Immunotherapy-mediated dermatological adverse events: the urgent need for a common, clinically meaningful, management st
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COMMENTARY
Immunotherapy-mediated dermatological adverse events: the urgent need for a common, clinically meaningful, management strategy Zoe Apalla 1
&
Vincent Sibaud 2
Received: 26 June 2020 / Accepted: 19 August 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020
Keywords Immune checkpoint inhibitors . Immunotherapy . Skin toxicity . Adverse events . Management
The introduction of immune checkpoint inhibitors as a treatment modality in advanced malignancies has revolutionized the field of oncology therapeutics. Immunotherapy-mediated adverse events (irAEs) represent a major drawback of their use. Dermatologic AE are among the most common irAEs, reported in about one-third of all treated patients [1]. Immune checkpoint inhibitors may deteriorate a preexisting autoimmune or inflammatory skin disorder, may trigger a recurrence, or may be responsible for a newly onset immune-mediated dermatosis. The most usual dermatologic manifestations, included in this spectrum, are eczema-like rash, psoriasis, maculopapular and lichenoid eruptions, autoimmune bullous skin disorders and vitiligo [1, 2] Pruritus, which is by far the most commonly reported symptom, can be present per se, or in conjunction with one of the aforementioned entities. Systemic corticosteroids and other immunomodulating/immunosuppressive drugs remain the mainstay of treatment, if severe skin involvement is present [3]. However, recent literature data suggest that a vast majority of skin toxicities can be managed with skin-directed therapy only [4], allowing unimpeded oncologic treatment and avoiding rebound phenomena related to the use of systemic
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00520-020-05701-9) contains supplementary material, which is available to authorized users. * Zoe Apalla [email protected] 1
Second Dermatology Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
2
Oncodermatology Department, Cancer University Institute, Toulouse Oncopole, Toulouse, France
corticosteroids, at least in certain cutaneous irAEs, like psoriasis. Treatment decisions, including drug withholds, interruptions, or permanent discontinuation, are vastly influenced by the severity of irAEs grading. As a rule, grades > 3 are considered clinically relevant and are mostly connected to higher rates of treatment modifications [5]. Considering that efficacy of immunotherapy maybe impeded by the concomitant use of immunomodulating/immunosuppressive drugs, the latter can also influence treatment decisions [3, 5]. As for all the other drug-derived toxicities, oncologists grade cutaneous irAEs based on certain criteria described in CTCAE (Common Terminology Criteria for Adverse Events) v.5. In a majority of skin toxicities, the grading is based on extend of skin rash (BSA%), impact on activities of daily living (ADL), and risk of death, while management is not skin-directed, but mostly based on the use of systemic corticosteroids, at least for the high-grade eruptions [5]. On the oth
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