Therapy with lebrikizumab for refractory peristomal irritant contact dermatitis

Dear Editors, Peristomal cutaneous complications occur in nearly two-thirds of all patients following stoma surgery and represent a frequent postoperative challenge.1, 2 From a dermatological perspective, these lesions are most commonly classified as peristomal irritant contact dermatitis (ICD), an umbrella term for all external irritations, which will also be used hereinafter. More specifically, they are moisture-associated skin damage.3 When peristomal ICD leads to leakage of the stoma appliance, the patient's quality of life may be profoundly affected, as routine daily activities become severely restricted.4 A 57-year-old female patient presented to our dermatology outpatient clinic with a peristomal skin disorder, persisting refractory for over a year, following a history of bladder cancer and postoperative placement of a urostomy after surgical intervention, chemotherapy, and radiotherapy five years prior. For the first four years, she tolerated the ostomy appliance without complications. Over the past year, however, she had developed ongoing, painful, and pruritic ICD severely impairing her quality of life, as reflected by a Dermatology Life Quality Index score of 30. Multiple ostomy systems were tried in cooperation with stoma care specialists, and urological consultations were obtained to evaluate alternative urinary diversion methods. External dermatological assessments and patch testing using the “German Standard” and “Rubber Series” revealed no positive reactions at the final 72-hour reading. Based on clinical findings, a diagnosis of peristomal ICD was established. This represents a non-allergic inflammatory skin response caused by direct chemical or mechanical irritation leading to disruption of the epidermal barrier. Various topical therapies, including corticosteroid-containing preparations, were administered without sustained success. Upon detection of yeast colonization, a compounded ointment containing mometasone, urea, and clotrimazole was prescribed. However, the major challenge associated with all topical treatments was reduced adherence of the ostomy appliance, resulting in leakage, further irritation caused by urine, and recurrent dermatitis. A prior course of systemic prednisolone (20 mg/day, tapered over three weeks) administered six months earlier had led to complete, but only temporary, remission; symptoms recurred immediately upon discontinuation. Due to persistent pain and incontinence, the patient's quality of life was profoundly impaired, preventing participation in daily and occupational activities. There were no indications of atopic conditions in either the patient's medical history or that of her first-degree relatives. Dermatological examination revealed generalized xerosis cutis without additional signs of atopic diathesis. A sharply demarcated eczematous plaque with partially exudative erosions was observed on the right abdominal region surrounding the urostomy site (Figure 1). Given the chronic course and resistance to conventional therapies, off-label systemic treatment with the IL-13 inhibitor lebrikizumab was initiated after obtaining informed consent and providing detailed oral and written information. The drug exerts its effect by inhibiting interleukin-13 (IL-13), a pivotal cytokine in skin inflammation, thereby reducing pruritus and erythematous lesions5. Lebrikizumab was administered at a dose of 500 mg subcutaneously at baseline and at week 2, followed by 250 mg subcutaneously every two weeks. No additional interventions, modifications in stoma care, or lifestyle changes were implemented during this period. Following the first injection, pain and pruritus markedly improved. After four weeks, the peristomal ICD had completely resolved, with restoration of continence and reliable adherence of the urostomy device (Figure 2). No adverse effects were observed, and laboratory findings remained within normal limits. Peristomal ICD often presents a major therapeutic challenge for both patients and clinicians, as exposure to the irritant factor cannot be fully avoided, and standard treatments frequently exacerbate the underlying skin condition. In the present case, a patient with therapy-refractory peristomal ICD achieved complete remission under systemic treatment with the IL-13 inhibitor lebrikizumab, representing, to our knowledge, the first reported case of its kind. This observation is noteworthy not only in terms of expanding potential therapeutic strategies but also for providing novel insights into the underlying pathomechanisms of ICD. Interleukin-13 is a pleiotropic cytokine that plays a pivotal role in the Th2-mediated immune response. It is critically involved in the pathogenesis of allergic diseases such as asthma and atopic dermatitis through induction of IgE synthesis, mucus hypersecretion, and airway hyperreactivity, resulting in symptoms including pruritus and dyspnea6. Although atopic diathesis and allergic contact mechanisms were absent in our patient, complete remission of symptoms was observed following the first administration of lebrikizumab. This raises the possibility that IL-13 may contribute to the inflammatory cascade underlying ICD, independent of atopic sensitization7. Further studies are warranted to elucidate the role of Th2 cytokines in the pathophysiology of ICD and to explore their potential as therapeutic targets. Open access funding enabled and organized by Projekt DEAL. None.