Journal of Dermatology & Dermatologic Surgery

CASE REPORT
Year
: 2022  |  Volume : 26  |  Issue : 3  |  Page : 3--4

Successful use of dupilumab for treatment-resistant pityriasis amiantacea


Maya Firsowicz, Tyler J Willenbrink, Nova Shu, Jason S Reichenberg 
 Division of Dermatology, Dell Medical School, Austin, TX, USA

Correspondence Address:
Dr. Maya Firsowicz
Health Transformation Building, 1601 Trinity St Building A, Austin, TX 78712
USA

Abstract

Pityriasis amiantacea (PA) is a scalp condition characterized by thick, adherent scales that are silvery or yellow–gray in color and bind down tufts of hair. PA is associated with several underlying dermatologic conditions including psoriasis, seborrheic dermatitis, atopic dermatitis, tinea capitis, pityriasis rosea, and Darier's disease. Although there is no consensus on standard treatment, PA is generally treated with keratolytic agents and/or ketoconazole shampoo. More resistant cases may require systemic therapies, including tumor necrosis factor-alpha inhibitors. We report a case of a 57-year-old female with severe PA resistant to numerous treatments including topical steroids, salicylic acid shampoo, intralesional steroid injections, mycophenolate mofetil, adalimumab, and apremilast. Following treatment with dupilumab, our patient experienced complete resolution of her PA. These results suggest that dupilumab may have in a role in the management of treatment-resistant PA, particularly when associated with eczematous dermatitis.



How to cite this article:
Firsowicz M, Willenbrink TJ, Shu N, Reichenberg JS. Successful use of dupilumab for treatment-resistant pityriasis amiantacea.J Dermatol Dermatol Surg 2022;26:3-4


How to cite this URL:
Firsowicz M, Willenbrink TJ, Shu N, Reichenberg JS. Successful use of dupilumab for treatment-resistant pityriasis amiantacea. J Dermatol Dermatol Surg [serial online] 2022 [cited 2022 Dec 8 ];26:3-4
Available from: https://www.jddsjournal.org/text.asp?2022/26/3/3/354303


Full Text

 Introduction



Pityriasis amiantacea (PA) is associated with several underlying dermatologic conditions including psoriasis, seborrheic dermatitis, atopic dermatitis, and tinea capitis. Although there is no consensus on standard treatment, keratolytic agents and/or ketoconazole shampoo are often used. More resistant cases may require systemic therapies, including tumor necrosis factor-alpha inhibitors, which has been previously described. This study describes the novel case of a 57-year-old female with PA who responded to treatment with dupilumab.

 Case Report



A 57-year-old female presented to our clinic with thick, adherent scale on the scalp, clinically consistent with PA. Biopsy from a representative area of the scalp demonstrated spongiosis, acanthosis, and hyperkeratosis with focal parakeratosis, compatible with an eczematous eruption. The patient also had psoriasiform plaques on the gluteal cleft and eczematous plaques on the extremities, suggesting an overlap of psoriasis and an eczematous dermatitis. A fungal culture of the scalp was unremarkable. Patch testing was performed and showed a 1 +reaction to glutaraldehyde and Methylchloroisothiazolinone (MCI) and methylisothiazolinone (MI).

The patient was treated with topical steroids, salicylic acid shampoo, mycophenolate mofetil, adalimumab, apremilast, and strict avoidance of contact allergens. Her condition failed to improve on this regimen, and she later developed nonscarring alopecia within areas of PA. Although her hair loss improved with intralesional triamcinolone injections and excimer laser, the scaling on her scalp and body continued to progress.

Given the recalcitrant PA and the persistent, scaling plaques on the body, the patient was started on dupilumab 300 mg every other week. At 3 months, she began to see scalp improvement, and by 6 months, she had >75% scalp clearance. At 12-month follow-up, the patient had complete clearance of her PA, as well as resolution of the eruption on her body.

 Discussion



PA is a scalp condition characterized by thick, adherent scales that are often silvery or yellow–gray in color and bind down tufts of hair.[1],[2] PA is associated with several underlying dermatologic conditions including psoriasis, seborrheic dermatitis, atopic dermatitis, tinea capitis, pityriasis rosea, and Darier's disease.[1],[3],[4] Staphylococcus aureus has been isolated from scalp samples of PA at a significantly higher frequency compared to unaffected scalp, suggesting a possible role in the pathogenesis. Nonscarring alopecia often occurs in areas of involved scalp,[2] although cases of scarring alopecia have been reported.[5] Some studies have demonstrated a slight female predominance of PA[2] with an age range of 5–49 years.[6]

The diagnosis of PA is primarily clinical, but identification of the underlying cause often requires histopathologic, bacterial, and mycologic examinations. Histologic examination often shows eczematous changes with parakeratosis and lymphocyte migration into the epidermis.[1],[2] Although there is no consensus regarding the standard treatment regimen for PA, keratolytic agents and/or ketoconazole shampoo often provide improvement.[1],[5] More resistant cases may require systemic therapies, including tumor necrosis factor-alpha inhibitors.[7]

Our patient presented with PA secondary to a suspected overlap of psoriasis and an eczematous dermatitis. While resistant to multiple systemic biologic agents, the patient's PA cleared over the course of 1 year with dupilumab. Dupilumab has emerged as an effective treatment for atopic dermatitis and has also been used off-label for numerous other conditions, including chronic pruritus, allergic contact dermatitis, alopecia areata, and urticaria.[8] The response of this patient's condition to dupilumab in the clinical setting of both psoriasis and an eczematous dermatitis underscores the therapeutic benefit dupilumab may have in PA.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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