A 43-year-old female with moderate AD presented to our clinic because of recurrent general erythematosquamous papules and plaques for more than one year. The patient was previously diagnosed as AD according to local guidelines [7]. She received long-term conventional treatments regularly, including topical glucocorticoid and antibiotics, and oral antihistamine, but achieved limited effects. Afterwards, she started to receive subcutaneous injection of dupilumab with a total of 10 doses for 4 months. General rash and itch achieved remission, but new facial dermatitis developed and became refractory after the third dose of dupilumab (Fig. 1). Thus, treatment regimen was switched to abrocitinib after finishing the 4-month dupilumab treatment and then a drug withdrawal interval of about 50 days. The patient developed lip swelling 6 h after receiving the first dose of abrocitinib (with a dose of 100 mg), and after 15 h she developed facial swelling, erythema and exudation with burning sensation.

Scattered erythema occurred on the face and neck after the third dose of dupilumab injection in the patient with moderate atopic dermatitis

The patient denied any known allergens, did not use new skincare products or other drugs, and was not exposed to significant sunlight. Physical examination found diffuse facial swelling, erythema and exudation around the eyes, nostrils and forehead (Fig. 2). Laboratory tests showed a change of serum eosinophil count from 0.57 × 109/L before abrocitinib treatment to 0.65 × 109/L after treatment. Antinuclear antibody levels were both 1:320 (speckled pattern) before and after treatment, and anticentromere antibody levels were both strongly positive (+++). UVA and UVB-MED tests indicated mild photosensitivity. Other laboratory results including assessment of coagulation, liver, kidney and thyroid function, Interleukin-6 level and rheumatoid factors were within the normal range. The patient was initially diagnosed as abrocitinib-induced exacerbation of facial dermatitis, and according to the World Allergy Organization (2024) recommendation [8], reaction of the patient could be classified as delayed effects (i.e., after the first 30 min of drug administration). The patient was then treated with intravenous dexamethasone and the symptoms improved after one week of treatment. After one month she resumed using dupilumab.

Exacerbation of facial dermatitis with swelling occurred 15 h after initiation of abrocitinib treatment, manifested as diffuse facial swelling, erythema and exudation on the forehead and nostrils

However, facial erythema with burning sensation occurred persistently and posed substantial burden (Fig. 3). Since a score of 3 was determined using the Naranjo adverse drug reaction assessment [9], there was no conclusive evidence on abrocitinib-induced hypersensitivity. Thus, the patient received drug provocation test for further diagnosis. Abrocitinib tablet was administered orally at incremental doses (10 mg, 50 mg, 100 mg) every 3 days. No exacerbation of facial dermatitis or new rashes were observed during the test, indicating that the aforementioned exacerbation of facial dermatitis was not caused by abrocitinib.

Persisted non-pruritic facial erythema with burning sensation when returned to dupilumab treatment