QCan you patch test patients on dupilumab?
While it is common to think of allergic contact dermatitis as a single homogeneous CD4+ T-cell mediated disease, dermatologists should remember that different allergens provoke heterogenous Th1/Th17 and Th2/Th22 phenotypes (for example, nickel and fragrance allergens, respectively).1
Then it should not be surprising that IL4r-mediated Th2 blockade by dupilumab may have variable effect on patch test positivity. While there are reports of relevant positive patch tests in patients on dupilumab,2 there is significant concern that dupilumab may attenuate patch test reactions and lead to false negative results.3,4
Practically speaking, it may be acceptable to patch test a patient on dupilumab if there is clinical concern that withdrawal of dupilumab could result in significant flare. It would be ideal to patch test patients off drug if possible, and ideally patch testing should be undertaken prior to initiation of systemic immunosuppressants.5
There is currently no consensus on how long patients should be off drug, but I generally wait 2 weeks if the patient is amenable.
- Leonard A, Guttman-Yassky E. The Unique Molecular Signatures of Contact Dermatitis and Implications for Treatment. Clinical Reviews in Allergy & Immunology. 2018. doi:10.1007/s12016-018-8685-0. PMID: 29754191.
- Puza CJ, Atwater AR. Positive Patch Test Reaction in a Patient Taking Dupilumab. Dermatitis. 2018. doi: 10.1097/DER.0000000000000346. PMID: 29494389.
- de Wijs LEM, van der Waa JD, Nijsten T, Silverberg JI, Kunkeler ACM, Hijnen DJ. Effects of dupilumab treatment on patch test reactions: A retrospective evaluation. Clin Exp Allergy. 2021. doi:10.1111/cea.13892
- Raffi J, Botto N. Patch Testing and Allergen-Specific Inhibition in a Patient Taking Dupilumab. JAMA Dermatol. 2019. doi: 10.1001/jamadermatol.2018.4098. PMID: 30484816.
- Chen JK, Jacob SE, Nedorost ST, Hanifin JM, Simpson EL, Boguniewicz M, Watsky KL, Lugo-Somolinos A, Hamann CR, Eberting CL, Silverberg JI, Thyssen JP. A Pragmatic Approach to Patch Testing Atopic Dermatitis Patients: Clinical Recommendations Based on Expert Consensus Opinion. Dermatitis. 2016. doi: 10.1097/DER.0000000000000208. PMID: 27427820.