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Did you know that about 10% of people using Dupixent develop awful face and neck dermatitis?
This issue (more officially called Dupilumab Facial Redness (DFR)) wasn’t flagged during the randomized FDA trials, but has some dermatologists concerned because DFR can be incredibly severe, just as it was for one of my clients.
Since Dupixent is a biologic drug used by some with Eczema and Topical Steroid Withdrawal to ease symptoms, this new problem isn’t ideal.
Rather than just assume that the person has a sensitivity to Dupixent, new research is showing that this may be a different problem — Malasezzia hypersensitivity.
If you recall, Malasezzia is a fungal organism that normally lives in your skin’s microbiome.
It really shouldn’t be causing an issue like this, but something about the way that Dupixent interacts with your immune system along with a compromised skin barrier could play a role.
Here are the current papers discussing this topic so you have something to bring to your prescribing dermatologist so you can get the help you need if you are experiencing this!
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In this episode:
- Facial + neck redness that occurs in about 10% of Dupixent users
- What current research on what may be driving this weird “side effect”
- Treatment options listed in currently published articles
- The blood test marker that could be helpful in getting a clear diagnosis
- What to do if YOU have face + neck redness from Dupixent
Quotes:
Approximately 10% of Dupixent users develop red, inflamed, dry, scaly and itchy face + neck rashes requiring antifungal medication treatment.
Dupixent Facial Redness was never described or mentioned in the Dupixent clinical trials for the FDA (which is surprising considering that it impacts approximately 10% of patients).
219: Dupixent Red Face + Neck Rash Associated With Fungal Overgrowth (FULL TRANSCRIPT)
Welcome back to episode #219 of the Healthy Skin Show!
In today’s episode, I want to talk about some emerging information that is crucial for anyone on Dupixent (or considering the medication) to hear about.
The reason is that in about 10% of people who try Dupixent (even those using it for Topical Steroid Withdrawal) may develop a red face, neck and upper chest area that can be very inflamed, scaly, dry and itchy.(1)
Everywhere else will likely look great, but this area becomes a real problem.
Cases had been reported online, but no one really had any idea what was causing certain individuals to develop this weird reaction…
Until now — and wow, is this going to blow your mind!
How I Learned About This Crazy Dupixent Side Effect
A wonderful client of mine has been really miserable with TSW for a while now and was seeking some relief so that she could be a better mom to her kids.
We discussed her starting Dupixent to see if it could help lower the severity of her symptoms.
But we didn’t anticipate that she’d end up with a bright red, inflamed and itchy face, neck and chest while everything else seemed to heal up.
Her prescribing dermatologist was stumped and wasn’t sure what was going on. My client shared her concern that it could potentially be coming from Dupixent from what she’d read online.
So her doctor stopped her on the medication.
A few weeks later, her doctor returned from a medical conference and mentioned to her that information was presented at this conference that her face and neck flare-up could be connected to a fungal problem, but refused to treat her since my client had stopped Dupixent.
This info was relayed to me and I started searching for research online about this.
How Dupixent Red Face + Neck Is Connected To Fungal Overgrowth
Turns out that a few papers had already popped up about this topic known more formally as dupilumab (aka. Dupixent) facial redness (DFR)…
One research letter published in September 2019 in JAMA Dermatology mentions that the new occurrence of Head-Neck dermatitis in some Dupixent users could be due to a potential activation of the Th17 pathway that allows for the proliferation of Malassezia and thus an increasing severity of what would later become known as DFR.(2)
Another paper published in October 2019 in the Journal of American Academy of Dermatology details the exact issue in two cases wherein the patients became sensitized to Malassezia. The one patient was found to have an “elevated serum level of Malassezia-specific immunoglobulin E”. Treatment in both of these cases was “oral itraconazole 200 mg once daily” for 1 month.(1)
Then Dr. Julie Greenberg (one of my favorite guests here on the Healthy Skin Show) gave a presentation at the Integrative Dermatology Symposium 2021 mentioning the connection between dupilumab facial redness and Malassezia. For practitioners out there, you can likely find the presentation called “Yeasty Beasty! Malassezia in Skin Disease + an Integrative Approach to Treatment” on the LearnSkin platform.
You might recall that Dr. Greenberg came on the show to discuss Malasezzia on episode 173 and its role in chronic skin problems. I highly recommend that you check that episode out — but as a quick refresher to help you connect some dots here — Malassezia is a commensal fungal organism that lives within the skin microbiome.
Upon arriving home from the conference, I found yet another paper on this published in Dermatologic Therapy in September 2021 called “Dupilumab facial redness: Clinical characteristics and proposed treatment in a cohort” and subsequently reported on Dermatology Advisor.(3)
To briefly summarize, researchers reviewed 101 eczema patients for dupilumab facial redness and found that 13 patients fit the criteria and were subsequently treated for hypersensitivity to Malassezia. They used 200mg of oral Fluconazole weekly along with a topical antifungal for 4 weeks. One person required a second round of meds which was 100 mg of Itraconazole daily for a month. Unfortunately, about half of the group seemed to relapse after approximately 3 months time.(4)
What To Do If You’re On Dupixant + Develop Red Face and Neck
I’m not saying with 100% certainty that if you develop dupilumab facial redness that you have fungal overgrowth.
At the time of this episode’s publication, there’s simply not enough research out there on this topic… especially considering that DFR was never described or mentioned in the Dupixent clinical trials for the FDA (which is rather surprising considering that it seems to impact around 10% of patients).(5)
But more research and papers are coming out pointing in this direction which is why I wanted to create this episode (and its corresponding show notes with all current research) so you now have something to bring to your prescribing doctor.
There’s a real chance that they have no idea about this research and papers published connecting dots between Malasezzia hypersensitivity and Dupixent.
I asked a rep from Dupixent about this problem at the Integrative Dermatology Symposium 2021 and she didn’t have any answers for me about it and said she’d refer my question to their team of experts whom I’d hear back from.
Well, it’s now two weeks later and I’ve never heard from anyone who works for Dupixent to answer my questions.
Rather than hold my breath, I’d rather educate you on this issue so you can seek help with proof of current research in hand (linked studies are below in the references section). Your prescribing doctor is the point person who needs to be notified so you can hopefully get appropriate treatment.
Perhaps they can also run testing for serum Malassezia-specific immunoglobulin E to help identify what’s going on rather than just assume you’re sensitive to the medication itself.
If you’ve got any questions or thoughts to share about this, leave a comment below so I can address them.
Then take a moment to share this episode with people who are dealing with eczema + TSW so that they can be informed (just as you are) about this challenge facing those who use Dupixent. This information could help them find relief on their healing journey.
Thank you so much for turning in and I look forward to seeing you in the next episode!
REFERENCES
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6818397/
- https://jamanetwork.com/journals/jamadermatology/fullarticle/2749354
- https://onlinelibrary.wiley.com/doi/10.1111/dth.15140
- https://www.dermatologyadvisor.com/home/topics/dermatitis/oral-and-topical-antifungals-beneficial-for-dupilumab-facial-redness-in-ad/
- https://www.jaad.org/article/S0190-9622(19)30990-9/fulltext
Wow, this happened to me! I was on dupixent for about 5 months starting in late 2017 and my neck and face never healed. At that time my dermatologist knew that sometimes dupixent didn’t work for those areas and that they can commonly be caused by yeast so he put me on a round of fluconazole which helped. But I never thought that dupixent could actually have caused the flare and yeast sensitivity!! Super interesting.
It’s a shame that it’s taken this long for this issue to really be identified, but at least now a bit more attention is being paid to it and more case reports are being shared. But yes, when you essentially block one inflammatory pathway, there can be consequences to that.
This is happening to my 14 year old son right now in 2022. He has severe eczema and we finally gave in to Dupixent. He is severely suffering with itchy, red, scaly, dry, and gooey forehead. He also now has scaly skin between and on his eyes, upper lip, and his poor neck is so red and scaly. Also, his underarms and chest area are going crazy as well. He has suffered his entire life, but this is so bad he is almost willing to choose eczema over his entire body just to get ride of it on his face and neck. It so hard and I do not know what to do, we have a wonderful dermatologist so I know we are in good hands. It’s so disappointing that this is a side effect and he is a part of the 10%. It’s heartbreaking and devastating.
Hi Layla, I’d encourage you to bring this information and the references below to your derm (who you said is wonderful) and get some help… this is a sign of a fungal problem and the derm can help you deal with it. It’s frustrating to have this happen, but perhaps look at it as an important clue for your son’s case.
Is your face back to normal now?
This happened to my 9yo daughter. She was also on dupixent for 5 months for eczema on her arms. It completely cleared up the arms like miracle. She never had face eczema. Sometimes her face would get dry but nothing like her arm eczema. Now, her face and neck were cherry tomato red. I brought it up to her dr (allergy specialist who prescribed it). He didn’t believe it could be a side effect. He prescribed yet another medication- protopic (as if we didn’t have enough meds) for the face and said if it does not clear up go to a dermatologist. Rather then buying another medicine I made a dermatologist appointment. She told me to skip the next dupixent and apply desonide to clear it up and see if it comes back. I took the plunge and got the desonide. After 3-4 days of applying it, it cleared it up. But we have now skipped 2 months— afraid her face will flare. In all honesty, I rather she have arm eczema then face. Now, her arms are getting bad again – dry itchy and darker then her norm skin. Her face hasn’t quiet gone back to the way it was prior to dupixent but it is better. Her face gets a little red after showers but we apply a good moisturizer over night and morning her face is good. But, her arms are not. I also noticed that her neck is darker then the rest of her skin similar to her arms. I almost want to take the plunge and give her dupixent so she can sleep at night without the arm itching but I am holding off because I can’t go back to how her face /neck reacted to it. I just wonder if I can do anything else for her face if it really is a fungal over growth. Also, i did report this to dupixent as well.
The same thing has happened to me. Looking back at my history I understand that the eczema episodes I’ve had were initially caused by mold exposure 23 years ago. Each time I was exposed my eczema would flare. Then it turned into food sensitivity and chemicals sensitivity. I’ve been on dupixent for 9 months but was taking fluconazole for foot fungus (and it helped my eczema and thyroid too!) for the a few months leading up to starting dupixent and a few months into starting dupixent. I’ve had neck flare ups the whole time I’ve been on dupixent (which I never had before) and I started having the facial flare-ups (which I’ve never had before) at the same time my foot fungus started coming back. Now I’m back on fluconazole and considering stopping dupixent and doing a big cleanse. I only started dupixent and fluconazole because I became allergic to most foods and supplements I eat/take on my eczema and fungal cleanses (because I had another mold exposure). There are many natural ways to treat eczema and they’ve worked amazingly well for me in the past – I’m hoping dupixent gave my body the relief it needed long enough for me to go back to the natural remedies.
Hi Carmen! Can you tell me what helped you after you stopped please! My daughter has been exposed to mold and has nasal polyps and a fungal infection growing in her sinuses, but they started her on Dupixent now she is breaking out on her elbows with what looks like a herpes rash.. but I’m not saying that it may be fungal and the duplex and is making it worse…
Just a thought.
I am not in the medical field; however, I would research if the 10% reacting to redness of face and neck drink wine. Wine contains sulphites which have been known to cause flushing, among other things. Perhaps, the introduction of Duplxent may cause this reaction, particularly, depending on the amount of wine and frequency of use.
Hi Christine, everyone I know (current clients) who either has this now or did in the past was not drinking alcohol at all at the time. I understand the logic, but when I say “flushing”, it’s typically more like bright red skin that’s painful, burning and horrifically itchy which wouldn’t be confused with flushing from wine due to sulfite sensitivity.
This is very interesting and I am wondering if this could this also be the eye problem? I stated Dupixent end of June 2021, with some eye issues, everyone thought it was eye eczema, along with a full blown body flare that I had been dealing with for 12 years. Within 2 weeks the body flares were clear, but the facial flares began and the eyes, OMG the eyes, red, swollen, dry, itchy, light sensitivity, tearing, burning and eye pain. I have just left the eye clinic have been on Bepreve, with no relief, then Paddaday, minimal relief, then Tobramycin for 4 weeks. Finally got some relief after 2 weeks. Week 3 started weaning off and the Eyes are back. Now being referred to another Opthamologist who works closely with a Dermatologist. No one seems to be able to diagnose this, therefore they cannot treat it.
Have you heard of any correlation?
Hi Deborah, yes there are known side effects that deal with the eyes, but why yours are lasting longer than the duration of the medication, I cannot say. I’m not a doctor, but my guess would be that something got tripped when on the medication and perhaps created an inflammatory situation that is calling for more attention. I do know that in Dr. Julie Greenberg’s talk, she did mention the correlation of Malasezzia and blepharitis and other eye issues such as Zeis Gland and Meibomian Gland dysfunction. Perhaps there is something there going on to ask your ophthalmologist about. I’m so sorry you’re going through this — my dad was an ophthalmologist and after working for him years ago, I know how awful eye issues like this can be. Perhaps sharing this information with your doctors could help them find a solution for you!
Hi Jennifer –
Since you know my case and history, you are aware that I have never tried Dupixent. However you are aware that after 2 or 3 years of improvement, this spring my skin flared into full blown TSW – which I thought had been fully cleared. I was stunned to be experiencing a revisitation of all the worst symptoms including the painful red skin, worse on my face and scalp, full body eczema, itching, leg edema, hair loss, body temperature disturbance and sleep disruption – all at the worst level I had ever experienced.
Since I had not taken a steroid since 2017 and thought they had cleared, was following food and self care protocols recommended by you – including appropriate liver support, no food restriction but no gluten, sugar, or alcohol, the re-expression of the symptoms at this level was disappointing to say the least. However, I was moved to re-audit your skin rash rebuild class, and also re-listen to several of your podcasts including one where Peter Lio talks about skin infections as symptom drivers, and I have been especially interested in the Kiran Krishnan info on IGG 2000 and histamine, AND the new info on the Malassezia connection. I am not a scientist but a very good observer of my own process. I am more than ever convinced that the microbial influence on these symptoms cannot be discounted. I started to notice a difference in the expression of symptoms on my face – when there was a lot of pain and peeling, I suspected bacteria. But when I saw just plan old dry skin crusting – my intuition was there was a more predominant expression of Malessezia in the form of a fungus or mold. In the last month I have made an effort to be very mindful of my own self care protocols, and as you know, I have upped my intake of IGG 2000 to about 1/5mg capsule per hour. I remove the scaling using clean 100% cotton bar towels and now I use 3 or 4 – I have been changing them during my showers so I am not contaminating different areas of my body even during one shower. AND – the GSE (grapefruit seed extract in glycerine) I use to manage staph infections, I researched more carefully and discovered the glycerine is anti fungal so I have been mixing drops of plain vegetable glycerine in jojoba (having ascertained the jojoba doesn’t feed the malassezia) and I am seeing changes. First the facial skin became less red and inflamed. I was not waking up with my eyes slitted and facial skin covered in flakes and scales. The overnight trans epithelial water loss has been much retarded by the glycerine. And I am more than ever convinced that this flaking is not so much dry skin but the expression of the microbial activity originating inside my body in sinus cavities, and other orifices AND already present in biofilms on my skin that form what I have come to experience as similar to bread mold, expressed most densely overnight and in the am. So as I awaken today with NO flaking skin on my face, hairline, eyebrows, earlobes or neck, AND no facial flushing for the first time in 6 months, I am wondering whether there is any scientific value in my protocols, in my high dosing the IGG 2000, or that I am presently supplementing with only glycine and B6 until I complete some GI related labs early next week. Is the anti fungal veg glycerine topical beneficial or is all of this the result of finally getting through the TSW so my adrenals are starting to function again? Thank you for reading everyone, and Jen, hope this sharing is useful to the scientists who are diligently observing and trying to help us get relief from these tormenting skin symptoms. Blessings and thanks to you and all in the trenches helping us resolve these conditions and restore our lives.
Yeesh! This is good to know. (Here’s another case of let-the-consumer-beware.) I’d been thinking about trying Dupixent, but now I strongly believe that it’s not an answer for me. Almost 30 years ago a medical doctor claimed that sometimes the Food and Drug Administration had such a big backlog of new drugs awaiting their approval that instead of waiting till sufficient testing could be done, they would stamp their approval on some new ones and then, if they received enough complaints about severe adverse reactions from using any of these drugs, they would disapprove them and get them pulled from the market. Whether or not that is true, the Dupixent information you presented gives me pause. Thank you!
I was on Dupixent for about six months the last half of 2018 and stopped because of this reaction! At the time, my dermatologist was dismayed I wanted to stop treatment. I had already been experiencing some other mild side effects but this was intolerable. The itching, redness and hives came on after I ate anything and also whenever I was exposed to any scent. My skin was always dry and peeling no matter what I applied and with diet restrictions. I’ve since cleared up, but it took nearly a year. I’ll never know if it was malessezia hypersensitivity, but I’m really glad this info is coming out for anyone considering using it. Thank you!
I am currently dealing with this issue/adverse reaction and in researching today I found out about the connection to alcohol as I personally have had a strong reaction that I after just a few sips of red wine! Immediate flushing/burning/erythema! I read that there are other cases of this: https://www.mdedge.com/dermatology/article/244038/atopic-dermatitis/dupilumab-induced-facial-flushing-after-alcohol
I actually emailed in to both my dermatologist and allergist today and will be following up tomorrow based on what I’m finding out online. I hate that as a patient we have to take our health into our own hands. I also have a strong reaction when I drive or walk outside on a sunny day – burning and even on my ears. I’d rather deal with the eczema on my body.
So frustrating in particular if it doesn’t resolve quickly which is likely the case.
Personally I have a rosacea-like reaction as well and I’m allergic to propylene glycol so steroid creams are not an option but I use tacrolimus which is not helping like it used to for the regular eczema on my body and face prior.
It is quite disturbing…
Hi Mary Ann, you’re definitely not alone in noticing this issue. From my clinical experience, when someone reacts to alcohol in that way we suspect a histamine overload and/or fungal overgrowth. So it’s still relatively in line with what I’ve discussed in this article. I hope you were able to get some help from your derm.
Thank you for bringing this research to light. I am on Dupixent as well and this exact phenomenon has happened to me as well. I flare up in my face, neck, and upper chest with red, scaly skin and it can last for up to 1 week, then go away for a few days, only to come back again. I have also struggled with red inflamed eyes, but that side effect has become less over time. I was prescribed Ivermectin by my dermatologist after sharing a case report on facial redness I found online, but this has not really had an impact on the symptom. It seems my redness gets worse during the day as I eat and drink things, in particular it seems to get worse when I drink coffee. Additionally my head gets beet-red any time I drink just a drop of alcohol, which was also a side-effect that developed after starting Dupixent. I am getting close to calling it quits with Dupixent due to these persistent issues, but it does clear up all other parts of my body and does take away my systemic itch.
Hi Rune, typically when someone reacts like that to alcohol, we suspect a potential histamine issue or fungal overgrowth.
Hi Rune – Did you end up quitting Dupixent? How are your facial flares?
I got severe facial flares when starting Dupixent two years ago to treat full body involved severe atopic dermatitis and TSW. Dr. Treated flares with two mild prednisone tapers. Flares went away and have not come back. Mayindicate that some flares are not fungal related…I don’t know. But I DO know that Dupixent saved my life.
Hi Jeff, we obviously can’t say that it’s entirely a fungal issue and this podcast episode is not here to bash Dupixent, but this is a common side effect so at the time of the publication, I was sharing what was presently known from other doctors and case reports. As time goes on, we learn more about why side effects show up. I’m glad that Dupixent was helpful for you as it has been for other clients as well.
Great information here. I’ve been on Dupixent to clear up nasal polyps and constant congestion. I’ve been tested for environmental and food allergies, all of which were negative. Long story short, Dupixent seems to be the only thing that clears it up.
I was using Duplixent for about 6 months and noticed that I started getting flare-ups of eczema between my eyebrows and occasionally at the ridge between my nose and cheek. That moved into eczema/psoriasis on my scalp… bad lately.
All of these point to your information regarding a fungal infection. However, I have also started getting red patches on my knuckles, specifically my right hand. It does not itch or hurt; it just looks terrible.
I started rubbing castor oil, blackseed extract, and rose hip (my wife uses it nightly), which seemed to help flare-ups on my face. This does not seem to help the redness of my knuckles. I did not read anything in your article about knuckles, but I was wondering if that could also be a sign of a fungal infection.
Hi Jake, I’m not aware of any connection with rash issues on the knuckles and fungal overgrowth at this point in time. There are other locations where a rash COULD potentially point towards internal fungal overgrowth, but that is not one of the areas.
This is happening to me and I’ve been freaking out because I’ve tried every cream, stopped use of every makeup product and nothing helped – I have an appt next week (1 month in to dupixent) and I will definitely bring this in – thank you for the hope 🙂
Same thing here. Are you still on Dupixent? How is the facial flare?