INDIVIDUAL ARTICLE: USCOM Algorithm for the Prevention and Management of Cutaneous Immunotherapy-Related Adverse Events

BACKGROUND

In 2023, nearly 2 million patients will be diagnosed with cancer in the United States and at least 40% will be eligible for treatment with an immune checkpoint inhibitor (ICI). Cutaneous immune related adverse events (cirAEs) from ICIs are common and include pruritus as well as maculopapular, eczematous, bullous, lichenoid, and psoriasiform reactions. All clinicians interfacing with cancer patients must expedite proper evaluation and diagnosis, treatment, and/or consultation that supports the need for evidence-directed guidelines.

MATERIALS AND METHODS

A panel of advisors was selected, and a systematic literature review generated foundational evidence to develop a treatment algorithm for cirAEs via a modified Delphi process. Iterations of the algorithm were performed until the group met consensus.

RESULTS

An algorithm that tailors the management of cirAEs was developed based on the CTCAE v.5 grading of skin disorders. Representative clinical images and suggested diagnostic measures, supplement the algorithm.

CONCLUSION

Recognition and treatment of cirAEs guided through a multidisciplinary, physician-developed algorithm will limit disruption of immunotherapy, optimize quality of life, and enhance overall outcomes in patients treated with ICIs. J Drugs Dermatol. 2023;22:11(Suppl 1):s3-10.

Addressing the Need for Diversity in Scalp Cooling Trials

This Viewpoint emphasizes the importance of diverse representation in research on scalp cooling to avoid hair loss during chemotherapy.

Bacterial Decolonization for Prevention of Radiation Dermatitis: A Randomized Clinical Trial

Importance

Evidence-based approaches for the prevention of acute radiation dermatitis (ARD) are limited, and additional strategies are necessary to optimize care.

Objective

To determine the efficacy of bacterial decolonization (BD) to reduce ARD severity compared with standard of care.

Design, Setting, and Participants

This phase 2/3 randomized clinical trial was conducted from June 2019 to August 2021 with investigator blinding at an urban academic cancer center and enrolled patients with breast cancer or head and neck cancer receiving radiation therapy (RT) with curative intent. Analysis was performed on January 7, 2022.

Interventions

Intranasal mupirocin ointment twice daily and chlorhexidine body cleanser once daily for 5 days prior to RT and repeated for 5 days every 2 weeks through RT.

Main Outcomes and Measures

The primary outcome as planned prior to data collection was the development of grade 2 or higher ARD. Based on wide clinical variability of grade 2 ARD, this was refined to grade 2 ARD with moist desquamation (grade 2-MD).

Results

Of 123 patients assessed for eligibility via convenience sampling, 3 were excluded, and 40 refused to participate, with 80 patients in our final volunteer sample. Of 77 patients with cancer (75 patients with breast cancer [97.4%] and 2 patients with head and neck cancer [2.6%]) who completed RT, 39 were randomly assigned BC, and 38 were randomly assigned standard of care; the mean (SD) age of the patients was 59.9 (11.9) years, and 75 (97.4%) were female. Most patients were Black (33.7% [n = 26]) or Hispanic (32.5% [n = 25]). Among patients with breast cancer and patients with head and neck cancer (N = 77), none of the 39 patients treated with BD and 9 of the 38 patients (23.7%) treated with standard of care developed ARD grade 2-MD or higher (P = .001). Similar results were observed among the 75 patients with breast cancer (ie, none treated with BD and 8 [21.6%] receiving standard of care developed ARD grade ≥2-MD; P = .002). The mean (SD) ARD grade was significantly lower for patients treated with BD (1.2 [0.7]) compared with patients receiving standard of care (1.6 [0.8]) (P = .02). Of the 39 patients randomly assigned to BD, 27 (69.2%) reported regimen adherence, and only 1 patient (2.5%) experienced an adverse event related to BD (ie, itch).

Conclusions and Relevance

The results of this randomized clinical trial suggest that BD is effective for ARD prophylaxis, specifically for patients with breast cancer.

Trial Registration

ClinicalTrials.gov Identifier: NCT03883828.

Association of Staphylococcus aureus Colonization With Severity of Acute Radiation Dermatitis in Patients With Breast or Head and Neck Cancer

Importance

Pathogenesis of acute radiation dermatitis (ARD) is not completely understood. Pro-inflammatory cutaneous bacteria may contribute to cutaneous inflammation after radiation therapy.

Objective

To evaluate whether nasal colonization with Staphylococcus aureus (SA) before radiation therapy is associated with ARD severity in patients with breast or head and neck cancer.

Design, Setting, and Participants

This prospective cohort study with observers blinded to colonization status was conducted from July 2017 to May 2018 at an urban academic cancer center. Patients aged 18 years or older with breast or head and neck cancer and plans for fractionated radiation therapy (≥15 fractions) with curative intent were enrolled via convenience sampling. Data were analyzed from September to October 2018.

Exposures

Staphylococcus aureus colonization status before radiation therapy (baseline).

Main Outcomes and Measures

The primary outcome was ARD grade using the Common Terminology Criteria for Adverse Event Reporting, version 4.03.

Results

Among 76 patients analyzed, mean (SD) age was 58.5 (12.6) years and 56 (73.7%) were female. All 76 patients developed ARD: 47 (61.8%) with grade 1, 22 (28.9%) with grade 2, and 7 (9.2%) with grade 3. The prevalence of baseline nasal SA colonization was higher among patients who developed grade 2 or higher ARD compared with those who developed grade 1 ARD (10 of 29 [34.5%] vs 6 of 47 [12.8%]; P = .02, by χ2 test).

Conclusions and Relevance

In this cohort study, baseline nasal SA colonization was associated with development of grade 2 or higher ARD in patients with breast or head and neck cancer. The findings suggest that SA colonization may play a role in the pathogenesis of ARD.

Detection of novel therapies using a multi-national, multi-institutional registry of cutaneous immune-related adverse events and management

BACKGROUND

Cutaneous immune-related adverse events (cirAEs) remain a prevalent and common sequelae of immune checkpoint inhibitor (ICI) therapy, often necessitating treatment interruption and prolonged immune suppression. Treatment algorithms are still poorly defined, based on single-institution case reports without adequate safety assessments, and subject to publication bias.

METHODS

Data in this registry were collected through a standardized REDCap form distributed to dermatologists via email listserv.

RESULTS

Ninety-seven cirAEs were reported from 13 institutions in this registry. Topical and systemic steroids were the most common treatments used; however, targeted treatment matched to disease morphology was identified at numerous sites. Novel cirAE therapy uses that to our knowledge have not been previously described were captured including tacrolimus for the treatment of follicular, bullous, and eczematous eruptions and phototherapy for eczematous eruptions. Moreover, further evidence of cirAE treatment applications sparsely described in literature were also captured in this study including dupilumab and rituximab for bullous eruptions, phototherapy for lichenoid and psoriasiform eruptions, and acitretin for psoriasiform eruptions, among others. No serious adverse events were reported. Numerous targeted therapeutics including dupilumab, rituximab, and psoriasis biologics, among others, were associated with a cirAE grade improvement of ≥2 grades in every patient treated.

CONCLUSION

This study suggests that a multi-institutional registry of cirAEs and management is not only feasible but that the information collected can be used to detect, evaluate, and rigorously assess targeted treatments for cirAEs. Further expansion and modification to include treatment progression may allow for sufficient data for specific treatment recommendations to be made.

Abstract 2833: Exploring the impact of IL-17 pathway modification on radiation dermatitis and radiation therapy efficacy

Here we explore the role of Interleukin-17 (IL-17) in the promotion of radiation dermatitis (RD) and radiation therapy (RT) efficacy. RD is a common and potentially treatment-limiting skin toxicity that occurs following RT. When the treated tumor is close to the skin, as in head and neck or breast cancer, RD is the most common acute adverse event which negatively impacts patients’ quality of life; however, evidence-based treatments are limited. We performed RNA sequencing of RT-treated skin in both human skin and a murine model, which each showed increased expression of IL-17 Receptor type C (IL-17RC). To further explore the role of the IL-17 pathway in the development of RD, both genetic knockout of IL-17RC and pharmacologic blocking of IL-17A in mouse models were studied, and both were found to have attenuated histopathological signs of RD, including inflammation, acanthosis, and fibrosis when compared to controls. After establishing the importance of the IL-17 pathway on RD, we explored the impact of such IL-17 pathway modification on the anti-tumorigenic efficacy of RT, an important step when considering a future IL-17 neutralizing therapy for RD. A Trans-PyMT murine model of triple-negative breast cancer was used to evaluate the impact of IL-17A neutralization on RT efficacy. There was no difference found in the efficacy of RT in mice treated with IL-17A neutralizing antibody as compared with saline control. Overall, we present a clinically relevant murine model which advances our understanding of the immunopathogenesis of RD and suggests further exploration of targeted therapies for RD prophylaxis is warranted. Additionally, we show that modifying the IL-17 pathway is effective in mitigating RD phenotype with no impact on RT efficacy.

Citation Format: Megan E. Pirtle, Yana Kost, Alana Deutsch, Kosaku Shinoda, Beth N. McLellan. Exploring the impact of IL-17 pathway modification on radiation dermatitis and radiation therapy efficacy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 2833.

Abstract 3219: Development of a quality-of-life assessment module in patients with radiation dermatitis

Introduction: Radiation dermatitis (RD) is one of the most common side effects of radiation therapy (RT), experienced by up to 95% of oncology patients. RD can be progressive, painful, and difficult to manage, thereby profoundly affecting patients’ quality of life (QOL). Current QOL assessments address dermatologic or oncologic concerns, with no existing tool integrating both areas to enable assessment of RD-specific QOL. Furthermore, RD grade does not consistently correlate with QOL scores in these assessments. The aims of this study are to identify unexplored QOL concerns in patients with RD and to create a new, RD-specific, validated assessment module to evaluate QOL in this patient population.

Methods: We conducted open-ended interviews with 20 patients with breast cancer with current or former RD during a radiation oncology clinic visit to determine RD-specific QOL concerns. We analyzed the most high-yield concerns to determine areas that are not addressed by current QOL assessments. With a workgroup of radiation oncologists, dermatologists, a psycho-oncologist, and patients, we evaluated our findings and used common themes to generate a new QOL survey.

Results: Among our patient cohort, 3 (15%) were undergoing current RT, 7 (35%) were at their first post-RT visit, 9 (45%) were at a follow-up visit within 12 months of completing RT, and 1 (5%) was at a follow-up visit over 12 months after completing RT. We uncovered four key areas affecting patients that are not incorporated into current QOL assessments: changes in clothing in 18 (90%) patients (e.g. wearing looser clothing, changing to a different bra, using a layer of bandages), changes in skin color in 17 (85%) patients (hyper- or hypopigmentation), changes in sleep due to skin changes in 13 (65%) patients (e.g. difficulty finding a comfortable position), and changes in ability to use the affected side in 9 (45%) patients (e.g. carrying items, avoiding contact with irritating material). We incorporated these four areas of concern into a six-question, RD-specific QOL assessment module to the Skindex-16, a validated and widely used QOL assessment in dermatology.

Conclusions: This pilot study enabled us to discover previously unexplored QOL concerns in patients with RD that are not addressed in current dermatology and oncology focused assessments. Future work includes validation of this module in patients with acute RD with the goal of identifying opportunities to optimize treatment and enhance patient-centered care for this population.

Citation Format: Olivia S. Allen, Alyson B. Moadel-Robblee, Jana Fox, Johnny Yap, Beth N. McLellan. Development of a quality-of-life assessment module in patients with radiation dermatitis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3219.

An Unexpected Postsurgical Phenomenon After Total Knee Arthroplasty: Nummular Eczema: A Case Report and Literature Review

CASES

Two elderly women each presented with a unilateral, erythematous rash 1 year after total knee arthroplasty (TKA) for osteoarthritis. Both cases were diagnosed as postsurgical nummular eczema (NE) and treated successfully with topical corticosteroids.

CONCLUSION

We highlight a novel clinical presentation of postsurgical NE associated with TKA, previously reported only with breast reconstruction. Postsurgical NE may mimic periprosthetic infection or implant-related allergic contact dermatitis. Timely diagnosis and appropriate treatment in these cases prevented unnecessary testing and hospital admission for revision surgery. This case series highlights the varied presentation and wide differential diagnosis associated with postsurgical NE.

The Role of Fat Reducing Agents on Adipocyte Death and Adipose Tissue Inflammation

Deoxycholic Acid (DCA), which is an FDA-approved compound for the reduction of submental fat, has evolved through an unanticipated and surprising sequence of events. Initially, it was used as a solvent for Phosphatidylcholine (PDC), which was thought to promote lipolysis, but it was later proven to be the bioactive component of the formula and is currently widely used as Kybella. It has also been used off-label to treat other types of fat deposits like lipomas, HIV lipodystrophy, and excess orbital fat. Despite widespread clinical use, there has been no consensus clarifying the mechanisms of DCA and PDC alone or in combination. Furthermore, despite PDC's removal from the FDA-approved formula, some studies do suggest it plays an important role in fat reduction. To provide some clarity, we conducted a PubMed search and reviewed 41 articles using a comprehensive list of terms in three main categories, using the AND operator: 1) Phosphatidylcholines 2) Deoxycholic Acid, and 3) Lipoma. We isolated articles that studied PDC, DCA, and a PDC/DCA compound using cell biology, molecular and genetic techniques. We divided relevant articles into those that studied these components using histologic techniques and those that utilized specific cell death and lipolysis measurement techniques. Most morphologic studies indicated that PDC/DCA, DCA, and PDC, all induce some type of cell death with accompanying inflammation and fibrosis. Most morphologic studies also suggest that PDC/DCA and DCA alone are non-selective for adipocytes. Biochemical studies describing PDC and DCA alone indicate that DCA acts as a detergent and rapidly induces necrosis while PDC induces TNF-α release, apoptosis, and subsequent enzymatic lipolysis after at least 24 hours. Additional papers have suggested a synergistic effect between the two compounds. Our review integrates the findings of this growing body of literature into a proposed mechanism of fat reduction and provides direction for further studies.

Comparison of Survival Outcomes With/Without Adjuvant Radiation Therapy in Desmoplastic Melanoma

BACKGROUND

Desmoplastic melanoma (DM) is a rare variant of cutaneous melanoma with a high rate of local recurrence. Recent studies have indicated a potential benefit in local control with the addition of adjuvant radiotherapy (RT).

OBJECTIVE

This study sought to evaluate the outcomes of adjuvant RT for patients with DM.

MATERIALS AND METHODS

The National Cancer Database was queried (2004-2015) for patients with newly diagnosed, nonmetastatic DM. Patients were divided into 2 groups based on the adjuvant therapy they received: RT or observation. Statistics included multivariable logistic regression to determine factors predictive of receiving adjuvant RT, Kaplan-Meier analysis to evaluate overall survival (OS), and Cox proportional hazards modeling to determine variables associated with OS.

RESULTS

There was no difference in median OS between patients treated with RT when compared with patients observed (111.4 months vs 133.9 months, p = .1312). On multivariable analysis, older age, T stage ≥2, N stage ≥1, and no receipt of immunotherapy were associated with worse OS.

CONCLUSION

In this large study evaluating efficacy of adjuvant RT in DM, no overall survival benefit was observed among patients receiving adjuvant RT.

US Cutaneous Oncodermatology Management (USCOM): A Practical Algorithm

BACKGROUND

An increasing number of patients survive or are living with cancer. Anticancer treatments frequently have cutaneous adverse events (cAEs) that may severely impact patients' quality of life and interrupt anticancer treatment. The US Cutaneous Oncodermatology Management (USCOM) project aims to improve cancer patients' and survivors' quality of life by offering tools for preventing and managing cAEs.

METHODS

An algorithm was designed to reduce the incidence of cAEs, treat cAEs, and maintain healthy skin using general measures and over-the-counter agents to support all healthcare providers treating oncology patients, including physicians, nurses, pharmacists, and advanced providers. The panel used a modified Delphi approach, developed, discussed, and reached a consensus on statements and an evidence-based algorithm.

RESULTS

The USCOM algorithm includes education on cAEs for patients and clinicians supporting prevention, treatment, and maintenance using skincare measures before, during, and after cancer treatment. A skincare regimen including hygiene, moisturization, and sun protection products should be safe and effective in helping to minimize cAEs and improving skin conditions such as erythema, xerosis, pruritus, and photosensitivity. The number and quality of studies evaluating skincare formulations and regimens for cAEs are increasing, but the evidence on the benefits of specific formulations is still scarce.

CONCLUSIONS

The algorithm focuses on general measures and skincare to prevent or reduce the severity of cAEs. Increased awareness of cAEs by the multidisciplinary team treating and guiding the cancer patient throughout their care may improve patient outcomes. J Drugs Dermatol. 2021;20:9(Suppl):s3-19.

Dermatologic Adverse Events of Systemic Anticancer Therapies: Cytotoxic Chemotherapy, Targeted Therapy, and Immunotherapy

Over the past 2 decades, rapid advancement in systemic anticancer therapeutics has led to astounding improvement in survival rates of patients with cancer. However, this celebrated progress has brought with it an evolving spectrum of drug toxicities that limit their prodigious capabilities. Cutaneous adverse events are of the most frequent of these toxicities, with substantial impact on quality of life and commonly resulting in dose reduction or change in therapy. Thus, familiarity with the array of dermatologic manifestations caused by these drugs is prudent for patient treatment. As such, the advent of dedicated oncodermatologists, and their introduction into multidisciplinary cancer care, has been crucial in optimizing treatment through therapeutic achievement and overall well-being. This review will address the epidemiology, clinical presentations, and management strategies of the major dermatologic adverse events of systemic anticancer agents, including cytotoxic chemotherapy, targeted therapy, and immunotherapy.

Single-cell transcriptomics in dermatology

The skin is an ecosystem composed of specialized cell types that work together to serve as a physical protective barrier. Single-cell resolution is therefore essential to deconvolve skin's heterogeneity by identifying novel, distinct cell subsets in health and disease. Single-cell RNA sequencing is a highly meticulous methodology used to study the distinct transcriptional profiles of each cell within large tissue libraries at uniquely high resolution. The investigative capabilities achieved by this methodology allow previously unattainable analyses, including identification of rare cell populations, evaluation of cell-to-cell variation, and the ability to track trajectories of distinct cell lineages through development. In the past decade, application of transcriptomic analysis to skin biology and dermatology has greatly advanced understanding of homeostatic physiology in the skin, as well as a multitude of dermatologic diseases. Single-cell RNA sequencing offers tremendous promise for identification of novel therapeutic targets in dermatologic diseases, with broad implications of improving therapeutic interventions.

Estrogen-deficient skin: The role of topical therapy

Menopause is a major turning point in a woman's life that is characterized by declining ovarian function and decreased serum estrogen levels. The resulting hormonal changes particularly affect the skin, with postmenopausal symptoms such as loss of structural architecture and increased propensity to damage becoming rapidly noticeable. Interestingly, studies have shown that estrogen deprivation in postmenopausal conditions accelerates many skin changes, including dryness, atrophy, fine wrinkling, and poor wound healing. Thus, the effects of low estrogen on the skin are an important endogenous cause of aging skin in women, yet topical treatment strategies that target cutaneous symptoms are limited. The goal of this article is to provide an overview of the role of estrogen in the skin and changes associated with estrogen deficiency, as well as review alternatives to systemic estrogen therapy and describe the effects of these interventions on cutaneous aging in postmenopausal skin. Specifically, clinical studies that utilize topical estrogens and topical isoflavones, which are soy-derived compounds that interact with estrogen receptors, are discussed.

A National Survey of Medical Coding and Billing Training in United States Dermatology Residency Programs

BACKGROUND

Due to frequent changes in medical coding systems, billing for outpatient visits through Evaluation and Management (E & M) services has become increasingly complicated. As a result, physicians often bill improperly, costing the United States health care system billions of dollars annually. Despite the importance of proper documentation, medical coding and billing is largely ignored during residency training.

OBJECTIVE

Assess the exposure to and quality of medical coding and billing training in dermatology residency programs.

METHODS

A questionnaire was distributed to dermatology programs in the United States consisting of questions pertaining to didactic education for, experience with, and resident knowledge of medical coding and billing.

RESULTS

138/443 dermatology residents participated (31.2% response rate). 79% of residents reported receiving some type of formal training. Nearly 89% reported personally billing patient visits to some degree, with 41.3% billing for 100% of outpatient visits. Over 75% of residents were able to answer basic billing questions and 70% correctly billed a patient visit when given a complex clinical scenario. Despite these results, only 37% of residents reported feeling confident in their billing abilities. Lastly, 94.9% of respondents believed medical coding and billing should be integrated into dermatology training curriculums.

CONCLUSIONS

The majority of dermatology residents have opportunities to learn medical coding and billing through didactics and clinical experiences. Many residents were able to answer correctly questions that tested their basic knowledge of E&M coding. These results are encouraging and reflect the recognition of the importance of medical coding and billing training during residency. J Drugs Dermatol. 2018;17(6):678-682.

Beyond Traditional Treatment: The Importance of Psychosocial Therapy in Vitiligo

Vitiligo is an acquired depigmentation disorder of the skin. Patients with vitiligo often face a challenging disease course, having to cope with a condition that is known to be physically disfiguring, psychologically devastating, and socially stigmatizing. Although an extensive amount of research has been directed towards the dermatologic treatment of vitiligo, an overall lack of data exists investigating treatment of the psychological and emotional burden of patients with vitiligo. This paper reviews the literature for treatment options in patients with vitiligo that specifically target the psychosocial domain. Despite being limited in quantity, several studies have proven the benefits of adjuvant care in the form of group therapy, cognitive behavioral therapy, and self-help programs. Although preliminary evidence is promising, larger prospective studies are needed to further define the role of these psychosocial interventions before integrating them in a more official capacity into the standard of care for patients with vitiligo. Because of the considerable impact of vitiligo beyond its physical symptoms, dermatologists ought to consider the utility of adjuvant therapies to adequately address impairments in self-esteem, body image, and quality of life in patients with vitiligo. J Drugs Dermatol. 2018;17(6):688-691.

Cutaneous toxicity as a predictive biomarker for clinical outcome in patients receiving anticancer therapy

The relationship between treatment outcome and cutaneous toxicity induced by anticancer therapy has gained attention in the past decade. In this article, we have provided an overview of the 3 main classes of anticancer agents-specifically, molecularly targeted kinase inhibitors, immune checkpoint inhibitors, and cytotoxic chemotherapeutics-and described the data evaluating the association between cutaneous toxicity induced by these agents and survival benefit. Although preliminary studies are promising with regard to the potential role of cutaneous toxicities as a surrogate biomarker of efficacy of treatment, larger prospective studies are needed to confirm this relationship. Dermatologists have a unique opportunity to collaborate with oncologists in the multidisciplinary treatment paradigm by helping to identify and manage these dermatologic events in patients with cancer. A heightened awareness of these toxicities is critical, as it can potentially allow recognition of the efficacy of anticancer therapy and may influence treatment decisions and patient outcomes.