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To the Editor, Introduction Dupilumab is a fully human monoclonal antibody against the α subunit of the interleukin (IL)-4 receptor (IL-4Rα), and inhibits IL-4 and IL-13 signalling pathways. These pathways are involved in B-cell differentiation, immunoglobulin (Ig) E production, and a Th-2dominant immune response [1]. IL-4 and IL-13 are important drivers of various atopic or allergic diseases, such as atopic dermatitis (AD) [2, 3]. Dupilumab has demonstrated efficacy and safety against multiple Th-2type inflammatory diseases including AD [1–3], asthma [4], chronic rhinosinusitis with nasal polyps [5] and eosinophilic oesophagitis [6] in clinical trials, and has recently been used for AD, asthma, and chronic rhinosinusitis with nasal polyposis when existing treatments fail [7]. Adverse effects of dupilumab have been noted to include pathologies of the ocular surface, including conjunctivitis, blepharitis, keratitis, eye pruritus, dry eye, nasopharyngitis, upper respiratory tract infection, herpes simplex virus, exacerbation of AD, injection-site infection, facial redness, alopecia, and arthralgia [8, 9]. Biologic therapies such as dupilumab inhibit certain cytokines and suppress inflammation of the target organs, but often paradoxically induce or enhance inflammation in other organs. These phenomena are called “paradoxical reactions” [10]. Head and neck erythema have been reported as paradoxical reactions after dupilumab therapy for AD [11]. Histological examination of skin biopsies of such erythema have revealed a psoriasiform reaction pattern suggestive of a drug-induced skin reaction [11]. The frequency of conjunctivitis in clinical trials of dupilumab and in real-world data from a systematic review and meta-analysis have been reported as 8.6–22.1% and 26.1%, respectively [8, 9]. This report presents a case of allergic conjunctivitis associated with eosinophilia as paradoxical reactions induced by dupilumab therapy for AD.

Serum IgE reduction and paradoxical eosinophilia associated with allergic conjunctivitis after dupilumab therapy