Dupilumab Combined with Topical 5% Minoxidil for Severe Alopecia Areata in a 2-Year-Old Child with Type 2 Immune Features: A Case Report.

BACKGROUND: Severe alopecia areata (AA) in very young children is difficult to manage because evidence-based treatment options are limited and currently approved Janus kinase (JAK) inhibitor therapies do not cover children younger than 12 years. Type 2 immune activity may contribute to AA in a subset of patients with atopic features, providing a rationale for considering dupilumab. CASE PRESENTATION: A 2-year-and-5-month-old girl with a 2-year history of progressive scalp hair loss presented with severe diffuse AA (Severity of Alopecia Tool [SALT] score, 85%). She had a history of eczema, a family history of eczema, and mildly elevated total serum immunoglobulin E. Baseline dermoscopy showed sparse vellus hairs and occasional black dots without prominent perifollicular erythema or vascular changes. Previous topical and systemic treatments had produced minimal improvement. INTERVENTION AND OUTCOME: After discussion with the family regarding the off-label nature, uncertainties, potential risks, and alternatives, subcutaneous dupilumab was initiated together with topical 5% minoxidil. Initial regrowth was observed at week 7, followed by progressive improvement; the SALT score decreased to approximately 9% by week 37. No treatment-related adverse events were reported during 9 months of follow-up. CONCLUSION: This case adds to emerging evidence that dupilumab may be considered in carefully selected pediatric patients with severe, treatment-refractory AA and features suggestive of type 2 immune involvement. Because minoxidil was continued concomitantly, baseline inflammatory activity was limited, and spontaneous regrowth cannot be excluded, the clinical improvement cannot be attributed to dupilumab alone.