D2.362 - Dual biological therapy with dupilumab and ixekizumab in a patient with asthma, nasal polyposis, atopic dermatitis and psoriasis

Introduction: Observational studies have supported both coexistence and mutual exclusivity of atopic  dermatitis (AD), a Th 2 disease  and psoriasis, a Th1/Th17 disease. Rarely, patients may present with both of these systemic inflammatory diseases. Additionally there are reports of psoriasis occurring in patients with AD receiving a biological treatment and vice versa patients with paradoxical eczema after biological treatment for psoriasis. Dual biologic therapy targeting both pathways of inflammation is infrequently described, although there are rare reports with promising results.

Purpose: We report a patient with severe asthma with nasal polyposis and psoriasis who presented severe atopic dermatitis while he was on treatment with ixekizumab  and omalizumab.

Background: A 57 year old man was diagnosed with eosinophilic asthma and nasal polyposis in 2004.Due to the increased severity of his respiratory symptoms the patient started treatment with omalizumab in March 2015 with a favorable response. On November 2021 he developed clearly defined, red and scaly plaques and was diagnosed with severe plaque psoriasis. He started treatment with apremilast with initial  remission. Two years later, on 2nd of October 2023, his psoriasis became refractory to apremilast and his treatment changed to ixekizumab. The patient was asymptomatic but in March 2024 he developed diffuse erythema, xerosis, papules, papulovesicles, edema, crusting, scaling and severe pruritus.   

Methods: A biopsy was perfomed which showed spongiosis, acanthosis and parakeratosis and AD was diagnosed. In order to control both his respiratory disease and AD it was decided to replace omalizumab with dupilumab while ixekizumab was continued. The patient’s AD  responded quickly while his asthma, nasal polyposis and psoriasis remained well controlled. One year into the treatment with the combination  of dupilumab and ixekizumab the patient remains asymptomatic. No adverse events have been occurred during this observation period .

Conclusion:  Severe psoriasis and severe AD can rarely co-exist in the same patient and the treatment of both conditions can be a therapeutic challenge to the clinician.In these patients dual biological therapy targeting different inflammatory pathways should be considered. Larger studies are needed to further evaluate  the efficacy and safety of dual biologic therapy.