Dr Dulmage on IRAEs: Red Flags and Management

In this episode of Community Corner, Brittany Dulmage, MD, associate professor of dermatology and director of oncodermatology at The Ohio State University Wexner Medical Center, discusses early recognition and triage of immune-related adverse events (IRAEs), with a focus on cutaneous toxicities associated with immune checkpoint inhibitor therapy.

Dr Dulmage highlights that one of the most frequently overlooked early warning signs of clinically significant dermatologic IRAEs is pruritus. Itch may precede visible skin findings by weeks to months and can serve as an early indicator of more serious conditions such as bullous pemphigoid, a blistering autoimmune eruption. She emphasizes that persistent or treatment-refractory itch should prompt heightened clinical suspicion and early dermatology referral, even in the absence of a visible rash. Recognizing itch as a potential red flag may allow clinicians to intervene earlier and prevent progression to more severe cutaneous toxicity.

She also underscores the importance of baseline dermatologic history in risk stratification. Patients with preexisting inflammatory skin diseases, including eczema and psoriasis, are at increased risk of immune-mediated flares during immunotherapy. Awareness of these conditions prior to treatment initiation can help oncology teams anticipate complications and monitor more closely for early signs of exacerbation.

In terms of clinical workflow, she recommends empowering patients to closely monitor and promptly report new skin symptoms, particularly itch or evolving rashes. She further advocates for low thresholds for dermatology involvement and the use of supportive oncodermatology resources. This may include in-person consultation or teledermatology systems that allow rapid review of clinical images, facilitating earlier diagnosis and management.

Overall, she emphasizes that early recognition, patient education, and streamlined access to dermatologic expertise are key strategies for improving outcomes and minimizing morbidity from immune-related cutaneous adverse events in patients receiving immunotherapy.