Is Dupilumab safe for atopic dermatitis while breastfeeding?

Question

Hello doctor,

I am 33, and my atopic dermatitis has become so severe that I can barely function anymore. I had eczema as a child, but it went away during my teenage years and came back with vengeance after I had my first baby 18 months ago. The rashes cover my hands, arms, neck, and face, with these weeping patches that crack and bleed constantly. I cannot sleep more than two hours without waking up from itching and scratching. I tried every steroid cream, including Clobetasol, but they only work temporarily, and my skin is getting thin and bruising easily.

The dermatologist put me on Dupilumab injections three months ago, but insurance denied it twice already. I am still breastfeeding my daughter and worried about using too many steroids or other medications. I had to quit my job as a hairdresser because constant water exposure and chemicals made atopic dermatitis unbearable. My hands are so cracked and painful that I cannot even change diapers without crying. I also developed eye problems with red, itchy eyelids that the ophthalmologist said are related to the eczema. I tried elimination diets, cutting out dairy, gluten, and eggs, but nothing helped. I take antihistamines every night, but still wake up with blood under my fingernails from scratching in my sleep.

Is Dupilumab safe while breastfeeding?
Are there other treatments that actually work for severe atopic dermatitis?

Kindly help.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

You are suffering from severe chronic atopic dermatitis with secondary eczematous changes involving the face, neck, upper limbs, and hands. The disease appears to have flared postpartum, likely influenced by hormonal and immune modulation, as well as occupational aggravation from wet work and irritant exposure as a hairdresser.

Dupilumab remains the treatment of choice in such cases and is considered safe during lactation. Being a fully human monoclonal immunoglobulin G4 antibody, it has minimal transfer into breast milk and negligible oral bioavailability in the infant. Therefore, continuation of Dupilumab would be both rational and safe if insurance approval can be obtained.

While awaiting approval, non-steroidal topical immunomodulators such as Tacrolimus or Pimecrolimus can be used safely for maintenance, especially on facial and flexural areas, to minimise steroid-induced atrophy. Crisaborole may also be beneficial for localized lesions. Narrowband ultraviolet B phototherapy is another effective and lactation-safe alternative for widespread disease. Systemic immunosuppressants or Janus kinase inhibitors are generally avoided during breastfeeding.

For the hand dermatitis, emphasis should be placed on strict barrier protection, use of bland emollients (petrolatum-based), and avoidance of irritants. Cotton gloves under nitrile gloves during wet work, along with regular overnight occlusion with emollients, can significantly improve fissuring.

Your ocular involvement likely represents eczematous blepharitis, which can be managed with Tacrolimus 0.03% ointment applied sparingly to the eyelids and preservative-free lubricants. Steroid use around the eyes should be minimized.

I hope you are satisfied with my answer. For further queries, you can consult me at iCliniq.

Thank you.