PA20 Case series: effectiveness and safety of dupilumab for liver transplant recipients in paediatric patients with eczema

Abstract An eruptive eczematous eruption after oral tacrolimus use has been described. Histology shows eczema (with lymphocyte and eosinophils), which is thought to be secondary to an immune switch due to selective T helper 1 blockage. This type of eczema is highly symptomatic. We report a case series of four patients (aged 4–13 years, mean 8) with a background of liver transplantation, treated successfully with dupilumab for their new-onset eczema. Case 1 is a 4-year-old boy who had a partial matched liver transplant at age 3 months and began oral tacrolimus. Nine months later he had an extremely itchy scaly eruption on the torso, abdomen and hands that did not respond to superpotent topical steroids. Skin biopsy showed spongiosis only. The Eczema Area and Severity Index (EASI) score was 31 and his IgE was 26 000 kU L−1. Dupilumab was initiated at age 3 years. Six months later the EASI had markedly improved to 10 and the quality-of-life markers had improved dramatically. IgE had reduced to 264 kU L−1. Case 2 is a 7-year-old girl with severe hand and foot eczema, refractory to topical steroids. She had a maternal partial liver transplant secondary to biliary atresia and portal vein thrombosis at 1 year. Oral tacrolimus was started at the time of transplant. Five years later she had extremely symptomatic eczema, and dupilumab treatment was initiated with an improvement in the itch within 4 months. Case 3 is a 13-year-old boy with a liver transplantation secondary to giant cell hepatitis. He was immunosuppressed with mycophenolate mofetil and oral tacrolimus from age 2 years. Dupilumab was initiated and he has been on treatment for the past 2 years with no reported side-effects. His EASI score has improved from 24 to 5. Case 4 is a 7-year-old boy with skin type VI with a liver transplant age 1 year for biliary atresia and secondary portal hypertension, and a history of immune thrombocytopenia needing intravenous immunoglobulin and rituximab. The patient has been on oral tacrolimus. Around 2–3 years later he began developing perianal eczema, which then progressed to a more typical presentation affecting the popliteal and antecubital fossae. He also had multiple episodes of infections and 5 years later he began dupilumab (EASI 34). Nine months on his EASI is 5 and he is much happier. Our case series highlights that, in line with other case series, dupilumab is a safe and effective treatment. Our cohort of paediatric patients with severe eczema had liver transplantations and thus had no live vaccines throughout childhood. We report no side-effect sequelae at present.