Original article
Immune checkpoint-mediated psoriasis: A multicenter European study of 115 patients from the European Network for Cutaneous Adverse Event to Oncologic Drugs (ENCADO) group

https://doi.org/10.1016/j.jaad.2020.08.137Get rights and content

Background

Immune checkpoint inhibitor (ICI)–mediated psoriasis poses significant diagnostic and therapeutic challenges.

Objective

To report data on ICI-mediated psoriasis, emerging from the largest cohort to date, to our knowledge, and to propose a step-by-step management algorithm.

Methods

The medical records of all patients with ICI-mediated psoriasis were retrospectively reviewed across 9 institutions.

Results

We included a cohort of 115 individuals. Grade 1, 2, and 3 disease severity was reported in 60 of 105 (57.1%, 10 missing data), 34 of 105 (32.4%), and 11 of 105 (10.5%), respectively. The ratio between exacerbation and de novo cases was 1:4.3. The most common systemic therapy was acitretin (23 patients, 20.1%), followed by systemic steroids (8 patients, 7%), apremilast (7 patients, 6.1%), methotrexate (5 patients, 4.3%) and biologics (4 patients, 3.6%). Overall, 29 of 112 patients (25.9%) interrupted and 20 of 111 (18%) permanently discontinued ICIs because of psoriasis. Body surface area of greater than 10% at baseline had a 3.6 increased risk for ICI treatment modification (odds ratio, 3.64; 95% confidence interval, 1.27-10.45; P = .03) and a 6.4 increased risk for permanent discontinuation (odds ratio, 6.41; 95% confidence interval, 2.40-17.11; P < .001). Guttate psoriasis and grade 2 or 3 disease were significant positive predictors for antitumor response of ICI, whereas pruritus was a negative predictor.

Limitations

Retrospective design.

Conclusion

Acitretin, apremilast, and methotrexate are safe and effective modalities for ICI-mediated psoriasis. In most cases, ICI can be completed unhindered. A therapeutic algorithm is proposed.

Section snippets

Patients and methods

This was a multicenter, retrospective study of psoriasis related to immunotherapy, conducted in the name of the European Network for Cutaneous Adverse Event to Oncologic Drugs (ENCADO) group. For the aims of the study, we used the databases of 9 oncodermatology units from Greece, France, Italy, Spain, and Argentina and searched for psoriasis cases developing through the treatment course with ICI until the end of December 2019. Inclusion criteria were patients developing psoriasis after

Results

European Network for Cutaneous Adverse Event to Oncologic Drugs group members provided data of 115 patients with anti–PD-1/PD-L1–induced psoriasis that were included in the study. The mean (SD) follow-up period after psoriasis diagnosis was 9.3 (7.09) months.

Demographic characteristics of the study group are listed in Table I. Thirty-three of 115 (30.8%) patients had a personal history of psoriasis; in 20 out of 33 of them, the disease was active and clinically apparent upon ICI initiation.

Discussion

Psoriatic lesions have been reported in various case series of ICI treatment.7, 8, 9, 10, 11, 12 Several studies report that the majority of these patients are complicated with psoriasis on the setting of exacerbation of a pre-existing condition.10,13, 14, 15 We present, to our knowledge, the largest series to date of patients with cancer treated with ICIs, complicated with psoriasis. According to our analysis, 70% of the cases were affected by psoriasis de novo with unique disease features.

Conflicts of interest

None disclosed.

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    Funding sources: None.

    IRB approval status: Not applicable.

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