Netherton syndrome (NS) is a rare congenital barrier disorder caused by pathogenic variation in SPINK5, resulting in severe epidermal dysfunction and immune dysregulation. Although dupilumab is increasingly used in NS, molecular data describing treatment-associated tissue responses remain limited, particularly in genetically complex presentations. We investigated treatment-associated molecular trajectories during IL-4Rα blockade in two siblings with NS carrying heterozygous compound SPINK5 (c.2468dup & c.2243 A > G) and FLG (p.Arg501*) variants. Longitudinal whole-exome sequencing and paired bulk RNA sequencing of peripheral blood and lesional skin were performed before and after six months of dupilumab therapy. Transcriptomic changes were evaluated using effect-size– and rank-based approaches and contextualized through integration with publicly available NS reference datasets. Across both compartments, post-treatment transcriptional profiles exhibit coordinated shifts toward healthy-control–like expression states. Blood transcriptomes show reduced inflammatory, metabolic, and proliferative signatures alongside modulation of FURIN and increase expression of PAPPA, LPAR5, CELSR1, and ARHGEF19. Skin transcriptomes transition from neurosensory and follicular programs toward lipid metabolic organization, keratinocyte differentiation, and cornified-envelope–associated pathways. Cross-compartment integration highlights shared treatment-associated transcripts, including ADAM23, and candidate markers of immune–epithelial recalibration. Together, this exploratory dual-compartment longitudinal analysis provides rare molecular insight into biologic treatment response in a genetically complex NS context and establishes a foundational reference for future genotype-informed and biomarker-oriented studies. Netherton syndrome is a rare inherited skin disorder that causes severe inflammation and a weakened protective skin barrier. Although dupilumab is increasingly being used to treat this condition, its effects on the underlying biological mechanisms are not yet fully understood. To investigate this, we studied two siblings with Netherton syndrome and analyzed blood and skin samples collected before treatment and after six months of therapy. We found that dupilumab was associated with reduced inflammatory activity and gene expression patterns that became more similar to those seen in healthy individuals. These findings suggest that dupilumab may help restore both immune balance and skin barrier function, providing new insight into its mechanism of action and supporting the development of more personalized treatment strategies for people with Netherton syndrome. Bajo-Santos et al. longitudinally profile blood and skin transcriptomes before and after dupilumab treatment in two siblings with genetically complex Netherton syndrome. They observe that IL-4Rα blockade shifts molecular signatures toward healthy-like states, reducing inflammation and promoting epidermal differentiation and barrier-repair pathways.
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