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Martel J, Hanania HL, Patel AB. Immune checkpoint inhibitor-induced cutaneous toxicities: a review of histopathologic and clinical features. Hum Pathol 2023; 140:144-172. [PMID: 37141978 DOI: 10.1016/j.humpath.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/06/2023]
Abstract
Immune checkpoint inhibitors (ICIs) represent an emerging treatment option for a variety of cancer types. Through inhibition of programmed cell death protein 1 (PD-1), programmed cell death ligand 1 (PD-L1), and/or cytotoxic lymphocyte-associated antigen-4 (CTLA-4), ICIs activate the host's immune system causing a heightened anti-tumor response. However, off-target effects of ICIs can result in numerous different immune-related cutaneous adverse events (irCAEs). Beyond impacting quality of life, irCAEs can lead to dose limitations or discontinuation of anti-cancer therapies. Correct diagnosis is necessary for expedient and appropriate management. Skin biopsies are often performed to increase diagnostic accuracy and guide clinical management. An extensive literature review was performed using the PubMed database to identify the reported clinical and histopathologic features of irCAEs. This comprehensive review primarily details the histopathologic features of various irCAEs reported to date. Clinical presentation and immunopathogenesis are also discussed in relation to histopathology.
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Affiliation(s)
- Julianna Martel
- Department of Dermatology, The University of Texas, MD Anderson Cancer Center, Houston, TX, 77030, USA
| | | | - Anisha B Patel
- Department of Dermatology, The University of Texas, MD Anderson Cancer Center, Houston, TX, 77030, USA.
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2
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Burshtein A, Burshtein J, Rekhtman S. Extragenital lichen sclerosus: a comprehensive review of clinical features and treatment. Arch Dermatol Res 2023; 315:339-346. [PMID: 36198917 DOI: 10.1007/s00403-022-02397-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 07/18/2022] [Accepted: 09/07/2022] [Indexed: 11/24/2022]
Abstract
Lichen sclerosus (LS) is a chronic inflammatory skin disease commonly affecting the anogenital area with less frequent extragenital occurrence. Extragenital LS cutaneous manifestations vary and precipitating factors are not well described. Recent evidence for etiology and clinical associations of extragenital LS provide insight into disease recognition and pathogenesis. Novel diagnostic techniques as well as treatment standardization have the potential to improve management of this rare condition. This review details both past and new insights into the pathogenesis, clinical manifestations, and treatment options of extragenital LS.
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Affiliation(s)
- Aaron Burshtein
- Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 1991 Marcus Avenue, Suite 300, New Hyde Park, NY, 11042, USA
| | - Joshua Burshtein
- Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 1991 Marcus Avenue, Suite 300, New Hyde Park, NY, 11042, USA
| | - Sergey Rekhtman
- Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 1991 Marcus Avenue, Suite 300, New Hyde Park, NY, 11042, USA.
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Alharbi A, Khobrani A, Noor A, Alghamdi W, Alotaibi A, Alnuhait M, Haseeb A. Risk of Lichen Sclerosus and Lichen Planus in Patients Receiving Immune Checkpoint Inhibitors. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:580. [PMID: 36612904 PMCID: PMC9819784 DOI: 10.3390/ijerph20010580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/19/2022] [Accepted: 12/22/2022] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICIs) are recommended for various types of cancer. On the other hand, these ICIs may cause immune-related adverse events (irAEs). Lichen sclerosus (LS) and lichen planus (LP) are two distinct phenotypes of irAEs that occur in a subset of patients treated with ICIs. These adverse effects have a detrimental effect on the patient's quality of life and treatment phases; however, the clinical evaluation and assessment of LS and LP remain uncertain. This study aims to assess and evaluate the risk of LS and LP associated with the use of ICIs via a systematic review of the literature and the USA FDA Adverse Events FAERS database. METHOD The study searched electronic databases such as PubMed, Medline, Cochrane, and Google Scholar for case reports on immune-checkpoint-inhibitor-associated lichen sclerosus and lichen planus published in English between inception and 31 December 2021. The FDA's adverse event reporting system (FAERS) database was also analyzed. RESULTS Thirty-eight case reports and two retrospective studies with a total of 101 patients, in addition to the FAERS data, were evaluated. More cases involved lichen planus (78.9%) than lichen sclerosis (21%). Nivolumab and pembrolizumab were most frequently reported with LS and LP, among other ICIs. Thirty-six out of thirty-eight patients with LS or LP experienced complete remission, while two patients experienced partial remission. Most of the cases had an excellent response to corticosteroids (92.1%), while the remainder had moderate (5.2%) and poor (2.6%) responses. Additionally, the reporting odds ratio (ROR) of the FAERS database indicated a favorable association for ICIs, the risk of LP, and LS. A stronger association was uniquely found between nivolumab and pembrolizumab. CONCLUSION There have been published case reports for these adverse events. Healthcare providers should be aware of the possibility of lichen sclerosis and lichen planus developing in patients receiving ICIs which could necessitate hospitalization or discontinuation. Regulatory agencies are advised to monitor the risks as a potential safety signal.
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Affiliation(s)
- Ahmad Alharbi
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah 24382, Saudi Arabia
- Qassim Health Cluster, Ministry of Health, Buraidah 52385, Saudi Arabia
| | - Attiah Khobrani
- Pharmaceutical Care Services, King Abdullah Medical City, Ministry of Health, Makkah 21955, Saudi Arabia
| | - Afnan Noor
- Pharmaceutical Care Department, King Faisal Specialist Hospital & Research Center, Jeddah 22234, Saudi Arabia
| | - Waad Alghamdi
- Pharmacovigilance Directorate, Saudi Food and Drug Authority, Riyadh 13513, Saudi Arabia
| | - Abdulmalik Alotaibi
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah 24382, Saudi Arabia
| | - Mohammed Alnuhait
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah 24382, Saudi Arabia
| | - Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah 24382, Saudi Arabia
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Mital R, Cartron AM, Trinidad JC, Spaccarelli N, Gibbons-Fideler IS, Kaffenberger BH, Chung CG. Novel cutaneous eruptions in the setting of programmed cell death protein 1 inhibitor therapy. JAAD Case Rep 2022; 31:124-127. [PMID: 36583144 PMCID: PMC9792734 DOI: 10.1016/j.jdcr.2022.11.020] [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: 11/25/2022] Open
Affiliation(s)
- Rohan Mital
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Alexander M. Cartron
- Department of Dermatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - John C. Trinidad
- Department of Dermatology, Massachusetts General Hospital, Cambridge, Massachusetts
| | - Natalie Spaccarelli
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | | | - Catherine G. Chung
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio,Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio,Correspondence to: Catherine G. Chung, MD, 2050 Kenny Rd MMT 930, Columbus, OH 43221.
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Arif T, Fatima R, Sami M. Extragenital lichen sclerosus: A comprehensive review. Australas J Dermatol 2022; 63:452-462. [PMID: 35950883 DOI: 10.1111/ajd.13890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 04/16/2022] [Accepted: 06/16/2022] [Indexed: 11/30/2022]
Abstract
Lichen sclerosus (LS) is a chronic inflammatory mucocutaneous disease of unknown aetiology. About 85% of total cases of LS are genital cases, while extragenital form is seen in only 15-20% of cases. Extragenital LS (EGLS) can occur simultaneously with genital form; however, in 6% of the cases, only extragenital form has been described. Genetic, autoimmune, infectious, environmental and hormonal factors are implicated in its aetiology. Extragenital LS presents as asymptomatic white opalescent papules, which cluster in plaques and slowly progress over time resulting in parchment-like skin usually involving upper trunk, neck and shoulders. Lesions are frequently accompanied by purpura/haemorrhagic spots. The relationship with morphoea has been a topic of debate. Association with several autoimmune diseases has been observed. Diagnosis is usually based on clinical and dermoscopic examination and further supported by histopathological findings. LS needs to be differentiated from several other dermatological conditions such as discoid lupus erythematosus, vitiligo, mycosis fungoides (hypopigmented variant), lichen planus, graft-versus-host disease and morphoea depending upon the stage of the disease. Generally, extragenital LS is believed to lack carcinogenic potential. However, case reports with possible malignant transformation have been described. In this article, the authors have described a concise review of the extragenital form of LS.
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Affiliation(s)
- Tasleem Arif
- Ellahi Medicare Clinic, Srinagar, Kashmir, India
| | - Rafiya Fatima
- Department of Dermatology, Tadawi General Hospital, Dammam, Saudi Arabia
| | - Marwa Sami
- Ellahi Medicare Clinic, Srinagar, Kashmir, India
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Bhardwaj M, Chiu MN, Pilkhwal Sah S. Adverse cutaneous toxicities by PD-1/PD-L1 immune checkpoint inhibitors: Pathogenesis, Treatment, and Surveillance. Cutan Ocul Toxicol 2022; 41:73-90. [PMID: 35107396 DOI: 10.1080/15569527.2022.2034842] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Introduction-The therapeutic use of humanized monoclonal programmed cell death 1 (PD-1) (pembrolizumab, and nivolumab) and programmed cell death ligand-1 (PD-L1) (atezolizumab, avelumab, durvalumab) immune checkpoint inhibitors (ICPi) as potent anticancer therapies is rapidly increasing. The mechanism of signaling of anti-PD-1/PD-L1 involves triggering cytotoxic CD4+/CD8 + T cell activation and subsequent abolition of cancer cells which induces specific immunologic adverse events that are specific to these therapies. These drugs can cause numerous cutaneous reactions and are characterized as the most frequent immune-related adverse events (irAEs). Majority of cutaneous irAEs range from nonspecific eruptions to detectible skin manifestations, which may be self-limiting and present acceptable skin toxicity profiles, while some may produce life-threatening complications.Objective-.This review aims to illuminate the associated cutaneous irAEs related to drugs used in oncology along with the relevant mechanism(s) and management.Areas covered-Literature was searched using various databases including Pub-Med, Google Scholar, and Medline. The search mainly involved research articles, retrospective studies, case reports, and clinicopathological findings. With this review article, an overview of the cutaneous irAEs with anti-PD-1/PD-L1 therapy, as well as suggestions, have been provided, so that their recognition at early stages could help in better management and would prevent treatment discontinuation.Article highlightsCutaneous adverse effects are the most prevalent immune-related adverse events induced by anti-PD-1/PD-L1 immune-checkpoint antibodies.Cutaneous toxicities mainly manifest in the form of maculopapular rash and pruritus.More specific cutaneous complications can also occur, including vitiligo, worsened psoriasis, lichenoid dermatitis, mucosal involvement (e.g., oral lichenoid reaction), dermatomyositis, lupus erythematosus.Cutaneous manifestations can be life-threatening including Stevens-Johnson syndrome/toxic epidermal necrolysis (TEN).Dermatologic toxicities are usually mild, readily manageable, and rarely result in significant morbidity.Adequate management of the cutaneous adverse event and recognition in early stages could lead to the prevention of worsening of the lesions and limit treatment disruption.
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Affiliation(s)
- Maitry Bhardwaj
- Faculty of Pharmaceutical Sciences, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, 160014, India
| | - Mei Nee Chiu
- Faculty of Pharmaceutical Sciences, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, 160014, India
| | - Sangeeta Pilkhwal Sah
- Faculty of Pharmaceutical Sciences, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, 160014, India
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Meet the expert: Topical management of vulvar dermatoses. J Geriatr Oncol 2021; 13:282-286. [PMID: 34824022 DOI: 10.1016/j.jgo.2021.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 09/26/2021] [Accepted: 10/21/2021] [Indexed: 11/22/2022]
Abstract
Vulvar dermatoses are often debilitating chronic skin conditions associated with pain and pruritus. In oncologic patients, cancer treatments can precipitate and exacerbate vulvar dermatoses. Cytotoxic chemotherapy, hormonal therapies, and local pelvic radiation therapy can lead to vulvar symptoms, and cancer treatment-induced vulvar conditions include graft-versus-host-disease and radiation dermatitis. There have also been reports of lichen sclerosus development or exacerbation secondary to hormonal therapy and immune checkpoint inhibitors, attributed to proposed hormonal and immunologic pathogenesis of lichen sclerosus. Early recognition and treatment of these conditions can significantly improve quality of life. In this review, we summarize the clinical features and management characteristics of six types of common vulvar dermatoses that may present in the oncologic patient.
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Quach HT, Johnson DB, LeBoeuf NR, Zwerner JP, Dewan AK. Cutaneous adverse events caused by immune checkpoint inhibitors. J Am Acad Dermatol 2021; 85:956-966. [PMID: 34332798 DOI: 10.1016/j.jaad.2020.09.054] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 11/25/2022]
Abstract
IMPORTANCE Immune checkpoint inhibitors (ICIs) have emerged as active therapies for a variety of cancers. Cutaneous toxicities are common immune-related adverse events and patients will often be referred to dermatologists for evaluation. OBSERVATIONS Cutaneous adverse events to ICIs can have a variety of clinical presentations. Among the more common are eczematous, morbilliform, and lichenoid dermatoses, as well as vitiligo and pruritus. Less common adverse events include psoriasiform dermatoses, bullous disorders, and severe cutaneous adverse reactions, including Stevens-Johnson syndrome, toxic epidermal necrolysis, and drug reaction with eosinophilia and systemic symptoms. Because of the immunologic mechanism of ICIs, there are also a variety of rheumatologic adverse reactions with cutaneous manifestations, such as scleroderma, dermatomyositis, cutaneous lupus erythematosus, and various vasculitides. These cutaneous reactions often respond to topical or systemic steroids, although specific toxicities may have alternative treatments available. CONCLUSIONS AND RELEVANCE As they become more widely prescribed, dermatologists will see an increasing number of patients with cutaneous adverse events caused by ICI therapies. Accurately diagnosing and treating these toxicities is paramount to achieving the most favorable outcomes for patients.
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Affiliation(s)
- Henry T Quach
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Nicole R LeBoeuf
- Department of Dermatology, The Center for Cutaneous Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeffrey P Zwerner
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anna K Dewan
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee.
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Simonsen AB, Kaae J, Ellebaek E, Svane IM, Zachariae C. Cutaneous adverse reactions to anti-PD-1 treatment-A systematic review. J Am Acad Dermatol 2020; 83:1415-1424. [PMID: 32320766 DOI: 10.1016/j.jaad.2020.04.058] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 02/06/2023]
Abstract
The use of the humanized monoclonal anti-programmed cell death 1 antibodies pembrolizumab and nivolumab as potent anticancer therapies is rapidly increasing. However, since their approval, numerous cases of cutaneous reactions have been reported. Cutaneous adverse reactions to these agents have yet to be fully characterized and range from nonspecific eruptions to recognizable skin manifestations, which may be localized and vary from mild to life threatening. This systematic review article provides an overview of the various adverse cutaneous reactions to pembrolizumab and nivolumab therapy and offers suggestions for their management.
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Affiliation(s)
- Anne Birgitte Simonsen
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Jeanette Kaae
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Eva Ellebaek
- Department of Oncology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Inge Marie Svane
- Department of Oncology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Claus Zachariae
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
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Di Altobrando A, Bruni F, Alessandrini A, Starace M, Misciali C, Piraccini BM. Severe de-novo palmoplantar and nail psoriasis complicating Nivolumab treatment for metastatic melanoma. Dermatol Ther 2020; 33:e13363. [PMID: 32239596 DOI: 10.1111/dth.13363] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 03/17/2020] [Accepted: 03/28/2020] [Indexed: 12/18/2022]
Abstract
Nivolumab, a fully human IgG4 immune checkpoint modulator, binds to the programmed cell death 1 (PD-1) receptor on T cells and blocks their inhibition. Thus, it increases the anticancer host immune response by allowing T cells to attack tumor cells. Although anti-PD-1 immunotherapy is typically well accepted, deregulation of immune tolerance caused by nivolumab may determine immune-related adverse events, among which skin toxicities represent the most common. We report a case of severe new-onset palmoplantar and nail psoriasis after receiving nivolumab treatment for metastatic melanoma.
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Affiliation(s)
- Ambra Di Altobrando
- Department of Experimental, Diagnostic and Specialty Medicine-Division of Dermatology, University of Bologna, Bologna, Italy
| | - Francesca Bruni
- Department of Experimental, Diagnostic and Specialty Medicine-Division of Dermatology, University of Bologna, Bologna, Italy
| | - Aurora Alessandrini
- Department of Experimental, Diagnostic and Specialty Medicine-Division of Dermatology, University of Bologna, Bologna, Italy
| | - Michela Starace
- Department of Experimental, Diagnostic and Specialty Medicine-Division of Dermatology, University of Bologna, Bologna, Italy
| | - Cosimo Misciali
- Department of Experimental, Diagnostic and Specialty Medicine-Division of Dermatology, University of Bologna, Bologna, Italy
| | - Bianca M Piraccini
- Department of Experimental, Diagnostic and Specialty Medicine-Division of Dermatology, University of Bologna, Bologna, Italy
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