Is Nivolumab (nivolumab) associated with the development or exacerbation of psoriasis?

Nivolumab Can Cause or Exacerbate Psoriasis as an Immune-Related Adverse Event

Yes, nivolumab is associated with the development and exacerbation of psoriasis as a documented immune-related adverse event (irAE). Multiple case reports and clinical guidelines confirm this association, with psoriasis occurring as both a de novo condition and as exacerbation of pre-existing disease in patients receiving nivolumab therapy 1, 2, 3, 4, 5.

Mechanism and Prevalence

Nivolumab, as a PD-1 inhibitor, works by enhancing T-cell activity against tumor cells, but this immune activation can lead to various immune-related adverse events, including dermatologic toxicities:

• Skin toxicities are among the most frequent adverse events with PD-1 inhibitors (34% of patients) 6
• While rash (15%) and pruritus (13-20%) are more common, psoriasiform eruptions are specifically documented 6
• Psoriasis can appear as:
  • Exacerbation of pre-existing psoriasis
  • De novo psoriasis in patients with no prior history
  • Various forms including plaque psoriasis, palmoplantar psoriasis, and pustular psoriasis 4, 5

Clinical Presentation and Timing

The clinical presentation of nivolumab-induced psoriasis has several characteristics:

• Onset typically occurs within the first few weeks of treatment, but can appear at any time during therapy 6
• Presentations range from mild localized plaques to severe widespread involvement 1, 4
• Special forms reported include:
  • Palmoplantar psoriasis 3, 5
  • Pustular psoriasiform eruptions 4
  • Psoriasis with nail involvement 3, 5
• Can be accompanied by psoriatic arthritis in some cases 3

Management Approach

Management of nivolumab-induced psoriasis follows a severity-based approach:

For Mild to Moderate Cases (Grade 1-2):

1. Continue nivolumab therapy
2. Implement topical treatments:
   • Topical corticosteroids (moderate to high potency)
   • Topical emollients
   • Antihistamines for associated pruritus 6

For Severe Cases (Grade 3-4):

1. Temporarily withhold or permanently discontinue nivolumab depending on severity and response to treatment 6
2. Systemic therapy options:
   • Oral corticosteroids (prednisone 0.5-1 mg/kg/day)
   • Consider biologic agents (e.g., ustekinumab) for refractory cases 4
3. Dermatology consultation for specialized management

Important Clinical Considerations

1. Risk assessment: Patients with a history of psoriasis should be monitored more closely during nivolumab therapy 6

2. Differential diagnosis: Rule out other causes of skin eruptions including:

   • Drug reactions from concomitant medications
   • Infections
   • Other autoimmune conditions 6

3. Monitoring: Regular skin examinations during nivolumab treatment to detect early signs of psoriasis or other dermatologic toxicities

4. Treatment decisions: The decision to continue or discontinue nivolumab depends on:

   • Severity of psoriasis (BSA involvement and symptoms)
   • Response to topical/systemic treatments
   • Benefit of continued cancer treatment versus risk of worsening skin disease 1

Conclusion

Clinicians should be vigilant for psoriasis as a potential immune-related adverse event in patients receiving nivolumab. Early recognition and appropriate management can help maintain effective cancer treatment while minimizing dermatologic complications. In most cases, mild to moderate psoriasis can be managed without discontinuing nivolumab, but severe cases may require treatment interruption and specialized dermatologic care.