Dupilumab-Associated Facial and Neck Erythema: An Updated Systematic Review of Management Strategies

Facial and neck erythema (FNE) is a bothersome adverse effect associated with dupilumab treatment for atopic dermatitis (AD). It is unclear how to optimally manage this condition. To systematically review and summarize cases of dupilumab-associated FNE and to identify reported etiologies and management strategies. A search was conducted on EMBASE and MEDLINE databases to update a systematic review published in 2021. We identified 867 cases of dupilumab-related FNE, of which 54.9% were de novo 39.2% were worsening of preexisting FNE. Reported etiologies of dupilumab-induced FNE included allergic contact dermatitis (21.2%, 184/867), Malassezia furfur hypersensitivity (13.5%, 117/867), and residual AD (2.8%, 24/867). Reported management strategies included topical monotherapy (28.4%, 253/892; most commonly, topical corticosteroids (TCS) with topical calcineurin inhibitors [TCIs]), oral monotherapy (21.3%, 190/892; most commonly oral antifungals and upadacitinib), and combination of topical/oral treatments (8.1%, 72/892; most commonly TCS/TCI/oral antifungal combination). Complete resolution (CR) was seen with topical antifungals (69.6%, 16/23), oral antifungals (66.1%, 82/124), and upadacitinib (100%, 35/35). Of patients who continued dupilumab with no subsequent intervention, 27.7% (13/47) had CR. This study is limited by a lack of standardized reporting, a lack of head-to-head or placebo comparison, and potential publication bias. Dupilumab-associated FNE has the potential to resolve with topical and oral medications. Prospective, controlled studies are indicated to elucidate optimal management strategies.