Managing Dermatologic Toxicities in Patients with Active Cancer

Conclusions

• For patients with cancer, many common dermatologic treatments can be used safely, but the key is to choose therapies that do not compromise cancer care.
• Topical therapies are strongly favored because their risk-benefit profile is excellent and systemic absorption is usually not a major concern.
• Prednisone can work quickly, but it is best reserved for more severe cases because of its side effects and its potential to interfere with immune checkpoint inhibitor therapy.
• Dapsone and methotrexate appear to be reasonable steroid-sparing options in selected patients, with the main concerns being anemia, renal function, or drug toxicity rather than worsening the underlying cancer.
• Cyclosporine, azathioprine, and mycophenolate mofetil are generally less attractive choices in active cancer because they suppress immune surveillance, and azathioprine is especially concerning because it is directly mutagenic.
• Omalizumab appears to be very safe from an oncologic standpoint and is supported by multiple datasets showing no meaningful increase in cancer incidence.
• Dupilumab also appears safe in patients with cancer and may provide rapid relief of pruritus and inflammatory skin disease without clear evidence of increasing recurrence or progression.
• Rituximab is presented as a relatively safe option, including in the setting of immune checkpoint inhibitor-related toxicity, especially when used as monotherapy.
• IVIG should be used cautiously, particularly during active immune checkpoint inhibitor treatment, because it may reduce the effectiveness of therapeutic antibodies and has been associated with worse outcomes.
• Phototherapy is generally acceptable in patients with cancer, but extra caution is needed when the cancer therapy itself is photosensitizing.
• JAK inhibitors remain uncertain: some data suggest increased malignancy risk, especially non-melanoma skin cancer, but emerging studies also suggest they may sometimes enhance checkpoint inhibitor responses.
• Overall, the best approach is individualized care that maximizes symptom control while minimizing harm and avoiding unnecessary interruption of cancer therapy.