What can I do to treat scalp eczema during a flare?
Published On: Dec 7, 2020
Last Updated On: Jun 23, 2021
In this edition of Ask the Ecz-perts, dermatologists Peter Lio, MD, and Amy Paller, MD, answer your questions about biologics.
Lio is assistant professor of clinical dermatology and pediatrics dermatology at Northwestern University Feinberg School of Medicine and the founding director of the Chicago Integrative Eczema Center.
Paller is chair of the department of dermatology at Northwestern University Feinberg School of Medicine and a pediatric dermatologist at the Ann and Robert H. Lurie Children’s Hospital of Chicago.
About 75% of my patients get at least 75% better (easy to remember!). That still leaves a quarter who are not where they need to be. Most stay on dupilumab (Dupixent) for at least six months; some longer. But if they are doing great (clear or just about totally clear and not needing much topical therapy), we talk about taking a holiday and seeing how things go.
It’s so good to hear that things are going well. It is a little tricky to figure out how to come off. I have usually been going to monthly dosing for a few months and then stopping. It may be even better to just stop when it is time, though it is hard to know. If your doctor is interested, they can read my paper here which has some of the direct data I was referencing.
Eczema and asthma are both TH2 type inflammatory conditions. They often do run together and have a lot in common — so much so that Dupilumab works for both of them and has FDA approval for both conditions.
Honest to goodness, we have not seen this. That, of course, does not mean it is impossible or doesn’t happen, but I’m very happy to say that most people do not seem to suffer withdraws at all. In fact, there tends to be a relative remission state afterward.
If you are referring to required vaccinations before traveling, live vaccines should not be used while on dupilumab (Dupixent), as they have not been studied. This is something you’d want to discuss with the travel clinic or the administering physician. More information on that can be found here.
I think the belly is the best area in general, but it is certainly worth it to try the thigh. Some patients prefer that. I also think that there are a few things to help mitigate the pain:
1. Use a cold pack to the skin for a bit before the shot.
2. Make sure the dupilumab is warmed up to room temperature.
3. If you can use a “buzzy,” that helps as well.
This is an important line of questioning that everyone is starting to explore in the research community now. I think the safest answer is that we don’t yet know how things will fit together, but it does seem that some JAK inhibitors are even more powerful than even dupilumab against inflammation. An awesome comparison can be found here.
Peter Lio, MD, assistant professor of clinical dermatology and pediatrics dermatology at Northwestern University Feinberg School of Medicine and founding director of the Chicago Integrative Eczema Center
Theoretically, there is no increased risk of COVID-19 while on Dupixent. It works by suppressing a very specific arm of the immune system called TH2, which is only known to be helpful in handling parasite infection. We know of no issue in handling viral infections. As such, it may be the safest “systemic”/non-topical medicine out there during this pandemic.
That would be amazing, but the chemical structure of Dupixent is that of a monoclonal antibody. These are very large and are dissolved internally when we swallow them, so they can’t be made topical or given in pill form.
We don’t have enough long-term data to understand if some people on Dupixent will have long-term benefits that continue after they go off the drug. Some flare quickly after stopping, while others can be off the drug for months and continue to do well.
We have no way to predict this, and since most patients on Dupixent have a long history of more severe eczema, we largely encourage people who are responding to Dupixent to stay on the medication. It will be interesting when we have more experience in children to see if Dupixent can modify the history of the eczema (that is, possibly cure it) or the risk of developing allergic conditions like asthma or hay fever if given much earlier in life before it becomes chronic.
Amy Paller, MD, chair of the department of dermatology at Northwestern University Feinberg School of Medicine and pediatric dermatologist at the Ann and Robert H. Lurie Children’s Hospital of Chicago