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Kramer N, Müller G, Zierold S, Röckel M, Fröhlich W, Schefzyk M, Kumbrink J, Hassel JC, Berking C, Ziemer M, Nashan D, French LE, Vera J, Kerl-French KE, Gutzmer R, Heinzerling L. Checkpoint inhibitor-induced bullous pemphigoid differs from spontaneous bullous pemphigoid. J Eur Acad Dermatol Venereol 2024; 38:e722-e728. [PMID: 38400651 DOI: 10.1111/jdv.19860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 01/24/2024] [Indexed: 02/25/2024]
Affiliation(s)
- N Kramer
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany
| | - G Müller
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany
| | - S Zierold
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany
| | - M Röckel
- Department of Dermatology, Uniklinikum Erlangen, Comprehensive Cancer Center Erlangen - EMN, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - W Fröhlich
- Department of Dermatology, Uniklinikum Erlangen, Comprehensive Cancer Center Erlangen - EMN, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - M Schefzyk
- Department of Dermatology and Allergy, Hannover Medical School, Hannover, Germany
| | - J Kumbrink
- Institute of Pathology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - J C Hassel
- Department of Dermatology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, Heidelberg, Germany
| | - C Berking
- Department of Dermatology, Uniklinikum Erlangen, Comprehensive Cancer Center Erlangen - EMN, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - M Ziemer
- Department of Dermatology, Allergology and Venerology, University Medical Center, Leipzig, Germany
| | - D Nashan
- Department of Dermatology, Hospital Dortmund, Dortmund, Germany
| | - L E French
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - J Vera
- Department of Dermatology, Uniklinikum Erlangen, Comprehensive Cancer Center Erlangen - EMN, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - K E Kerl-French
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany
| | - R Gutzmer
- Department of Dermatology, Johannes Wesling Medical Center, Ruhr University Bochum Campus Minden, Minden, Germany
| | - L Heinzerling
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany
- Department of Dermatology, Uniklinikum Erlangen, Comprehensive Cancer Center Erlangen - EMN, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
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Ziemer M, Livingstone E. [Drug-related exanthema under immunotherapy and targeted oncological therapy]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2024; 75:440-450. [PMID: 38772932 DOI: 10.1007/s00105-024-05350-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Oncological therapies can cause a variety of mucocutaneous adverse events. Exanthematous adverse events can be challenging in the context of the urgent need for cancer treatment due to their spread, sometimes rapid progression, and mucous membrane or organ involvement. MATERIALS AND METHODS This article provides an overview of the most important exanthematic dermatoses as side effects of modern drug-based tumor therapies with diagnostic and therapeutic information for clinicians, taking into account the current literature and guidelines. RESULTS Exanthematous adverse events of immune checkpoint inhibitors, EGFR antagonists, kinase inhibitors, bispecific T‑cell engagers, and the CCR4 inhibitor mogamulizumab are reviewed in detail. CONCLUSIONS Cutaneous side effects are common across all drug classes and cover a broad spectrum. While some adverse events are specific to one drug class, many exanthemas can occur with both oncological immunotherapies and various targeted therapies. A reliable diagnosis, dose adjustment or discontinuation of the offending agent in consultation with the treating oncologists and appropriate symptomatic therapy are important for correct management. In the case of severe, life-threatening drug reactions, however, permanent discontinuation of the drug is essential.
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Affiliation(s)
- Mirjana Ziemer
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsmedizin Leipzig, Philipp-Rosenthal-Str. 23, 04103, Leipzig, Deutschland.
| | - Elisabeth Livingstone
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsmedizin Essen, Hufelandstr. 55, 45122, Essen, Deutschland
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de Nicolas-Ruanes B, Ballester-Martinez A, Garcia-Mouronte E, Berna-Rico E, Azcarraga-Llobet C, Fernandez-Guarino M. From Molecular Insights to Clinical Perspectives in Drug-Associated Bullous Pemphigoid. Int J Mol Sci 2023; 24:16786. [PMID: 38069109 PMCID: PMC10706090 DOI: 10.3390/ijms242316786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 11/19/2023] [Accepted: 11/22/2023] [Indexed: 12/18/2023] Open
Abstract
Bullous pemphigoid (BP), the most common autoimmune blistering disease, is characterized by the presence of autoantibodies targeting BP180 and BP230 in the basement membrane zone. This leads to the activation of complement-dependent and independent pathways, resulting in proteolytic cleavage at the dermoepidermal junction and an eosinophilic inflammatory response. While numerous drugs have been associated with BP in the literature, causality and pathogenic mechanisms remain elusive in most cases. Dipeptidyl peptidase 4 inhibitors (DPP4i), in particular, are the most frequently reported drugs related to BP and, therefore, have been extensively investigated. They can potentially trigger BP through the impaired proteolytic degradation of BP180, combined with immune dysregulation. DPP4i-associated BP can be categorized into true drug-induced BP and drug-triggered BP, with the latter resembling classic BP. Antineoplastic immunotherapy is increasingly associated with BP, with both B and T cells involved. Other drugs, including biologics, diuretics and cardiovascular and neuropsychiatric agents, present weaker evidence and poorly understood pathogenic mechanisms. Further research is needed due to the growing incidence of BP and the increasing identification of new potential triggers.
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Affiliation(s)
- Belen de Nicolas-Ruanes
- Dermatology Department, Hospital Universitario Ramon y Cajal, 28034 Madrid, Spain (C.A.-L.); (M.F.-G.)
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Didona D, Schmidt MF, Maglie R, Solimani F. Pemphigus and pemphigoids: Clinical presentation, diagnosis and therapy. J Dtsch Dermatol Ges 2023; 21:1188-1209. [PMID: 37587612 DOI: 10.1111/ddg.15174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/11/2023] [Indexed: 08/18/2023]
Abstract
Pemphigus and pemphigoid are two potentially life-threatening groups of autoimmune diseases, characterized by autoantibodies targeting structural components of desmosomes or hemidesmosomes, respectively. Affected patients typically show itchy/painful plaques or blistering skin lesions and/or impairing mucosal blistering and erosions, which may strongly impact their quality of life. Since the milestone work of Walter Lever in 1953, who differentiated these two groups of diseases by histopathological analysis of the level of antibody-mediated skin cleavage, enormous progresses occurred. Achievements made in laboratory diagnostics now allow to identify antigen specific structural proteins of the skin that are targeted by pathogenic autoantibodies. These progresses were accompanied by an increased understanding of the pathogenesis of these diseases thanks to the establishment of animal models reproducing disease and on studies on skin and blood of affected individuals, which have been leading to novel and disease-specific treatments. Yet, given their phenotypical overlap with more common dermatological diseases, correct diagnosis and appropriate treatment are often delayed, in some cases leading to irreversible sequelae, including organ dysfunction (i.e., loss of vision in mucous membrane pemphigoid). Here, we provide a concise overview of the clinical appearance, diagnosis and therapeutic management of pemphigus and pemphigoid diseases.
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Affiliation(s)
- Dario Didona
- Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
| | - Morna F Schmidt
- Department of Dermatology and Allergology, University Hospital RWTH Aachen, Aachen, Germany
| | - Roberto Maglie
- Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
- Department of Health Sciences, Section of Dermatology, University of Florence, Florence, Italy
| | - Farzan Solimani
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Germany
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5
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Didona D, Schmidt MF, Maglie R, Solimani F. Pemphigus- und Pemphigoid-Erkrankungen: Klinik, Diagnostik und Therapie: Pemphigus and pemphigoids: Clinical presentation, diagnosis and therapy. J Dtsch Dermatol Ges 2023; 21:1188-1211. [PMID: 37845066 DOI: 10.1111/ddg.15174_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/11/2023] [Indexed: 10/18/2023]
Abstract
ZusammenfassungPemphigus und Pemphigoid sind seltene Autoimmunkrankheiten der Haut mit potenziell lebensbedrohlichem Verlauf. Autoantikörper gegen epidermale und junktionale Strukturproteine (Desmosomen sowie Hemidesmosomen) führen bei Betroffenen typischerweise zu juckenden, schmerzhaften Plaques oder Blasen an der Haut und/oder Blasenbildung und Erosionen der Schleimhäute mit möglicher Einschränkung der Lebensqualität. Seit der bahnbrechenden Arbeit von Walter Lever im Jahr 1953, dem es gelang, mittels histopathologischer Untersuchung diese beiden Krankheitsgruppen anhand des Musters der Antikörper‐vermittelten Blasenbildung zu differenzieren, wurden enorme Fortschritte im Verständnis der Erkrankungen erzielt. Die Errungenschaften in der Labordiagnostik ermöglichten die Identifikation von Zielstrukturen zur präzisen Unterscheidung verschiedener Varianten der bullösen Autoimmunerkrankungen. Diese Fortschritte gingen dank der Entwicklung von Tiermodellen mit einem besseren Verständnis der Pathogenese einher. Außerdem haben Studien an Haut und Blut betroffener Patienten zu neuen und krankheitsspezifischen Behandlungen geführt. Aufgrund ihrer Seltenheit und der klinischen Ähnlichkeit mit anderen dermatologischen Erkrankungen verzögern sich die korrekte Diagnosestellung und die Einleitung einer entsprechenden Therapie häufig, was in einigen Fällen zu irreversiblen Folgeerscheinungen, einschließlich Funktionsstörungen von Organen (zum Beispiel Verlust des Sehvermögens beim Schleimhautpemphigoid) führt. Wir geben hier einen Überblick über das klinische Erscheinungsbild, den Diagnosealgorithmus und das therapeutische Management von Pemphigus‐ und Pemphigoid‐Erkrankungen.
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Affiliation(s)
- Dario Didona
- Klinik für Dermatologie und Allergologie, Philipps-Universität Marburg, Marburg, Deutschland
| | - Morna F Schmidt
- Klinik für Dermatologie und Allergologie, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Roberto Maglie
- Klinik für Dermatologie und Allergologie, Philipps-Universität Marburg, Marburg, Deutschland
- Abteilung für Gesundheitswissenschaften, Abteilung für Dermatologie, Universität Florenz, Florenz, Italien
| | - Farzan Solimani
- Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, Korporatives Mitglied der Freien Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Deutschland
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Deutschland
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6
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Allais BS, Fay CJ, Kim DY, Semenov YR, LeBoeuf NR. Cutaneous immune-related adverse events from immune checkpoint inhibitor therapy: Moving beyond "maculopapular rash". Immunol Rev 2023; 318:22-36. [PMID: 37583051 DOI: 10.1111/imr.13257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/27/2023] [Indexed: 08/17/2023]
Abstract
Uncoupling toxicity from therapeutic effect lies at the foundation of the current state of the field of cutaneous immune-related adverse events to immune checkpoint inhibitor therapy. This will be achieved through understanding the drivers of toxicity, tumor response, and resistance via large, well-powered population-level studies, institutional cohort data, and cellular-level data. Increasing diagnostic specificity through the application of consensus disease definitions has the power to improve clinical care and each approach to research. Cutaneous immune-related adverse events are associated with increased survival, and their treatment must invoke the maintenance of a delicate balance between immunosuppression, anti-tumor effect of immune checkpoint inhibitor therapy, and quality of life. The multidisciplinary care of cancer patients with adverse events is critical to optimizing clinical and translational research outcomes and, as such, dermatologists are vital to moving the study of cutaneous adverse events forward.
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Affiliation(s)
- Blair S Allais
- Inova Schar Cancer Institute, Melanoma and Skin Cancer Center, Fairfax, Virginia, USA
| | - Christopher J Fay
- The Center for Cutaneous Oncology, Department of Dermatology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel Y Kim
- Harvard-MIT Health Sciences and Technology Program, Harvard Medical School, Boston, Massachusetts, USA
| | - Yevgeniy R Semenov
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nicole R LeBoeuf
- The Center for Cutaneous Oncology, Department of Dermatology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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7
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Merli M, Accorinti M, Romagnuolo M, Marzano A, Di Zenzo G, Moro F, Antiga E, Maglie R, Cozzani E, Parodi A, Gasparini G, Sollena P, De Simone C, Caproni M, Pisano L, Fattore D, Balestri R, Sena P, Vezzoli P, Teoli M, Ardigò M, Vassallo C, Michelerio A, Satta RR, Dika E, Melotti B, Ribero S, Quaglino P. Autoimmune bullous dermatoses in cancer patients treated by immunotherapy: a literature review and Italian multicentric experience. Front Med (Lausanne) 2023; 10:1208418. [PMID: 37547602 PMCID: PMC10400335 DOI: 10.3389/fmed.2023.1208418] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/30/2023] [Indexed: 08/08/2023] Open
Abstract
Cutaneous immune-related adverse events are frequently associated with immune checkpoint inhibitors (ICIs) administration in cancer patients. In fact, these monoclonal antibodies bind the cytotoxic T-lymphocyte antigen-4 and programmed cell death-1/ligand 1 leading to a non-specific activation of the immune system against both tumoral cells and self-antigens. The skin is the most frequently affected organ system appearing involved especially by inflammatory manifestations such as maculopapular, lichenoid, psoriatic, and eczematous eruptions. Although less common, ICI-induced autoimmune blistering diseases have also been reported, with an estimated overall incidence of less than 5%. Bullous pemphigoid-like eruption is the predominant phenotype, while lichen planus pemphigoides, pemphigus vulgaris, and mucous membrane pemphigoid have been described anecdotally. Overall, they have a wide range of clinical presentations and often overlap with each other leading to a delayed diagnosis. Achieving adequate control of skin toxicity in these cases often requires immunosuppressive systemic therapies and/or interruption of ICI treatment, presenting a therapeutic challenge in the context of cancer management. In this study, we present a case series from Italy based on a multicenter, retrospective, observational study, which included 45 patients treated with ICIs who developed ICI-induced bullous pemphigoid. In addition, we performed a comprehensive review to identify the cases reported in the literature on ICI-induced autoimmune bullous diseases. Several theories seeking their underlying pathogenesis have been reported and this work aims to better understand what is known so far on this issue.
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Affiliation(s)
- Martina Merli
- Dermatology Clinic, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Martina Accorinti
- Dermatology Clinic, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Maurizio Romagnuolo
- Dermatology Unit, Department of Internal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, Milan, Italy
| | - Angelo Marzano
- Dermatology Unit, Department of Internal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, Milan, Italy
| | - Giovanni Di Zenzo
- Laboratory of Molecular and Cell Biology, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
| | - Francesco Moro
- Laboratory of Molecular and Cell Biology, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
| | - Emiliano Antiga
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Roberto Maglie
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Emanuele Cozzani
- Section of Dermatology, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Dermatology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Aurora Parodi
- Section of Dermatology, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Dermatology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Giulia Gasparini
- Section of Dermatology, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Dermatology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Pietro Sollena
- Dermatology Unit, Department of Surgical and Medical Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Clara De Simone
- Dermatology Unit, Department of Surgical and Medical Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Dermatology Unit, University Department of Medicine and Translational Surgery, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Marzia Caproni
- Immunopathology and Rare Skin Diseases Unit, Section of Dermatology, Department of Health Sciences, Azienda Unità Sanitaria Locale Toscana Centro, University of Florence, Florence, Italy
| | - Luigi Pisano
- Section of Dermatology, Department of Health Sciences, Azienda Unità Sanitaria Locale Toscana Centro, University of Florence, Florence, Italy
| | - Davide Fattore
- Section of Dermatology, Department of Clinical Medicine and Surgery, Università Degli Studi di Napoli Federico II, Naples, Italy
| | - Riccardo Balestri
- Division of Dermatology, Outpatient Consultation for Rare Diseases, APSS, Trento, Italy
| | - Paolo Sena
- Dermatology Unit ASST-Papa Giovanni XXIII, Bergamo, Italy
| | - Pamela Vezzoli
- Dermatology Unit ASST-Papa Giovanni XXIII, Bergamo, Italy
| | - Miriam Teoli
- Porphyria and Rare Diseases, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | - Marco Ardigò
- Porphyria and Rare Diseases, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | - Camilla Vassallo
- Dermatology Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Michelerio
- Dermatology Unit, Ospedale Cardinal Massaia, Asti, Italy
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Rosanna Rita Satta
- Department of Medical, Surgical, and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Emi Dika
- Melanoma Center, Dermatology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Unit of Dermatology, Department of Medical and Surgical Sciences, DIMEC, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Barbara Melotti
- Oncology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Simone Ribero
- Dermatology Clinic, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Pietro Quaglino
- Dermatology Clinic, Department of Medical Sciences, University of Turin, Turin, Italy
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8
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Chang ALS, Zaba L, Kwong BY. Immunotherapy for keratinocyte cancers. Part II: Identification and management of cutaneous side effects of immunotherapy treatments. J Am Acad Dermatol 2023; 88:1243-1255. [PMID: 37268391 DOI: 10.1016/j.jaad.2022.07.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 07/11/2022] [Accepted: 07/26/2022] [Indexed: 06/04/2023]
Abstract
Keratinocytic cancers (KCs), specifically cutaneous squamous cell and basal cell carcinomas, can respond to topical, intralesional, or systemic immunotherapies, but cutaneous adverse events (CAEs) may occur. Understanding these risks, early recognition of these CAEs, and effective treatment may enable patients to continue their anticancer immunotherapies without dose impact. Immune checkpoint inhibitor-related CAEs after KCs can have multiple clinical presentations, with specific observed types including psoriasis and bullous pemphigoid. Cutaneous toxicities can require biopsies to confirm the diagnosis, especially in patients who are not responsive to topical or oral steroids, since the selection of biologic drugs depends on accurate diagnosis. Different types of CAEs from immune checkpoint inhibitors have been associated with different oncologic outcomes in various primary cancer types, and this remains to be determined for KC patients. CAE characterization and management after immune checkpoint inhibitors in KC patients is a rapidly growing field that needs specific and prospective studies.
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Affiliation(s)
- Anne Lynn S Chang
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California.
| | - Lisa Zaba
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
| | - Bernice Y Kwong
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
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9
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Wang J, Hu X, Jiang W, Zhou W, Tang M, Wu C, Liu W, Zuo X. Analysis of the clinical characteristics of pembrolizumab-induced bullous pemphigoid. Front Oncol 2023; 13:1095694. [PMID: 36937423 PMCID: PMC10022695 DOI: 10.3389/fonc.2023.1095694] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 02/16/2023] [Indexed: 03/06/2023] Open
Abstract
Background Pembrolizumab, a programmed cell death protein 1 checkpoint inhibitor, is a novel drug used to treat a variety of advanced malignancies. However, it can also result in many immune-related adverse events, with cutaneous toxicities being the most frequent. Regarding pembrolizumab-induced skin adverse reactions, bullous pemphigoid (BP) has the worst effects on quality of life. Recently, there have been more and more reports of BP incidents resulting from pembrolizumab therapy in patients with cancer. This study aimed to define the clinical characteristics, diagnosis and management of pembrolizumab-induced BP and identify potential differences between classical BP and pembrolizumab-induced BP. Methods Case reports, case series, and case analyses of pembrolizumab-induced BP up to 10 December 2022 were collected for retrospective analysis. Results Our study included 47 patients (33 males and 14 females) from 40 studies. The median age was 72 years (range 42-86 years). The median time to cutaneous toxicity was 4 months (range 0.7-28 months), and the median time to bullae formation was 7.35 months (range 0.7-32 months). The most common clinical features were tense bullae and blisters (85.11%), pruritus (72.34%), and erythema (63.83%) on the limbs and trunk. In 20 of the 22 cases tested, the serum anti-BP180 autoantibodies were positive. However, in 10 cases (91.90%, 10/11) the circulating autoantibodies of anti-BP230 were negative. 40 patients had skin biopsies and the skin biopsy revealed subepidermal bullae or blister eosinophil infiltration in 75.00% of patients with pembrolizumab-induced BP, 10.00% of patients with lymphocyte infiltration and 20.00% of patients with neutrophil infiltration. There were 20 patients (50%) with eosinophilic infiltration around the superficial dermis vessels, 8 patients (20.00%) with lymphocyte infiltration around the superficial dermis vessels, and 4 patients (10.00%) with neutrophil infiltration around the superficial dermis vessels. Direct immunofluorescence detected linear immunoglobulin G (IgG) IgG and/or complement C3 along the dermo-epidermal junction in 36 patients (94.74%) with BP. IgG positivity was detected by indirect immunofluorescence in 81.82% of patients with BP. All patients were in complete remission (95.65%,44/46) or partial remission (4.35%, 2/46) of BP, whereas 9/46 patients had a relapse or refractory. The majority of patients achieved BP remission after discontinuation of pembrolizumab with a combination of topically and systemically administered steroid treatments, or other medications. The median duration of BP remission was 2 months (range 0.3-15 months). Conclusion A thorough diagnosis of pembrolizumab-induced BP should be made using clinical signs, biochemical markers, histopathological and immunopathological tests. Pembrolizumab-induced BP had similar clinical characteristics to classic BP. Temporary or permanent discontinuation of pembrolizumab therapy may be required in patients with perbolizumab-induced BP depending on the severity of BP and the response to medication. Pembrolizumab-induced BP may be effectively treated using topical and systemic steroid treatments in combination with other medications (e.g., doxycycline, niacinamide, dapsone, rituximab, intravenous immunoglobulins, dupilumab, cyclophosphamide, methotrexate, mycophenolate mofetil, and infliximab). Clinicians should provide better management to patients with BP receiving pembrolizumab to prevent progression and ensure continuous cancer treatment.
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Affiliation(s)
- Jianglin Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Xin Hu
- Department of Pharmacy, Taojiang County People’s Hospital, Yiyang, China
| | - Wei Jiang
- Department of Pharmacy, Nanxian Hospital of Traditional Chinese Medicine, Yiyang, China
| | - Wenjie Zhou
- Department of Pharmacy, Yongzhou Third People’s Hospital, Yongzhou, China
| | - Mengjie Tang
- Department of Pathology, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Cuifang Wu
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Wei Liu
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Wei Liu,
| | - Xiaocong Zuo
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
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Pan CX, Pisano CE, DeSimone MS, Nambudiri VE. A 72-year-old man with nonhealing facial erosions and bullae. JAAD Case Rep 2022; 27:99-102. [PMID: 36039335 PMCID: PMC9418044 DOI: 10.1016/j.jdcr.2022.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Catherina X. Pan
- Harvard Medical School, Boston, Massachusetts
- Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Catherine E. Pisano
- Harvard Medical School, Boston, Massachusetts
- Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts
- Dana-Farber Cancer Institute, Cutaneous Oncology, Boston, Massachusetts
| | - Mia S. DeSimone
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Vinod E. Nambudiri
- Harvard Medical School, Boston, Massachusetts
- Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts
- Dana-Farber Cancer Institute, Cutaneous Oncology, Boston, Massachusetts
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Schauer F, Rafei-Shamsabadi D, Mai S, Mai Y, Izumi K, Meiss F, Kiritsi D. Hemidesmosomal Reactivity and Treatment Recommendations in Immune Checkpoint Inhibitor-Induced Bullous Pemphigoid-A Retrospective, Monocentric Study. Front Immunol 2022; 13:953546. [PMID: 35936009 PMCID: PMC9355658 DOI: 10.3389/fimmu.2022.953546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Immune checkpoint inhibitors (ICI) induce T-cell-mediated antitumour responses. While ICI were initially successfully applied in metastasized melanoma, they are now approved for several tumour entities. Numerous autoimmune disorders have been reported to occur as adverse events of the treatment, among them bullous pemphigoid (BP), with less than 1% of the patients experiencing ICI-induced BP. This number is higher than the estimated prevalence of autoimmune bullous diseases in the general population of Germany, which lies around 0.05%. We here describe our cohort of eight patients, who developed a bullous pemphigoid under or shortly after ICI treatment. Half of them had a severe subtype (as shown by BPDAI >57) and showed a median onset of ICI-BP after 10 months of ICI initiation. Six patients had a palmar and/or plantar involvement, while oral involvement occurred in one case. All patients had linear epidermal IgG depositions in split skin in the indirect immunofluorescence. In four out of five biopsies available for direct immunofluorescence, linear IgG and C3 depositions were detected at the basement membrane, while one patient showed linear IgM staining. Moderate to high levels of FLBP180 autoantibodies were found in seven of eight cases. The disease can still be active after ICI discontinuation, while rituximab might be required for remission. Finally, four tumour samples were stained histochemically for collagen XVII (BP180), but no enhanced expression was found.
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Affiliation(s)
- Franziska Schauer
- Department of Dermatology, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - David Rafei-Shamsabadi
- Department of Dermatology, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Shoko Mai
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yosuke Mai
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kentaro Izumi
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Frank Meiss
- Department of Dermatology, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Dimitra Kiritsi
- Department of Dermatology, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
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