Dupilumab and Growth Trends in Pediatric Atopic Dermatitis

By Daniel Okafor

In dupilumab (Dupixent; Sanofi and Regeneron) trials involving children with atopic dermatitis, treated patients had numerically higher bone alkaline phosphatase levels than placebo recipients, a pattern consistent with greater bone formation.

Eingun James Song, MD, reviewed that placebo-controlled trial signal in a Dermatology Times Expert Perspectives custom video series. He is a dermatologist, director of clinical research, and co-chief medical officer at Frontier Dermatology. His discussion focused on bone growth, possible causes of impaired growth, and when growth concerns should accelerate treatment.

“Of course, we cannot hang our head on just a single test alone,” Song said.

What does bone alkaline phosphatase show?

Bone alkaline phosphatase is produced by osteoblasts and reflects bone formation and mineralization. In growing children, it tracks well with skeletal growth, so numerically higher values generally favor growth at this age.

The placebo group’s values were not low. They sat toward the lower end of the reference range, while the dupilumab-treated group had numerically higher results. That difference points in a favorable direction, but one biomarker cannot stand alone as a verdict on growth.

Song said the biomarker finding gains weight when clinicians pair it with growth data. Together, the results showed a consistent trend toward growth catch-up in children below the 40th percentile.

The takeaway is straightforward: use the laboratory marker as one piece of evidence, then interpret it alongside a child’s growth curve.

What can impair growth in pediatric atopic dermatitis?

Song identified four contributors to impaired growth in children with atopic dermatitis:

• Inflammation, which he counted among the main drivers of altered bone growth.
• Poor sleep, potentially one of the most relevant factors because sleep loss may limit growth hormone secretion.
• Medications that affect bone health, including topical and oral corticosteroids.
• Restrictive diets driven by parental concern about food allergy.

He said the four factors are difficult to rank because inflammation in atopic dermatitis does not exist in isolation. His wording reflects a multifactorial problem rather than a single-cause explanation.

Adjusting for topical corticosteroid use still showed a benefit for dupilumab-treated patients. Steroid exposure therefore did not explain the full observed benefit. The children in the studies were also shorter, while their weight and body mass index tended to be on the higher side, which argues against malnutrition as the sole explanation.

Poor sleep may limit growth hormone secretion, a pathway that connects to insulin-like growth factor and bone growth. Song also described the effect of elevated interleukin-4 and interleukin-13 on osteoblast function as more theoretical, while continuing to place chronic inflammation among the main drivers.

For clinicians, the practical takeaway is simple: assess inflammation, sleep, medication exposure, and nutrition together instead of attributing impaired growth to steroids alone.

When should treatment become urgent?

For an older child without severe disease, growth is less central to treatment selection. For a younger child who appears smaller than expected, Song prioritizes starting an effective and safe medication as soon as possible.

Song identified dupilumab as the only systemic agent FDA-approved for moderate to severe atopic dermatitis in children younger than 12. That makes it the systemic therapy he most often prioritizes when a child is losing ground on growth curves.

He also weighs practical barriers. Phototherapy can be slow and difficult for caretakers to schedule. Topical therapies remain important, but often do not achieve clear skin and good sleep.

“If a patient is really falling off the growth curves, we really need to prioritize our most effective therapies,” Song said.

Song tells caretakers that the window to intervene may be limited. His approach is not to wait for every possible explanation to become apparent; it is to control severe disease and protect growth as early as possible in a young child falling behind.

The next clinical step is to pair measured growth with disease control, rather than rely on one laboratory value or one isolated factor.