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Unmasking an ocular risk: keratoconus in atopic dermatitis patients treated with dupilumab

Eye (2026)Cite this article

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Atopic dermatitis (AD) is associated with an increased risk of developing keratoconus (KCN). This reported risk is around 10x greater for adults with severe AD compared to the general population [1]. Keratoconus is a progressive corneal disorder characterised by thinning and deformation of the cornea, and it is suspected that the increased risk of KCN in patients with AD is attributable to ocular inflammation and mechanical rubbing from symptomatic dryness [2]. Dupilumab, a monoclonal antibody that inhibits interleukin-4 (IL-4) and interleukin-13 (IL-13) signalling, is indicated for the treatment of patients with moderate-to-severe AD. It has demonstrated significant efficacy in treating AD [3]; however, despite its benefits, dupilumab has been associated with various ocular side effects. The potential impact of dupilumab on the risk of KCN in patients with AD has not been previously studied [4].

We conducted a retrospective cohort study using data on TriNetX from 2018 onward, after dupilumab was FDA-approved in March of 2017. Adults with a diagnosis of atopic dermatitis (ICD-10: L20) and no prior diagnosis of KCN (ICD-10: H18.67) were eligible to be included. The dupilumab cohort included patients with at least one prescription for dupilumab (RxNorm: 1876376). The control cohort included patients exclusively prescribed topical corticosteroids. The index date was defined as the date of the first prescription for dupilumab. We performed 1:1 propensity score matching on demographics, risk factors associated with KCN, and appointments with an ophthalmologist (Table 1). In a primary analysis, exposure was defined by at least one prescription for dupilumab; in a secondary analysis, at least two prescriptions were required to assess whether sustained exposure altered risk. Risk ratios (RR) with 95% confidence intervals (CIs) were calculated based on the cumulative incidence of keratoconus at three years after the index date.

Table 1 Baseline characteristics before and after propensity score matching (No. [%]).
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Data availability

The data used in this study were obtained from the TriNetX research network. All data are de-identified per HIPAA standards and cannot be shared by the authors. Access is available to licensed TriNetX users.

References

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Authors and Affiliations

  1. Texas A&M College of Medicine, Bryan, TX, USA

    Jawad Muayad, Zaryab Alam, Umer Nadir & Stanislav N. Tolkachjov

  2. Division of Dermatology, Baylor University Medical Center, Dallas, TX, USA

    Allison Petronzio, Umer Nadir & Stanislav N. Tolkachjov

  3. Division of Ophthalmology, Baylor College of Medicine, Houston, TX, USA

    Asad Loya

  4. Epiphany Dermatology, Dallas, TX, USA

    Umer Nadir & Stanislav N. Tolkachjov

  5. Department of Dermatology, University of Texas at Southwestern, Dallas, TX, USA

    Stanislav N. Tolkachjov

Authors
  1. Jawad Muayad
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  2. Zaryab Alam
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  3. Allison Petronzio
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  4. Asad Loya
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  5. Umer Nadir
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  6. Stanislav N. Tolkachjov
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Contributions

JM and ZA contributed to study design, data analysis, and manuscript drafting. AP, AL, and UN provided clinical expertise and critical manuscript revision. ST supervised the project, contributed to the study design, and provided final manuscript approval. All authors reviewed and approved the final version of the manuscript.

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Correspondence to Stanislav N. Tolkachjov.

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Competing interests

Dr. Tolkachjov is a speaker and investigator for Kerecis, Boehringer Ingelheim, Regeneron, and CASTLE Biosciences. No relevant COI for any authors.

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Muayad, J., Alam, Z., Petronzio, A. et al. Unmasking an ocular risk: keratoconus in atopic dermatitis patients treated with dupilumab. Eye (2026). https://doi.org/10.1038/s41433-025-04235-w

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