BG07 Usage of dupilumab treatment in generalized bullous pemphigoid in two older Asian patients with favourable outcomes

Abstract Bullous pemphigoid (BP) is an autoimmune blistering disease typically seen in older patients. These patients generally present with preexisting multiple comorbidities and pharmacotherapy, which pose treatment challenges. This report presents two cases of older East Asian patients with bullous pemphigoid treated using dupilumab with complete clinical remission after 6–8 weeks of treatment. A 79-year-old man presented with a 7-month history of generalized itchy red rashes without mucosal involvement. The indirect immunofluorescence study showed positive findings of a split-skin roof pattern and a titre > 1 : 160. Based on these findings, the diagnosis was consistent with a presentation of BP. He developed gastritis after initially taking oral prednisolone 20 mg per day. Nonsteroidal immunosuppressive treatment options were also discussed. Dupilumab treatment was initiated as the patient refused regular blood test monitoring. Complete clinical remission was achieved after 6 weeks of dupilumab. The second case is an 80-year-old woman who presented with a 1-year history of progressively worsening lower-limb blisters. Other significant medical history included osteoporosis, parkinsonism, past cerebrovascular events that left her wheelchair bound, congestive cardiac failure and multiple drug therapy. Due to her comorbidities and multiple pharmacotherapies, she was initiated on dupilumab. She achieved clinical remission after 8 weeks. Neither patient reported adverse events during the course of treatment. Dupilumab has become a consideration in the treatment of BP, especially in cases with multiple comorbidities like those involved in this case report. Dupilumab is a human IgG4 monoclonal antibody that targets interleukin 4 receptor α, causing reduced interleukin 4 and interleukin 13 signalling in T helper 2-type responses. Given that both cytokines are involved in the pathogenesis of BP, including eosinophil recruitment and anti-BP180 antibody production, dupilumab may a good alternative for patients who have experienced adverse events from other therapies. Based on previous studies, the recommended dosage was 600 mg initially, then 300 mg fortnightly. Both patients of East Asian descent responded favourably to the treatment and were able to achieve remission within 8 weeks, which reflected a satisfactory outcome from dupilumab treatment, especially with the absence of adverse events. As a result, dupilumab could be a welcome option in treatment of BP, especially as the typical patient with BP is older and may have multiple existing comorbidities or a preexisting immunocompromised state.