Skin toxicity – Grade 2-4 – Medium risk

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)