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irAE Skin — SCE Medical Oncology MCQ

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HardImmunotherapy & Targeted TherapyirAE SkinSCE Medical Oncology

A 55-year-old woman on atezolizumab for TNBC develops a new skin rash. On examination, she has tense bullae on erythematous bases affecting her trunk and proximal limbs. Nikolsky sign is negative. Biopsy shows linear IgG at the dermal-epidermal junction. What is the diagnosis?

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Correct answer: E — Bullous pemphigoid (immune-related)

Bullous pemphigoid is a recognised dermatological irAE with checkpoint inhibitors, characterised by tense (not flaccid) bullae on erythematous bases, negative Nikolsky sign (distinguishing from pemphigus vulgaris), and linear IgG deposits at the basement membrane zone on direct immunofluorescence. Management includes topical super-potent corticosteroids (clobetasol) for localised disease and systemic corticosteroids for widespread disease. ICI is typically held for grade 3+. Dermatology referral is essential.

Reference: ESMO 2024 irAE Management Guidelines; Sibaud et al Ann Oncol 2016