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Pach JJ, Mbonu N, Bhullar S, Cohen JM, Leventhal JS. Immune Checkpoint Inhibitor-Induced Psoriasis: Diagnosis, Management, and a Review of Cases. Dermatol Clin 2024; 42:481-493. [PMID: 38796277 DOI: 10.1016/j.det.2024.02.012] [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] [Indexed: 05/28/2024]
Abstract
Immune checkpoint inhibitors (ICIs) are effective antitumor agents but are associated with immune-related adverse events. ICI-induced psoriasis commonly presents in patients with a history of psoriasis but may occur de novo, and it has a significant physical and psychosocial impact. ICI-induced and non-ICI-induced psoriasis are likely mediated by similar cytokines, and similar treatments are employed. Topical treatment often suffices, and when needed, several systemic treatments appear to be effective without impacting antitumor response. Development of psoriasis may indicate a superior response to ICIs. Thus, recognition and management of ICI-induced psoriasis is essential to avoid ICI interruption and maximize therapeutic potential.
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Affiliation(s)
- Jolanta J Pach
- Department of Dermatology Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Nina Mbonu
- Meharry Medical College, 1005 Drive Db Todd Jr Boulevard, Nashville, TN 37208, USA
| | - Shaman Bhullar
- Department of Dermatology Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Jeffrey M Cohen
- Department of Dermatology Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Jonathan S Leventhal
- Department of Dermatology Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA.
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2
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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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3
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Sun X, Mei X, Liu Y. Exacerbation of psoriasis induced by Nivolumab in a patient with stage IIIc gastric adenocarcinoma: A case report and literature review. J Transl Autoimmun 2023; 6:100193. [PMID: 36852017 PMCID: PMC9958049 DOI: 10.1016/j.jtauto.2023.100193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 08/19/2022] [Indexed: 02/17/2023] Open
Abstract
Nivolumab, the programmed cell death 1 inhibitor, is a kind of immune checkpoint inhibitor commonly used to treat advanced cancers. Unfortunately, such drugs often induce various immune-related adverse events involving different body systems, with psoriasis being one of the skin toxicities. We report the clinical features of an exacerbated psoriasis induced by using nivolumab after three days in a patient with stage IIIc gastric adenocarcinoma. At the same time, we searched 27 case reports published from 2015 to 2021 over the world and systematically summarized the clinical manifestation of a total of 44 cases with psoriasis caused or exacerbated by Nivolumab. Commonly traditional treatment could be useful, and small molecule drugs such as apremilast are effective among some patients. However, more studies are needed to evaluate the efficacy and safety of biologics or small molecule drugs in treating psoriasis induced by nivolumab.
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Affiliation(s)
- Xiaojie Sun
- Clinical Trial and Cosmetics Testing Center, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, 210042, China
| | - Xiaole Mei
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, China.,Key Laboratory of Basic and Translational Research on Immunological Dermatology, Chinese Academy of Medical Sciences, Nanjing, Jiangsu, 210042, China
| | - Yi Liu
- Clinical Trial and Cosmetics Testing Center, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, 210042, China
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4
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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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5
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Apalla Z, Rapoport B, Sibaud V. Dermatologic immune-related adverse events: The toxicity spectrum and recommendations for management. Int J Womens Dermatol 2022; 7:625-635. [PMID: 35005180 PMCID: PMC8721136 DOI: 10.1016/j.ijwd.2021.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/04/2021] [Accepted: 10/17/2021] [Indexed: 01/15/2023] Open
Abstract
Immune checkpoint inhibitors are a new class of oncologic drugs that act via the inhibition of checkpoints, thereby unlocking the immune system to attack cancer cells. Their emergence has radically changed the concept of therapy in oncologic patients. However, despite their overall favorable profile, their use has been associated with specific toxicities that may potentially affect treatment. The so-called immune-related adverse events (irAEs) mostly correspond to dysimmune reactions that can affect nearly every organ system, in theory, notably with the development of colitis, hepatitis, pneumonitis, or thyroiditis. Dermatologic irAEs are also among the most common, reaching a rate of approximately 40%. They are characterized by a wide phenotypic range, including mainly eczematous or lichenoid rashes, psoriasis, or autoimmune bullous disorders. Pruritus may accompany the aforementioned rashes or develop as an isolated symptom without the presence of skin changes. Depigmentation and hair/nail changes can be also observed in association with immune checkpoint inhibitor treatment. In the current article, we present an overview of the clinical spectrum of irAEs and provide tips for early recognition and management of dermatologic irAEs. We highlight the role that dermatologists can play in relieving patients and allowing for oncologic treatment to be maintained and administered more safely.
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Affiliation(s)
- Zoe Apalla
- Second Dermatology Department, School of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Bernardo Rapoport
- Immunology Department, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,The Medical Oncology Centre of Rosebank, Johannesburg, South Africa
| | - Vincent Sibaud
- Oncodermatology Department, Cancer University Institute, Toulouse Oncopole, France
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6
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Apalla Z, Nikolaou V, Fattore D, Fabbrocini G, Freites-Martinez A, Sollena P, Lacouture M, Kraehenbuehl L, Stratigos A, Peris K, Lazaridou E, Richert B, Vigarios E, Riganti J, Baroudjian B, Filoni A, Dodiuk-Gad R, Lebbé C, Sibaud V. European recommendations for management of immune checkpoint inhibitors-derived dermatologic adverse events. The EADV task force 'Dermatology for cancer patients' position statement. J Eur Acad Dermatol Venereol 2021; 36:332-350. [PMID: 34910332 DOI: 10.1111/jdv.17855] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 11/10/2021] [Accepted: 11/18/2021] [Indexed: 12/14/2022]
Abstract
The introduction of immune checkpoint inhibitors (ICIs) opened a new era in oncologic therapy. The favourable profile of ICIs in terms of efficacy and safety can be overshadowed by the development of immune-related adverse events (irAEs). Dermatologic irAEs (dirAEs) appear in about 40% of patients undergoing immunotherapy and mainly include maculopapular, psoriasiform, lichenoid and eczematous rashes, auto-immune bullous disorders, pigmentary disorders, pruritus, oral mucosal lesions, hair and nail changes, as well as a few rare and potentially life-threatening toxicities. The EADV task force Dermatology for Cancer Patients merged the clinical experience of the so-far published data, incorporated the quantitative and qualitative characteristics of each specific dirAEs, and released dermatology-derived, phenotype-specific treatment recommendations for cutaneous toxicities (including levels of evidence and grades of recommendation). The basic principle of management is that the interventions should be tailored to serve the equilibrium between patients' relief from the symptoms and signs of skin toxicity and the preservation of an unimpeded oncologic treatment.
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Affiliation(s)
- Z Apalla
- Second Dermatology Department, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - V Nikolaou
- First Department of Dermatology, "Andreas Sygros" Hospital for Skin Diseases, National and Kapodestrian University of Athens, Medical School, Athens, Greece
| | - D Fattore
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - G Fabbrocini
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - A Freites-Martinez
- Servicio de Dermatología, Hospital Ruber Juan Bravo y Universidad Europea, Madrid, España
| | - P Sollena
- Dipartimento di Scienze Mediche e Chirurgiche, Dermatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Dermatologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - M Lacouture
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - L Kraehenbuehl
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Parker Institute for Cancer Immunotherapy, Ludwig Collaborative and Swim Across America Laboratory, Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
| | - A Stratigos
- First Department of Dermatology, "Andreas Sygros" Hospital for Skin Diseases, National and Kapodestrian University of Athens, Medical School, Athens, Greece
| | - K Peris
- Dipartimento di Scienze Mediche e Chirurgiche, Dermatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Dermatologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - E Lazaridou
- Second Dermatology Department, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - B Richert
- Department of Dermatology, Brugmann & Saint-Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - E Vigarios
- Department of Oral Medicine, Institut Claudius Regaud, Institut Universitaire du Cancer Toulouse-Oncopole, Toulouse, France
| | - J Riganti
- Hospital Italiano of Buenos Aires, Buenos Aires, Argentina
| | - B Baroudjian
- Dermatology Department, Saint Louis Hospital, Université de Paris, AP-HP, INSERM U976, Paris, France
| | - A Filoni
- Section of Dermatology, Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy
| | - R Dodiuk-Gad
- Dermatology Department, Emek Medical Center, Afula, Israel
| | - C Lebbé
- Dermatology Department, Saint Louis Hospital, Université de Paris, AP-HP, INSERM U976, Paris, France
| | - V Sibaud
- Oncodermatology Department, Cancer University Institute, Toulouse Oncopole, Toulouse, France
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7
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Seervai RNH, Heberton M, Cho WC, Gill P, Murphy MB, Aung PP, Nagarajan P, Torres-Cabala CA, Patel AB, Ruiz-Bañobre J, Om A, Yamamoto T, Nikolaou V, Curry JL. Severe de novo pustular psoriasiform immune-related adverse event associated with nivolumab treatment for metastatic esophageal adenocarcinoma. J Cutan Pathol 2021; 49:472-481. [PMID: 34888886 DOI: 10.1111/cup.14185] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/15/2021] [Accepted: 12/06/2021] [Indexed: 12/12/2022]
Abstract
Breakthrough targeted therapies have produced significant improvements in survival for cancer patients, but have a propensity to cause cutaneous immune-related adverse events (irAEs). Psoriasiform irAEs, representing about 4% of dermatologic toxicities associated with immune checkpoint inhibitor (ICI) therapy, are usually mild, occur in older patients and present as an exacerbation of existing psoriasis after several doses of ICI therapy. We report a case of a 58-year-old woman with metastatic esophageal adenocarcinoma and no prior history of psoriasis who developed a pustular psoriasiform irAE, beginning 3 days after initiation of nivolumab and progressing to confluent erythroderma with pustules over 2 weeks despite topical steroid use. She had concurrent acrodermatitis enteropathica, clinically diagnosed and confirmed with a low serum zinc level, that improved with supplementation. Her psoriasiform irAE was refractory to systemic steroids and acitretin, prompting discontinuation of nivolumab and treatment with ustekinumab and concomitant slow taper of acitretin and prednisone. Pustular psoriasiform irAE is a rare but severe dermatologic toxicity resulting from ICI therapy. Given the diverse morphologic types of cutaneous irAEs that can occur during ICI therapy, a clinical and histopathologic examination of dermatologic toxicities is critical to identify patients who may benefit from biologic therapy.
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Affiliation(s)
- Riyad N H Seervai
- Medical Scientist Training Program, Baylor College of Medicine, Houston, Texas, USA.,Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas, USA.,Department of Dermatology, Baylor College of Medicine, Houston, Texas, USA
| | - Meghan Heberton
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Woo Cheal Cho
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pavandeep Gill
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mariela B Murphy
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Phyu P Aung
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Priyadharsini Nagarajan
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Carlos A Torres-Cabala
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anisha B Patel
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Juan Ruiz-Bañobre
- Medical Oncology Department, University Clinical Hospital of Santiago de Compostela, CIBERONC, Santiago de Compostela, Santiago, Spain
| | - Amit Om
- Department of Dermatology, Florida State University, Tallahassee, Florida, USA
| | - Toshiyuki Yamamoto
- Dermartment of Dermatology, Fukushima Medical University, Fukushima, Japan
| | - Vasiliki Nikolaou
- Cutaneous Toxicities Clinic, Oncodermatology Department, "Andreas Sygros" Hospital for Skin Diseases, Athens, Greece
| | - Jonathan L Curry
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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O'Keeffe C, Barbosa E, Gulmann C, O'Kane M. A challenging acral psorasiform eruption in the setting of pembrolizumab therapy. Dermatol Ther 2020; 33:e14524. [DOI: 10.1111/dth.14524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/03/2020] [Accepted: 11/06/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Ciara O'Keeffe
- Department of Dermatology Beaumont Hospital Dublin Ireland
| | - Elsa Barbosa
- Department of Dermatology Beaumont Hospital Dublin Ireland
| | | | - Marina O'Kane
- Department of Dermatology Beaumont Hospital Dublin Ireland
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9
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Treatment of Advanced Melanoma: Past, Present and Future. Life (Basel) 2020; 10:life10090208. [PMID: 32948031 PMCID: PMC7556013 DOI: 10.3390/life10090208] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 09/11/2020] [Accepted: 09/13/2020] [Indexed: 12/17/2022] Open
Abstract
Therapeutic options for treating advanced melanoma are progressing rapidly. Until six years ago, the regimen for treating advanced melanoma mainly comprised cytotoxic agents such as dacarbazine, and type I interferons. Since 2014, anti-programmed cell death 1 (PD1) antibodies have become recognized as anchor drugs for treating advanced melanoma with or without additional combination drugs such as ipilimumab. In addition, v-Raf murine sarcoma viral oncogene homolog B1 (BRAF) kinase inhibitors in combination with mitogen-activated protein kinase kinase (MEK) inhibitors are among the most promising chemotherapeutic regimens for treating advanced BRAF-mutant melanoma, especially in patients with low tumor burden. Since anti-PD1 antibodies are widely applicable for the treatment of both BRAF wild-type and mutated advanced melanomas, several clinical trials for drugs in combination with anti-PD1 antibodies are ongoing. This review focuses on the development of the anti-melanoma therapies available today, and discusses the clinical trials of novel regimens for the treatment of advanced melanoma.
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