No evidence of increased risk for Coronavirus Disease 2019 (COVID‐19) in patients treated with Dupilumab for atopic dermatitis in a high‐epidemic area – Bergamo, Lombardy, Italy

Dear editor,

Atopic dermatitis (AD) is a chronic inflammatory skin disease. Patients with AD have increased infection risk, including skin infections and systemic infections. Dupilumab, a fully human monoclonal antibody, blocks the shared receptor component for interleukin‐4 (IL‐4) and IL‐13. Dupilumab is approved for inadequately controlled moderate‐to‐severe AD. ¹

A meta‐analysis recently investigated the risk of infection in atopic dermatitis patients receiving Dupilumab. This analysis pooled data from seven randomized, placebo‐controlled Dupilumab trials in adults with moderate‐to‐severe AD. Dupilumab is associated with reduced risk of severe infections and non‐herpetic skin infections and does not increase overall infection rates vs. placebo in patients with moderate‐to‐severe AD. ²

A severe outbreak of coronavirus disease 2019 (COVID‐19) emerged in China in December 2019 and then rapidly spread worldwide. The number of people with COVID‐19 is now dramatically increasing in Italy, and, to date, it remains a severe urgent public health emergency. ³ The first documented case in our hospital (ASST Papa Giovanni XXIII, Bergamo Hospital) was identified on 21 February 2020. ⁴

These days there is a significant amount of curiosity regarding the cutaneous manifestations COVID‐19 related ⁵ and the implications that this infection could bring in about clinical dermatology practice and to patients in therapy. ⁶ , ⁷

We have decided to advise patients treated with biological drugs to scrupulously comply with hygiene rules and protective devices use, to avoid crowded places, to maintain social distancing and not to spontaneously suspend ongoing therapy but to inform the dermatologist in case of the onset of symptoms as suggested by the Italian Society of Dermatologists (SIDeMaST) ⁸ and by the European Task Force on Atopic Dermatitis (ETFAD). ⁹ We report below our experience with patients treated with biological therapy for atopic dermatitis in Bergamo, an area of high epidemic for COVID‐19.

Our patients being treated with Dupilumab are residents in the provinces of Bergamo (n = 25, 86.6%), Lecco (n = 2, 6.7%), Brescia (n = 1, 3.3%), Monza‐Brianza (n = 1, 3.3%), Sondrio (n = 1, 3.3%), Lombardy areas with a high incidence of COVID‐19 infections. ¹⁰

All patients (n = 30, 20 males, 10 females, mean age 35.5 ± 11.9 years, range 19–54 years) were contacted by telephone or underwent a dermatological visit to the hospital, 40–45 days after the beginning of the spread of the coronavirus infection in the Bergamo area. None of the patients reported a coronavirus infection confirmed with nasal swab or serological tests. None of the patients reported contacting established cases (positive nasal swab test) of COVID‐19 patients. None of the patients reported coming into contact with suspected, but not established, cases of COVID‐19. No patient reported serious symptoms that required hospitalization. One patient (3.3%) reported mild respiratory flu‐like symptoms resolved in 5 days. None of the patients developed or reported a worsening of the cutaneous clinical condition.

Based on our experience, we observed that it is essential to advise and empower patients on activities to limit the risk of infection (hand hygiene, social distancing, use of protective devices), to report any symptoms to the dermatologist. Fortunately, no cases of COVID‐19 in Dupilumab patients have been observed despite the high risk of contagion area.

The mechanism of action of the drug, the average age of the patients and the data of the randomized studies seem to reassure about the COVID‐19 infectious risk that patients on Dupilumab therapy may have. Further observations on a larger number of patients receiving Dupilumab are needed to investigate the risk of coronavirus infection.