Dupilumab-Treated Patients with Atopic Dermatitis at Increased Risk of Psoriasis

Individuals with atopic dermatitis being treated with dupilumab are at an increased risk of developing psoriasis, new findings suggest, compared to individuals receiving other systemic drugs.1

These data were the result of a recent analysis authored by a team of investigators, such as Teng-Li Lin, MD, from the department of dermatology at the Buddhist Tzu Chi Medical Foundation’s Dalin Tzu Chi Hospital in Taiwan. Lin and coauthors noted that prior research had shown that psoriasis is a concern among those with atopic dermatitis treated with dupilumab, a monoclonal antibody designed to target the interleukin (IL)–4 receptor α subunit.

The treatment has been extensively implemented in moderate to severe atopic dermatitis, but despite prior data indicating its safety, there have been several unexpected adverse events associated with clinical use.2,3 One of these is the development of psoriasis.

“This study aimed to investigate the risk of psoriasis in patients with [atopic dermatitis] who were treated with dupilumab, hypothesizing that dupilumab would be associated with an increased psoriasis risk compared with other systemic agents,” Lin et al wrote.1

The TriNetX Global Collaborative Network, a large-scale research platform that compiles de-identified patient health data from a variety of health care organizations (HCOs) around the world, was used for Lin et al's retrospective cohort analysis. TriNetX has, since the platform's inception in2014, allowed partnerships between academic institutions as well as industry stakeholders by giving increased access to longitudinal health information, spanning between 10 - 20 years.

The platform has also become a widely implemented as a resource for medical research. Its largest dataset, the Global Collaborative Network features an array of medical records covering approximately 153 million patients from 128 participating institutions across 17 countries. These data include diagnostic codes, demographics, clinical measurements, and medication usage.

In Lin and colleagues' assessment, they evaluated a population of 214,430 adults with an atopic dermatisis diagnosis. These trial subjects had been identified via the TriNetX Global dataset. During their analysis, the investigators compared 2 cohorts of subjects: those newly beginning dupilumab use and those who initiated treatment with other systemic therapies such as methotrexate, corticosteroids, cyclosporine, azathioprine, and mycophenolate mofetil. The latter group did not have prior exposure to dupilumab.

The investigative team sought to diminish the impact of confounding variables, so they performed 1:1 propensity score matching. In this process, they balanced different variables such as sex, age, race, current health conditions among subjects, prior medication utilization, and lab values. The team's primary outcome of interest was determined to be the development of new-onset psoriasis.

Lin and coauthors used Kaplan-Meier curves for the purposes of estimating cumulative incidence, and they used Cox proportional hazards models to evaluate participants' relative risk. After the process of matching, each arm of the study included 9,860 individuals. The combined sample was 55.2% female and these individuals had a mean age of 44.8 years.

The participants were 18.2% Black or African American, 10.2% Asian, and 50.2% White. Within a three-year follow-up period, the investigators found that cumulative incidence of psoriasis had been higher among the subjects treated with dupilumab versus those given other systemic therapies (2.86% versus 1.79%, P < .001).1

The team found that the number needed to harm (NNH) for psoriasis with dupilumab was calculated at 94. The hazard ratio (HR) for psoriasis development in the dupilumab arm of the study was shown to be 1.58 (95% confidence interval [CI], 1.25–1.99), which they added would suggest a significantly increased risk. However, they did not identify a statistically significant difference for the development of psoriatic arthritis (HR, 1.97; 95% CI, 0.75–5.18).

This elevated risk of psoriasis was noted as having persisted across subgroups, including those with low baseline serum immunoglobulin E (IgE) levels—defined as less than 0.048 mg/dL (to convert to mg/L, multiply by 10)—and those without other allergic comorbidities (HR, 1.42; 95% CI, 1.06–1.89), with an HR of 1.59 (95% CI, 1.26–2.01). Lin et al found that their additional validation among those with asthma but without atopic dermatitis confirmed a similar link between dupilumab implementation and new-onset psoriasis (HR, 2.13; 95% CI, 1.38–3.31).

“This cohort study found that patients with [atopic dermatitis] receiving treatment with dupilumab had an increased psoriasis risk compared with those receiving other systemic agents,” the investigators concluded.1 “Despite the increased relative risk, an estimated NNH of 94 reflected the limited clinical relevance of the absolute risk. This risk should be weighed against dupilumab’s proven efficacy in treating [atopic dermatitis].”

References

1. Lin T, Fan Y, Wu C, et al. Psoriasis Risk in Patients With Atopic Dermatitis Treated With Dupilumab. JAMA Dermatol. Published online June 18, 2025. doi:10.1001/jamadermatol.2025.1578.

2. Hasan I, Parsons L, Zinn Z, et al. Dupilumab therapy for atopic dermatitis is associated with increased risk of cutaneous T cell lymphoma: a retrospective cohort study. J Am Acad Dermatol. 2024;91(2):255-258. doi:10.1016/j.jaad.2024.03.039.

3. Jo CE, Finstad A, Drucker AM, et al. Facial and neck erythema associated with dupilumab treatment: a systematic review. J Am Acad Dermatol. 2021;84(5):1339-1347. doi:10.1016/j.jaad.2021.01.012.