Dupixent for Psoriasis: A New Era of Treatment Explained

April 18, 2024

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Psoriasis is a common immune-mediated skin condition affecting over 8 million Americans. It is characterized by raised, red, scaly plaques that can be itchy and painful. For those with mild psoriasis, topical treatments like corticosteroids are often the first line of defense. However, moderate to severe cases may require systemic medications – including recently approved biologic drugs like Dupixent (dupilumab).

Dupixent works by blocking certain proteins that play a role in inflammation. Early research showed great promise in treating recalcitrant moderate to severe psoriasis. However, case reports have recently emerged showing dupilumab may unexpectedly induce or exacerbate psoriasis in some patients.

Another topical medication called Eucrisa (crisaborole) was also approved in 2016 for mild to moderate atopic dermatitis. As a non-steroidal phosphodiesterase-4 (PDE4) inhibitor, Eucrisa may have potential off-label use in psoriasis management as well.

This article provides an overview of using Dupixent and Eucrisa in psoriasis treatment, including efficacy, side effects, and alternatives for patients who may not respond favorably.

Dupixent (Dupilumab) for Psoriasis

Dupixent is a monoclonal antibody that blocks interleukin-4 (IL-4) and interleukin-13 (IL-13) signaling. These are key cytokines involved in Type 2 helper T-cell (Th2)-mediated inflammation.

By inhibiting IL-4/13 pathways, Dupixent can:

  • Reduce cytokine production
  • Inhibit inflammatory responses
  • Improve pruritus and associated lesions

In a phase 3 clinical trial, 72% of patients with moderate to severe plaque psoriasis achieved PASI 75 response (75% clearance in Psoriasis Area and Severity Index score) after 16 weeks of Dupixent treatment.

After a 52-week open label extension, 80% of continued Dupixent users maintained PASI 75. Nearly 60% achieved PASI 90.

Thus, the research indicates excellent efficacy of dupilumab in psoriasis for most patients initially. However, its long-term effects have recently come into question for a subset of users.

In some cases, dupilumab therapy has been associated with new onset or exacerbated psoriatic lesions within weeks to months of initiation.

The mechanism is not fully understood but may involve imbalance between Type 1 (IFN-γ dominated) and Type 17 (IL-17 dominated) pathways. These instances of “dupilumab-induced psoriasis” can be frustrating for both patients and providers.

Managing Side Effects

For patients experiencing significant psoriatic flares on Dupixent:

  • Topical corticosteroids may help transiently
  • Phototherapy (light therapy) can quickly reduce plaques
  • Switching to a different systemic agent is often necessary long-term

Fortunately, research shows Dupixent-triggered psoriasis tends to improve after stopping dupilumab. However, flares may initially worsen before starting to resolve.

Careful monitoring for new skin findings is prudent in any patient beginning systemic immunomodulators like dupilumab. Switching agents quickly at the first sign of drug-induced psoriasis can help minimize its severity.

Eucrisa (Crisaborole) for Psoriasis Treatment

Eucrisa (crisaborole) ointment is a topical PDE4 inhibitor approved for mild to moderate atopic dermatitis (eczema).

By blocking PDE4, Eucrisa prevents breakdown of cyclic adenosine monophosphate (cAMP) inside immune cells. This leads to reduced inflammatory cytokine release.

One small study showed crisaborole improved psoriasis severity by 51% after 8 weeks. Moreover, it can likely be combined with other topicals like steroids.

Larger trials are still needed. But these early findings suggest Eucrisa may hold promise for off-label psoriasis therapy, especially in sensitive skin regions. Its non-steroidal nature also avoids risks of skin atrophy or systemic absorption.

For now though, Eucrisa remains approved only for atopic dermatitis rather than psoriasis. Its efficacy outside of clinical trials is still unproven.

Coexistence of Psoriasis and Atopic Dermatitis

Traditionally, psoriasis and atopic dermatitis were viewed as completely separate diseases without overlap in the same patient.

However, it’s become increasingly clear that these Th1- and Th2-mediated skin conditions can in fact coexist, especially in adults. Recent studies found nearly 25% of psoriasis patients also have atopic dermatitis throughout life.

For those experiencing flares of both disorders concurrently, pay close attention for:

  • Areas of thicker, scaling plaques (psoriasis)
  • Regions of red, flaky, intensely itchy rashes (atopic dermatitis)

Careful diagnosis is important prior to initiating any topical or systemic treatments. Dupixent is only FDA-approved for atopic dermatitis. While Eucrisa is approved for AD, its usage in psoriasis remains experimental.

Seeking patch testing or skin biopsies can also help distinguish between eczema, psoriasis, or overlapping presentations when the clinical diagnosis remains unclear.

Frequently Asked Questions

What are the most common side effects of Dupixent?

The most frequent side effects of Dupixent include injection site reactions, conjunctivitis, oral herpes infections, and psoriatic skin lesions. Mild cases can often be managed with adjunctive treatments but moderate reactions may require changing systemic therapy.

Is Eucrisa ointment more effective than topical steroids?

For atopic dermatitis, research found comparable efficacy between high potency topical corticosteroids and Eucrisa. However, steroids carry higher risks of skin damage over time. For treatment-resistant dermatitis on sensitive skin (face, genitals), Eucrisa may be favorable. Its efficacy compared to topical steroids in psoriasis is still being investigated.

The mechanism behind Dupixent-induced psoriasis is not fully understood. It may relate to overcorrection of Th2 inflammation, causing an imbalance with Th1/Th17 pathways. These changes result in flaring psoriasis despite Dupixent’s efficacy in other Th2-dominant diseases like atopic dermatitis.

What is the difference between psoriasis and atopic dermatitis?

Psoriasis causes well-demarcated, thick, scaly red plaques favoring extensor surfaces like elbows and knees. It results from hyperproliferation of skin keratinocytes mediated by IL-23/Th17 cytokines. In contrast, atopic dermatitis shows ill-defined, intensely pruritic patches dominated by Th2 inflammation. Acute AD lesions weep clear fluid. Chronic plaques appear lichenified.

If my psoriasis worsens on Dupixent, what are my options?

For psoriatic flares induced by Dupixent, first-line treatment involves topical steroids and continued close monitoring. Phototherapy is also quickly effective for resistant plaques. However, many patients require transition to oral systemic or biologic alternatives long-term, such as Otezla, Skyrizi, Tremfya, etc. Stopping dupilumab typically allows lesions to gradually revert towards baseline.

Key Takeaways

  • Dupixent (dupilumab) is highly effective for psoriasis but may unpredictably induce or worsen psoriatic lesions in some patients
  • Careful monitoring and early intervention is key to minimize severity of dupilumab-triggered psoriasis
  • Eucrisa (crisaborole) is an emerging topical PDE4 inhibitor that could offer additional treatment options for mild psoriasis
  • Psoriasis and atopic dermatitis can coexist, especially among adults – accurate diagnosis is vital before starting therapy
  • Various systemic and biologic alternatives exist for managing psoriatic disease unresponsive to initial Dupixent treatment

Understanding these nuances provides the greatest chance for optimal control of psoriatic disease using the available dermatological treatments. With expanding therapeutic options on the horizon, the future continues to brighten for those suffering from psoriasis and other immune-mediated skin conditions.

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