Clinical Case Summary
We present the case of a 28-year-old male patient with a history of atopic dermatitis (AD) since childhood and 10 years of diffused alopecia areata (AA), refractory to topical and systemic therapies (corticosteroids, cyclosporine, azathioprine and dupilumab, the latter interrupted after 4 months for an adverse reaction). He also had severe Crohn’s ileocolitis unsuccessfully treated with infliximab, adalimumab and ustekinumab. Ileal resection with ileocolic anastomosis due to intestinal subocclusion was performed.
On physical examination the patient showed a severe AD and AA diffused on his scalp, eyebrows and eyelashes (Figure 1A). A colonoscopy performed two years before showed a Rutgeerts i3 scale with severe recurrence of Crohn's disease (more than five aphthoid lesions in the neo-terminal ileum).
A therapy with upadacitinib 30 mg/die was started for AD and AA at week 0, since it was not approved for Crohn’s disease (CD).
After 1 month of treatment, significant dermatological improvement of both AD and AA was registered (Figure 1B). After 3 months the drug dosage was reduced to 15 mg/die due to side effects (acneiform facial eruption). The patient started to recover the hair and an almost complete recovery of the eyelashes, eyebrows and beard was assessed.
The patient’s stool frequency, abdominal pain and urgency improved. After 9 months of therapy, colonoscopy revealed normal ileal mucosa and a substenosis of ileocolic anastomosis. Further improvements of AA and AD were registered (Figure 1C).
A small intestine contrast-enhanced ultrasonography using oral contrast agent assessed a complete resolution of bowel inflammation (Figure 1D and 1E), with <3 mm wall diameter, normal wall layer discrimination and a Limberg score of 0.
Our case support the efficacy of upadacitinib for the treatment of concurrent AD, AA and CD, and up to our knowledge this is the first report of a successful treatment with upadacitinib in a patient with concomitant AD, AA and CD.
References
Figure 1. Dermatological manifestations of atopic dermatitis (AD) and alopecia areata (AA) in a 28-year-old patient, also affected by Crohn’s disease. He presented with severe AD, involving his face, hand, trunk, lower, and upper limbs [Eczema Area Severity Index (EASI): 45.1; Pruritus-Numeric Rating Scale (P-NRS): 10/10)] and AA diffused on his scalp, eyebrows and eyelashes with a Severity of Alopecia Tool (SALT) score of 100 (A); the same patient showing dermatological improvement of AA and AD after one month of upadacitinib therapy (EASI score 1, SALT 0) (B) and after nine months (C); small intestine contrast-enhanced ultrasonography using oral contrast agent picture with a complete resolution of bowel inflammation after nine months of treatment (D and E).