Skin toxicity – Grade 1
May 11, 2025Hepatitis
May 11, 2025Skin toxicity – Grade 2-4
Low Risk
- • Alopecia < grade 2
• Bullous dermatitis grade 2 (affecting 10-30% BSA)
• Dry skin > grade 2
• Erythema multiforme grade 2 (affecting 10-30% BSA)
• Erythroderma grade 2 (covering >90% BSA)
• Pruritus > grade 2 with moderate with skin changes from scratching limiting instrumental ADL
• Rash grade 2 covering 10-30% BSA with/without symptoms, limiting instrumental ADL
• Skin atrophy > grade 2 (covering > 10% BSA)
• Skin induration > grade 2
Assessment and Investigations
Perform anamnesis, clinical assessment, and basic lab test
Management escalation pathway
- Treat ambulatory
- Apply topical steroids as indicated
- Apply symptomatic treatment to associated symptoms (e.g. itching, dry skin) as indicated second-generation antihistamines
- If symptoms persist > 6 days consult dermatologist
Symptoms resolved to grade 0 or 1?
Yes
- Stop topical therapy
- Restart ICPI
No
- biopsy should be done
Medium Risk
- Bullous dematitis grade 2 (affecting > 30% BSA)
- Erythema multiforme grade 3 (>30% BSA oral and genital erosions)
- Erythroderma grade 3 (>90% BSA)
- Rash grade > (3 covering >30% BSA) associated with superinfection requiring antibiotics
Assessment and Investigations
Biopsy should be done
Management escalation pathway
- Treat ambulatory or hospitalize
- Apply topical steroids as indicated
- Apply symptomatic treatment to associated symptoms (e.g. itching, dry skin) as indicated second-generation antihistamines
- Initiate oral/iv methylprednisolone at a dose of 1mg/kg BW per day in case of steroid responsive toxicity
- Treat with antibiotics as indicated after taking swaps
Symptoms resolved to grade 0 or 1?
Yes
- restart ICPI (can be combined with topical corticoids but not with oral corticoids)
- Taper oral steroids over >1 month
- For bullous dermatitis, a long corticosteroid taper is indicated followed by a period of low dose corticosteroids (3-4 months with 4-8 mg/d)
No
- Hospitalize patient
- Consider increasing the dose of steroids to 2 mg/kg BW
- For bullous dermatitis resistant to corticoids Omalizumab (anti-IgE) might be considered (experience and not evidence based)
High Risk
- Steven Johnson syndrome
- Toxic epidermal necrolysis
- Bullous dermatis grade 4 (affecting > 30% BSA, blistering with electrolyte/fluid abnormalities)
- Erythema multiforme grade 4 (>30% BSA electrolyte/fluid abnormalities)
- Erythroderma grade 4 (>90% BSA Electrolyte/fluid abnormalities)
Assessment and Investigations
- Perform biopsy
- Perform blood analysis
Management escalation pathway
- Hospitalize in ICU/burn unit
- Apply electrolyte and fluid control
- Apply nutritional control initiated antibiotic therapy as indicated
- Apply general burn unit measures (e.g. sterile handling, antiseptic solution, repeated cultures, pain management …)
- Withhold ICPI and consider other causes (treatment related, paraneoplastic, …)
- Instore systemic immunosuppression (corticoids and beyond)
Continue
Continue with Medium Risk