Because of the now ubiquitous use of immunotherapies in cancer treatment, community dermatologists have an increasingly important role in identifying and often managing chronic adverse events (AEs) involving the skin, according to an expert on the frontlines.

For chronic vs acute cancer therapy regimens, “we are the ones equipped to manage the cutaneous side-effects with steroid-sparing therapies, so that the patient can stay on their potentially life-saving therapy,” reported Drew Kuraitis, MD, PhD, dermatologist at the Roswell Park Comprehensive Cancer Center, Buffalo, New York.

The greater emphasis on chronic relative to acute AEs is based on the fact that oncologists are knowledgeable and trained to manage common acute toxicities, Kuraitis reported. Even as a staff dermatologist at a major cancer center, Kuraitis finds himself most often involved in helping keep patients on therapy by controlling chronic events that are threatening the continuation of treatment.

“So the acute onset of alopecia, the rashes, the painful nails, the bulliform eruptions — these are all things that oncologists are pretty good at managing. It is rolled into their training,” said Kuraitis, speaking at Maui Derm Hawaii 2026.

Dermatologists Needed for Chronic Cancer Rx AEs

“Our place to shine is managing chronic cutaneous toxicities,” he said. 

For example, some cancer treatment-related acute skin eruptions are reasonably controlled with a short course of steroids, which oncologists know will be effective, but are contraindicated long-term because of immunosuppression, Kuraitis said. Beyond a bridging course of steroids, the ability of dermatologists to intervene with a growing array of nonsteroidal drugs, most of which they are already accustomed to employing for eczema, psoriasis, and bullous diseases, is critical.

This is increasingly relevant to the community dermatologist because immunotherapies are at least as prone to producing rashes and other cutaneous AEs as with chemotherapies, he said. While immunotherapies were once prescribed primarily in tertiary centers where experts familiar with these side-effects could manage the cases, “now every community oncologist is prescribing these,” and the cutaneous side-effects are sometimes delayed relative to those associated with chemotherapy.

Of the 2 million cases of newly diagnosed cancer cases encountered per year in the US, almost half receive systemic therapy. Almost all patients experience at least one treatment-related AEs, of which skin toxicities represent nearly 40%, according to data cited by Kuraitis.

For most patients, the skin rash associated with immune checkpoint inhibitors (ICIs), which were introduced in 2011 and now have more than 20 indications for treating malignancies, is a good sign, Kuraitis said. In general, the rash is associated with better outcomes.

Yet, these rashes, like many other AEs associated with ICIs, do not necessarily appear immediately. Kuraitis noted that the average onset is 30-40 days after starting therapy, but the range is 1 day to 1 year. Patients with a skin rash might also experience arthralgia, colitis, or a host of other complications, including myocarditis, that are driven by ICI-induced inflammation.

The goal for the dermatologist is to control the side-effects in order to keep patients on their assigned treatment. This is particularly true of first-line therapies, which typically offer the best opportunity for a sustained clinical benefit, according to Kuraitis. Indeed, he added, this goal “is the basis of oncodermatology,” the subspecialty that he practices.

Skin Rash Is Often a Positive Prognostic Sign

The reason that rash is a positive clinical sign is that it suggests that T cells have been activated. Although their attack on the skin and other tissues are off-target and can be the source of significant morbidity, Kuraitis said that describing the importance of T-cell activation to patients can temper the anxiety produced by the symptoms.

Fortunately, commonly used nonsteroidal therapies for rash, psoriasiform eruptions, vitiligo, and bullae will also work against the analogous cancer-related toxicities, according to Kuraitis. In fact, cancer treatment-related cutaneous eruptions “tend to follow the path of least resistance, so they are manifested in the conditions for which patients are already at risk, such as atopic dermatitis or psoriasis.”

For patients with a history of psoriasis, prophylaxis is now being considered in some cases to reduce the risk of rekindling the disease related to cancer therapy, a presentation that Kuraitis called “indistinguishable from idiopathic psoriasis.” 

There is a greater relative emphasis on finding nonsteroidal drugs to treat cutaneous toxicities related to ICIs, which is based on the fact that the dose of these treatments, unlike many chemotherapies, cannot be reduced without compromising efficacy, he noted.

The ICIs “are considered to be all or nothing in terms of efficacy,” said Kuraitis, who, at his own center, collaborates with oncologists to introduce drugs that both he and the cancer specialist agree are in the best interests of the patient.

Clearly, some nonsteroidal options are better choices than others. For example, Kuraitis reported that he hesitates to employ apremilast for psoriasiform eruptions even though it is effective because it can cause gastrointestinal side-effects. Because patients with cancer have other risks for gastrointestinal side-effects, use of apremilast can complicate the clinical picture.

Yet many drugs considered more potent appear to be just as well tolerated in cancer patients as in those without cancer. Most conspicuously, “I have zero hesitation for using biologics,” Kuraitis said, referring primarily to anti-interleukin (IL)-23 and IL-17 blockers. 

Similarly, he said rituximab and dupilumab are effective and generally reasonable choices in patients with pemphigus- or pemphigoid-like skin eruptions, respectively. 

Relative to most other nonsteroidals, JAK inhibitors are not generally considered an optimal first or even second choice for managing cutaneous toxicities, according to Kuraitis. “JAK inhibitors remain controversial for obvious reasons,” he said, referring to their immunomodulating effects.

Cancer-related cutaneous events may or may not be a clinical issue that community dermatologists wish to address, Kuraitis acknowledged, but he believes they should always inquire about cancer and cancer treatments when confronted with patients presenting with skin lesions of an unclear etiology. By recognizing these toxicities and starting treatment or referring patients to an oncodermatologist for treatment, the greater likelihood of successful treatment without modifying the cancer therapy might be, in some cases, life-saving. 

Kuraitis reported having financial relationships with Bausch Health and UCB.