From the Guidelines
Treatment of skin rash due to pembrolizumab typically involves a stepwise approach based on severity, with the most recent and highest quality study 1 guiding the management. For mild rashes (Grade 1), topical corticosteroids like triamcinolone 0.1% or betamethasone 0.1% cream applied twice daily are recommended, along with oral antihistamines such as cetirizine 10mg daily for itching. Moderate rashes (Grade 2) may require medium-potency topical steroids and consideration of oral prednisone at 0.5-1 mg/kg/day for 5-7 days with a taper. For severe rashes (Grade 3-4), pembrolizumab should be temporarily discontinued, and high-potency topical steroids plus oral prednisone at 1-2 mg/kg/day should be initiated, with dermatology consultation. Some key points to consider in the management of skin rash due to pembrolizumab include:
- The incidence of skin adverse events (AEs) with pembrolizumab, as reported in studies such as 1 and 1, which highlight the need for careful monitoring and management.
- The importance of gentle skin care with fragrance-free moisturizers and avoidance of sun exposure, as part of the overall management strategy.
- The potential for immune-related adverse events (irAEs) to occur with pembrolizumab, including skin reactions, and the need for prompt recognition and treatment, as discussed in 1.
- The role of dermatology consultation in the management of severe or persistent skin rashes, as emphasized in 1 and 1. Patients should be closely monitored for the development of skin rash and other irAEs, and managed promptly and effectively to minimize morbidity and mortality, and optimize quality of life, as the primary outcome.
From the FDA Drug Label
Immune-Mediated Dermatologic Adverse Reactions KEYTRUDA can cause immune-mediated rash or dermatitis Exfoliative dermatitis, including Stevens Johnson Syndrome, DRESS, and toxic epidermal necrolysis (TEN), has occurred with PD-1/PD-L1 blocking antibodies. Topical emollients and/or topical corticosteroids may be adequate to treat mild to moderate non-exfoliative rashes. Withhold or permanently discontinue KEYTRUDA depending on severity [see Dosage and Administration (2. 3)].
The treatment for skin rash due to pembrolizumab includes:
- Topical emollients
- Topical corticosteroids for mild to moderate non-exfoliative rashes
- Withholding or permanently discontinuing KEYTRUDA depending on the severity of the rash 2
From the Research
Treatment of Skin Rash due to Pembrolizumab
- The treatment of skin rash due to pembrolizumab typically involves the use of systemic steroids, such as prednisone, to manage the cutaneous adverse events 3.
- In some cases, topical corticosteroids, high-dose prednisolone, and antibiotics may be used to treat the rash, but these treatments may not always be successful 4.
- Isotretinoin may be required to achieve remission in cases of pembrolizumab-induced follicular eruption 4.
- For patients who develop plaque psoriasis as a result of pembrolizumab treatment, risankizumab, an anti-IL-23 inhibitor, may be an effective treatment option 5.
- The timing of onset of cutaneous adverse reactions associated with pembrolizumab can vary, with some reactions occurring within a few weeks of starting treatment, while others may occur after several months or even after discontinuation of therapy 6.
Management of Cutaneous Adverse Events
- It is essential to have a comprehensive understanding of the cutaneous toxicities associated with pembrolizumab to initiate prompt treatment and minimize the impact on the patient's quality of life 3.
- The development of cutaneous adverse events, especially hypopigmentation in patients with melanoma, may be associated with a better treatment response 7.
- In some cases, the cutaneous adverse events may be severe enough to require dose reduction or discontinuation of pembrolizumab, but this is not always necessary, and treatment can often be continued with appropriate management of the rash 3, 5.