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  • Presentation

Diagnosis and Management of Cutaneous Toxicities to Immune Cancer Therapies

Description

The presentation discusses cutaneous toxicities associated with immune cancer therapies, particularly focusing on the management and diagnosis of skin eruptions caused by immune checkpoint inhibitors like CTLA-4 and PD-1 inhibitors. These therapies have transformed cancer treatment, making previously terminal diagnoses into manageable chronic conditions. The speaker emphasizes the variety of skin reactions that can occur, including eczematous, lichenoid eruptions, and psoriasiform reactions, among others. Accurate diagnosis is crucial, highlighting the necessity of involving board-certified dermatologists in the management of these patients due to the complex nature of these skin issues. A systematic grading approach for skin eruptions, based on severity and impact on daily life, is outlined to facilitate communication with oncologists. Several case studies illustrate the differences in skin reactions among patients and how variations in treatment strategies, including topical steroids and biologics, can lead to dramatically improved patient outcomes, reinforcing the importance of tailored treatment. Lastly, the speaker encourages broad diagnostic exploration, reminding that not all skin issues in these patients are immunotherapy-related, and stresses collaboration between dermatologists and oncologists for optimal patient care.

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Conclusions

  • Immune checkpoint inhibitors have revolutionized cancer treatment, turning once-terminal conditions into chronic diseases or potentially survivable ones.
  • Patients undergoing immunotherapy can experience a wide variety of immune-related adverse events, particularly cutaneous toxicities, which require careful diagnosis and management.
  • The grading of cutaneous eruptions, such as rashes, is crucial for determining treatment approaches and interventions based on the severity and impact on the patient's quality of life.
  • Recognition and management of dermatitis related to immunotherapy require specialized knowledge from dermatologists to differentiate between different rashes and their treatments.
  • Patients can continue to have significant skin toxicities even with low body surface area affected, emphasizing the need for a comprehensive assessment of symptom severity and functional impairment.
  • Many immune-related skin eruptions can occur months after starting therapy, necessitating awareness of delayed reactions during treatment planning.
  • Management of immune-related dermatitis includes topical treatments, phototherapy, and potentially systemic biologic therapies, focusing on maintaining the patient's ongoing cancer treatment when possible.
  • For patients with pre-existing skin conditions, monitoring and tailored management strategies are necessary to prevent exacerbation during immunotherapy.
  • Corticosteroid use can negatively impact cancer treatment responses, highlighting caution in their use for skin toxicities associated with immune checkpoint inhibitors.
  • Holistic treatment decisions should consider the severity of dermatological symptoms, potential for rechallenging immunotherapy, and the overall therapeutic goals for cancer management.
  • Chang E, Pelosof L, Lemery S, et al. Systematic Review of PD-1/PD-L1 Inhibitors in Oncology: From Personalized Medicine to Public Health. Oncologist. 2021;26(10):e1786-e1799. doi:10.1002/onco.13887
  • Shi VJ, Rodic N, Gettinger S, Leventhal JS, Neckman JP, Girardi M, Bosenberg M, Choi JN. Clinical and Histologic Features of Lichenold Mucocutaneous Eruptions Due to Anti-Programmed Cell Death 1 and Anti-Programmed Cell Death Ligand 1 Immunotherapy. JAMA
  • Cornejo, Christine M et al. 'Immune checkpoint inhibitors and the development of granulomatous reactions.' Journal of the American Academy of Dermatology vol. 81,5 (2019): 1165-1175. doi:10.1016/j.jaad.2018.07.051
  • Petrelli, Fausto et al. 'Association of Steroids use with Survival in Patients Treated with Immune Checkpoint Inhibitors: A Systematic Review and Meta-Analysis.' Cancers vol. 12,3 546. 27 Feb. 2020, doi:10.3390/cancers12030546
  • Iorgulescu, J Bryan et al. 'Concurrent Dexamethasone Limits the Clinical Benefit of Immune Checkpoint Blockade in Glioblastoma.' Clinical Cancer Research: an official journal of the American Association for Cancer Research vol. 27,1 (2021): 276-287. doi:10.1158/1078-0432.CCR-20-2291
  • Said, Jordan T et al. 'Impact of biologic therapy on cancer outcomes in patients with immune checkpoint inhibitor-induced bullous pemphigoid.' Journal of the American Academy of Dermatology vol. 88,3 (2023): 670-671. doi:10.1016/j.jaad.2022.06.1186
  • Lo, Jonathan J et al. 'Biologic therapies for checkpoint inhibitor-induced cutaneous toxicities: a single-institution study of 17 consecutively treated patients.' Supportive Care in Cancer: official journal of the Multinational Association of Supportive Care in Cancer vol. 30,2 (2022): 989-994. doi:10.1007/s00520-021-06548-4