Pretreatment Demodex infestation predicts dupilumab-associated blepharoconjunctivitis in atopic dermatitis.

BACKGROUND

Dupilumab has revolutionized treatment of moderate-to-severe atopic dermatitis (AD). However, its use has been associated with ophthalmologic adverse events referred to as dupilumab-associated ocular surface disease (DAOSD), reported in up to 30% of patients. Although several risk factors have been proposed, the role of Demodex folliculorum remains poorly defined.

OBJECTIVES

To evaluate the association between eyelid Demodex infestation and DAOSD development during the first 16 weeks of dupilumab therapy.

METHODS

This prospective study enrolled 30 adults with moderate-to-severe AD initiating dupilumab. All patients underwent ophthalmologic evaluation, Ocular Surface Disease Index (OSDI) scoring, Schirmer testing, conjunctival cultures, and Demodex detection. Follow-up was performed at 16 weeks. Patients were stratified by DAOSD status.

RESULTS

DAOSD developed in 33% (n = 10), presenting as blepharoconjunctivitis. Baseline Demodex infestation was significantly more frequent in the DAOSD group (70.0% vs. 5.0%; p = .0004; OR = 44.3). Baseline Eczema Area and Severity Index (EASI) scores, IgE levels, and Schirmer results did not differ. Post-treatment OSDI scores were higher in DAOSD patients (median 37.5 vs. 4.6; p = .0001). Bacterial cultures were not associated with DAOSD.

CONCLUSIONS

Eyelid Demodex infestation is strongly associated with DAOSD development. Pretreatment screening may identify high-risk individuals. As most cases occur within 16 weeks, this study focused on the early treatment phase.