Immune checkpoint inhibitor-associated autoimmune bullous disease: A clinical review

Immune checkpoint inhibitors (ICIs) have markedly advanced oncology by enhancing the immune system's ability to combat malignancies. However, their use is increasingly associated with immune-related adverse events, including immunobullous dermatoses. These disorders, such as bullous pemphigoid, pemphigus vulgaris, linear immunoglobulin A bullous dermatosis, mucous membrane pemphigoid, paraneoplastic pemphigus, dermatitis herpetiformis, and lichen planus pemphigoides present significant diagnostic and therapeutic challenges. This clinical review explores the pathogenesis, clinical presentation, diagnosis, and management strategies of immunobullous dermatoses triggered by ICIs, highlighting the complex relationship between effective cancer treatment and immune regulation. ICI-induced immunobullous dermatoses closely mimic their conventional autoimmune counterparts but often have unique clinical considerations, such as delayed onset, mucosal predilection, and persistence post-discontinuation of medication. Diagnostic evaluation relies on clinical suspicion, histopathology, direct and indirect immunofluorescence, and enzyme-linked immunosorbent assays. Management typically involves corticosteroids and immunosuppressants, with biologics such as rituximab, dupilumab and omalizumab reserved for refractory cases. Decisions regarding the continuation of ICIs require individualized assessment, balancing cancer control with autoimmune toxicity. Dermatologic and oncologic teams must navigate dual priorities of mitigating autoimmune toxicity and preserving oncologic benefit.