What is the approach and treatment for immunotherapy-induced dermatitis?

From the Guidelines

The treatment for immunotherapy-induced dermatitis involves a stepwise approach based on severity, with the most recent guidelines from 2021 recommending identification, evaluation, and management of cutaneous toxicities 1. The approach to managing immunotherapy-induced dermatitis can be broken down into several key steps:

• For mild cases (grade 1), topical corticosteroids like triamcinolone 0.1% or betamethasone 0.1% applied twice daily are recommended, along with oral antihistamines such as cetirizine 10mg daily for itch relief.
• Moderate dermatitis (grade 2) may require medium-potency topical steroids and consideration of oral prednisone at 0.5-1mg/kg/day for 5-7 days with a taper.
• Severe cases (grade 3-4) necessitate immunotherapy interruption, hospitalization, and high-dose systemic corticosteroids (prednisone 1-2mg/kg/day) until improvement to grade 1, followed by a slow taper over 4-6 weeks. It's essential to note that the severity of cutaneous side effects is a critical factor in determining the management approach, and the 2021 guidelines provide a comprehensive framework for identification, evaluation, and management of cutaneous toxicities 1. Some key considerations in managing immunotherapy-induced dermatitis include:
• Regular use of moisturizers to help manage skin symptoms
• Avoidance of hot showers and irritating soaps to reduce skin irritation
• Early intervention to prevent rapid worsening of dermatitis and significant impact on quality of life
• Consideration of immunomodulators like tacrolimus ointment or systemic medications such as mycophenolate mofetil for steroid-refractory cases The underlying mechanism of immunotherapy-induced dermatitis involves T-cell activation against shared antigens in tumor and skin tissue, leading to inflammatory reactions that manifest as rash, pruritus, and other dermatological symptoms 1.

From the FDA Drug Label

CLINICAL PHARMACOLOGY The corticosteroids are a class of compounds comprising steroid hormones secreted by the adrenal cortex and their synthetic analogs. In pharmacologic doses, corticosteroids are used primarily for their anti-inflammatory and/or immunosuppressive effects Topical corticosteroids such as clobetasol propionate are effective in the treatment of corticosteroid-responsive dermatoses primarily because of their anti-inflammatory, antipruritic, and vasoconstrictive actions.

The approach and treatment for immunotherapy-induced dermatitis may involve the use of topical corticosteroids such as clobetasol propionate, due to their anti-inflammatory and immunosuppressive effects.

• Clobetasol propionate is a highly potent topical corticosteroid that can be used to treat corticosteroid-responsive dermatoses.
• The treatment should be used under the guidance of a physician and for the prescribed time period only.
• Patients should be evaluated periodically for evidence of HPA axis suppression.
• If irritation develops, the treatment should be discontinued and appropriate therapy instituted [2] [3].

From the Research

Approach to Immunotherapy-Induced Dermatitis

• The approach to immunotherapy-induced dermatitis involves identifying and managing the underlying cause of the dermatitis, which can be a challenging task due to the complexity of the immune system and the variety of immunotherapies available 4.
• A thorough medical history, including a detailed account of the patient's immunotherapy treatment, is essential in diagnosing immunotherapy-induced dermatitis 5, 4.
• Diagnostic tests, such as patch testing and skin biopsies, may be necessary to confirm the diagnosis and rule out other potential causes of dermatitis 5, 4.

Treatment of Immunotherapy-Induced Dermatitis

• The treatment of immunotherapy-induced dermatitis depends on the severity and type of dermatitis, as well as the patient's overall health and medical history 5, 6, 4.
• Topical corticosteroids and emollients are commonly used to manage mild to moderate dermatitis, while systemic corticosteroids and immunosuppressants may be necessary for more severe cases 5, 6, 4.
• In some cases, the immunotherapy treatment may need to be modified or discontinued to manage the dermatitis, and alternative treatments may be explored 4.
• The use of biologics, such as dupilumab, has shown promise in treating atopic dermatitis, a common type of dermatitis associated with immunotherapy 7.

Management of Specific Types of Dermatitis

• Atopic dermatitis, a common type of dermatitis associated with immunotherapy, can be managed with topical corticosteroids, emollients, and biologics, such as dupilumab 7, 6.
• Contact dermatitis, another type of dermatitis that can be induced by immunotherapy, can be managed by avoiding the offending allergen or irritant, and using topical corticosteroids and emollients to reduce inflammation and promote skin healing 5.
• Immune-related adverse events (irAEs), such as maculopapular rash and pruritus, can occur with immunotherapy and require prompt recognition and management to prevent exacerbation and minimize quality of life impairment 4.