Lichenoid drug reaction after ipilimumab/nivolumab combination therapy: A case report

Abstract

Nivolumab (PD-1 inhibitor) and ipilumumab (CTLA-4 inhibitor) are recently approved checkpoint inhibitors for treatment of non-small cell lung cancer. Immune-related adverse events related to the usage of checkpoint inhibitors are growing with their popularity. We present the case of a patient in combination treatment of nivolumab and ipilimumab who developed a lichenoid drug reaction, notable because it worsened to a bullous lichenoid drug reaction. Treatment with prednisone and withdrawal of checkpoint inhibitors aided in clinical resolution. Initial presentation of a lichenoid reaction that progressed to a bullous, desquamated presentation indicates the possibility of the prodromal rash progressing to a Stevens-Johnson Syndrome-like dermatosis. When dermatologists are consulted for rashes developed during checkpoint-inhibitor therapy, they should be aware that early treatment may prevent progression to bullae formation and desquamation and develop their treatment plans with this in mind.

Keywords: Bullous lichenoid drug reaction; combination therapy; ipilimumab; mesothelioma; nivolumab.

Figure 1.

Initial presentation of the patient’s dermatosis on day 1 of hospital admission. Flaccid bullae had burst, leaving exulcerations on the patient’s skin.

Figure 2.

Histopathology results. A, 20×, Hypergranulosis and the beginning of the subepidermal cleft with pigment deposition, a chronic inflammatory infiltrate of histiocytes and lymphocytes along with extravasation of erythrocytes. B, 40×, Immunohistochemical stain for type IV collagen showing the basement membrane at the bottom of the cleft.

Figure 3.

Patient recovery at the end of therapy. Photos taken 6 months after hospital discharge.