Dupilumab-Induced Vitiligo Managed Effectively With Nemolizumab and Targeted Topical Therapy

Dupilumab, a monoclonal antibody targeting the IL-4 and IL-13 pathways, has revolutionized the treatment of moderate-to-severe atopic dermatitis (AD). However, emerging evidence suggests rare immune-mediated adverse events, including vitiligo onset or exacerbation. The pathogenesis involves potential immune dysregulation and cytokine imbalance following IL-4/IL-13 inhibition. To report a case of dupilumab-induced vitiligo in a patient with AD and evaluate the therapeutic alternatives for management, we present a case report of a 57-year-old woman with longstanding AD who developed new-onset vitiligo following dupilumab therapy. The patient was subsequently switched to nemolizumab, an IL-31 receptor antagonist, and treated with topical tacrolimus 0.1% ointment on one hand and ruxolitinib cream on the contralateral hand to compare treatment efficacy. Three months after dupilumab initiation, the patient developed depigmented patches on bilateral metacarpophalangeal joints consistent with non-segmental vitiligo, with no prior history of vitiligo or autoimmune disease. Following transition to nemolizumab and topical treatments, significant improvement occurred within eight weeks. The hand treated with ruxolitinib demonstrated superior repigmentation compared to the tacrolimus-treated hand. This case highlights dupilumab's potential to induce vitiligo through Th2 cytokine inhibition and subsequent Th1/Th17 activation, promoting melanocyte destruction. The superior efficacy of topical JAK-STAT inhibition with ruxolitinib compared to tacrolimus suggests JAK pathway modulation may be more effective for managing biologic-induced pigmentary disorders. Clinicians should monitor for the development of vitiligo in dupilumab-treated patients.