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- Presentation
Interdisciplinary Pulmonology, Allergy, and Dermatology: Eosinophilic Syndromes and Biologic Therapy
Description
The speaker, a Mount Sinai dermatologist, reviews the intersection of dermatology with pulmonology and allergy, focusing on eosinophilic diseases and biologic therapy. They explain the IL-5 pathway and compare mepolizumab, benralizumab, and tezepelumab, emphasizing benralizumab’s rapid eosinophil depletion through antibody-dependent cell-mediated cytotoxicity. The talk then covers hypereosinophilic syndromes and eGPA, highlighting diagnostic clues such as marked persistent eosinophilia, tissue eosinophils, asthma, rhinosinusitis, and multi-organ involvement, with skin findings including erythroderma, purpura, vasculitic lesions, urticaria, and eczema-like eruptions. The importance of collaborating with pulmonology, allergy, ENT, and hematology is stressed to avoid delayed diagnosis in refractory patients. Evidence is presented that IL-5/IL-5R biologics can induce remission in eGPA and reduce steroid use. The speaker also warns that dupilumab may unmask or worsen eosinophilic syndromes in some patients, and that combining dupilumab with an eosinophil-lowering biologic may prevent this. Additional discussion covers paradoxical eczema with IL-5 blockade, limited and mixed results of IL-5 inhibitors in non-eosinophilic dermatologic disease, and emerging safety signals for asthma or rhinitis worsening with other biologics such as nemolizumab, risankizumab, guselkumab, and bimekizumab. Overall, the key message is to take a careful review of systems, recognize eosinophilic or atopic comorbidities early, and choose biologics thoughtfully based on the full clinical picture.
View moreConclusions
- Hypereosinophilic syndromes and EGPA should be suspected in refractory “atopic” patients with asthma, sinus disease, skin findings, or other organ involvement, because early recognition can prevent years of missed diagnosis.
- In HES and EGPA, IL-5–targeted biologics such as mepolizumab and benralizumab can produce marked eosinophil depletion, steroid-sparing benefit, and improvement in multisystem disease.
- Benralizumab appears especially effective in eosinophilic disorders because it rapidly depletes eosinophils and basophils, including marrow precursors, which may help reduce glucocorticoid dependence.
- ANCA status in EGPA helps predict the pattern of organ involvement, with ANCA-positive disease tending toward renal and neurologic disease and ANCA-negative disease tending toward cardiac and GI involvement.
- Dupilumab can be helpful in some eosinophilic syndromes, but in patients with high baseline eosinophilia or occult EGPA it may unmask or worsen systemic disease, so it is not always the best first choice.
- Combining dupilumab with an eosinophil-lowering biologic may prevent dupilumab-associated eosinophilic worsening in selected patients.
- Tezepelumab may be a useful option for refractory EGPA or other eosinophilic disease when IL-5/IL-5R therapy is inadequate, particularly for persistent asthma and sinus disease.
- IL-5 blockade is not broadly effective across all eosinophil-associated skin diseases, since trials in bullous pemphigoid, atopic dermatitis, and chronic spontaneous urticaria were largely negative.
- Eosinophil depletion alone does not guarantee clinical improvement in tissue eosinophilic disease, likely because some disorders show compensatory Th2 cytokine skewing after treatment.
- IL-5/IL-5R therapy can paradoxically worsen eczema in some asthma patients, and switching to IL-4Rα blockade may improve both skin and airway disease.
- Dermatologists should watch for bidirectional effects of biologics on the lungs and allergy system, because some agents that help skin disease can worsen asthma or rhinitis.
- Nemolizumab may trigger asthma events in patients with even mild baseline asthma, so it should be used cautiously in patients with active respiratory disease.
- IL-23 blockade, including risankizumab and guselkumab, may be associated with asthma worsening in predisposed patients, suggesting that immune-pathway shifts can have off-target respiratory consequences.
- Bimekizumab may also worsen asthma or allergic rhinitis in a subset of patients, reinforcing the need for coordinated allergy/pulmonology follow-up in biologic-treated patients.
- Overall, the key clinical message is to take a thorough multisystem history and choose biologics with the patient’s pulmonary and allergic comorbidities in mind.
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