Long term outcomes among patients with pre-existing psoriasis undergoing immune checkpoint inhibitor therapy: a case series and literature review

Long term outcomes among patients with pre-existing psoriasis undergoing immune checkpoint inhibitor therapy: a case series and literature review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Long term outcomes among patients with pre-existing psoriasis undergoing immune checkpoint inhibitor therapy: a case series and literature review Trenton Greif, Namie Fotion, David Streeter, Adela R. Cardones This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6658189/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Psoriasiform adverse cutaneous reactions to immune checkpoint inhibitor (ICI) therapy for cancer are potentially treatment-limiting. Few studies have investigated long-term outcomes related to exacerbations of pre-existing psoriasis and their impact on the efficacy of cancer treatment. Understanding outcomes in patients with autoimmune disease is important to guide management of these reactions and avoid unnecessary exclusion from ICI therapy. We conducted a retrospective cohort study using the University of Kansas Cancer Center database. We identified 20 adult patients with pre-existing psoriasis who were treated with ICIs between 2013 and 2022 and had at least one year of follow-up. Of these, 15 experienced exacerbation of their psoriasis during ICI therapy. Patients with exacerbation completed a higher median number of ICI cycles than those with unaffected psoriasis (16 vs. 9 cycles). Rates of ICI discontinuation due to side effects were similar between the two groups (26% vs. 20%). Kaplan-Meier analysis showed that patients with psoriasis exacerbation had significantly better progression-free survival compared to unaffected patients (p = 0.015). Although overall mortality was lower in the exacerbation group (40% vs. 60%), this difference was not statistically significant. Two patients with severe flares discontinued ICIs and initiated systemic therapy for psoriasis. One continued to show tumor remission, while the other maintained stable tumor burden, highlighting the variability and chronicity of flare responses. Overall, ICIs appear to be tolerable in patients with pre-existing psoriasis. Despite the high rate of exacerbation, most flares were mild and manageable with topical therapy, and most patients were able to complete their treatment. The comparable discontinuation rates and greater number of ICI cycles among those with flares suggest that psoriasis exacerbation does not necessarily impede cancer therapy. These findings support the inclusion of patients with psoriasis in ICI treatment protocols and suggest that cutaneous irAEs may be associated with improved therapeutic outcomes. Although limited by small sample size and retrospective design, this study contributes to the growing body of evidence supporting safe ICI use in patients with pre-existing autoimmune skin disease. INTRODUCTION Immune checkpoint inhibitors (ICIs) targeting downregulatory T-cell receptors such as CTLA-4, PD-1, and PD-L1 have improved outcomes in advanced malignancies. 1 , 2 However, ICIs can cause immune-related adverse events (irAEs) due to immune system uninhibition, including dermatologic, gastrointestinal, and hepatic effects, with potential mortality. 3 , 4 Psoriasiform reactions represent a minority (3.8%) of irAEs. 5 Psoriasis itself is a chronic autoinflammatory skin condition affecting over 3% of U.S. adults 6 , characterized by erythematous, scaly plaques. Few studies have specifically evaluated psoriasiform reactions to ICIs. Their impact on treatment efficacy and optimal management remains unclear, leading to possible exclusion of patients with psoriasis from ICI therapy. METHODS We performed a retrospective cohort study using the University of Kansas Cancer Center database (Jan 1, 2010–Mar 1, 2023), identifying patients with pre-existing psoriasis who received at least one ICI. Inclusion criteria: age ≥ 18, confirmed psoriasis prior to ICIs, and at least 1 year of follow-up unless follow-up was limited by death. Data collected included demographics, ICI regimen, cancer type, psoriasis treatment and status at ICI initiation, psoriasis flare severity, ICI discontinuation and reason, anti-psoriatic treatment changes, cancer progression, mortality, and follow-up duration. Kaplan-Meier survival models were constructed using version 4.2.2 of the R programming language. RESULTS Among 334 patients receiving ICIs between 2013–2022, 25 had pre-existing psoriasis; 20 met inclusion criteria (Table 1 ). None had psoriatic arthritis. Psoriasis status at ICI initiation was documented in 12/20: 9 had active disease (7 on topicals, 2 untreated), and 3 had inactive disease (2 on systemic therapy, 1 off treatment). Phototherapy was not used. Psoriasis activity at ICI initiation could not be confirmed in 8 patients. ICIs and cancer types are listed in Table 1 . Indications included melanoma (6), non-small cell lung cancer (5), and small cell lung cancer (2). Median follow-up was 652 days. Fifteen of 20 patients (75%) experienced psoriasis exacerbation during ICI therapy. Of these, 10 had mild flares requiring only topicals; 5 had severe/profound flares. Two patients with severe flares discontinued ICIs and initiated systemic therapy (acitretin, secukinumab). One patient interrupted ICI therapy due to cellulitis but resumed and completed treatment. Five patients discontinued ICI therapy: 2 due to severe flares, 2 due to mild flares, and 1 with stable psoriasis due to unrelated irAE (hemophagocytic lymphohistiocytosis). One patient with a severe flare died before completing therapy, unrelated to malignancy or irAE. Cancer progression occurred in 6/15 (40%) of patients with flares, versus 4/5 (80%) in those without. Kaplan-Meier analysis showed lower progression-free survival among unaffected patients (p = 0.015). Overall mortality was higher in the unaffected group (60% vs. 40%), though this difference was not statistically significant. DISCUSSION Psoriasiform dermatitis following ICIs has been reported, but few studies focus on patients with pre-existing psoriasis. Most combine de novo and pre-existing cases and lack long-term follow-up. Cutroneo et al. (2021) reported 315 ICI-associated psoriasiform reactions, 70.8% in patients with prior psoriasis. 5 Halle et al. (2021) studied 76 patients with pre-existing psoriasis; 57% had flares, 53% managed with topicals, 21% required systemic therapy, and 5% discontinued ICIs. 7 Nikolaou et al. (2020) reviewed 115 ICI-induced psoriasis cases (70% de novo); 26% paused and 18% permanently discontinued ICIs. 8 Yu et al. (2022) performed a meta-analysis of 191 patients with pre-existing psoriasis: 45% had flares, 10.8% were grade 3–4, and 18.5% discontinued ICIs. 9 In comparison, 75% of our cohort experienced flares. Two patients (10%) discontinued ICIs and began systemic therapy. Notably, both remained on systemic treatment > 1 year post-ICI, with divergent cancer outcomes (remission vs. stable disease), highlighting the variable chronicity of ICI-induced flares. Unexpectedly, patients with exacerbations received more ICI cycles (median 16 vs. 9), likely due to outliers—one receiving 76 cycles. One-year mortality was higher in the unaffected group (40% vs. 20%). Total mortality was also higher (60% vs. 40%). These findings contrast with expectations and suggest flares may not limit treatment. In fact, they may be associated with more favorable cancer outcomes, echoing evidence linking irAEs with treatment response. This study is limited by small sample size and lack of statistical power. Additionally, we were not able to control for other mortality factors such as malignancy stage. Akin to other studies, many of the patients did not have an independent skin evaluation by a dermatologist. Descriptors of a patient’s skin disease were often qualitative describing “mild” or “severe” disease rather than quantitative as body surface area or grade. Cutaneous irAEs can be therapy-limiting. However, our findings suggest that patients with pre-existing psoriasis can feasibly receive ICI therapy. Though flares were common, most were manageable with topical treatment, and the majority completed therapy. There is growing evidence that dermatologic irAEs may correlate with better therapeutic response. Careful clinical evaluation is important in both clinical care and research into the nature of these reactions. An evaluation by a dermatologist can aid in both goals. 10 This may help us better describe and characterize these reactions and possibly spur better insight into immunologic changes and consequences of ICI therapy. Declarations Funding source: None. Conflict of Interest: No conflict of interest. IRB Approval: IRB- approval was obtained from the University of Kansas Medical Center IRB. Patient consent: Not applicable. Waiver of consent was approved for this retrospective study. References Wolchok JD, Chiarion-Sileni V, Gonzalez R, Grob JJ, Rutkowski P, Lao CD, Cowey CL, Schadendorf D, Wagstaff J, Dummer R, Ferrucci PF, Smylie M, Butler MO, Hill A, Márquez-Rodas I, Haanen JBAG, Guidoboni M, Maio M, Schöffski P, Carlino MS, Lebbé C, McArthur G, Ascierto PA, Daniels GA, Long GV, Bas T, Ritchings C, Larkin J, Hodi FS. Long-Term Outcomes With Nivolumab Plus Ipilimumab or Nivolumab Alone Versus Ipilimumab in Patients With Advanced Melanoma. J Clin Oncol. 2022 Jan 10;40(2):127-137. doi: 10.1200/JCO.21.02229. Epub 2021 Nov 24. PMID: 34818112; PMCID: PMC8718224. Robert C, Carlino MS, McNeil C, Ribas A, Grob JJ, Schachter J, Nyakas M, Kee D, Petrella TM, Blaustein A, Lotem M, Arance A, Daud AI, Hamid O, Larkin J, Anderson J, Krepler C, Grebennik D, Long GV. Seven-Year Follow-Up of the Phase III KEYNOTE-006 Study: Pembrolizumab Versus Ipilimumab in Advanced Melanoma. J Clin Oncol. 2023 Aug 20;41(24):3998-4003. doi: 10.1200/JCO.22.01599. Epub 2023 Jun 22. PMID: 37348035. Naidoo J, Page DB, Li BT, Connell LC, Schindler K, Lacouture ME, Postow MA, Wolchok JD. Toxicities of the anti-PD-1 and anti-PD-L1 immune checkpoint antibodies. Ann Oncol. 2015 Dec;26(12):2375-91. doi: 10.1093/annonc/mdv383. Epub 2015 Sep 14. Erratum in: Ann Oncol. 2016 Jul;27(7):1362. PMID: 26371282; PMCID: PMC6267867. Wang DY, Salem JE, Cohen JV, Chandra S, Menzer C, Ye F, Zhao S, Das S, Beckermann KE, Ha L, Rathmell WK, Ancell KK, Balko JM, Bowman C, Davis EJ, Chism DD, Horn L, Long GV, Carlino MS, Lebrun-Vignes B, Eroglu Z, Hassel JC, Menzies AM, Sosman JA, Sullivan RJ, Moslehi JJ, Johnson DB. Fatal Toxic Effects Associated With Immune Checkpoint Inhibitors: A Systematic Review and Meta-analysis. JAMA Oncol. 2018 Dec 1;4(12):1721-1728. doi: 10.1001/jamaoncol.2018.3923. Erratum in: JAMA Oncol. 2018 Dec 1;4(12):1792. PMID: 30242316; PMCID: PMC6440712. Cutroneo P, Ingrasciotta Y, Isgrò V, Rullo EV, Berretta M, Fiorica F, Trifirò G, Guarneri C. Psoriasis and psoriasiform reactions secondary to immune checkpoint inhibitors. Dermatol Ther. 2021 Mar;34(2):e14830. doi: 10.1111/dth.14830. Epub 2021 Feb 11. PMID: 33527643. Rachakonda TD, Schupp CW, Armstrong AW. Psoriasis prevalence among adults in the United States. J Am Acad Dermatol. 2014 Mar;70(3):512-6. doi: 10.1016/j.jaad.2013.11.013. Epub 2014 Jan 2. PMID: 24388724. Halle BR, Betof Warner A, Zaman FY, Haydon A, Bhave P, Dewan AK, Ye F, Irlmeier R, Mehta P, Kurtansky NR, Lacouture ME, Hassel JC, Choi JS, Sosman JA, Chandra S, Otto TS, Sullivan R, Mooradian MJ, Chen ST, Dimitriou F, Long G, Carlino M, Menzies A, Johnson DB, Rotemberg VM. Immune checkpoint inhibitors in patients with pre-existing psoriasis: safety and efficacy. J Immunother Cancer. 2021 Oct;9(10):e003066. doi: 10.1136/jitc-2021-003066. PMID: 34635495; PMCID: PMC8506877. Nikolaou V, Sibaud V, Fattore D, Sollena P, Ortiz-Brugués A, Giacchero D, Romano MC, Riganti J, Lallas K, Peris K, Voudouri D, Lallas A, Fabbrocini G, Lazaridou E, Carrera C, Annunziata MC, Rossi E, Patri A, Rigopoulos D, Stratigos AJ, Apalla Z. Immune checkpoint-mediated psoriasis: A multicenter European study of 115 patients from the European Network for Cutaneous Adverse Event to Oncologic Drugs (ENCADO) group. J Am Acad Dermatol. 2021 May;84(5):1310-1320. doi: 10.1016/j.jaad.2020.08.137. Epub 2020 Dec 3. PMID: 33279646. Yu Y, Zhou Y, Zhang X, Tan K, Zheng J, Li J, Cui H. Immune Checkpoint Inhibitors in the Treatment of Patients With Cancer and Preexisting Psoriasis: A Systematic Review and Meta-Analysis of Observational Studies. Front Oncol. 2022 Jul 15;12:934093. doi: 10.3389/fonc.2022.934093. PMID: 35912183; PMCID: PMC9334704. Cardones AR, Sullivan KM, Green C, Chao NJ, Rowe-Nichols K, Bañez LL, Burton CS, Horwitz ME, Long GD, Rao CL, Sarantopoulos S, Sidhu-Malik N, Sung AD, Hall RP 3rd. Interrater Reliability of Clinical Grading Measures for Cutaneous Chronic Graft-vs-Host Disease. JAMA Dermatol. 2019 Jul 1;155(7):833-837. doi: 10.1001/jamadermatol.2018.5459. PMID: 30994873; PMCID: PMC6583829 Tables Table 1. Summary of demographic, clinical history and outcome measures between those with psoriasis exacerbation or other immune-related adverse event (irAE) on Immune Checkpoint Inhibitors (ICIs) versus unaffected. Psoriasis Exacerbation (N = 15) Psoriasis Unaffected (N = 5) Total (N=20) Median Age yrs (Range) 71 (49 - 85) 71 (68 - 79) 71 (49 – 85) Female 53.3% (8) 60% (3) 55% (11) Race White 100% (15) 100% (5) 100% (20) Ethnicity Non-Hispanic 93.3% (14) 100% (5) 95% (19) Declined 6.7% (1) 0% 5% (1) Median follow-up period, days (range) 666 (53 – 2610) 638 (261 – 1900) 652 (53 – 2610) Cancer Type Melanoma 33.3% (5) 20% (1) 30% (6) Non-small cell lung cancer 33.3% (5) 0% 25% (5) Small cell lung cancer 6.7% (1) 20% (1) 10% (2) Both NSCLC and SCLC 6.7% (1) 0% 5% (1) Cutaneous SCC 6.7% (1) 0% 5% (1) Oral SCC 6.7% (1) 0% 5% (1) Invasive ductal cell carcinoma 0% 20% (1) 5% (1) Pleomorphic sarcoma of the hip 0% 20% (1) 5% (1) Urothelial cell carcinoma of the bladder 6.7% (1) 0% 5% (1) Hepatocellular carcinoma 0% 20% (1) 5% (1) ICI Agent Pembrolizumab 40% (6) 60% (3) 45% (9) Nivolumab 26.7% (4) 0% 20% (4) Atezolizumab 13.3% (2) 20% (1) 15% (3) Ipilimumab 0% 20% (1) 5% (1) Nivolumab + Imilimumab 6.7% (1) 0% 5% (1) Durvalumab 6.7% (1) 0% 5% (1) Cemiplimab 6.7% (1) 0% 5% (1) ICI Discontinue Reason Psoriasis Exacerbation 13% (2) 0% 10% (2) Other 13% (2) 20% (1) 15% (3) Patient expired (causes other than malignancy or irAE) 7% (1) 0% 5% (1) Cancer Progression / Lack of Response 40% (6) 80% (4) 50% (10) Median Total ICI Cycles Received (range) 16 (1 - 76) 9 (1 – 11) 10 (1 – 76) Median ICI Cycles Until Flare (range) 4 (1 – 7) - - 1-Year Mortality 20% (3) 40% (2) 25% (5) Total Mortality 40% (6) 60% (3) 45% (9) Table 2. Summary of prior studies looking at patients receiving immune checkpoint inhibitors (ICIs) in the setting of pre-existing psoriasis. Study Methods % Exacerbated Follow-up from time of ICI, Median (range) Time from first ICI to psoriasis flare, median or mean (range) Total number of ICI cycles completed, median (range) Treatment for cutaneous disease Oncologic Outcomes, Mortality Greif et al. (This study) Retrospective study 20 patients with pre-ICI diagnosis of psoriasis, with at least 1-yr follow-up after first ICI. 15 (75%) of patients with exacerbation. 652 days (53 – 2610) 4 (1 – 7) doses, median 16 (1 - 76) in those with an exacerbation 9 (1 – 11) in those with no exacerbation. 2 patients given systemic therapy (acitretin, secukinumab). 2 patients required premature discontinuation of ICIs due to psoriasis flare and 1 required interruption of therapy. 1 year mortality 20% in those with an exacerbation vs 40% without. Cutroneo et al. Retrospective EudraVigilance study including 315 patients with psoriasis and/or psoriasiform reactions to ICIs. 223 (70.8%) of reports were patients with pre-existing psoriasis. Number of patients with pre-existing psoriasis but no flare unknown. None Not Available Not Available 145 treated with topicals alone 24 received phototherapy 10 patients required systemic treatment Not Available Halle et al. Multicenter retrospective study from 8 international academic centers. 76 patients with pre-existing psoriasis. 43 patients (57%) with exacerbation: 39 (51%) cutaneous, 7 (9%) arthritic flare. 25.1 months (0.2 - 99) 44 days, mean Not Available 9 patients given systemic therapy (acitretin or prednisone). Median progression free survival was 39 months in the flare group vs 8.7 months without a flare (P =0.049). 5 patients (7%) discontinued ICIs due to flare. Nikolaou et al. Multicenter, retrospective study from ENCADO* member centers, group with anti–PD-1/PD-L1–induced psoriasis. 33 patients (30.8%) with pre-existing psoriasis. 33 patients (30.8%) had pre-existing psoriasis. 20 had clinically active disease at the time of ICI initiation. Number of patients with pre-existing psoriasis but no flare unknown. Not Available 11.2 doses (mean), including those with new onset psoriasis. Not Available 47 patients (40.9%) were treated with systemic therapy. 21 acitretin 8 systemic steroids 7 apremilast 5 methotrexate 4 biologics 29 of 112 patients (25.9%) interrupted ICIs due to psoriasis**. 20 of 111 patients (18%) permanently discontinued ICIs**. Guttate psoriasis (2.73-fold, P = 0.05) and more than 10% BSA (2.55-fold, P = 0.03) were positive predictors for probability of response to ICI. Pruritus had a decreased probability for response (OR = 0.38, P = 0.03). Yu et al. Systematic review and meta-analysis of 12 studies including 191 patients with pre-existing psoriasis. 45% with exacerbation. Median follow-up from 4.7 -25.1 months. 44 days Not Available 80 patients received phototherapy with 6 also given acitretin A few patients were given oral steroids, methotrexate, apremilast or biologic agents ICI discontinuation due to irAEs was 18.5%. Objective response rate of ICIs was 38.1 and the disease control rate was 64.5%. * European Network for Cutaneous Adverse Event to Oncologic Drugs ** Denominator discrepancy is not clarified in the original article. Additional Declarations No competing interests reported. Supplementary Files SupplementalPsoriasisandICI.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6658189","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":463997028,"identity":"1625c270-94b7-4225-b466-c701cabdda1e","order_by":0,"name":"Trenton Greif","email":"","orcid":"","institution":"University of Kansas Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Trenton","middleName":"","lastName":"Greif","suffix":""},{"id":463997031,"identity":"2756acb2-5e67-4dd5-b958-0d2cb45f48f9","order_by":1,"name":"Namie Fotion","email":"","orcid":"","institution":"University of Kansas School of Medicine-Wichita","correspondingAuthor":false,"prefix":"","firstName":"Namie","middleName":"","lastName":"Fotion","suffix":""},{"id":463997032,"identity":"dc3381ab-0e1a-46e8-bdb6-15d9209c6a50","order_by":2,"name":"David Streeter","email":"","orcid":"","institution":"University of Kansas Medical Center","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Streeter","suffix":""},{"id":463997034,"identity":"f859b760-a3df-4476-941c-808bf9572475","order_by":3,"name":"Adela R. Cardones","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYLACHhDB3gblHSBaC88xkrVIpBGphb/98LMPbyruyMnPfJYmdaOGQY7vRgJ+LRJn0oxnzjnzzNjgdtox6ZxjDMaShLQw3GAwZuZtO5y4QTq9TTq3gSFxAyEt8jfYP4O01M+feRyspZ6gFoMbPGBbEhhusB0DaUkwIKTF8ExOMeOcM4cNN5xJS7bOOSZhOPPMA/xa5I4f38zwpuKwvHz7McPbOTU28nzHCdiCDiRIUz4KRsEoGAWjADsAANHIRWmF5nUrAAAAAElFTkSuQmCC","orcid":"","institution":"University of Kansas Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Adela","middleName":"R.","lastName":"Cardones","suffix":""}],"badges":[],"createdAt":"2025-05-13 18:53:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6658189/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6658189/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":98422491,"identity":"c87ea4cd-f5d5-4b52-84c6-d9e780f89b11","added_by":"auto","created_at":"2025-12-17 16:31:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":517228,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6658189/v1/d33b87ba-7a2b-42e9-a8be-610daa79336c.pdf"},{"id":83758984,"identity":"01f5e1a8-6105-4cdb-b644-379c7ee5ed75","added_by":"auto","created_at":"2025-06-02 08:53:53","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":181614,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalPsoriasisandICI.docx","url":"https://assets-eu.researchsquare.com/files/rs-6658189/v1/f3264c17d605a7efe1b9d948.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eLong term outcomes among patients with pre-existing psoriasis undergoing immune checkpoint inhibitor therapy: a case series and literature review\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eImmune checkpoint inhibitors (ICIs) targeting downregulatory T-cell receptors such as CTLA-4, PD-1, and PD-L1 have improved outcomes in advanced malignancies.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e However, ICIs can cause immune-related adverse events (irAEs) due to immune system uninhibition, including dermatologic, gastrointestinal, and hepatic effects, with potential mortality. \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePsoriasiform reactions represent a minority (3.8%) of irAEs.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Psoriasis itself is a chronic autoinflammatory skin condition affecting over 3% of U.S. adults\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e, characterized by erythematous, scaly plaques. Few studies have specifically evaluated psoriasiform reactions to ICIs. Their impact on treatment efficacy and optimal management remains unclear, leading to possible exclusion of patients with psoriasis from ICI therapy.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eWe performed a retrospective cohort study using the University of Kansas Cancer Center database (Jan 1, 2010\u0026ndash;Mar 1, 2023), identifying patients with pre-existing psoriasis who received at least one ICI. Inclusion criteria: age\u0026thinsp;\u0026ge;\u0026thinsp;18, confirmed psoriasis prior to ICIs, and at least 1 year of follow-up unless follow-up was limited by death.\u003c/p\u003e \u003cp\u003eData collected included demographics, ICI regimen, cancer type, psoriasis treatment and status at ICI initiation, psoriasis flare severity, ICI discontinuation and reason, anti-psoriatic treatment changes, cancer progression, mortality, and follow-up duration. Kaplan-Meier survival models were constructed using version 4.2.2 of the R programming language.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eAmong 334 patients receiving ICIs between 2013\u0026ndash;2022, 25 had pre-existing psoriasis; 20 met inclusion criteria (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). None had psoriatic arthritis. Psoriasis status at ICI initiation was documented in 12/20: 9 had active disease (7 on topicals, 2 untreated), and 3 had inactive disease (2 on systemic therapy, 1 off treatment). Phototherapy was not used. Psoriasis activity at ICI initiation could not be confirmed in 8 patients.\u003c/p\u003e \u003cp\u003eICIs and cancer types are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Indications included melanoma (6), non-small cell lung cancer (5), and small cell lung cancer (2). Median follow-up was 652 days.\u003c/p\u003e \u003cp\u003eFifteen of 20 patients (75%) experienced psoriasis exacerbation during ICI therapy. Of these, 10 had mild flares requiring only topicals; 5 had severe/profound flares. Two patients with severe flares discontinued ICIs and initiated systemic therapy (acitretin, secukinumab). One patient interrupted ICI therapy due to cellulitis but resumed and completed treatment.\u003c/p\u003e \u003cp\u003eFive patients discontinued ICI therapy: 2 due to severe flares, 2 due to mild flares, and 1 with stable psoriasis due to unrelated irAE (hemophagocytic lymphohistiocytosis). One patient with a severe flare died before completing therapy, unrelated to malignancy or irAE. Cancer progression occurred in 6/15 (40%) of patients with flares, versus 4/5 (80%) in those without. Kaplan-Meier analysis showed lower progression-free survival among unaffected patients (p\u0026thinsp;=\u0026thinsp;0.015). Overall mortality was higher in the unaffected group (60% vs. 40%), though this difference was not statistically significant.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003ePsoriasiform dermatitis following ICIs has been reported, but few studies focus on patients with pre-existing psoriasis. Most combine de novo and pre-existing cases and lack long-term follow-up. Cutroneo et al. (2021) reported 315 ICI-associated psoriasiform reactions, 70.8% in patients with prior psoriasis.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHalle et al. (2021) studied 76 patients with pre-existing psoriasis; 57% had flares, 53% managed with topicals, 21% required systemic therapy, and 5% discontinued ICIs.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Nikolaou et al. (2020) reviewed 115 ICI-induced psoriasis cases (70% de novo); 26% paused and 18% permanently discontinued ICIs.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Yu et al. (2022) performed a meta-analysis of 191 patients with pre-existing psoriasis: 45% had flares, 10.8% were grade 3\u0026ndash;4, and 18.5% discontinued ICIs.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn comparison, 75% of our cohort experienced flares. Two patients (10%) discontinued ICIs and began systemic therapy. Notably, both remained on systemic treatment\u0026thinsp;\u0026gt;\u0026thinsp;1 year post-ICI, with divergent cancer outcomes (remission vs. stable disease), highlighting the variable chronicity of ICI-induced flares.\u003c/p\u003e \u003cp\u003eUnexpectedly, patients with exacerbations received more ICI cycles (median 16 vs. 9), likely due to outliers\u0026mdash;one receiving 76 cycles. One-year mortality was higher in the unaffected group (40% vs. 20%). Total mortality was also higher (60% vs. 40%). These findings contrast with expectations and suggest flares may not limit treatment. In fact, they may be associated with more favorable cancer outcomes, echoing evidence linking irAEs with treatment response.\u003c/p\u003e \u003cp\u003eThis study is limited by small sample size and lack of statistical power. Additionally, we were not able to control for other mortality factors such as malignancy stage. Akin to other studies, many of the patients did not have an independent skin evaluation by a dermatologist. Descriptors of a patient\u0026rsquo;s skin disease were often qualitative describing \u0026ldquo;mild\u0026rdquo; or \u0026ldquo;severe\u0026rdquo; disease rather than quantitative as body surface area or grade.\u003c/p\u003e \u003cp\u003eCutaneous irAEs can be therapy-limiting. However, our findings suggest that patients with pre-existing psoriasis can feasibly receive ICI therapy. Though flares were common, most were manageable with topical treatment, and the majority completed therapy. There is growing evidence that dermatologic irAEs may correlate with better therapeutic response. Careful clinical evaluation is important in both clinical care and research into the nature of these reactions. An evaluation by a dermatologist can aid in both goals.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e This may help us better describe and characterize these reactions and possibly spur better insight into immunologic changes and consequences of ICI therapy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding source: None.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConflict of Interest: No conflict of interest.\u003c/p\u003e\n\u003cp\u003eIRB Approval: IRB- approval was obtained from the University of Kansas Medical Center IRB.\u003c/p\u003e\n\u003cp\u003ePatient consent: Not applicable. Waiver of consent was approved for this retrospective study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWolchok JD, Chiarion-Sileni V, Gonzalez R, Grob JJ, Rutkowski P, Lao CD, Cowey CL, Schadendorf D, Wagstaff J, Dummer R, Ferrucci PF, Smylie M, Butler MO, Hill A, M\u0026aacute;rquez-Rodas I, Haanen JBAG, Guidoboni M, Maio M, Sch\u0026ouml;ffski P, Carlino MS, Lebb\u0026eacute; C, McArthur G, Ascierto PA, Daniels GA, Long GV, Bas T, Ritchings C, Larkin J, Hodi FS. Long-Term Outcomes With Nivolumab Plus Ipilimumab or Nivolumab Alone Versus Ipilimumab in Patients With Advanced Melanoma. J Clin Oncol. 2022 Jan 10;40(2):127-137. doi: 10.1200/JCO.21.02229. Epub 2021 Nov 24. PMID: 34818112; PMCID: PMC8718224.\u003c/li\u003e\n \u003cli\u003eRobert C, Carlino MS, McNeil C, Ribas A, Grob JJ, Schachter J, Nyakas M, Kee D, Petrella TM, Blaustein A, Lotem M, Arance A, Daud AI, Hamid O, Larkin J, Anderson J, Krepler C, Grebennik D, Long GV. Seven-Year Follow-Up of the Phase III KEYNOTE-006 Study: Pembrolizumab Versus Ipilimumab in Advanced Melanoma. J Clin Oncol. 2023 Aug 20;41(24):3998-4003. doi: 10.1200/JCO.22.01599. Epub 2023 Jun 22. PMID: 37348035.\u003c/li\u003e\n \u003cli\u003eNaidoo J, Page DB, Li BT, Connell LC, Schindler K, Lacouture ME, Postow MA, Wolchok JD. Toxicities of the anti-PD-1 and anti-PD-L1 immune checkpoint antibodies. Ann Oncol. 2015 Dec;26(12):2375-91. doi: 10.1093/annonc/mdv383. Epub 2015 Sep 14. Erratum in: Ann Oncol. 2016 Jul;27(7):1362. PMID: 26371282; PMCID: PMC6267867.\u003c/li\u003e\n \u003cli\u003eWang DY, Salem JE, Cohen JV, Chandra S, Menzer C, Ye F, Zhao S, Das S, Beckermann KE, Ha L, Rathmell WK, Ancell KK, Balko JM, Bowman C, Davis EJ, Chism DD, Horn L, Long GV, Carlino MS, Lebrun-Vignes B, Eroglu Z, Hassel JC, Menzies AM, Sosman JA, Sullivan RJ, Moslehi JJ, Johnson DB. Fatal Toxic Effects Associated With Immune Checkpoint Inhibitors: A Systematic Review and Meta-analysis. JAMA Oncol. 2018 Dec 1;4(12):1721-1728. doi: 10.1001/jamaoncol.2018.3923. Erratum in: JAMA Oncol. 2018 Dec 1;4(12):1792. PMID: 30242316; PMCID: PMC6440712.\u003c/li\u003e\n \u003cli\u003eCutroneo P, Ingrasciotta Y, Isgr\u0026ograve; V, Rullo EV, Berretta M, Fiorica F, Trifir\u0026ograve; G, Guarneri C. Psoriasis and psoriasiform reactions secondary to immune checkpoint inhibitors. Dermatol Ther. 2021 Mar;34(2):e14830. doi: 10.1111/dth.14830. Epub 2021 Feb 11. PMID: 33527643.\u003c/li\u003e\n \u003cli\u003eRachakonda TD, Schupp CW, Armstrong AW. Psoriasis prevalence among adults in the United States. J Am Acad Dermatol. 2014 Mar;70(3):512-6. doi: 10.1016/j.jaad.2013.11.013. Epub 2014 Jan 2. PMID: 24388724.\u003c/li\u003e\n \u003cli\u003eHalle BR, Betof Warner A, Zaman FY, Haydon A, Bhave P, Dewan AK, Ye F, Irlmeier R, Mehta P, Kurtansky NR, Lacouture ME, Hassel JC, Choi JS, Sosman JA, Chandra S, Otto TS, Sullivan R, Mooradian MJ, Chen ST, Dimitriou F, Long G, Carlino M, Menzies A, Johnson DB, Rotemberg VM. Immune checkpoint inhibitors in patients with pre-existing psoriasis: safety and efficacy. J Immunother Cancer. 2021 Oct;9(10):e003066. doi: 10.1136/jitc-2021-003066. PMID: 34635495; PMCID: PMC8506877.\u003c/li\u003e\n \u003cli\u003eNikolaou V, Sibaud V, Fattore D, Sollena P, Ortiz-Brugu\u0026eacute;s A, Giacchero D, Romano MC, Riganti J, Lallas K, Peris K, Voudouri D, Lallas A, Fabbrocini G, Lazaridou E, Carrera C, Annunziata MC, Rossi E, Patri A, Rigopoulos D, Stratigos AJ, Apalla Z. Immune checkpoint-mediated psoriasis: A multicenter European study of 115 patients from the European Network for Cutaneous Adverse Event to Oncologic Drugs (ENCADO) group. J Am Acad Dermatol. 2021 May;84(5):1310-1320. doi: 10.1016/j.jaad.2020.08.137. Epub 2020 Dec 3. PMID: 33279646.\u003c/li\u003e\n \u003cli\u003eYu Y, Zhou Y, Zhang X, Tan K, Zheng J, Li J, Cui H. Immune Checkpoint Inhibitors in the Treatment of Patients With Cancer and Preexisting Psoriasis: A Systematic Review and Meta-Analysis of Observational Studies. Front Oncol. 2022 Jul 15;12:934093. doi: 10.3389/fonc.2022.934093. PMID: 35912183; PMCID: PMC9334704.\u003c/li\u003e\n \u003cli\u003eCardones AR, Sullivan KM, Green C, Chao NJ, Rowe-Nichols K, Ba\u0026ntilde;ez LL, Burton CS, Horwitz ME, Long GD, Rao CL, Sarantopoulos S, Sidhu-Malik N, Sung AD, Hall RP 3rd. Interrater Reliability of Clinical Grading Measures for Cutaneous Chronic Graft-vs-Host Disease. JAMA Dermatol. 2019 Jul 1;155(7):833-837. doi: 10.1001/jamadermatol.2018.5459. PMID: 30994873; PMCID: PMC6583829\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Summary of demographic, clinical history and outcome measures between those with psoriasis exacerbation or other immune-related adverse event (irAE) on Immune Checkpoint Inhibitors (ICIs) versus unaffected.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003ePsoriasis Exacerbation\u003c/p\u003e\n \u003cp\u003e(N = 15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003ePsoriasis Unaffected\u003c/p\u003e\n \u003cp\u003e(N = 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003e(N=20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian Age yrs (Range)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e71 (49 - 85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e71 (68 - 79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e71 (49 \u0026ndash; 85)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e53.3% (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e60% (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e55% (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRace\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eWhite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e100% (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e100% (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e100% (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eNon-Hispanic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e93.3% (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e100% (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e95% (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eDeclined\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6.7% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e5% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian follow-up period, days (range)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e666 (53 \u0026ndash; 2610)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e638 (261 \u0026ndash; 1900)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e652 (53 \u0026ndash; 2610)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCancer Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eMelanoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e33.3% (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e20% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e30% (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eNon-small cell lung cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e33.3% (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e25% (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eSmall cell lung cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6.7% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e20% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e10% (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eBoth NSCLC and SCLC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6.7% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e5% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eCutaneous SCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6.7% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e5% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eOral SCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6.7% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e5% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eInvasive ductal cell carcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e20% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e5% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003ePleomorphic sarcoma of the hip\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e20% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e5% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eUrothelial cell carcinoma of the bladder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6.7% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e5% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eHepatocellular carcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e20% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e5% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eICI Agent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003ePembrolizumab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;40% (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e60% (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e45% (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eNivolumab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e26.7% (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e20% (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eAtezolizumab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;13.3% (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e20% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e15% (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eIpilimumab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e20% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;5% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eNivolumab + Imilimumab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6.7% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;5% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eDurvalumab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6.7% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;5% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eCemiplimab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6.7% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;5% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eICI Discontinue Reason\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003ePsoriasis Exacerbation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e13% (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e10% (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eOther\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e13% (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e20% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e15% (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003ePatient expired (causes other than malignancy or irAE)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e7% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e5% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCancer Progression / Lack of Response\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e40% (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e80% (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e50% (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian Total ICI Cycles Received (range)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e16 (1 - 76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e9 (1 \u0026ndash; 11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e10 (1 \u0026ndash; 76)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian ICI Cycles Until Flare (range)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (1 \u0026ndash; 7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1-Year Mortality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e20% (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e40% (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e25% (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Mortality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e40% (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e60% (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e45% (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2. Summary of prior studies looking at patients receiving immune checkpoint inhibitors (ICIs) in the setting of pre-existing psoriasis.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"978\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eStudy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eMethods\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;% Exacerbated\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eFollow-up from time of ICI, Median (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eTime from first ICI to psoriasis flare, median or mean (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTotal number of ICI cycles completed, median (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eTreatment for cutaneous disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003eOncologic Outcomes, Mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eGreif et al. (This study)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eRetrospective study 20 patients with pre-ICI diagnosis of psoriasis, with at least 1-yr follow-up after first ICI.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e15 (75%) of patients with exacerbation.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e652 days (53 \u0026ndash; 2610)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e4 (1 \u0026ndash; 7) doses, median\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e16 (1 - 76) in those with an exacerbation\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9 (1 \u0026ndash; 11) in those with no exacerbation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 patients given systemic therapy (acitretin, secukinumab).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003e2 patients required premature discontinuation of ICIs due to psoriasis flare and 1 required interruption of therapy.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 year mortality\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e20% in those with an exacerbation vs 40% without.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eCutroneo et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eRetrospective EudraVigilance study including 315 patients with psoriasis and/or psoriasiform reactions to ICIs.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e223 (70.8%) of reports were patients with pre-existing psoriasis. \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNumber of patients with pre-existing psoriasis but no flare unknown.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eNot Available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eNot Available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e145 treated with topicals alone\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24 received phototherapy\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 patients required systemic treatment\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003eNot Available\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eHalle et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eMulticenter retrospective study from 8 international academic centers. \u0026nbsp;76 patients with pre-existing psoriasis.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e43 patients (57%) with exacerbation: 39 (51%) cutaneous, 7 (9%) arthritic flare.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e25.1 months (0.2 - 99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e44 days, mean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eNot Available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e9 patients given systemic therapy (acitretin or prednisone). \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003eMedian progression free survival was 39\u0026thinsp;months in the flare group vs 8.7\u0026thinsp;months without a flare (P =0.049).\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 patients (7%) discontinued ICIs due to flare.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eNikolaou et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eMulticenter, retrospective study from ENCADO* member centers, group with anti\u0026ndash;PD-1/PD-L1\u0026ndash;induced psoriasis. 33 patients (30.8%) with pre-existing psoriasis.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e33 patients (30.8%) had pre-existing psoriasis.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20 had clinically active disease at the time of ICI initiation.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNumber of patients with pre-existing psoriasis but no flare unknown.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eNot Available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e11.2 doses (mean), including those with new onset psoriasis. \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eNot Available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e47 patients (40.9%) were treated with systemic therapy.\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e21 acitretin\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e8 systemic steroids\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e7 apremilast\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e5 methotrexate\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e4 biologics\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003e29 of 112 patients (25.9%) interrupted ICIs due to psoriasis**.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20 of 111 patients (18%) permanently discontinued ICIs**.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGuttate psoriasis (2.73-fold, P = 0.05) and more than 10% BSA (2.55-fold, P = 0.03) were positive predictors for probability of response to ICI.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePruritus had a decreased probability for response (OR = 0.38, P = 0.03).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eYu et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eSystematic review and meta-analysis of 12 studies including 191 patients with pre-existing psoriasis.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e45% with exacerbation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eMedian follow-up from 4.7 -25.1 months.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e44 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eNot Available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e80 patients received phototherapy with 6 also given acitretin\u003c/li\u003e\n \u003cli\u003eA few patients were given oral steroids, methotrexate, apremilast or biologic agents\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003eICI discontinuation due to irAEs was 18.5%.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eObjective response rate of ICIs was 38.1 and the disease control rate was 64.5%.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* European Network for Cutaneous Adverse Event to Oncologic Drugs\u003c/p\u003e\n\u003cp\u003e** Denominator discrepancy is not clarified in the original article.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6658189/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6658189/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePsoriasiform adverse cutaneous reactions to immune checkpoint inhibitor (ICI) therapy for cancer are potentially treatment-limiting. Few studies have investigated long-term outcomes related to exacerbations of pre-existing psoriasis and their impact on the efficacy of cancer treatment. Understanding outcomes in patients with autoimmune disease is important to guide management of these reactions and avoid unnecessary exclusion from ICI therapy.\u003c/p\u003e\n\u003cp\u003eWe conducted a retrospective cohort study using the University of Kansas Cancer Center database. We identified 20 adult patients with pre-existing psoriasis who were treated with ICIs between 2013 and 2022 and had at least one year of follow-up. Of these, 15 experienced exacerbation of their psoriasis during ICI therapy. Patients with exacerbation completed a higher median number of ICI cycles than those with unaffected psoriasis (16 vs. 9 cycles). Rates of ICI discontinuation due to side effects were similar between the two groups (26% vs. 20%).\u003c/p\u003e\n\u003cp\u003eKaplan-Meier analysis showed that patients with psoriasis exacerbation had significantly better progression-free survival compared to unaffected patients (p = 0.015). Although overall mortality was lower in the exacerbation group (40% vs. 60%), this difference was not statistically significant. Two patients with severe flares discontinued ICIs and initiated systemic therapy for psoriasis. One continued to show tumor remission, while the other maintained stable tumor burden, highlighting the variability and chronicity of flare responses.\u003c/p\u003e\n\u003cp\u003eOverall, ICIs appear to be tolerable in patients with pre-existing psoriasis. Despite the high rate of exacerbation, most flares were mild and manageable with topical therapy, and most patients were able to complete their treatment. The comparable discontinuation rates and greater number of ICI cycles among those with flares suggest that psoriasis exacerbation does not necessarily impede cancer therapy. These findings support the inclusion of patients with psoriasis in ICI treatment protocols and suggest that cutaneous irAEs may be associated with improved therapeutic outcomes. Although limited by small sample size and retrospective design, this study contributes to the growing body of evidence supporting safe ICI use in patients with pre-existing autoimmune skin disease.\u003c/p\u003e","manuscriptTitle":"Long term outcomes among patients with pre-existing psoriasis undergoing immune checkpoint inhibitor therapy: a case series and literature review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-02 08:53:48","doi":"10.21203/rs.3.rs-6658189/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"99dc0594-c821-4698-aa15-e598cc2c7bed","owner":[],"postedDate":"June 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-11T07:39:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-02 08:53:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6658189","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6658189","identity":"rs-6658189","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}