support patients through treatment to facilitate optimized anti-cancer management while limiting cutaneous toxicities and maximizing quality of life.16 Patients receiving dermatologic care are more likely to resume their ICI after a cirAE and may even have better outcomes.
Project Update
The United States Cutaneous Oncodermatology Management (USCOM) project was developed to improve cancer patients’ and survivors’ quality of life by offering tools for preventing and managing cutaneous adverse events related to cancer therapy.
The USCOM consortium has previously published 2 foundational algorithms for skin management in cancer patients: 1) an algorithm to reduce the incidence of cirAEs, treat cirAEs, and maintain healthy skin using general measures and over-the-counter agents,17 and 2) an algorithm to prevent and treat acute radiation dermatitis.18 These algorithms aim to support all healthcare providers treating oncology patients, including physicians, nurses, pharmacists, and advanced providers.
The next step in the project is to develop a practical algorithm for the prevention and treatment of immunotherapy-related cutaneous adverse events, which we propose here.
MATERIALS AND METHODS
A selected group of multidisciplinary advisors used the AGREE II instrument following the modified Delphi method to develop the USCOM practical algorithm for the treatment of cirAEs.19,20 The modified Delphi method is a communication technique for interactive decision-making for medical projects.20
During a face-to-face meeting on February 4, 2023, the outcome of a systematic literature review identifying the spectrum of cirAEs, specifically pruritus and the inflammatory dermatoses, and addressing their prevention and treatment was discussed and the practical algorithm was developed based on the assembled evidence coupled with the panel’s experience and opinion. An online process was used to fine-tune the practical algorithm and prepare and review the publication.
Literature Review
The systematic literature review included guidelines, consensus papers, and clinical or other research publications on the prevention and management of cirAEs published in English from January 2010 to October 2022. Articles were excluded if they contained no original data (unless a review article was deemed relevant), if they were not relevant to cirAEs, or if the publication language was other than English.
A dermatologist and a physician-scientist conducted the searches on October 26 and 27, 2022. PubMed was the primary search engine, with Google Scholar as a secondary source. The search criteria used were as follows: cirAEs AND isolated pruritus OR psoriasis OR lichen planus OR eczematous eruptions OR bullous eruptions AND QoL OR prevention OR treatment OR maintenance with prescription therapy OR skincare OR adjunctive skincare OR education of staff and patients.
The results of the searches were evaluated independently by 2 reviewers who resolved discrepancies through discussion. The searches yielded 106 publications. Ninety-four papers remained after excluding duplicates and articles not deemed relevant (other subjects, low quality). The 94 included papers addressing cirAEs were comprised of: 2 guidelines and algorithms, 8 systematic literature reviews, 10 consensus papers, 17 reviews, 42 clinical studies, and 15 other research studies. Case reports were included because they provide valuable information in this fast-developing field. Moreover, cirAEs possess complex issues, including their presentation and appropriate management on a patient-to-patient basis, that are difficult to capture in randomized controlled settings. Two reviewers evaluated the literature search results and graded the clinical publications. Grading and rating of evidence included study type and quality (grade A to C) and level of evidence (level 1 to level 4) using pre-established criteria.18 The paucity of studies on cirAE treatment, with both general skincare and prescription medications, made grading less relevant; however, the guidelines, systematic literature reviews, and consensus papers provided valuable information.
The Algorithm
An algorithm for the prevention and management of cirAEs was created based on the results of the systematic literature review as well as expert experience and opinion (Figure 1). As with the USCOM Algorithm II for the prevention and management of acute radiation dermatitis,18 the proposed algorithm expands on the USCOM algorithm for cancer-treatment-related cAEs,17 which uses the Common Terminology Criteria for Adverse Events (CTCAE) grading system v.5 (Table 1).
As with other anticancer therapies, early identification of severe cAEs – which may be detected by signs and symptoms including fever, skin pain, epidermal changes, high body surface area involvement, or laboratory abnormalities – is an important first step because, regardless of the cutaneous reaction, the patient will require immediate evaluation by a clinician and possibly a dermatologist. Often inpatient or ICU-level care is required for management. When red flag signs or symptoms are not present, recommendations become specific to type of cutaneous reaction with therapeutic distinctions for the following classes: eczematous or maculopapular, bullous, lichenoid, and psoriasiform eruptions as well as pruritus. Evaluation for more systemic organ involvement should be performed
