Bullous Pemphigoid as an Adverse Reaction to Pembrolizumab: Two Case Reports

Abstract

Checkpoint inhibitors are novel and promising treatment options for different types of cancer. Programmed cell death 1 (PD-1) inhibitors, such as pembrolizumab, have been shown to significantly raise the survival rates of disseminated malignant melanoma (MM). Autoimmune adverse reactions are very common in checkpoint inhibitors. We present 2 cases of bullous pemphigoid, as adverse reactions to pembrolizumab-treated MM.

Pembrolizumab-induced bullous pemphigoid

“…Similar to our 2 cases, several patients also developed erythematous papules and plaques before bullae development. Most cases were successfully treated with a combination of systemic and topical steroids with steroid-sparing drugs, such as methotrexate, added for refractory disease 8, 9, 10. In certain cases, including our second patient, exacerbation of bullous lesions may be seen several months after discontinuation of anti–PD-1 therapy.…”

Severe bullous pemphigoid in a metastatic lung cancer patient treated with pembrolizumab

“…In most of the reported cases, the severity of BP associated with anti PD-1 antibodies is relatively mild. 2,3,5 In addition, the clinical features are basically similar to those of common BP. 2,3,5 In our case, the patient exhibited severe mucosal involvement and cellulitis-like lesions such as leg swelling with redness and elevated serum CRP levels.…”

“…2,3,5 In addition, the clinical features are basically similar to those of common BP. 2,3,5 In our case, the patient exhibited severe mucosal involvement and cellulitis-like lesions such as leg swelling with redness and elevated serum CRP levels. Clinicians should be aware of the possibility that BP associated with anti PD-1 antibodies may exhibit such severe and atypical clinical features.…”

“…2 In most cases, the severity of BP is mild, and their clinical features are basically similar to those of common BP. 2,3 Here, we report a case of severe BP with characteristic clinical features in a patient treated with pembrolizumab.…”

Nivolumab-induced severe bullous pemphigoid in a patient with renal cancer: a case report and literature review

“…As steroids can potentially diminish immunomodulatory actions, topical steroids are first-line treatment for BP and are largely safe due to their limited systemic absorption. Meanwhile, oral nicotinamide and tetracycline (doxycycline or minocycline) have demonstrated a good effect in mild or moderate cases whilst completely avoiding systemic steroids [14,15] . The role of nicotinamide in treating BP is modulating inflammatory cytokines and acting as poly adenosine diphosphate ribose polymerase inhibitor [16] .…”