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Paradoxical morphea-like reaction after initiation of dupilumab for nodular prurigo

Year: 2025

Type: article

Abstract: Paradoxical morphea-like reaction after initiation of dupilumab for nodular prurigo ଝ Dear Editor, Localized morphea, or localized scleroderma, is an autoimmune connective tissue disorder characterized by inflammation and sclerosis of the skin and sometimes deeper tissues.The pathophysiology is not fully understood, likely multifactorial, involving interactions among genetic factors, infections, medications, and immune pathway alterations that promote fibrosis.1 A 68-year-old male with a history of epithelioid hemangioma in the proximal right ulna presented with pruritic, excoriated erythematous-violaceous papules and plaques (Fig. 1).Histopathology revealed focal epidermal erosion accompanied by marked epidermal hyperplasia, hypergranulosis, and spongiosis, along with a perivascular and interstitial lymphocytic infiltrate in the superficial dermis; findings consistent with nodular prurigo (Fig. 2).Treatment with dupilumab was initiated with an initial dose of 600 mg, followed by 300 mg administered every two weeks.After six months of treatment, painful skin lesions appeared on the right elbow and trunk.Physical examination revealed an indurated, shiny brownish plaque extending from the midarm to the distal third of the forearm on the right upper limb, as well as several oval plaques on both flanks of the trunk (Fig. 3).The patient's blood count was normal, without eosinophilia, and autoimmunity and serology studies showed no abnormalities.Histopathology of the trunk lesion showed dermal changes, including edema, vascular ectasia, and progressive sclerosis extending into the subcutaneous tissue (Fig. 4).Additionally, a predominantly lymphohistiocytic inflammatory infiltrate was observed, along with perivascular and interstitial involvement.Immunohistochemical staining for CD34 revealed the loss of dermal dendritic cells (Fig. 2).

Source: Anais Brasileiros de Dermatologia

DOI: 10.1016/j.abd.2025.501193

Authors: José González Fernández, Mariano Ara Martín, Sergio García González, Sara Pilar Martínez Cisneros, Mar García García, Sonia de la Fuente Meira

Institutions: Universidad de Zaragoza, Hospital Clínico Universitario Lozano Blesa, Instituto de Investigación Sanitaria Aragón

Language: English

Topic: Systemic Sclerosis and Related Diseases

Subfield: Pathology and Forensic Medicine

Field: Medicine

Domain: Health Sciences

SDG: Good health and well-being

Open Access status: gold

Estimated APC paid: $1,700