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  • Presentation

Morbilliform Reactions to Immunotherapy

Description

Dr. Nima Malani from UCLA presented on morbilliform reactions to immunotherapy, particularly focusing on immune checkpoint inhibitors that have transformed cancer treatment by enhancing immune system activity. While effective in fighting cancer, these therapies can lead to significant immune-related adverse events (irAEs), especially in the skin, which often manifest early in the treatment process. Studies indicate that 60-90% of patients taking ipilimumab and 30-70% receiving PD1 blockers experience some form of irAE, with heightened risks associated with patients having pre-existing inflammatory conditions. Skin reactions can range from mild to severe and are usually treated with topical or systemic steroids, while ongoing monitoring is crucial. Malani discussed the varying timing and types of skin reactions, including maculopapular eruptions, which can signify a positive treatment prognosis in some patients. He also emphasized the importance of understanding the different skin reactions, including Stevens-Johnson syndrome and drug rash with eosinophilia and systemic symptoms (DRESS), along with their treatment protocols, highlighting that immunotherapy-related reactions might necessitate holding therapy and adjusting subsequent treatment approaches based on the severity and type of skin reaction. Overall, the presentation underscored the complexities of managing skin reactions in immunotherapy patients and the potential implications for ongoing cancer treatment.

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Conclusions

  • Immunotherapy using immune checkpoint inhibitors can lead to a high incidence of immune-related adverse events (irAEs), particularly skin-related ones.
  • Patients with pre-existing inflammatory skin conditions have a higher risk and severity of cutaneous immune-related adverse events while on immunotherapy.
  • Development of cutaneous irAEs can be a positive prognostic indicator, suggesting improved overall survival in some patients.
  • Cutaneous manifestations such as maculopapular eruptions often occur within the first weeks of treatment and can be significantly itchy.
  • Management of cutaneous irAEs may require holding immunotherapy and employing various treatment modalities such as systemic corticosteroids.
  • Patients can potentially be rechallenged with immunotherapy after resolution of cutaneous irAEs, depending on the severity and response to treatment.
  • Severe cutaneous adverse reactions (SCARs) like SJS/TEN may occur with a mortality risk of up to 30%, particularly with PD-1 inhibitors, and require prompt cessation of treatment and intensive management.
  • Newer classifications such as Progressive Immunotherapy-Related Mucocutaneous Eruption (PIRME) highlight the complexity and variability of reactions to immunotherapy.
  • Further research is needed to clarify the mechanisms behind cutaneous irAEs and the safety of rechallenging patients with the same class of immunotherapy after adverse events.
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