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Fay CJ, Jakuboski S, Mclellan B, Allais BS, Semenov Y, Larocca CA, LeBoeuf NR. Diagnosis and Management of Dermatologic Adverse Events from Systemic Melanoma Therapies. Am J Clin Dermatol 2023; 24:765-785. [PMID: 37395930 PMCID: PMC10796164 DOI: 10.1007/s40257-023-00790-8] [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] [Accepted: 05/02/2023] [Indexed: 07/04/2023]
Abstract
The advent of protein kinase inhibitors and immunotherapy has profoundly improved the management of advanced melanoma. However, with these therapeutic advancements also come drug-related toxicities that have the potential to affect various organ systems. We review dermatologic adverse events from targeted (including BRAF and MEK inhibitor-related) and less commonly used melanoma treatments, with a focus on diagnosis and management. As immunotherapy-related toxicities have been extensively reviewed, herein, we discuss injectable talimogene laherparepvec and touch on recent breakthroughs in the immunotherapy space. Dermatologic adverse events may severely impact quality of life and are associated with response and survival. It is therefore essential that clinicians are aware of their diverse presentations and management strategies.
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Affiliation(s)
- Christopher J Fay
- Department of Dermatology, Brigham and Women's Hospital, and the Center for Cutaneous Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA
| | | | - Beth Mclellan
- Department of Dermatology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Blair S Allais
- Department of Dermatology, Brigham and Women's Hospital, and the Center for Cutaneous Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Yevgeniy Semenov
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cecilia A Larocca
- Department of Dermatology, Brigham and Women's Hospital, and the Center for Cutaneous Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Nicole R LeBoeuf
- Department of Dermatology, Brigham and Women's Hospital, and the Center for Cutaneous Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA.
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Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): Focus on the Pathophysiological and Diagnostic Role of Viruses. Microorganisms 2023; 11:microorganisms11020346. [PMID: 36838310 PMCID: PMC9966117 DOI: 10.3390/microorganisms11020346] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/31/2023] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a heterogeneous, multiorgan and potentially life-threatening drug-hypersensitivity reaction (DHR) that occurs several days or weeks after drug initiation or discontinuation. DHRs constitute an emerging issue for public health, due to population aging, growing multi-organ morbidity, and subsequent enhanced drug prescriptions. DRESS has more consistently been associated with anticonvulsants, allopurinol and antibiotics, such as sulphonamides and vancomycin, although new drugs are increasingly reported as culprit agents. Reactivation of latent infectious agents such as viruses (especially Herpesviridae) plays a key role in prompting and sustaining aberrant T-cell and eosinophil responses to drugs and pathogens, ultimately causing organ damage. However, the boundaries of the impact of viral agents in the pathophysiology of DRESS are still ill-defined. Along with growing awareness of the multifaceted aspects of immune perturbation caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the ongoing SARS-CoV-2-related disease (COVID-19) pandemic, novel interest has been sparked towards DRESS and the potential interactions among antiviral and anti-drug inflammatory responses. In this review, we summarised the most recent evidence on pathophysiological mechanisms, diagnostic approaches, and clinical management of DRESS with the aim of increasing awareness on this syndrome and possibly suggesting clues for future research in this field.
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Du J, Yan H, Xu Z, Yang B, He Q, Wang X, Luo P. Cutaneous toxicity of FDA-approved small-molecule kinase inhibitors. Expert Opin Drug Metab Toxicol 2021; 17:1311-1325. [PMID: 34743659 DOI: 10.1080/17425255.2021.2004116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION By 1 January 2021, the FDA has approved a total of 62 small-molecule kinase inhibitors (SMKIs). The increasing clinical use of small-molecule kinase inhibitors has led to some side effects, the most common of which is cutaneous toxicity, as reflected by approximately 90% (57 of 62) of the FDA-approved SMKIs have reported treatment-related cutaneous toxicities. Since these cutaneous toxicities may have a crucial influence on the emotional, physical and psychosocial health of the patients, it is of great importance for doctors, patients, oncologists and interrelated researchers to be aware of the cutaneous side effects of these drugs in order to make the diagnosis accurate and the treatment appropriate. AREAS COVERED This review aims to summarize the potential cutaneous toxicities and the frequency of occurrence of FDA-approved 62 SMKIs, and provide a succinct overview of the potential mechanisms of certain cutaneous toxicities. The literature review was performed based on PubMed database and FDA official website. EXPERT OPINION It is significant to determine the risk factors for SMKI-induced cutaneous toxicity. The mechanisms underlying SMKI-induced cutaneous toxicities remain unclear at present. Future research should focus on the mechanisms of SMKI-induced cutaneous toxicities to find out mechanistically driven therapies.
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Affiliation(s)
- Jiangxia Du
- Center for Drug Safety Evaluation and Research of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Hao Yan
- Center for Drug Safety Evaluation and Research of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Zhifei Xu
- Center for Drug Safety Evaluation and Research of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Bo Yang
- Institute of Pharmacology & Toxicology, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Qiaojun He
- Center for Drug Safety Evaluation and Research of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Xiaohong Wang
- Department of Chemotherapy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences, Hangzhou, China
| | - Peihua Luo
- Center for Drug Safety Evaluation and Research of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
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Kohlmann J, Reschke R, Mockenhaupt M, Ziemer M. Severe skin eruption with features of drug reaction with eosinophilia and systemic symptoms (DRESS) during vemurafenib treatment of melanoma. J Eur Acad Dermatol Venereol 2021; 36:e242-e244. [PMID: 34704628 DOI: 10.1111/jdv.17775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 10/15/2021] [Accepted: 10/22/2021] [Indexed: 11/29/2022]
Affiliation(s)
- J Kohlmann
- Department of Dermatology, University of Leipzig Medical Center, Leipzig, Germany
| | - R Reschke
- Department of Dermatology, University of Leipzig Medical Center, Leipzig, Germany
| | - M Mockenhaupt
- Dokumentationszentrum schwerer Hautreaktionen' (dZh) Department of Dermatology, Medical Center and Medical Faculty, University of Freiburg, Freiburg, Germany
| | - M Ziemer
- Department of Dermatology, University of Leipzig Medical Center, Leipzig, Germany
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Maloney NJ, Rana J, Yang JJ, Zaba LC, Kwong BY. Clinical features of drug-induced hypersensitivity syndrome to BRAF inhibitors with and without previous immune checkpoint inhibition: a review. Support Care Cancer 2021; 30:2839-2851. [PMID: 34546454 DOI: 10.1007/s00520-021-06543-9] [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: 03/28/2021] [Accepted: 09/04/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Cutaneous reactions to BRAF inhibitors are common, but severe reactions resembling or consistent with drug-induced hypersensitivity syndrome (DIHS)/drug reaction with eosinophilia and systemic symptoms (DRESS) are relatively rare. Several reports suggest that cutaneous reactions including DRESS/DIHS to BRAF inhibitors are more frequent and severe in the setting of previous immune checkpoint inhibition (ICI). METHODS To characterize existing literature on these reports, we queried the PubMed/MEDLINE database for cases of DIHS/DRESS to BRAF inhibitors. RESULTS We identified 23 cases of DIHS to BRAF inhibitors following checkpoint inhibition and 14 cases without prior checkpoint inhibitor therapy. In both cohorts, DIHS occurred relatively early, with median time to onset from drug exposure of 8-10 days. Patients who received prior ICI were less likely to have peripheral eosinophilia (26% vs 71%), atypical lymphocytes (9% vs 50%), renal involvement (61% vs 79%), hepatic involvement (52% vs 86%), and lymphadenopathy (9% vs 43%) compared to patients who did not receive prior ICI. Thrombocytopenia was more common with prior ICI (17% vs 7%). Only patients who received prior ICI experienced hypotension (26%) during the course of their DIHS. All cases of BRAF-induced DIHS generally improved on systemic steroids/supportive care, and no cases of death were identified. CONCLUSION Dermatologists should consider a diagnosis of DIHS following BRAF inhibitor initiation, particularly in the setting of past checkpoint inhibition, with atypical features including relatively rapid onset and steroid responsiveness, lack of peripheral eosinophilia, lymphocytosis, or lymphadenopathy, and increased risk of thrombocytopenia and hypotension.
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Affiliation(s)
- Nolan J Maloney
- Department of Dermatology, Stanford University Medical Center and Cancer Institute, 780 Welch Road, CJ220F, Palo Alto, CA, 94304-5779, USA
| | - Jasmine Rana
- Department of Dermatology, Stanford University Medical Center and Cancer Institute, 780 Welch Road, CJ220F, Palo Alto, CA, 94304-5779, USA
| | - Jason J Yang
- Division of Dermatology, Department of Medicine, David Geffen School of Medicine At UCLA, Los Angeles, CA, USA
| | - Lisa C Zaba
- Department of Dermatology, Stanford University Medical Center and Cancer Institute, 780 Welch Road, CJ220F, Palo Alto, CA, 94304-5779, USA
| | - Bernice Y Kwong
- Department of Dermatology, Stanford University Medical Center and Cancer Institute, 780 Welch Road, CJ220F, Palo Alto, CA, 94304-5779, USA.
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Tardieu M, Néron A, Duvert-Lehembre S, Amine Larabi I, Barkaoui M, Emile JF, Seigneurin A, Boralevi F, Donadieu J. Cutaneous adverse events in children treated with vemurafenib for refractory BRAF V600E mutated Langerhans cell histiocytosis. Pediatr Blood Cancer 2021; 68:e29140. [PMID: 34109735 DOI: 10.1002/pbc.29140] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 04/16/2021] [Accepted: 04/29/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND The somatic BRAFV600E mutation occurs in 38-64% of pediatric cases of Langerhans cell histiocytosis (LCH). Vemurafenib (VMF), a BRAF inhibitor, was approved for refractory BRAFV600E mutated LCH. In adults, VMF causes frequent cutaneous adverse events (CAE) including skin tumors (squamous cell carcinomas, melanomas), but little is known in children. The objective of this study was to evaluate the frequency, clinical spectrum, and severity of CAEs in children treated with VMF for LCH. In addition, a correlation between CAE occurrence and VMF dose, residual plasma levels (RPLs), and efficacy was searched for. PROCEDURE Multicentric retrospective observational study including patients <18 years treated with VMF alone for refractory BRAFV600E mutated LCH in 13 countries between October 1, 2013 and December 31, 2018. RESULTS Fifty-seven patients: 56% female, median age 2.1 years (0.2-14.6), median treatment duration 4.1 months (1.4-29.7). Forty-one patients (72%) had at least one CAE: photosensitivity (40%), keratosis pilaris (32%), rash (26%), xerosis (21%), and neutrophilic panniculitis (16%). No skin tumor was observed. Five percent of CAEs were grade 3. None were grade 4 or led to permanent VMF discontinuation. Dose reduction was necessary for 12% of patients, temporary treatment discontinuation for 16%, none leading to loss of efficacy. VMF dose, median RPL, and efficacy were not correlated with CAE occurrence. CONCLUSIONS At doses used for pediatric LCH, CAEs are frequent but rarely severe and have little impact on the continuation of treatment when managed appropriately. Regular dermatological follow-up is essential to manage CAEs and screen for possible induced skin tumors.
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Affiliation(s)
- Mathilde Tardieu
- Pediatric Dermatology Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Amélie Néron
- Dermatology Department, Grenoble Alpes University Hospital, Grenoble, France
| | | | - Islam Amine Larabi
- Department of Pharmacology and Toxicology, Paris-Saclay University (Versailles Saint-Quentin-en-Yvelines University), Inserm U-1173, Raymond Poincaré Hospital, Garches, France
| | - Mohamed Barkaoui
- French Reference Center for Langerhans Cell Histiocytosis, Trousseau Hospital, Paris, France
| | - Jean-Francois Emile
- Pathology Department & EA4340-BECCOH, Ambroise Paré Hospital, AP-HP & Versailles SQY University, Boulogne, France
| | - Arnaud Seigneurin
- TIMC-IMAG Laboratory, Grenoble Alpes University, Grenoble Alpes University Hospital, Grenoble, France
| | - Franck Boralevi
- Pediatric Dermatology Unit, Hôpital Pellegrin-Enfants, Bordeaux, France
| | - Jean Donadieu
- French Reference Center for Langerhans Cell Histiocytosis, Trousseau Hospital, Paris, France
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Maximova N, Maestro A, Zanon D, Marcuzzi A. Rapid recovery of postnivolumab vemurafenib-induced Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome after tocilizumab and infliximab administration. J Immunother Cancer 2020; 8:jitc-2019-000388. [PMID: 32066648 PMCID: PMC7057420 DOI: 10.1136/jitc-2019-000388] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2020] [Indexed: 12/17/2022] Open
Abstract
Background Immune checkpoint inhibitors such as nivolumab and targeted BRAF inhibitors have dramatically altered the treatment outcomes of metastatic melanoma over the past few years. Skin toxicity is the most common adverse event (AE) related to the commonly used BRAF inhibitor vemurafenib, affecting more than 90% of patients. Vemurafenib-related severe AEs with early onset are reported in patients who were previously treated with anti-programmed cell death-1 (anti PD-1) antibodies. A prolonged administration of systemic steroids is the first-line treatment of severe or life-threatening AEs. We report the case of a woman suffering from vemurafenib-related severe, rapidly worsening Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome, resolved in a few hours after single-dose administration of a combination of TNF-α antagonist infliximab with interleukin (IL)-6 receptor antagonist tocilizumab. Case presentation A 41-year-old woman treated with single-agent nivolumab presented with a melanoma progression. Biopsy samples were revised, revealing a BRAF V600E mutation. The patient was started on vemurafenib and cobimetinib treatment only 10 days after the last administration of nivolumab. On the third day of anti-BRAF therapy, profound lymphopenia was detected, and maculopapular eruption appeared afterward. Subsequently, the clinical conditions deteriorated further, and the woman was admitted on an emergency basis with high fever, respiratory and cardiocirculatory failure, diffuse rash, generalized edema, and lymphadenopathy. Diagnosis of DRESS syndrome with overexpressed capillary leakage was made. A single dose of tocilizumab was administered with an improvement of cardiocirculatory and renal function in a few hours. Because of worsening of liver function, skin lesions and mucositis, a single dose of infliximab was prescribed, and dramatic improvement was noted over the next 24 hours. Dabrafenib and trametinib were initiated, and coinciding with washout of infliximab from the patient’s blood, the drug toxicity recurred. Conclusion Anti-IL-6 and anti-TNF-α target treatment of very severe AEs may afford an immediate resolution of potentially life-threatening symptoms and reduce the duration and the costs of hospitalization. Maintenance of therapeutic infliximab blood concentrations permits an early switch to dabrafenib after vemurafenib-related AEs.
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Affiliation(s)
- Natalia Maximova
- Bone Marrow Transplant Unit, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy
| | - Alessandra Maestro
- Pharmacy and Clinical Pharmacology Unit, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy
| | - Davide Zanon
- Pharmacy and Clinical Pharmacology Unit, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy
| | - Annalisa Marcuzzi
- Department of Chemical and Pharmaceutical Sciences, University of Ferrera, Ferrera, Italy
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8
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Torres‐Navarro I, de Unamuno‐Bustos B, Botella‐Estrada R. Systematic review of BRAF/MEK inhibitors‐induced Severe Cutaneous Adverse Reactions (SCARs). J Eur Acad Dermatol Venereol 2020; 35:607-614. [DOI: 10.1111/jdv.16894] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/22/2020] [Accepted: 07/29/2020] [Indexed: 12/13/2022]
Affiliation(s)
- I. Torres‐Navarro
- Dermatology Department Hospital Universitario y Politécnico la Fe València Spain
| | - B. de Unamuno‐Bustos
- Dermatology Department Hospital Universitario y Politécnico la Fe València Spain
| | - R. Botella‐Estrada
- Dermatology Department Hospital Universitario y Politécnico la Fe València Spain
- Department of Medicine Universitat de València València Spain
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Abstract
OPINION STATEMENT The treatment of advanced melanoma has undergone a dramatic transformation over the last decade with the advent of targeted and immunomodulatory therapies. This transition from cytotoxic chemotherapy has yielded improvements in both survival and quality of life; yet despite their therapeutic advantages, these treatments have been associated with a diverse range of cutaneous adverse events (AEs). These range from relatively benign eczematous conditions to more severe inflammatory and bullous disorders, and can include induction of second malignancies. AEs can result in serious morbidity and risk of mortality if not recognised and managed early. As a consequence of their novelty, and rapid uptake, these agents have been subject to intense scrutiny and there is a general understanding that cutaneous AEs should be anticipated in treatment plans. Dermatologists should be integrated into management teams to assist in the development of treatment protocols for anticipated common AEs and to provide expert management of more severe, rare or unusual AEs. Our experience has shown a reduction in treatment interruptions, more rapid recognition of unusual AEs and improved management pathways for patients suffering cutaneous AEs.
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Kushnirsky M, Feun LG, Gultekin SH, de la Fuente MI. Prolonged Complete Response With Combined Dabrafenib and Trametinib After BRAF Inhibitor Failure in BRAF-Mutant Glioblastoma. JCO Precis Oncol 2020; 4:PO.19.00272. [PMID: 32923904 PMCID: PMC7446525 DOI: 10.1200/po.19.00272] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2019] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Lynn G. Feun
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
- Department of Medicine, University of Miami, Miami, FL
| | | | - Macarena I. de la Fuente
- Department of Neurology, University of Miami, Miami, FL
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
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11
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Case Reports of DRESS Syndrome and Symptoms Consistent with DRESS Syndrome Following Treatment with Recently Marketed Monoclonal Antibodies. Autoimmune Dis 2019; 2019:7595706. [PMID: 31308976 PMCID: PMC6594346 DOI: 10.1155/2019/7595706] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/14/2019] [Accepted: 05/28/2019] [Indexed: 12/17/2022] Open
Abstract
Background Monoclonal antibodies constitute a potent and broadly tolerable drug class, representing for some conditions the first newly approved treatment in years. As such, many are afforded “fast-track” or “breakthrough therapy” designations by the U.S. Food and Drug Administration, leading to provisional approval before Phase III clinical trials are reported. Although these drugs are usually safe, some patients experience life-threatening complications—myositis and encephalitis have led to permanent or temporary recalls. Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a hypersensitivity condition easily missed due to its long incubation period and nonspecific presentation. This minireview is primarily intended as an abbreviated guide for practitioners who may be using these powerful treatments. Methodology We searched PubMed using a string of symptoms consistent with DRESS syndrome and monoclonal antibodies approved by the FDA since 2015. Then, we excluded studies reporting dermatological complications of reactivation of nonherpetic infection, immunodeficiency-related infection, or reactions to the injection site or infusion. We searched for and accessed prior reviews and background studies via PubMed, Mendeley, and Google Scholar. Results Two cases of DRESS syndrome were identified in the literature, both the result of treatment with daclizumab. There was one additional case of encephalitis without cutaneous symptoms caused by daclizumab. Drug-induced hypersensitivity dermatitis was reported following treatment with nivolumab and two cases of combination treatment with ipilimumab and either nivolumab or durvalumab produced maculopapular rash and bullae in the first patient and lichenoid dermatitis and blisters in the second patient. Conclusions Daclizumab was the only recently approved monoclonal antibody associated with DRESS syndrome as such. Limitations in the diagnostic reliability of DRESS syndrome as a clinical entity and the lack of negative clinical trial reporting suggest enhanced vigilance on the part of clinicians and regulators may be warranted.
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12
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Severe skin toxicity with organ damage under the combination of targeted therapy following immunotherapy in metastatic melanoma. Melanoma Res 2019; 28:451-457. [PMID: 29985833 DOI: 10.1097/cmr.0000000000000472] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Targeted therapy combination (TTC: antiRAF+antiMEK) is known to improve metastatic melanoma survival. Few severe skin toxicities (grade ≥3) are described with first-line TTC (17% for vemurafenib+cobimetinib and none for dabrafenib+trametinib) in a phase III trial. Among our 42 patients treated by TTC between January 2014 and March 2017, 4.8% (2/42) of those treated in the first line presented severe skin rash versus 19% (8/42) of patients treated in the second line after previous immunotherapy. In particular, we observed one case of Stevens-Johnson syndrome and four cases of severe drug reaction with eosinophilia and systemic symptoms syndrome under TTC in patients who had received immunotherapy previously. Thus, previous immunotherapy appears to play an important role in the skin rash onset and severity induced by TTC.
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13
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Chen P, Chen F, Zhou B. Systematic review and meta-analysis of prevalence of dermatological toxicities associated with vemurafenib treatment in patients with melanoma. Clin Exp Dermatol 2018; 44:243-251. [PMID: 30280426 DOI: 10.1111/ced.13751] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2017] [Indexed: 12/12/2022]
Affiliation(s)
- P. Chen
- Department of Pharmacy; Renmin Hospital of Wuhan University; Wuhan China
| | - F. Chen
- Department of Pharmacy; Dongfeng Hospital; Hubei University of Medicine; Shiyan China
| | - B. Zhou
- Department of Pharmacy; Renmin Hospital of Wuhan University; Wuhan China
- School of Pharmaceutical Sciences; Wuhan University; Wuhan China
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14
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Ros J, Muñoz-Couselo E. DRESS syndrome due to vemurafenib treatment: switching BRAF inhibitor to solve a big problem. BMJ Case Rep 2018; 2018:bcr-2018-224379. [PMID: 30275021 DOI: 10.1136/bcr-2018-224379] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
We present a case report of an early-onset drug reaction with eosinophilia and systemic symptoms (DRESS syndrome) induced by vemurafenib (BRAF inhibitor) in a middle-age man affected by a metastatic, BRAF mutant melanoma who was started on first-line metastatic treatment with vemurafenib and cobimetinib.After initiating the treatment, the patient presented an extensive cutaneous rash with eosinophilia and renal impairment. Due the constellation of signs and symptoms, a diagnosis of DRESS syndrome was made which strongly contraindicated the reintroduction of vemurafenib due to its hypersensibility reaction. Thus, vemurafenib was stopped immediately, and we started corticoid treatment with clinical improvement.Due to the contraindication to start vemurafenib again, after multidisciplinary view of the case and having balanced the risks and benefits, we successfully performed a switch to another BRAF inhibitor in a progressively ascending pattern, without any skin toxicity and with a good response of the metastatic melanoma.
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Affiliation(s)
- Javier Ros
- Medical Oncology, Vall d'Hebron Hospital, Barcelona, Spain
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15
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Liu RC, Consuegra G, Fernández-Peñas P. Management of the cutaneous adverse effects of antimelanoma therapy. Melanoma Manag 2017; 4:187-202. [PMID: 30190925 DOI: 10.2217/mmt-2017-0015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 10/17/2017] [Indexed: 02/08/2023] Open
Abstract
The advent of targeted therapy and immunotherapy has revolutionized the management of advanced melanoma. However, these novel therapies are associated with adverse effects (AEs), of which cutaneous toxicities are the most frequently observed. These cutaneous AEs can exert significant morbidity and impact on patient quality of life, hence the recognition and management of AEs is fundamental in preventing interruption or cessation of survival-prolonging treatments. Additionally, knowledge of these AEs are necessary in order for healthcare professionals to counsel patients when starting treatment and in the initiation of AE prophylaxis. The incidence and clinical presentation of the cutaneous toxicities of novel melanoma therapies will be discussed, and treatment guidelines provided.
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Affiliation(s)
- Rose Congwei Liu
- Department of Dermatology, Westmead Hospital, Sydney 2145, Australia.,Westmead Clinical School, University of Sydney Medical School, Sydney 2145, Australia.,Department of Dermatology, Westmead Hospital, Sydney 2145, Australia.,Westmead Clinical School, University of Sydney Medical School, Sydney 2145, Australia
| | - Germana Consuegra
- Department of Dermatology, Westmead Hospital, Sydney 2145, Australia.,Westmead Clinical School, University of Sydney Medical School, Sydney 2145, Australia.,Department of Dermatology, Westmead Hospital, Sydney 2145, Australia.,Westmead Clinical School, University of Sydney Medical School, Sydney 2145, Australia
| | - Pablo Fernández-Peñas
- Department of Dermatology, Westmead Hospital, Sydney 2145, Australia.,Westmead Clinical School, University of Sydney Medical School, Sydney 2145, Australia.,Department of Dermatology, Westmead Hospital, Sydney 2145, Australia.,Westmead Clinical School, University of Sydney Medical School, Sydney 2145, Australia
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16
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Abstract
Melanoma is an aggressive skin cancer that can rapidly metastasize to become fatal, if not diagnosed early. Despite recent therapeutic advances, management of melanoma remains difficult. Therefore, novel molecular targets and strategies are required to manage this neoplasm. This study was undertaken to determine the role of the sirtuin SIRT6 in melanoma. Employing a panel of human melanoma cells and normal human melanocytes, we found significant SIRT6 mRNA and protein upregulation in melanoma cells. Further, using a tissue microarray coupled with quantitative Vectra analysis, we demonstrated significant SIRT6 overexpression in human melanoma tissues. Lentiviral short hairpin RNA-mediated knockdown of SIRT6 in A375 and Hs 294T human melanoma cells significantly decreased cell growth, viability, and colony formation, induced G1-phase arrest and increased senescence-associated beta-galactosidase staining. As autophagy is important in melanoma and is associated with SIRT6, we used a qPCR array to study SIRT6 knockdown in A375 cells. We found significant modulation in several genes and/or proteins (decreases in AKT1, ATG12, ATG3, ATG7, BAK1, BCL2L1, CLN3, CTSB, CTSS, DRAM2, HSP90AA1, IRGM, NPC1, SQSTM1, TNF, and BECN1; increases in GAA, ATG10). Our data suggests that increased SIRT6 expression may contribute to melanoma development and/or progression, potentially via senescence-and autophagy-related pathways.
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Cho YT, Yang CW, Chu CY. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): An Interplay among Drugs, Viruses, and Immune System. Int J Mol Sci 2017; 18:E1243. [PMID: 28598363 PMCID: PMC5486066 DOI: 10.3390/ijms18061243] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 05/30/2017] [Accepted: 06/02/2017] [Indexed: 12/14/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe multiorgan hypersensitivity reaction mostly caused by a limited number of eliciting drugs in patients with a genetic predisposition. Patients with DRESS syndrome present with characteristic but variable clinical and pathological features. Reactivation of human herpesviruses (HHV), especially HHV-6, is the hallmark of the disease. Anti-viral immune responses intertwined with drug hypersensitivity make the disease more complicated and protracted. In recent years, emerging studies have outlined the disease more clearly, though several important questions remain unresolved. In this review, we provide an overview of DRESS syndrome, including clinical presentations, histopathological features, pathomechanisms, and treatments.
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Affiliation(s)
- Yung-Tsu Cho
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 10002, Taiwan.
| | - Che-Wen Yang
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 10002, Taiwan.
| | - Chia-Yu Chu
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 10002, Taiwan.
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18
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Trautmann A, Benoit S, Goebeler M, Stoevesandt J. "Treating Through" Decision and Follow-up in Antibiotic Therapy-Associated Exanthemas. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1650-1656. [PMID: 28499779 DOI: 10.1016/j.jaip.2017.03.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 03/08/2017] [Accepted: 03/31/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Immediate discontinuation or replacement of suspected drugs is considered standard medical care in acute exanthematous skin reactions. In the treatment of bacterial infections, structurally different alternative antibiotics, however, are commonly second choice options due to a suboptimal antimicrobial activity or an unfavorable side effect profile. Nonetheless, "treating through," the continuation of antibiotic treatment despite an objective exanthema, is practiced only rarely. OBJECTIVE We aimed to assess whether "treating through" is an option for patients with severe bacterial soft tissue infections (severe cellulitis) who experience maculopapular exanthema (MPE) during antibiotic therapy. METHODS We retrospectively reviewed clinical data from 18 patients who developed MPE within a few days after initiation of intravenous antibiotic treatment. A decision to "treat through" was made when the suspected antibiotics (β-lactams, clindamycin, ciprofloxacin) were clinically effective and the benefits of continued treatment outweighed potential risks. Clinical and laboratory findings were closely monitored in an inpatient setting. RESULTS In 2 patients, a modification of antibiotic therapy was deemed necessary due to a significant increase of liver enzymes within 4 days after the initial decision to "treat through." Because of a progression of MPE under ongoing treatment with cefuroxime and clindamycin, clindamycin was discontinued in 1 patient. In another 3 patients, antibiotic treatment was modified because of insufficient improvement of the soft tissue infection. In the remaining 12 "treated through" cases, the skin symptoms improved despite unchanged continued antibiotic treatment, and relevant laboratory parameters remained within the normal range. CONCLUSIONS Careful risk-benefit assessment may enable the continuation of antibiotic therapy despite MPE, provided that patients are under close medical observation.
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Affiliation(s)
- Axel Trautmann
- Department of Dermatology, Venereology, and Allergy, University Hospital Würzburg, Würzburg, Germany.
| | - Sandrine Benoit
- Department of Dermatology, Venereology, and Allergy, University Hospital Würzburg, Würzburg, Germany
| | - Matthias Goebeler
- Department of Dermatology, Venereology, and Allergy, University Hospital Würzburg, Würzburg, Germany
| | - Johanna Stoevesandt
- Department of Dermatology, Venereology, and Allergy, University Hospital Würzburg, Würzburg, Germany
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19
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Wilking-Busch MJ, Ndiaye MA, Huang W, Ahmad N. Expression profile of SIRT2 in human melanoma and implications for sirtuin-based chemotherapy. Cell Cycle 2017; 16:574-577. [PMID: 28166441 PMCID: PMC5384585 DOI: 10.1080/15384101.2017.1288323] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/21/2017] [Accepted: 01/24/2017] [Indexed: 10/20/2022] Open
Abstract
Melanoma is cancer of melanin-containing melanocyte cells. This neoplasm is one of the most deadly forms of skin cancer, and currently available therapeutic options are insufficient in significantly improve outcomes for many patients. Therefore, novel targets are required to effectively manage this neoplasm. Several sirtuins have previously been found to be upregulated in melanoma, so in this study, the expression profile of SIRT2 was determined. Employing a tissue microarray containing benign nevi, primary melanomas, and lymph node metastases, we have found that the tissue from lymph node metastases appears to have a significant upregulation of SIRT2 relative to primary tumors across the nuclear, cytoplasmic, and whole cell data. Additionally, SIRT2 staining was found to be higher in the nucleus of metastatic melanomas compared to cytoplasmic staining. As SIRT2 is considered to be a predominantly cytoplasmic protein, this is a novel and very interesting finding. This, combined with previous studies that show other sirtuins are increased in melanoma and involved in cellular proliferation and survival, leads to the suggestion that exploring pan-sirtuin inhibitors may be the best target for the next iteration of melanoma chemotherapeutics.
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Affiliation(s)
| | - Mary Ann Ndiaye
- Department of Dermatology, University of Wisconsin, Madison, WI, USA
| | - Wei Huang
- Department of Pathology and Laboratory Medicine, University of Wisconsin, Madison, WI, USA
| | - Nihal Ahmad
- Department of Dermatology, University of Wisconsin, Madison, WI, USA
- William S. Middleton VA Medical Center, Madison, WI, USA
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20
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Nomura H, Takahashi H, Suzuki S, Kurihara Y, Chubachi S, Kawada I, Yasuda H, Betsuyaku T, Amagai M, Funakoshi T. Unexpected recalcitrant course of drug-induced erythema multiforme-like eruption and interstitial pneumonia sequentially occurring after nivolumab therapy. J Dermatol 2017; 44:818-821. [DOI: 10.1111/1346-8138.13810] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 01/28/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Hisashi Nomura
- Department of Dermatology; Keio University School of Medicine; Tokyo Japan
| | - Hayato Takahashi
- Department of Dermatology; Keio University School of Medicine; Tokyo Japan
| | - Satsuki Suzuki
- Department of Dermatology; Keio University School of Medicine; Tokyo Japan
| | - Yuichi Kurihara
- Department of Dermatology; Keio University School of Medicine; Tokyo Japan
| | - Shotaro Chubachi
- Division of Pulmonary Medicine; Department of Medicine; Keio University School of Medicine; Tokyo Japan
| | - Ichiro Kawada
- Division of Pulmonary Medicine; Department of Medicine; Keio University School of Medicine; Tokyo Japan
| | - Hiroyuki Yasuda
- Division of Pulmonary Medicine; Department of Medicine; Keio University School of Medicine; Tokyo Japan
| | - Tomoko Betsuyaku
- Division of Pulmonary Medicine; Department of Medicine; Keio University School of Medicine; Tokyo Japan
| | - Masayuki Amagai
- Department of Dermatology; Keio University School of Medicine; Tokyo Japan
| | - Takeru Funakoshi
- Department of Dermatology; Keio University School of Medicine; Tokyo Japan
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21
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Ring J. Dermatology 2016: old problems - new challenges: editor's pick of the year 2016. J Eur Acad Dermatol Venereol 2016; 31:7-8. [PMID: 27995721 DOI: 10.1111/jdv.14061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- J Ring
- Department of Dermatology and Allergy, Biederstein, Technical University, Munich, Germany
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22
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Cutaneous Side Effects of BRAF Inhibitors in Advanced Melanoma: Review of the Literature. Dermatol Res Pract 2016; 2016:5361569. [PMID: 27042173 PMCID: PMC4794559 DOI: 10.1155/2016/5361569] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/07/2016] [Accepted: 02/15/2016] [Indexed: 01/08/2023] Open
Abstract
The incidence of melanoma has recently been increasing. BRAF mutations have been found in 40–60% of melanomas. The increased activity of BRAF V600E leads to the activation of downstream signaling through the mitogen-activated protein kinase (MAPK) pathway, which plays a key role as a regulator of cell growth, differentiation, and survival. The use of BRAF inhibitors in metastatic melanoma with BRAF mutation ensures clinical improvement of the disease. Vemurafenib and dabrafenib are two selective BRAF inhibitors approved by the Food and Drug Administration (FDA). Both drugs are well tolerated and successfully used in clinical practice. However, some adverse reactions have been reported in patients in the course of treatment. Cutaneous side effects are the most common adverse events among them with a broad spectrum. Both the case reports and several original clinical trials reported cutaneous reactions during the treatment with BRAF inhibitors. In this review, the common cutaneous side effects of BRAF inhibitors in the treatment of metastatic melanoma with BRAF V600E mutation were reviewed.
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