Onychodystrophy associated with dupilumab therapy for atopic
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A woman in her 60s with a history of severe atopic dermatitis for more than 40 years was started on dupilumab therapy. Prior to starting dupilumab, she had extensive involvement of eczematous plaques on the head, neck, chest, back, legs and arms, including hands. There was mild nail involvement with chronic paronychia of bilateral thumbnails. Three months after starting dupilumab, she reported dramatic improvement of her eczematous plaques in addition to new severe nail changes.

On physical exam of the bilateral thumbnails, there was hyperkeratosis of the nail bed and hyponychium, scaling of the lateral nail folds and eponychium with loss of adhesion of the cuticle to the nail plate, and bilateral distal and lateral onycholysis. The remaining fingernails and toenails had no changes. On the right thumbnail, koilonychia, onychorrhexis and irregular longitudinal nail plate fracturing were observed. The left nail plate exhibited multiple horizontal depressions consistent with Beau’s lines, a proximal median longitudinal groove and a mid-nail transverse split. Fungal culture from nail plate and periungual skin was negative.

Patient reported during discussions in a private group chat on a social media platform composed of patients with AD on dupilumab, that other patients also had similar nail findings. Despite nail changes, she continued dupilumab therapy 300 mg every 14 days given improvement of AD. Three months later, her nails had dramatically improved with residual longitudinal ridging, improving distal nail dystrophy and less prominent horizontal ridging. At her follow up visit, 15 months since starting dupilumab for AD, her nails had significant improvement with very mild changes including chronic paronychia with transverse ridges, longitudinal ridging and nail pits.

Source: https://www.jaadcasereports.org/article/S2352-5126(20)30765-7/fulltext?rss=yes