Efficacy and Safety of Dupilumab in Patients With Erythrodermic Atopic Dermatitis: A Post Hoc Analysis of 6 Randomized Clinical Trials

IMPORTANCE: Erythrodermic atopic dermatitis (AD) is a severe AD subtype defined by extensive skin involvement, leading to complications and sometimes hospitalization. OBJECTIVE: To assess dupilumab’s efficacy and safety in patients with erythrodermic AD in clinical trials. DESIGN, SETTING, AND PARTICIPANTS: This post hoc analysis included patients enrolled in 6 multicenter, multinational, randomized, double-blind, placebo-controlled trials. Patients included in this analysis met erythrodermic AD criteria of 90% or greater body surface area (BSA) affected by AD and Global Individual Sign Score for erythema of 1 or higher. Data analyses for this post hoc analysis were conducted between March 5, 2019, and October 24, 2020. INTERVENTIONS: Dupilumab once weekly or every 2 weeks, or placebo, either as monotherapy or with concomitant topical corticosteroids (TCS). MAIN OUTCOMES AND MEASURES: Efficacy (BSA, Eczema Area and Severity Index [EASI] score, Peak Pruritus Numerical Rating Scale [PP-NRS] score), changes in serum biomarkers (thymus and activation-regulated chemokine, total immunoglobulin E, lactate dehydrogenase), and safety (incidence of adverse events) at week 16. Data were pooled within each regimen; monotherapy and concomitant TCS results are shown separately. RESULTS: Of 3075 randomized patients, 209 met criteria for erythrodermic AD at baseline, with the median age being 31 and 39 years in the monotherapy and concomitant TCS trials, respectively, similar to the overall populations (34 and 36 years, respectively); 71.3% (n = 97) and 74.0% (n = 54) of patients, respectively, were male (compared with 58.7% and 60.6% in the overall populations). In patients with erythrodermic AD, dupilumab once weekly and every 2 weeks vs placebo significantly improved percentage of BSA affected by AD (least squares mean percent change [SE]) with monotherapy (−42.0% [7.7%] and −39.9% [6.5%] vs −17.2% [11.0%]; P = .03) and concomitant TCS (−63.2% [6.7%] and −56.1% [9.1%] vs −14.5% [7.3%]; P < .001); EASI score with monotherapy (−58.5% [9.0%] and −58.3% [7.9%] vs −22.3% [12.4%]; P = .004 and P = .003, respectively) and concomitant TCS (−78.9% [7.8%] and −70.6% [10.1%] vs 19.3% [8.2%]; P < .001); and PP-NRS score in monotherapy (−45.9% [7.8%] and −33.9% [6.6%] vs −0.6% [9.4%]; P < .001) and concomitant therapy (−53.0% [8.1%] and −55.7% [10.8%] vs −26.0% [8.8%]; P = .006 and P = .01, respectively). Nominally statistically significant improvement was seen as early as week 1 (EASI and PP-NRS scores with monotherapy). Biomarker levels were significantly reduced vs placebo. The most frequent adverse events in dupilumab-treated patients were injection-site reaction, conjunctivitis, and nasopharyngitis. CONCLUSIONS AND RELEVANCE: In this post hoc analysis of 6 randomized clinical trials, treatment with dupilumab resulted in rapid, sustained improvements in AD signs and symptoms with acceptable safety in patients with erythrodermic AD, similar to those in the trials’ overall patient population. TRIAL REGISTRATION: ClinicalTrials.gov Identifiers: NCT01859988, NCT02277743, NCT02277769, NCT03054428, NCT02260986, NCT02755649