Managing Immunotherapy Treatment Related Rash

Written by: Natasha Heimbigner, PharmD, Summit Cancer Centers
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Proper prevention and management of immunotherapy related rash is an important intervention for the patient’s quality of life and continuation of therapy.

Background

Immunotherapy is increasingly used in cancer treatment; improving outcomes for many patients with melanoma, non-small cell lung cancer, breast cancer, and a growing number of tumor types.¹ Although these agents have a range of adverse effects, the most commonly seen is dermatologic. These dermatologic adverse effects can manifest weeks to months after the first treatment, manifesting as a maculopapular or pruritic rash.^2,3,4 Other potential toxicities skin reactions include but are not limited to: bullous eruptions and Stevens–Johnson syndrome so understanding the difference of these specific skin reactions as well is important.

PQI Process

• Identify high risk patients – All immunotherapy patients
  • Note – patients may be reluctant to bring up adverse effects that they are experiencing. Ask directly if they have a rash.
• Determine the grading of the rash (pharmacist or provider)

• • Grade 1 – Covers < 10% body surface area or without symptoms. Mild or localized itching.
  • Grade 2 – Covers 10-30% body surface area with or without symptoms. Intense or widespread itching.
  • Grade 3-4 – Covers > 30% body surface area, limiting actives of daily living, severe itching, affects sleep, life threatening or requiring possible hospitalization.

• Recommended appropriate treatment based on grade of rash (additionally discuss therapy to physician/document in EMR) NOTE: Dose reduction of immunotherapy is not a recommended option. View associated NCCN references and sources for further information⁴.

• • Grade 1
    • Use fragrance free soaps for bathing and detergents for the clothes
      • Consult with medically integrated team to determine best relief care for patient
    • Topical corticosteroids twice daily
      • Triamcinolone 0.1% lotion or fluocinonide 0.05% cream
  • Grade 2
    • Topical corticosteroids twice daily
      • Triamcinolone 0.1% lotion or fluocinonide 0.05% cream
    • Oral antihistamines or GABA agonists for pruritus
      • Hydroxyzine 10mg tid or gabapentin 300mg tid, pregabalin 50mg tid
  • Grade 3
    • Hold immunotherapy until rash is grade ≤1
    • Oral corticosteroids (prednisone 0.5-1mg kg/day or equivalent) until symptoms are grade ≤1
  • Grade 4
    • Permanently discontinue
    • Consider topical antibiotics in combination with oral retinoids, IV corticosteroids, IM/IV antihistamines, IV Antibiotics and/or hydration

Patient-Centered Activities

• Provide education:
  • Counsel patient on all medications
  • Proper skin care tips and tricks
• Infection Prevention
• Monitor skin
  • Importance of calling provider if rash worsens

References:

1. Thompson JA, Schneider BJ, Brahmer J, et. Al. “Management of IOmmunotherapy-Related Toxicities, Version 1.2019” J Natl Compr Canc Netw. 2019 Mar 1;17(3):255-289. doi: 10.6004/jnccn.2019.0013. Accessed at: https://www.ncbi.nlm.nih.gov/pubmed/30865922
2. “Toxicities Associated with Checkpoint Inhibitor Immunotherapy.” UpToDate, uptodate.com/contents/toxicities-associated-with-checkpoint-inhibitor-immunotherapy#H645515. 23 March 2018
3. Puzanov I, Diaab A, Abdallah K, Al. “Managing toxicities associated with immune checkpoint inhibitors: consensus recommendations from the Society for Immunotherapy of Cancer (SITC) Toxicity Management Working Group.” J Immunother Cancer. 2017 Nov 21;5(1):95. doi: 10.1186/s40425-017-0300-z.
4. Phillips GS, Wu J, Hellmann MD, et. Al. “Treatment Outcomes of Immune-Related Cutaneous Adverse Events.” J Clin Oncol. 2019 Oct 20;37(30):2746-2758. doi: 10.1200/JCO.18.02141. Epub 2019 Jun 19

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