What are the risks of easy bruising associated with Dupixent (dupilumab) and hydrocortisone?

Risks of Easy Bruising with Dupixent and Hydrocortisone

Hydrocortisone is associated with easy bruising as a common side effect, while Dupixent (dupilumab) has not been specifically linked to increased bruising risk in clinical studies or guidelines. 1, 2

Hydrocortisone and Bruising

Mechanism and Risk

• Topical and systemic corticosteroids like hydrocortisone can cause skin thinning (atrophy) and easy bruising due to their effects on collagen synthesis 1
• These side effects are dose-dependent and increase with:
  • Higher daily dosage
  • Longer duration of treatment
  • Advanced age
  • Application to thin-skinned areas 2

Prevalence

• Skin thinning and easy bruising occur in approximately 50% of patients using corticosteroids regularly 2
• Risk increases significantly in elderly patients

Dupixent (Dupilumab) Side Effects

Common Side Effects

• Dupilumab's most common adverse effects include:
  • Conjunctivitis (5-16% of patients)
  • Injection site reactions
  • Facial redness
  • Herpes simplex virus infection 3, 4

Ocular Complications

• Dupilumab-related ocular surface disorders (DROSD) are the most significant adverse effects 3, 4
• These include:
  • Conjunctivitis
  • Blepharitis
  • Dry eyes
  • Keratitis in severe cases 3

No Documented Bruising Risk

• Current guidelines and clinical trials do not identify easy bruising as a reported side effect of dupilumab 3, 5
• The LIBERTY AD CAFÉ trial and other phase III studies did not report increased bruising as an adverse effect 5

Combination Therapy Considerations

Potential Additive Effects

• When using both medications concurrently:
  • Hydrocortisone may cause localized skin thinning and bruising
  • Dupilumab does not appear to exacerbate this risk
  • No specific drug interaction between dupilumab and hydrocortisone has been reported to increase bruising risk 3, 5

Management Recommendations

1. For hydrocortisone-related bruising:

   • Use the lowest effective dose for the shortest duration
   • Consider using a spacer device for inhaled formulations
   • Apply topical formulations sparingly, especially on thin-skinned areas
   • Monitor for skin thinning, particularly in elderly patients 1, 2

2. For dupilumab therapy:

   • Monitor primarily for ocular complications
   • No specific monitoring for bruising is required based on current guidelines 4

Clinical Approach

• If easy bruising develops:
  • Evaluate the pattern and location of bruising (localized vs. generalized)
  • Consider reducing hydrocortisone dose if possible
  • Do not discontinue dupilumab based solely on bruising concerns unless other causes have been ruled out
  • Consider dermatology consultation for severe or persistent bruising

Key Takeaway

While monitoring for the known side effects of both medications is important, patients and clinicians should be aware that hydrocortisone is the more likely culprit for any easy bruising that develops during combination therapy.