What is the next treatment option for a patient with a follicular rash, currently using Rinvoq (upadacitinib)?

Management of Follicular Rash in a Patient on Upadacitinib (Rinvoq)

For a patient with follicular rash while on Rinvoq (upadacitinib), the next treatment option should be a combination of topical corticosteroids with topical antibiotics in alcohol-free formulations for at least 14 days. 1

Assessment and Initial Management

• Grade of rash: Determine severity of the follicular rash

  • Grade 1: Continue upadacitinib and apply emollients regularly
  • Grade 2: Consider topical treatments while maintaining upadacitinib
  • Grade 3: Temporarily interrupt upadacitinib therapy

• Initial treatment approach:

  1. Apply emollients regularly to affected areas
  2. For signs of superadded infection, add topical antibiotics in alcohol-free formulations for at least 14 days 1

Specific Treatment Recommendations

Topical Treatments

• Topical corticosteroids: Select based on severity and location

  • Face: 1-2.5% hydrocortisone or Eumovate ointment (clobetasone butyrate 0.05%)
  • Body: Betnovate (betamethasone valerate 0.1%), Elocon (mometasone 0.1%), or Dermovate (clobetasol propionate 0.05%) 1
  • Apply for 2-3 weeks then reassess

• Topical antibiotics: Use alcohol-free formulations

  • Options include combination products like:
    • Fucidin H (hydrocortisone 1% + fusidic acid 2%)
    • Fucicort (betamethasone valerate 0.1% + fusidic acid 2%) 1

For Persistent or Worsening Rash

• Oral antibiotics: Consider tetracycline for at least 2 weeks if topical treatments are insufficient 1

• Antifungal options: If folliculitis has a fungal component

  • Ketoconazole shampoo or cream
  • Selenium sulfide preparations 2

Management Based on Severity

For Grade 2 Chronic Rash

• Intensify moisturizing
• Apply topical steroids for 2-3 weeks
• Consider dermatology consultation as this can significantly affect quality of life 1
• Consider oral antihistamines for itchy rash, but be aware that only some patients benefit and sedation may occur 1

For Grade 3 Rash

• Temporarily interrupt upadacitinib therapy
• Resume only when rash improves to grade ≤2
• Consider dose reduction of upadacitinib from 30 mg to 15 mg if currently on higher dose 3
• Refer to a dermatologist specializing in drug-related cutaneous adverse events 1

Advanced Options for Resistant Cases

If the above treatments fail to control the follicular rash:

• Isotretinoin: Consider oral isotretinoin for severe folliculitis not responding to antibiotics 4, 5

  • Has shown 90% stable remission rates in folliculitis decalvans 5
  • Works through multiple mechanisms: inhibiting sebaceous gland activity, altering follicular keratinization, and reducing inflammation 4

• Rotation therapy: Consider rotating between different antifungal agents to prevent resistance development 2

Maintenance and Prevention

• Regular use of antifungal products for maintenance
• Gentle cleansing with pH-neutral formulations
• Avoid greasy hair products that may facilitate yeast growth 2
• Keep affected areas dry and clean
• Apply hypoallergenic moisturizing creams once daily 2

Common Pitfalls to Avoid

• Inadequate treatment duration (ensure full 14-day course for antibiotics)
• Failure to address maintenance therapy (follicular rash may recur without proper maintenance)
• Prolonged use of potent topical corticosteroids (can potentially worsen skin condition)
• Using greasy topical products that inhibit absorption of wound exudate and promote superinfection 1, 2

Remember that follicular rash is a common side effect of JAK inhibitors like upadacitinib, with acne reported in 10-14% of patients on upadacitinib compared to 2% on placebo 6. Proper management can allow continued therapy while effectively controlling the rash.