Corticosteroid-Refractory Bullous Pemphigoid Due to Immune Checkpoint Inhibitors: A Telemedicine Challenge

Immune checkpoint inhibitors (ICIs) have become the new standard of care for many malignancies due to their higher efficacy and safer toxicity profile. However, immune-related adverse events (irAEs) can occur unpredictably and in a wide range of organs. Most irAEs present with mild to moderate toxicities. Rarely, severe and life-threatening events occur and can be fatal. Therefore, immediate recognition and management of irAEs are important. Early diagnosis and initiation of treatment with corticosteroids, coupled with diligent follow-up by specialists, are critical steps in optimizing outcomes for patients experiencing irAEs. We present a case report that illustrates the development and progression of severe cutaneous toxicity presenting as a rare bullous pemphigoid rash at the end of two years on nivolumab. It is essential to note that this occurred in an outpatient setting during the COVID-19 pandemic. In coordination with rural providers and telemedicine, the patient's corticosteroid-refractory ICI toxicity was treated successfully.