Bridging the gap: Treatment of atopic dermatitis with dupilumab during pregnancy

In this issue of the JEADV, two papers address a previously unmet need—providing evidence for the use of dupilumab in the treatment of atopic dermatitis (AD) during pregnancy.

Atopic dermatitis affects individuals of all ages and sexes and persists into adulthood in approximately 5–10% of cases. These cases often require active treatment in women of childbearing potential and during pregnancy.¹ However, women with moderate to severe AD—or with other conditions requiring systemic treatment—have frequently been left in a therapeutic limbo. Due to limited safety data, physicians often advise stopping systemic treatment before and during pregnancy to avoid any risk to the fetus.

In 2019, the European Task Force on Atopic Dermatitis published a position statement on treating conceiving, pregnant and lactating women with AD.² At that time, there was a significant lack of evidence regarding both topical and systemic treatments during pregnancy. Most recommendations for systemic immunosuppressants were extrapolated from data on other patient populations, particularly organ transplant recipients and women with connective tissue diseases. Notably, there was no available evidence on the safety of dupilumab use in pregnant AD patients. Since then, several Delphi exercises have attempted to refine these guidelines, though consensus has generally been limited to treatments already in use—most notably, cyclosporine.³

In the first paper, Preuss et al.⁴ utilize the US-based collaborative network TriNetX, which provides real-time access to up to 110 million electronic health records.⁴ From this vast dataset, they identified 293 women who had been exposed to dupilumab during pregnancy. Remarkably, the study found no increased risk of adverse pregnancy outcomes. In fact, the data suggested a reduced risk of preterm labour among dupilumab-exposed women.

The second paper, by S. Gregoriou et al.⁵ presents a systematic review of published case reports involving dupilumab use during pregnancy.⁵ The authors identified 14 publications, encompassing 61 pregnancies and 2 cases of breastfeeding. While 28 of the women discontinued dupilumab upon learning they were pregnant, fetal exposure had already occurred during some of the most critical periods of gestation. Even so, the study reported no adverse pregnancy outcomes among the cases reviewed.

Together, these two studies offer reassuring evidence for dermatologists managing moderate to severe AD in pregnant patients. The findings suggest that dupilumab does not increase the risk of adverse pregnancy outcomes and may even offer some benefits. Based on the data presented in this issue of the JEADV, it may be reasonable to consider continuing dupilumab in selected patients with moderate to severe, uncontrolled AD—especially when associated with comorbidities such as asthma—who become pregnant.

Christian Vestergaard has served on advisory boards/received honoraria/received grants from Pfizer, Novartis, LEO Pharma, Abbvie, Sanofi, MSD and Pierre Fabre; Mette Deleuran has served on advisory boards/received honoraria/received grants from Pfizer, Novartis, LEO Pharma, Abbvie, Sanofi, MSD, Almirall, Pierre Fabre, Kymab, Numab, Eli Lily, Regeneron, Union Therapeutics and Incyte. Mette Deleuran has received research support, travel support, honoraria for lecturing and/or consulting/advisory board agreements from AbbVie, Eli Lilly, LEO Pharma, Incyte, La Roche Posay, NUMAB Therapeutics AG, Pierre Fabre, Pfizer, Regeneron Pharmaceuticals, Inc., Sanofi Genzyme, Union Therapeutics, Mustela, Almirall and Kymab.