Management of Dupixent-Associated Facial Redness
Start preservative-free ocular lubricants 2-4 times daily immediately, as facial redness with Dupixent typically involves ocular surface inflammation, and assess for emergency "red flag" eye symptoms requiring ophthalmology evaluation within 24 hours. 1
Immediate Assessment for Emergency Referral
Before initiating treatment, evaluate for the following red flag symptoms that mandate emergency ophthalmology consultation within 24 hours 1:
- Visual acuity loss 2, 1
- Eye pain 2, 1
- Photophobia (light intolerance) 2, 1
- Corneal damage or ulceration 2, 1
Important caveat: Unilateral symptoms are unlikely to be dupilumab-related and suggest alternative pathology requiring standard ophthalmology pathways, as dupilumab-related ocular issues are characteristically bilateral 1.
Understanding the Condition
Dupilumab-related ocular surface disorders (DROSD) occur in 6-26% of patients and manifest as conjunctivitis, blepharitis, dry eye, and keratitis 1. The facial redness you observe is typically part of this broader ocular surface inflammatory process 2, 1. Importantly, only 4.2% of patients discontinue Dupixent due to these complications, meaning most cases are manageable while continuing therapy 1.
Treatment Algorithm by Severity
Mild Facial Redness (First-Line)
- Preservative-free ocular lubricants 2-4 times daily - this is the cornerstone of initial management even when symptoms appear primarily facial 1
- Continue Dupixent without interruption 2
- Monitor for progression over 2-4 weeks 2
Moderate Facial Redness (Second-Line)
- Continue preservative-free lubricants 2-4 times daily 1
- Add topical antihistamine eyedrops twice daily 1
- Reassess in 2-4 weeks 2
Severe Facial Redness (Third-Line)
- Continue preservative-free lubricants 1
- Add tacrolimus 0.1% ointment once daily to lid margins - this targets the periocular inflammation contributing to facial redness 1
- Refer to ophthalmology for assessment within 4 weeks 1
- Consider short-term topical corticosteroids if inflammation is severe 2
Additional Topical Options for Facial Redness
For redness specifically affecting facial skin (not just periocular areas):
- Topical oxymetazoline 0.05% applied daily - this α1-adrenergic agonist causes vasoconstriction and reduces facial redness appearance 2, 3
- Topical brimonidine tartrate 0.33% applied daily - FDA-approved for rosacea-related redness 2
- Hydrocortisone 1% cream for short-term use on facial skin (not in eyes) 2, 4
Critical warning: Both oxymetazoline and brimonidine carry risk of rebound erythema with prolonged use, so limit duration and counsel patients accordingly 2.
When to Consider Corticosteroid-Sparing Therapy
If topical corticosteroid drops are required for more than 6 weeks, introduce corticosteroid-sparing therapy to avoid adverse effects including elevated intraocular pressure 2. Options include:
- Tacrolimus ointment to lid margins (as above) 2, 1
- Close ophthalmology monitoring for corticosteroid-related complications 2
Special Populations Requiring Urgent Ophthalmology Referral
Refer within 4 weeks (not emergency) for 1:
- Children under 7 years with any ocular symptoms 1
- Severe redness at initial presentation 1
- Any case requiring tacrolimus treatment 1
When to Consider Switching Systemic Therapy
For patients with persistent DROSD requiring chronic ocular corticosteroids despite the above measures, discuss changing to alternative systemic therapy 2. Other biologics targeting IL-13 (tralokinumab, lebrikizumab) carry similar ocular risks, but JAK inhibitors do not have the same pattern of ocular adverse effects 2.
Common Pitfalls to Avoid
- Do not use preserved lubricants - preservatives worsen ocular surface inflammation 1
- Do not assume unilateral symptoms are dupilumab-related - investigate alternative causes 1
- Do not delay ophthalmology referral for red flag symptoms - visual outcomes depend on prompt intervention 2, 1
- Do not use alcohol-containing preparations on facial skin - these enhance dryness and worsen barrier function 2