18
Treatment
Table 1. Cutaneous Toxicities
1.2 Bullous Dermatoses
Workup/Evaluation:
• Physical exam.
• Rule out any other etiolog y of the skin problem, such as an infection, an effect of
another drug, or a skin condition linked to another systemic disease.
• Dermatolog y consultation for consideration of skin biopsy and direct
immunofluorescence. Further serologic work-up, such as enzyme-linked immunoassay
testing or indirect immunofluorescence may be pursued.
• Primer on monitoring for complicated cutaneous adverse drug reactions:
▶ Review of Systems: Skin pain ("like a sunburn"), fevers, malaise, myalgias,
arthralgias, abdominal pain, ocular discomfort or photophobia, sores or
discomfort in the nares, sores or discomfort in the oropharynx, odynophagia,
hoarseness, dysuria, sores or discomfort in the vaginal area for women or involving
the meatus of the penis for men, sores in the perianal area or pain with bowel
movements.
▶ Physical Exam: Include vital signs and a full skin exam specifically evaluating
all skin surfaces and mucous membranes (eyes, nares, oropharynx, genitals, and
perianal area). Assess for lymphadenopathy, facial or distal extremity swelling
(may be signs of drug-induced hypersensitivity syndrome/drug reaction with
eosinophilia and systemic symptoms (DRESS) (see section 1.3). Assess for
pustules or blisters or erosions in addition to areas of "dusky erythema" which may
feel painful to palpation.
Grading Management
G1: Asymptomatic or blisters
covering <10% BSA and no
associated erythema.
• If blisters are <10% BSA, are asymptomatic and
non-inflammatory (such as the case with friction
blisters or pressure blisters), cessation of ICPi is not
necessary and only observation/local wound care is
warranted.
• When symptomatic bullae or erosions, which are
"deroofed" vesicles or bullae, are noted on the
skin or mucosal surfaces, the cutaneous irAE is
considered at least Grade 2.
• See Grade 2 management recommendations.
(cont'd)
