Management of Facial Redness in Dupixent-Treated Patients
Start preservative-free ocular lubricants 2-4 times daily immediately, even if the redness appears purely facial, because dupilumab-related ocular surface disorders (DROSD) commonly present with periocular and facial involvement. 1, 2
Immediate Assessment for Red Flag Symptoms
Before initiating treatment, urgently assess whether the facial redness is accompanied by any concerning ocular symptoms using the RAPID acronym: 1, 2
- Redness plus Acuity loss or worsening
- Pain (ocular pain beyond simple irritation)
- Intolerance of light (photophobia)
- Damaged cornea visible or opacity
If any RAPID criteria are present, refer to ophthalmology within 24 hours for emergency evaluation. 1, 2
Severity Grading and Treatment Algorithm
Mild Facial Redness (Trace to Mild on Efron Scale)
First-line treatment: 1
- Preservative-free ocular lubricants containing hydroxypropyl-guar or hyaluronate 2-4 times daily 3
- Continue dupilumab therapy 1
- Reassess in 2-4 weeks 1
Moderate Facial Redness (Moderate on Efron Scale)
Escalate to second-line treatment: 1
- Continue preservative-free lubricants 2-4 times daily 1
- Add topical antihistamine eyedrops (olopatadine) twice daily 1, 2
- Refer to ophthalmology via standard pathway (within 4 weeks) if no response 1
Severe Facial Redness (Severe on Efron Scale)
Initiate third-line treatment and urgent referral: 1
- Continue preservative-free lubricants 2-4 times daily 1
- Add tacrolimus 0.1% ointment once daily to lid margins 1, 4
- Refer to ophthalmology for assessment within 4 weeks 1
Critical Clinical Considerations
Bilateral involvement is typical for dupilumab-related facial redness; unilateral symptoms suggest an alternative diagnosis requiring different management pathways. 1, 2
Redness severity and symptom severity may not correlate—classify severity based on whichever finding is worse. 1 For example, moderate redness with no symptoms still qualifies as moderate DROSD requiring second-line treatment. 1
Only 4.2% of patients discontinue dupilumab due to ocular complications, meaning most cases can be successfully managed while continuing therapy. 2
Special Populations
Children Under 7 Years
Refer to ophthalmology for assessment within 4 weeks before initiating any treatment beyond preservative-free lubricants, as these children have visual pathway plasticity and limited ability to communicate symptoms. 1, 3
Children 7-17 Years
Start preservative-free lubricants for mild-to-moderate cases, but seek ophthalmology advice before adding tacrolimus ointment. 1
Alternative Treatment Options for Refractory Cases
Oral itraconazole has demonstrated efficacy in clearing dupilumab facial redness in case reports, though this is not yet guideline-recommended. 5 This may be considered after consultation with ophthalmology for persistent cases. 5
Patch testing should be considered for cases unresponsive to topical treatment to identify potential contact allergens. 1, 4
Common Pitfalls to Avoid
Never use preserved artificial tears in patients requiring frequent dosing, as preservatives like benzalkonium chloride cause additional toxicity and worsen ocular surface disease. 3, 4
Avoid topical corticosteroids without ophthalmology supervision—while low-dose hydrocortisone 0.335% has shown efficacy in reducing ocular redness and inflammation in dry eye disease, prolonged use beyond 8 weeks risks serious complications including glaucoma and cataracts. 1, 6
Do not assume facial redness is purely dermatologic—the British Journal of Dermatology guidelines emphasize that facial redness in dupilumab-treated patients represents part of the DROSD spectrum and requires ocular-focused management. 1, 2
When to Consider Dupilumab Discontinuation
Initiate patient-centered discussion about withdrawing dupilumab only when ophthalmology confirms: 1