Video Blog: Checking Your Knowledge: Manifestations of Immune Checkpoint Inhibitors

In this video blog, Dr. James Song summarizes his lecture in the panel discussion, Checking Your Knowledge: Manifestations of Checkpoint Inhibitors on November 8, 2024, 5th Annual Elevate-Derm West Conference at the Westin Kierland Resort in Scottsdale, AZ.

In this video

Dr. Song frames checkpoint inhibitors as "revolutionary" for cancer patients, with durable responses — but notes the trade-off is immune-mediated side effects, and the skin is the most commonly affected organ, with roughly 50% of patients developing some rash or itch. Because patients who develop these eruptions tend to be the ones responding well to immunotherapy, he argues it's dermatology's responsibility to manage the skin so patients can stay on the drug and keep benefiting from an oncology standpoint. Presentations range widely — psoriasis, eczema, itch, bullous pemphigoid, lichenoid eruptions, alopecia areata, vitiligo — and are often mixed or atypical.

Since oncology colleagues generally aren't comfortable treating cutaneous manifestations and tend to reach for systemic steroids, Dr. Song stresses limiting systemic steroids (which can lower survival if used too early) and gravitating toward high-quantity topical corticosteroids plus targeted, morphology-based therapy: dupilumab for eczematous lesions, IL-23 or IL-17 inhibitors for psoriasis, and dupilumab or omalizumab for bullous pemphigoid. He reserves systemic steroids and drug cessation for serious reactions like Stevens-Johnson syndrome or TEN. He adds that timing offers clues — morbilliform rashes appear within the first couple of weeks, while DRESS, bullous pemphigoid, and vitiligo can be delayed three to six months, even after therapy stops, and tend to be harder to treat in this context.

• The skin is the most common organ affected by checkpoint inhibitors, with about 50% of patients developing a rash or itch — and these patients are often the ones responding best to immunotherapy.
• Managing the skin is dermatology's job, so patients can stay on effective cancer therapy rather than stopping the drug.
• Limit systemic steroids — too much early on can lower survival; favor high-quantity topical corticosteroids and morphology-based targeted therapy.
• Treat by morphology: dupilumab for eczematous lesions, IL-23 (or IL-17) inhibitors for psoriasis, dupilumab or omalizumab for bullous pemphigoid.
• Timing is a clue: morbilliform eruptions appear within a couple of weeks, while bullous pemphigoid, DRESS, and vitiligo can present three to six months later — even after therapy is stopped.