insights into pathogenesis and therapy can be made which may improve the lives of sufferers of both disease groups.