What are the management options for a differential rash associated with Cosentyx (secukinumab) treatment?

Management of Rash Associated with Cosentyx (Secukinumab)

For a rash developing on Cosentyx, immediately assess severity and rule out serious cutaneous reactions, then manage with topical corticosteroids and emollients for mild-to-moderate cases, while holding the drug for severe reactions until improvement occurs. 1

Initial Assessment and Risk Stratification

Critical First Steps

• Examine all skin surfaces including mucous membranes to identify blistering, skin sloughing, pustules, or dusky erythema that could indicate Stevens-Johnson syndrome, toxic epidermal necrolysis, or exfoliative dermatitis 1
• Check for signs of superinfection (increased warmth, purulence, spreading erythema) which occurs commonly with secukinumab-related rashes 1
• Assess body surface area involvement to grade severity and guide treatment decisions 2, 3

Common Rash Patterns with Cosentyx

• Urticaria and hypersensitivity reactions are documented adverse effects, with rare anaphylactic reactions reported 1
• Atopic dermatitis-like rash (SI-AD) can develop due to immune shift from Th17 to Th2, presenting with pruritic papules and plaques 4
• Dyshidrotic eczema affecting palms and soles has been reported in patients on secukinumab 5
• Prurigo nodularis with firm, pruritic nodules on trunk and extremities may emerge during treatment 6
• Psoriasiform drug hypersensitivity presenting as widespread pruritic papules and plaques 7

Treatment Algorithm Based on Severity

Mild Rash (<10% Body Surface Area)

• Continue Cosentyx without interruption if the rash is localized and non-severe 2, 3
• Apply emollients liberally 2-3 times daily, particularly after bathing when skin is damp, using 30-60g per application for arms or 100g for trunk 1, 2, 8
• Use mild-to-moderate potency topical corticosteroids (hydrocortisone 1-2.5% for face/groin, betamethasone valerate 0.1% or mometasone 0.1% for body) once daily 1, 2, 8
• Add non-sedating antihistamines (cetirizine 10mg or loratadine 10mg daily) for pruritus rather than sedating diphenhydramine 2

Moderate Rash (10-30% Body Surface Area or Persistent Grade 2)

• Consider holding Cosentyx temporarily and monitor weekly for progression 2, 3
• Escalate to medium-to-high potency topical corticosteroids (betnovate, elocon, or dermovate ointment) applied twice daily to affected areas 1, 2
• Continue intensive emollients and oral antihistamines 1, 2
• Apply topical antibiotics in alcohol-free formulations if signs of secondary infection develop, for at least 14 days 1
• Consider oral antibiotics (tetracycline, minocycline, or doxycycline for ≥2 weeks) if widespread infection suspected 1
• Refer to dermatology if rash persists beyond 2 weeks despite treatment, as chronic rash significantly impacts quality of life 1, 2

Severe Rash (>30% Body Surface Area or Grade 3)

• Hold Cosentyx immediately until rash improves to mild severity 1, 3
• Initiate systemic corticosteroids: oral prednisone 1 mg/kg/day with gradual taper over 4-6 weeks as toxicity resolves 3
• Continue high-potency topical corticosteroids, oral antihistamines, and intensive emollients 1, 3
• Obtain dermatology consultation urgently for biopsy and management guidance 1, 2
• Do not restart Cosentyx until rash has improved to <10% BSA 1, 3

Life-Threatening Reactions (Exfoliative Dermatitis, SJS/TEN)

• Discontinue Cosentyx permanently 1
• Admit patient urgently with dermatology and infectious disease involvement 3
• Initiate IV methylprednisolone 1-2 mg/kg with supportive care 3

Special Considerations for Secukinumab-Specific Rashes

Atopic Dermatitis-Like Rash (SI-AD)

• This represents an immune shift from Th17 to Th2 with elevated IgE, IL-10, and IL-4 levels 4
• Discontinue secukinumab and switch to alternative therapy (cyclosporine, JAK1 inhibitors, or different biologic class) 4
• Add oral antihistamines and topical glucocorticoids during transition 4
• Monitor immune markers (IgE, IL-10, IL-4) which should normalize after drug discontinuation 4

Candidal Infections

• Mucocutaneous candidiasis (including oral and esophageal) occurs more frequently with secukinumab but is typically mild-to-moderate 1
• These infections are non-serious, responsive to standard antifungal treatment, and do not require drug discontinuation 1
• Treat with topical or oral antifungals per local guidelines 1

Critical Pitfalls to Avoid

• Never use high-potency topical steroids in intertriginous areas (groin, axillae) due to increased risk of skin atrophy; use hydrocortisone 1% instead 1, 2
• Avoid prolonged sedating antihistamines (diphenhydramine) especially in patients who drive or operate machinery 2
• Do not restart Cosentyx at full dose after severe rash; refer to prescribing information for dose reduction guidance 1
• Immediately discontinue if any bullous or exfoliative features develop, as rare cases of exfoliative dermatitis are documented 1
• Do not attribute all rashes to drug reaction; consider differential diagnosis including infections, contact dermatitis, or disease flare 9

Monitoring and Follow-Up

• Weekly clinical assessment for moderate rashes to detect progression 3
• Serial photography to objectively track changes over time 3
• Reassess after 2 weeks of topical therapy; if no improvement, escalate treatment or refer to dermatology 1, 2
• Report all adverse events via appropriate pharmacovigilance channels (MHRA Yellow Card in UK, or Novartis PVI tool) 1