Bullous Pemphigoid Associated With a New Combination Checkpoint Inhibitor Immunotherapy

Novel immunotherapies including antibodies to programmed death ligand 1 (PD-1) and cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) have become common therapies for neoplasms including metastatic melanoma and non-small cell lung cancer (NSCLC). Dermatologic toxicity is the most common adverse event associated with these immunotherapies. We report a case of bullous pemphogoid (BP) in a patient receiving combination durvalumab and tremelimumab, two newer immunotherapy checkpoint inhibitors under investigation in phase III trials. J Drugs Dermatol. 2019;18(1):103-104.

Tofacitinib for the treatment of lichen planopilaris: A case series.

Lichen planopilaris (LPP) is an inflammatory cicatricial alopecia for which many different therapies are attempted with varying success. The Janus kinase (JAK) inhibitor, tofacitinib, has been shown to be effective in treating the noncicatricial alopecia, alopecia areata. As in alopecia areata, upregulation of interferon and JAK signaling may play a role in LPP. We retrospectively reviewed the cases of 10 patients with recalcitrant LPP who were treated with oral tofacitinib. Patients received oral tofacitinib 5 mg twice or three times daily for 2-19 months as either monotherapy or adjunctive therapy to other ongoing treatments including intralesional triamcinolone, hydroxychloroquine, and tacrolimus ointment. Eight patients had clinical improvement in LPP with tofacitinib as either monotherapy (4/10) or adjunctive therapy (4/10). LPP Activity Index (LPPAI) before and after treatment was measured in seven patients and was significantly different (6.22 before treatment, 3.08 after treatment; p value = .0014). Reduction in LPPAI ranged from 30 to 94%. One patient complained of 10 pound (4.5 kg) weight gain after 12 months on tofacitinib. No other adverse effects were reported. Treatment with oral tofacitinib either as monotherapy or adjunctive therapy can lead to measurable improvement in recalcitrant LPP.

Simple Intraoperative Technique to Improve Wound Edge Approximation for Residents.

Among the variables associated with surgical outcomes, cosmesis is important to patients and challenging to the early-learning resident. We offer a technique that allows alignment of wound edges by intraoperatively using a suture to determine where to place the next needle bite. This technique can be used to correct for variation in surface angle and malalignment with altered skin tension that is encountered during routine surgery and can be applied to intermediate and complex closures.

A review of bullous pemphigoid associated with PD-1 and PD-L1 inhibitors.

BACKGROUND: Dermatologic toxicity represents a substantial portion of all immune-related adverse events (irAEs) associated with PD-1/PD-L1 inhibitors. Bullous pemphigoid (BP) is a rare cutaneous side effect of these medications, which can initially be clinically indistinguishable from other, low-grade cutaneous toxicity. OBJECTIVE: To better characterize the clinical features of BP associated with PD-1/PD-L1 inhibitors, evaluate the efficacy of various treatment regimens, determine the frequency of prodromal pruritus, and assess whether immunological diagnostic studies for BP are warranted in patients treated with checkpoint inhibitors who develop intractable pruritus. METHODS: A comprehensive review of the English-language medical literature was performed using key terms. Papers published on any date and from all origins were considered. Fourteen publications, containing 21 patient cases, were selected independently by two reviewers and deemed relevant to the present publication. RESULTS: Pruritus was a prominent feature of the majority (12/21) of cases and preceded or occurred concurrently with BP development. Bullae developed within 6-8 months of initiation of PD-1/PD-L1 inhibitors; however, a smaller subset of patients did not develop bullae for 1-1.5 years following initiation of therapy. Mean time to pruritus was similar for pembrolizumab and nivolumab at 19 and 21 weeks, respectively. Development of BP required discontinuation of immunotherapy in 76% (16/21) of cases. CONCLUSION: Prodromal or "non-bullous" variants of BP must be considered in patients treated with checkpoint inhibitors who develop protracted or worsening pruritus. Early diagnostic immunological evaluation of the skin may lead to improved patient outcomes by facilitating timely initiation of treatment and prevent disruptions in cancer therapy.