Immunotherapy skin toxicity

  Dermatologic adverse events to immunotherapies are of topmost importance because they are usually the first to appear, within approximately 3 weeks of the patient starting therapy. They are also among the most common: about 30% to 40% of all patients treated with immunotherapies will develop some type of dermatologic side effect. Some of the most common include rash, itching, skin color changes, and hair loss. However, the most common, by far, are itching of the skin without presence of a rash and rashes that can present in various ways. These generally occur within the first couple of months, but they can occur at any time during immunotherapy treatment, even years after the patient has finished therapy

1. Grade 1 or 2 rashes, high-potency, topical steroids are used—strong topical steroids, not an over-the-counter solution. Some topical steroids are now available as a spray.
2. Grade 3 rashes, of course, oral prednisone at approximately 0.5 to 1 mg/mg/kg per day, tapered over a course of 4 weeks. If the rash recurs after that, you should consider using a steroid-sparing agent, usually a biologic agent.
3. Late skin toxicity- vitiligo, alopecia areata, autoimmune blistering conditions like bullous pemphigoid

 How is the rash of immunotherapy different from Osimertinib rash?

• Osimertinib causes acneiform rash, usually affects the face and chest,
•  immunotherapies can cause an acneiform rash very infrequently. Immunotherapy rashes affect mainly the trunk and extremities.
• immunotherapy rashes differ in appearance from acneiform—they present more like psoriasis, like eczema, or like hives

Underutilized treatments for skin toxicity:

• pruritus- pregabalin, omalizumab, doxepin, dupixent

General advice for patients on immunotherapy

fragrance-free detergents and soaps, protective clothing, sunscreen when outside

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