Cutaneous adverse effects of biologic medications

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Figure 1
Palmar psoriasis eruption in a patient receiving infliximab treatment for Crohn disease.
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Figure 2
Inverse psoriasis induced by infliximab treatment for Crohn disease.
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Figure 3
Acneiform eruption in a patient receiving dovitinib for glioblastoma.
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Figure 4
Eruptive squamous cell carcinoma keratoacanthomas in a patient receiving ruxolitinib for primary myelofibrosis.
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Figure 5
Toxic epidermal necrolysis in a patient receiving pembrolizumab for Sézary syndrome.

TABLE 1

Cutaneous adverse effects of tumor necrosis factor alpha antagonists

Examples	Cutaneous side effects	Management strategies
Adalimumab Certolizumab Etanercept Golimumab Infliximab	Infusion reactions and injection site reactions	Preinfusion treatment with oral antihistamines, acetaminophen, and intravenous steroids
	Cutaneous infections (bacterial, viral)	Frequent skin examinations, low threshold to perform cultures and initiate bacterial or fungal-targeted topical or oral therapy Consider varicella zoster vaccination before starting therapy
	Psoriasis	Topical therapy, methotrexate, cyclosporine, phototherapy
	Eczematous dermatitis	Gentle skin care, liberal emollients, topical steroids
	Lichenoid reactions	Discontinuation or reduction of therapy dose, topical steroids
	Cutaneous leukocytoclastic vasculitis	Discontinuation of therapy, initiation of systemic prednisone, switch to other immunosuppressive medication
	Nonmelanoma and melanoma skin cancer	Routine skin cancer surveillance, broad-spectrum sunscreen, sun avoidance, skin self-examination

TABLE 2

Cutaneous adverse effects of epidermal growth factor receptor inhibitors

Examples	Cutaneous side effects	Management strategies
Cetuximab Erlotinib Gefitinib Panitumumab	Papulopustular acneiform eruption	Prevention with minocycline or doxycycline Topical and systemic corticosteroids, antibiotics, oral isotretinoin Oral histamine 1 (H1) antihistamines and gamma aminobutyric acid agonists for pruritus
	Paronychial inflammation	Topical antibiotics, topical corticosteroids, electrodessication for larger lesions, rarely photodynamic therapy
	Stevens-Johnson syndrome–toxic epidermal necrolysis	Discontinue therapy

TABLE 3

Cutaneous adverse effects of small-molecule tyrosine kinase inhibitors

Examples	Adverse effects	Management strategies
Axitinib Bosutinib Dabrafenib Dasatinib Dovitinib Imatinib Nilotinib Pazopanib Ponatinib Ruxolitinib Sorafenib Sunitinib Vandetanib Vemurafenib	Rash (exanthematous papular eruption)	Discontinue and then reintroduce at lower dose, temporary course of oral corticosteroid
	Hand-foot skin reactions	Topical emollients, topical urea, salicylic acid, topical corticosteroid
	Keratoacanthoma, squamous cell carcinoma	Phototherapy, intralesional methotrexate, retinoids and excision
	Acneiform eruption	Topical antiseptics and antibiotics, oral antibiotics, systemic isotretinoin, short course of a low-dose systemic corticosteroid

TABLE 4

Cutaneous adverse effects of cell surface-targeted monoclonal antibodies

Examples	Adverse effects	Management strategies
Anakinra Avelumab Ipilimumab Nivolumab Pembrolizumab Rituximab Tocilizumab Tofacitinib	Infusion reactions	Premedicate with acetaminophen and diphenhydramine 30 minutes before the first and second infusions
	Serum sickness	Pulse methylprednisolone therapy
	Stevens-Johnson syndrome/toxic endothelial necrolysis and vesiculobullous dermatitis	Discontinue therapy
	Rash (lichenoid, bullous, psoriasiform, macular, morbiliform morphologies)	Topical corticosteroids, systemic steroids