A recent case highlights the challenges and potential solutions for managing conjunctivitis caused by biologic treatments in patients with atopic dermatitis (AD). AD is a chronic inflammatory skin disease marked by severe itching and eczema. It involves a mix of factors, including genetics, immune system imbalances, skin barrier problems, and changes in the skin’s microbiome. Key immune signals called Th2 cytokines, such as interleukin-4, -13, and -31, drive inflammation and itching in the disease. New biologic drugs targeting these cytokines, including dupilumab, lebrikizumab, and tralokinumab, have shown promise in treating moderate to severe AD. However, conjunctivitis—an inflammation of the eye’s conjunctiva—has emerged as a common side effect, affecting about 10% of patients, sometimes severe enough to disrupt treatment.
In a detailed report, a 50-year-old man with long-term AD was successfully treated with lebrikizumab after other therapies, including topical corticosteroids and the oral JAK inhibitor upadacitinib, provided incomplete relief. The patient’s skin symptoms and intense itching significantly improved under lebrikizumab, but about a month into the treatment, he developed severe eye redness and itching diagnosed as conjunctivitis. Standard treatments using artificial tears, antihistamine eye drops, and corticosteroids failed to improve his symptoms over two months.
Faced with worsening conjunctivitis, doctors switched his eye treatment to tacrolimus ophthalmic suspension, an immunosuppressive eye drop not officially approved for conjunctivitis but used for similar allergic eye conditions. Remarkably, the patient’s eye inflammation and discomfort resolved within three weeks, allowing him to continue lebrikizumab therapy and maintain good control over his AD symptoms.
The exact reasons why biologics cause conjunctivitis are not fully understood. One theory suggests that blocking IL-4 and IL-13 may increase activity of molecules like OX40L, contributing to allergic eye inflammation. Other possible factors include transient increases in eosinophils—immune cells involved in allergies—and reduced tear production caused by altered immune signaling. While typical treatments involve artificial tears, antihistamines, and mild corticosteroids like fluorometholone, some cases prove resistant, requiring stronger immunosuppressive eye drops such as tacrolimus or cyclosporine. These medications, while off-label for conjunctivitis, have shown success in similar conditions and in managing biologic-induced conjunctivitis unresponsive to conventional therapy.
This case underscores the importance of close collaboration between dermatologists and ophthalmologists when treating patients on biologics who develop eye symptoms. Effective management of conjunctivitis may allow patients to continue life-changing biologic therapies without interruption. It also points to the need for more research into the safety and effectiveness of immunosuppressive eye drops for this purpose.
Overall, biologic therapies like lebrikizumab represent a significant advance in treating atopic dermatitis. However, managing side effects such as conjunctivitis remains a clinical challenge. This report offers hope that with appropriate ophthalmic care, patients can maintain their treatment and quality of life while minimizing eye complications. Further studies are essential to develop clear guidelines and optimize treatment strategies for biologic-associated conjunctivitis in AD patients.
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