Management of Dupilumab-Associated Facial Redness
Start preservative-free ocular lubricants 2-4 times daily immediately, as facial redness from Dupixent frequently involves concurrent ocular surface disease, and assess urgently for red flag eye symptoms requiring emergency ophthalmology evaluation within 24 hours. 1
Immediate Assessment for Red Flag Symptoms
First, determine if emergency ophthalmology referral is needed by checking for any of these red flag symptoms alongside facial redness: 1
- Visual acuity loss (patient-reported worsening vision) 2, 1
- Eye pain 2, 1
- Photophobia (light sensitivity) 2, 1
- Visible corneal damage or ulceration 2, 1
If any red flag symptom is present, refer for same-day ophthalmology assessment or eye casualty within 24 hours. 2, 1 Note that unilateral eye symptoms are very unlikely to be dupilumab-related and suggest an alternative diagnosis requiring standard ophthalmology pathways. 2, 1
Initial Treatment Algorithm
For All Patients with Facial Redness:
Continue Dupixent without interruption while initiating treatment, as only 4.2% of patients ultimately discontinue due to ocular complications. 1 The facial redness occurs in 4-10% of patients, typically appearing 8-24 weeks after starting dupilumab. 3, 4
Severity-Based Treatment:
Mild Facial Redness:
- Start preservative-free ocular lubricants 2-4 times daily (even if symptoms appear purely facial, as eye involvement is common) 1
- Monitor for progression over 2-4 weeks 1
Moderate Facial Redness:
- Continue preservative-free ocular lubricants 2-4 times daily 1
- Add topical antihistamine eyedrops twice daily 1
- Reassess in 2-4 weeks 1
Severe Facial Redness:
- Continue preservative-free ocular lubricants 2-4 times daily 1
- Add tacrolimus 0.1% ointment once daily to lid margins 1
- Consider short-term topical corticosteroids if inflammation is severe 1
- Refer to ophthalmology for assessment within 4 weeks 1
Additional Topical Options for Facial Skin
For the facial redness itself (not ocular):
- Topical oxymetazoline 0.05% applied daily can reduce facial redness appearance 1
- Topical brimonidine tartrate 0.33% applied daily is FDA-approved for rosacea-related redness 1
- Hydrocortisone 1% cream for short-term use on facial skin only (not in eyes) 1
Tacrolimus ointment combined with dupilumab is effective and safe for facial dermatitis, with rapid improvement of facial lesions and no increased risk of herpes simplex complications. 5
Non-Urgent Ophthalmology Referral Criteria
Refer to ophthalmology within 4 weeks for: 1
- Severe redness at onset requiring tacrolimus treatment 1
- Children under 7 years with any ocular symptoms 1
- Patients requiring topical corticosteroid drops for more than 6 weeks (to introduce corticosteroid-sparing therapy) 1
Long-Term Management Considerations
If facial redness persists despite treatment:
- The reaction typically resolves after 8-12 weeks even with continued dupilumab use 3
- For patients requiring chronic ocular corticosteroids despite treatment, discuss changing to alternative systemic therapy 1
- JAK inhibitors do not have the same pattern of ocular adverse effects as IL-13 targeting biologics 1
Critical Pitfalls to Avoid
- Do not delay ophthalmology referral for red flag symptoms, as visual outcomes depend on prompt intervention 1
- Do not assume purely facial symptoms exclude ocular involvement—bilateral eye disease is typical for dupilumab-related reactions 1
- Avoid alcohol-containing preparations on facial skin, as they enhance dryness and worsen barrier function 1
- Do not discontinue dupilumab prematurely—most cases are manageable while continuing therapy 1