Prevalence of inverse psoriasis subtype with immune checkpoint inhibitors

Abdulhadi Jfri; Bonnie Leung; Jordan T Said; Yevgeniy Semenov; Nicole R LeBoeuf

doi:10.1093/immadv/ltac016

Prevalence of inverse psoriasis subtype with immune checkpoint inhibitors

Immunother Adv. 2022 Sep 23;2(1):ltac016. doi: 10.1093/immadv/ltac016. eCollection 2022.

Authors

Abdulhadi Jfri^{1

2

3

4

5

6

7}, Bonnie Leung^{3

8}, Jordan T Said^{1

2

3}, Yevgeniy Semenov^{1

8}, Nicole R LeBoeuf^{1

2

3}

Affiliations

¹ Dermatology Department, Harvard Medical School, Boston, MA, USA.
² Department of Dermatology, Brigham and Women's Hospital, Boston, MA, USA.
³ Center for Cutaneous Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
⁴ Division of Dermatology, King Abdulaziz Medical City, Jeddah, Saudi Arabia.
⁵ College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.
⁶ King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
⁷ Division of Dermatology, Department of Medicine, Ministry of the National Guard-Health Affairs, Jeddah, Saudi Arabia.
⁸ Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA.

Abstract

Background: Cutaneous immune-related adverse events (irAEs) are the most common irAEs caused by immune-checkpoint inhibitors (ICI). Psoriasiform eruptions, both de novo and flares, may occur. Evidence is lacking on inverse psoriasis subtype.

Methods: A retrospective study was conducted at Dana-Farber Cancer Institute/Mass General Brigham through February 2020 using databases. Confirmed inverse psoriasis cases pre-/post-ICI initiation either independently or in conjunction with other psoriasis subtypes were included. Known psoriasis cases without flare post-ICI were excluded.

Results: A total of 262 (3%) individuals with any ICI-mediated psoriasiform cutaneous irAE were identified out of the 8683 DFCI ICI-treated patients. Of these, 13 (5% of psoriasis patients) had inverse psoriasis (mean age 68.7 years; 7/13 male sex). Median (range) time from ICI initiation to inverse psoriasis development or flare was 7 (4-12) and 3.5 (2-6) weeks, respectively. Pruritus occurred in 12/13 (92.30%) cases. 11 (85%) had inguinal involvement; other sites included gluteal cleft (6; 46%), inframammary (3; 23%), perianal (2; 15%), axilla (2; 15%), umbilicus (2; 15%), and infra-abdominal folds (1; 8%). Most (9/13) individuals had more than one site involved. The Common Terminology Criteria for Adverse Events severity was 1 in 10 (76.92%) individuals and 2 in 3 (15.38%) individuals. Six (46.15%) patients were treated initially by oncology with topical (nystatin, econazole, or clotrimazole) or systemic antifungals (fluconazole) for median (range) of 3.5 (1-7) months without improvement, for presumed candida intertrigo.

Conclusion: Patients on ICI may develop inverse psoriasis, which may be initially confused for fungal intertrigo. Delayed diagnosis can prolong symptoms, while patients are treated ineffectively with topical/systemic antifungals for presumed candida infection. Oncologist and dermatologist awareness is important to improve diagnosis of ICI-mediated inverse psoriasis, its management and affected patients' quality of life.

Keywords: flexural psoriasis; immune checkpoint inhibitors; immune-related adverse events; intertriginous psoriasis; inverse psoriasis; skin toxicity.