Nivolumab-induced severe bullous pemphigoid in a patient with renal cancer: a case report and literature review

Wu, Xiaorong; Palvai, Sreekanth; Jalil, Awais

doi:10.20517/2394-4722.2020.77

Cited by 6 publications

(10 citation statements)

References 25 publications

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“…Often, mild and localized pruritus is the only clinical symptom before quickly progressing to hemorrhagic blisters on the chest, abdomen, thighs, and upper arms. 9 The average time to diagnosis in nine reported cases was 9.4 months. 12 A review of 21 cases with PD‐1‐induced BP found that nine were associated with nivolumab in which the median time to cutaneous toxicity and bullae formation was 12 weeks.…”

Section: Discussionmentioning

confidence: 94%

“…Increasing usage of immunotherapy for cancer management has resulted in an increased incidence of BP as a cutaneous toxicity. 9 …”

Section: Discussionmentioning

confidence: 99%

“…BP in oncologic patients may be paraneoplastic, drug‐induced, secondary to cancer therapy, or idiopathic. Increasing usage of immunotherapy for cancer management has resulted in an increased incidence of BP as a cutaneous toxicity 9 …”

Section: Discussionmentioning

confidence: 99%

“…Increasing usage of immunotherapy for cancer management has resulted in an increased incidence of BP as a cutaneous toxicity. 9 The characteristics of the underlying malignancy may also contribute to BP development following PD-1 inhibitor therapy. A study evaluating general cutaneous side effects of anti-PD-1 therapy reported 11 patients with BP; primary tumors were either melanoma (5), non-small cell lung carcinoma (2), urothelial carcinoma (2), or head and neck squamous cell carcinoma (1).…”

Section: Bp In Association With Pd-1 Inhibitor Therapymentioning

confidence: 99%

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Lichen planus pemphigoides: A unique form of bullous and lichenoid eruptions secondary to nivolumab

Shah

Bhate

Hernandez

2022

Dermatologic Therapy

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The widespread use of PD-1 inhibitors to treat various solid tumors has brought certain challenges for the clinician, including immune-related adverse events (irAEs).Cutaneous toxicities are among the most observed irAEs. Bullous and lichenoid dermatoses following PD-1 inhibitor therapy have been described. Here we report a novel case of lichen planus pemphigoides, featuring characteristics of both bullous pemphigoid and lichen planus, in a patient treated with nivolumab for renal cell carcinoma. We subsequently review all three cutaneous conditions which may arise in the context of PD-1 inhibitor therapy.

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Section: Discussionmentioning

confidence: 94%

“…Increasing usage of immunotherapy for cancer management has resulted in an increased incidence of BP as a cutaneous toxicity. 9 …”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Bp In Association With Pd-1 Inhibitor Therapymentioning

confidence: 99%

See 2 more Smart Citations

Lichen planus pemphigoides: A unique form of bullous and lichenoid eruptions secondary to nivolumab

Shah

Bhate

Hernandez

2022

Dermatologic Therapy

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“…While most of these side effects are mild to moderate in severity, some manifestations can progress to high-grade and potentially life-threatening situations - such as bullous pemphigoid. [ 3 , 4 ] Since 2015, more than 40 cases of immunotherapy-related BP have been reported, involving either the skin or mucous membrane. Of these case reports, only 1 described the development of BP following concomitant use of both nivolumab and RT.…”

Section: Introductionmentioning

confidence: 99%

Development of bullous pemphigoid following radiation therapy combined with nivolumab for renal cell carcinoma

et al. 2021

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Rationale: Concern for immune-related adverse events from immunotherapy and radiation therapy are well-documented; however, side effects are mostly mild to moderate. However, high-grade, potentially life-threatening adverse events are increasing. While case reports regarding immunotherapy-related bullous pemphigoid (BP) have been rising, only 1 has described BP following concomitant use of both nivolumab and radiation therapy (RT). For that patient, nivolumab was used for 10 weeks prior to RT and development of PB followed 7 weeks later. This case presents a patient who tolerated nivolumab well for 38 months prior to developing BP less than 2 weeks after completing RT. Patient concerns: We present the case of DH, a 67-year-old gentleman on nivolumab for metastatic renal cell carcinoma to the lung since May of 2017. Following progressing lung nodules, the patient had his nivolumab paused and completed a course of short-beam radiation therapy. After restarting nivolumab post-radiation, the patient presented with itchy rash and blisters on his arm, legs, and trunk. Diagnosis: DH consulted dermatology following development of rash and was diagnosed with bullous dermatosis, likely bullous pemphigoid. Bullous pemphigoid following concomitant nivolumab (OPDIVO), despite prior tolerance and no history of autoimmune disease, was confirmed by biopsy a month later. Interventions: Initial treatment was betamethasone 0.05% cream mixed 1:1 with powder to form paste applied twice daily. Given progressive symptoms and confirmatory biopsy of BP, nivolumab was held and 100 mg doxycycline and 80 mg prednisone daily was prescribed for a week, reduced to 60 mg during the second week. Outcomes: A week following discontinuation of nivolumab and beginning of doxycycline and prednisone, the blistering and rash was almost entirely resolved. Four months later, nivolumab was restarted and the patient continued low-dose tapering of prednisone until December. Since completing prednisone, the patient has shown no recurrence of bullous pemphigoid and has not developed any other immune-related adverse events to nivolumab upon rechallenge. Follow-up through October 2021 demonstrates the patient's sites of disease, both in- and out-field, have remained responsive to treatment. Lessons: Treating physicians should be aware of off-target effects of radiotherapy for oligoprogressive disease, which may include abscopal toxicities and the development of new immune-related adverse effects.

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Association of Bullous Pemphigoid With Immune Checkpoint Inhibitor Therapy in Patients With Cancer

et al. 2022

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IMPORTANCEThere is limited information on immune checkpoint inhibitor-induced bullous pemphigoid (ICI-BP) in patients with cancer, with most existing studies being case reports or small case series from a single institution. Prior review attempts have not approached the literature in a systematic manner and have focused only on ICI-BP secondary to anti-programmed cell death 1 (PD-1) or programmed cell death ligand 1 (PD-L1) therapy. The current knowledge base of all aspects of ICI-BP is limited.OBJECTIVE To characterize the risk factors, clinical presentation, diagnostic findings, treatments, and outcomes of ICI-BP in patients with cancer as reported in the current literature.EVIDENCE REVIEW A systematic review was performed using PubMed, Embase, Web of Science, and the Cochrane Database of Systematic Reviews according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Articles reporting data on individual patients who met preestablished inclusion criteria were selected, and a predefined set of data was abstracted. When possible, study results were quantitatively combined.FINDINGS In total, 70 studies reporting data on 127 individual patients undergoing ICI therapy for cancer (median [IQR] age, 71 [64-77] years; 27 women [21.3%]) were included. In pooled analyses, patients ranged in age from 35 to 90 years. Immune checkpoint inhibitor-induced bullous pemphigoid often occurred during the course of anti-PD-1, PD-L1, or cytotoxic T lymphocyte-associated antigen 4 therapy but was also found to develop up to several months after treatment cessation. Prodromal symptoms, such as pruritus or nonspecific skin eruptions, were found in approximately half of the patient population. Histopathologic or serologic testing, when undertaken, was a helpful adjunct in establishing diagnosis. Treatment with immunotherapy was discontinued after ICI-BP development in most patients. The most common treatments were systemic and topical corticosteroids. Steroid-sparing therapies, such as antibiotics and other systemic immunomodulators, were also used as adjuvant treatment modalities. Biologic and targeted agents, used predominantly in cases refractory to treatment with corticosteroids, were associated with marked symptomatic improvement in most patients. CONCLUSIONS AND RELEVANCEThe results of this systematic review suggest that ICI-BP often poses a therapeutic challenge for patients with cancer who are receiving immunotherapy. Further research on the early recognition, diagnosis, and use of targeted treatment modalities will be essential in developing more personalized treatment options for affected patients while minimizing morbidity and mortality.

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Nivolumab-induced severe bullous pemphigoid in a patient with renal cancer: a case report and literature review

Cited by 6 publications

References 25 publications

Lichen planus pemphigoides: A unique form of bullous and lichenoid eruptions secondary to nivolumab

Lichen planus pemphigoides: A unique form of bullous and lichenoid eruptions secondary to nivolumab

Development of bullous pemphigoid following radiation therapy combined with nivolumab for renal cell carcinoma

Association of Bullous Pemphigoid With Immune Checkpoint Inhibitor Therapy in Patients With Cancer

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