21
Table 1. Cutaneous Toxicities
G3: Skin sloughing covering
<10% BSA with mucosal
involvement associated signs
(e.g., erythema, purpura,
epidermal detachment,
and mucous membrane
detachment).
• Hold ICPi therapy and consult with dermatolog y.
• Admit to burn unit and/or consult wound services
with attention to supportive care including fluid
and electrolyte balance, minimizing insensible
water losses, and preventing infection.
• Treat skin with topical emollients and other
petrolatum emollients, oral antihistamines, and
high strength topical corticosteroids. Dimethicone
may also be offered as an alternative to petrolatum.
• Administer IV methylprednisolone (or equivalent)
0.5–1 mg/kg and convert to oral corticosteroids on
response, wean over at least 4 weeks.
• Given the immune mechanism of action of
these medicines, use of immune suppression (see
Table A2) is warranted and should be offered.
The usual prohibition of corticosteroids for
Stevens-Johnson Syndrome is not relevant
here, as the underlying mechanism is a T-cell
immune directed toxicity. Adequate suppression
is necessary with corticosteroids or other agents
and may be prolonged in cases of DRESS/Drug
Hypersensitivity Syndrome.
• For mucous membrane involvement of SJS or TEN,
appropriate consulting services should be offered
to guide management in preventing sequelae from
scarring (e.g., ophthalmolog y, otolaryngolog y,
urolog y, g ynecolog y, etc. as appropriate).
G4: Skin erythema and
blistering/sloughing covering
≥10% BSA with associated
signs (e.g., erythema, purpura,
epidermal detachment,
mucous membrane
detachment) and/or systemic
symptoms and concerning
associated blood work
abnormalities (e.g., liver
function test elevations in the
setting of DRESS/DIHS).
• Permanently discontinue ICPi.
• Admit patient immediately to a burn unit
or intensive care unit (ICU) with consulted
dermatolog y and wound care services. Consider
further consultations based on management of
mucosal surfaces (e.g., ophthalmolog y, urolog y,
g ynecolog y, otolaryngolog y, etc.).
• Initiate IV methylprednisolone (or equivalent) 1–2
mg/kg, tapering when toxicity resolves to normal.
• IVIG or cyclosporine may also be considered in
severe or steroid-unresponsive cases.
• Consider pain/palliative consultation and/or
admission in patients presenting with DRESS
manifestations.
(cont'd)
