New alcohol flushing in a patient with atopic dermatitis under therapy with dupilumab

Dear Editor, Atopic dermatitis (AD) is a common, recurrent, and pruritic inflammatory skin disorder with complex immunopathogenesis characterized by a dominant T helper (TH)2 response that manifests as eczematous lesions, often associated with allergic rhinitis and asthma (Eshtiaghi & Gooderham, 2018). Dupilumab is a monoclonal antibody that targets the alpha subunit of the Interleukin (IL)-4 receptor and, thus, downregulates activity of IL-4 and IL-13. Dupilumab was shown to significantly improve clinical outcome parameters as well as patient-reported outcomes in patients with AD (Awosika, Kim, Mazhar, Rengifo-Pardo, & Ehrlich, 2018). Dupilumab was approved by the Food and Drug Administration in April 2017 for the treatment of adult patients with moderate-tosevere AD whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable (Seegraber, Srour, Walter, Knop, & Wollenberg, 2018). A flush is defined as a transient, involuntary erythema of the upper region of the body, because of an uncontrollable response of the nervous system leading to widening of the capillaries of the involved skin. A multitude of triggers can provoke a flush. These include inter alia excitement, embarrassment, exercise, fever, but also neoplastic and endocrine disorders. Flushing may also be triggered by drugs or other substances, like alcohol, that cause widening of the capillaries (Lafont et al., 2014). We report the case of a 19-year-old Caucasian female patient suffering from AD since her childhood. In the context of atopic diathesis, the patient also had multiple immediate-type allergies including pollen, dust mites, and animal hairs. Apart from that, the patient was healthy. In December 2017, the patient presented in our outpatient department with an exacerbation of AD. Due to refractory course of the disease under topical steroids and topical calcineurin inhibitors,