Disseminated nummular eczema following nivolumab treatment: Successful management with dupilumab

An 80-year-old man, without allergies, developed widespread eczema presenting as coin-shaped plaques with severe itching (Figure 1). Nivolumab was prescribed for clear cell renal carcinoma with sternal metastasis. After completing therapy at 2 years, skin lesions appeared few days later. Initial treatments failed, including topical steroids as betamethasone and clobetasol, doxycycline, cetirizine, and tacrolimus. Biopsy confirmed eczematous dermatitis. The total count of serum eosinophils was 0.66 × 10^3/µL (0−0.5 × 10^3/µL), considering a grade 3 immune-related adverse event. Intense pruritus persisted. Dupilumab, started 8 months after eczema onset and combined with tacrolimus cream for 1 year, resulted in significant improvement with minimal lesions and normal eosinophil counts (Figure 2), after which it was discontinued. Under oncology surveillance, the patient achieved a 58% partial tumor response, with no recurrence of his skin condition.

Nivolumab can lead to cutaneous immune-related adverse events (cirAEs)¹ and 41% are eczematous reactions.² Dupilumab, an IL-4a receptor antagonist, is a novel option for various cirAEs, including eczema resistant to conventional drugs,^{3, 4} with a response rate of 44.1% attributed to reduced Th2-axis activation.²

Elevated eosinophils correlate with the severity of cirAEs.² This case highlights the efficacy of dupilumab in treating nummular eczema as a cirAE, as seen in other conditions such as nivolumab-induced bullous pemphigoid.⁵

Betzabé Quiles Martínez: Literature review, manuscript writing and patient follow-up. Judith G. Domínguez Cherit: Final manuscript review and patient follow-up. Ángela Rosales Sotomayor: Literature review and initial patient assessment. Andrea Malagón Liceaga: Literature review and manuscript writing. Jorge Gonzalez Torres: Literature review and manuscript writing.

The authors declare no conflict of interest.

All patients in this manuscript have given written informed consent for participation in the study and the use of their deidentified, anonymized, aggregated data and their case details (including photographs) for publication. Ethical Approval: not applicable.