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Updated: Jul 4, 2025
Induction of Ocular Surface Inflammation and Collection of Involved Tissues
Published on: August 4, 2022
Ocular surface disease in moderate-to-severe atopic dermatitis patients and the effect of biological therapy
Roselie Achten1, Judith Thijs1, Marlot van der Wal2
1Department of Dermatology and Allergology, National Expertise Center for Atopic Dermatitis, University Medical Center Utrecht, Utrecht, The Netherlands.
Abstract:
Atopic dermatitis (AD) is a chronic inflammatory skin disease for which new targeted therapies are currently available. Due to the increased rates of ocular surface disease (OSD) reported during treatment with these new targeted treatments, more insight into the occurrence and pathomechanism of OSD in moderate-to-severe AD patients is needed. Therefore, this review's first part highlights that most patients with moderate-to-severe AD already have characteristics of OSD before starting targeted treatment. Remarkably, not all AD patients with OSD report ocular symptoms. OSD in AD is associated with less conjunctival goblet cells (GC) compared to healthy controls. In addition, OSD severity in AD patients is associated with high AD activity, the presence of eyelid and/or facial eczema, and high levels of AD-related severity biomarkers in tear fluid. The second part of this review highlights that pre-existing ocular pathology (e.g. in combination with the use of ophthalmic medication or eyelid eczema) may be associated with the development of dupilumab-associated ocular surface disease (DAOSD). During dupilumab treatment, DAOSD (which can be new-onset OSD or worsening of pre-existing OSD) is observed in approximately one-third of the dupilumab-treated AD patients. Anti-inflammatory ophthalmic treatment improves DAOSD, and dose reduction of dupilumab may also be an effective treatment option. The pathomechanism of DAOSD is still not fully elucidated. In a prospective study low, but stable conjunctival GC numbers were observed in moderate-to-severe AD patients, before and during dupilumab treatment. However, the Mucin 5 AC (MUC5AC) expression of GCs decreased during dupilumab treatment, suggesting an impairment of the GC function by dupilumab treatment. In addition, higher dupilumab tear fluid levels were found in dupilumab-treated AD patients with moderate-to-severe OSD compared to patients with no or mild OSD, whereas the dupilumab serum levels are similar. Clinicians should be aware of the frequent occurrence of OSD in moderate-to-severe AD patients, and a low-threshold referral to an ophthalmologist is recommended.
Insights
Most moderate-to-severe atopic dermatitis (AD) patients have ocular surface disease (OSD) before treatment. Dupilumab therapy can cause or worsen OSD, necessitating ophthalmologist consultation.
Area of Science:
- Ophthalmology
- Dermatology
- Immunology
Background:
- Atopic dermatitis (AD) is a chronic inflammatory skin condition with increasing targeted therapy options.
- Ocular surface disease (OSD) is frequently observed in AD patients, often preceding targeted treatments.
- Understanding OSD in moderate-to-severe AD is crucial due to reported increased rates during new therapies.
Purpose of the Study:
- To review the prevalence and characteristics of OSD in moderate-to-severe AD patients.
- To investigate the development and potential mechanisms of dupilumab-associated OSD (DAOSD).
- To provide clinical recommendations for managing OSD in AD patients undergoing targeted therapy.
Main Methods:
- Literature review of studies on OSD in AD patients.
- Analysis of OSD prevalence and risk factors in moderate-to-severe AD.
- Examination of DAOSD occurrence, clinical presentation, and potential pathomechanisms during dupilumab treatment.
Main Results:
- Most moderate-to-severe AD patients exhibit OSD characteristics before initiating targeted therapy.
- OSD in AD is linked to reduced conjunctival goblet cells, high disease activity, and specific biomarkers.
- DAOSD affects approximately one-third of dupilumab-treated AD patients, potentially linked to pre-existing ocular conditions and reduced Mucin 5AC expression.
Conclusions:
- OSD is common in moderate-to-severe AD, often present before treatment.
- Dupilumab treatment can lead to new-onset or worsening OSD, with potential mechanisms involving goblet cell function.
- Clinicians should proactively screen for OSD in AD patients and refer to ophthalmology when indicated.
