Cutaneous Immunotherapy Toxicity Guidelines

Scope & key aims of the national guidelines

• To meet the needs of patients and their medical teams in the NHS 
• To ensure they include and are supported by the latest evidence in the management of skin toxicities 
• To be a simple user-friendly practical & educational guide for oncology staff to safely & effectively manage the majority of cutaneous toxicities:

-To ensure patient safety by highlighting Red Flag symptoms
-To provide practical advice on prescribing topical therapies
-To maintain immunotherapy intensity and treatment where possible by optimising topical therapies and thereby reducing the need for oral corticosteroids and breaks in immunotherapy treatment
-To provide clear advice on when to call the dermatology team for support and when to reassess patients

• To provide more detailed specific toxicity guidance for dermatologists
• To account for varying models of care, levels of expertise and access to dermatologists across the country

-Highlighting the importance of photographs to facilitate virtual reviews

• To create patient information to support these guidelines

Please note that the management of patients in primary care is beyond the scope of this guideline. We also recognise that not all centres will have 24-hour access to dermatology services. All patients will however have 24-hour access to their oncology service with details made available by the prescribing oncologist. If there is concern about a cutaneous toxicity then patients should be advised to make immediate contact with their oncology centre. It is the responsibility of the secondary or tertiary care team to prescribe any treatments for toxicities. Only if the toxicity is likely to be a longer-term issue would the oncology team liaise with the patient’s GP to discuss the prescribing of ongoing treatments for this purpose.

The guideline consists of two key documents:

1. Management Algorithm

• A simple 2-page document to guide initial management for the majority of toxicities based on severity grading

2.  Specific Mucocutaneous Toxicity Management Table

• Provides key principles and detailed investigation and 1st, 2nd and sometimes 3rd line management advice for the “Red Flag Toxicities” and the majority of mucocutaneous toxicities that may be encountered

Detailed supporting guides

In addition to these two key guideline documents, more detailed information and practical advice can be found in the following guides:

3.  Principles of Corticosteroid Usage

• Guidance and principles of corticosteroid prescribing and essential clinical considerations

4.  Topical Prescription Guide

• Information on emollients, topical steroids and a miscellaneous section including information on combination topical corticosteroid and anti-microbial treatments and shampoo.
• Lists commonly prescribed topicals, their formulations and quantities and frequencies to be prescribed to ensure a patient has adequate supply for a 4-week period
• Also contains a quick reference guide providing practical advice for use in clinic

5.  Patient Information

• An essential component of the practical toolkit containing education and links to more detailed information and resources
• Recommend that all patients receiving immunotherapy (and in particular those with a family or past history of autoimmune disease/ pre-existing dermatoses) are signposted to this guide BEFORE starting immunotherapy, as it provides key practical information.