Dupilumab-Associated Facial Erythema: A Case of Sustained Improvement With Topical Roflumilast
Alexandra GolantAuthorDr Golant presents a case of dupilumab-associated facial erythema successfully managed with topical roflumilast, achieving complete clearance while maintaining uninterrupted dupilumab therapy.
Case presentation
A 42-year-old White woman receiving dupilumab developed new-onset facial erythema. Her medical history was notable for atopic disease, including asthma and seasonal allergies. The patient had a history of AD since childhood that worsened as an adult. She had tried and failed multiple topical steroids, topical calcineurin inhibitors, courses of oral prednisone, and phototherapy.
She was initiated on dupilumab due to the persistence of moderate to severe AD despite these interventions. After dupilumab treatment was initiated, she experienced significant clearance of skin lesions and pruritus. The new-onset facial erythema began approximately 18 months into her treatment course with dupilumab, despite the remainder of her body being clear.
Physical examination
On examination, erythematous patches were present across the perioral and central facial regions, with a small number of scattered papules. She reported significant pruritus as well as intermittent burning sensations.
Diagnostic review
Based on the clinical presentation and treatment history, a working diagnosis of dupilumab-associated facial erythema was made.
Facial erythema arising during dupilumab treatment can present a therapeutic challenge, particularly given its heterogeneous and incompletely understood pathogenesis. Potential contributing factors include Malassezia hypersensitivity, rosacea-like inflammation, allergic contact dermatitis, and persistent or inadequately controlled AD.
Treatment discussion and outcome
The patient was initially treated with topical ruxolitinib 1.5% cream twice daily for 4 weeks; however, the facial eruption did not show significant improvement. Short courses of topical minocycline foam and oral itraconazole were given, both without significant response. Treatment was subsequently changed to incorporate topical roflumilast 0.15% cream applied once daily to affected areas.
Over the following months, the facial eruption progressively improved. At 9 months, only mild residual eczematous patches remained on the face. Daily roflumilast cream use was continued, with further improvement observed through 24 months, achieving complete clearance of itch and skin lesions. No tolerability issues were reported, and treatment with dupilumab was continued without interruption during this time.
Clinical insight
In this patient, response to topical ruxolitinib was inadequate, whereas a regimen incorporating topical roflumilast was associated with progressive improvement over longer-term follow-up.
The decision to incorporate topical roflumilast was supported by its broad anti-inflammatory activity through phosphodiesterase-4 inhibition, which modulates inflammatory pathways beyond the type 2 cytokine signaling targeted by dupilumab. Its nonsteroidal formulation also offers an attractive option for long-term management of inflammation in sensitive skin areas like the face. Importantly, this case illustrates that topical roflumilast can be used to successfully manage facial erythema concomitantly with dupilumab treatment, without the need for interruption or discontinuation.