Dermatologic Reactions to Immune Checkpoint Inhibitors

Skin Toxicities and Immunotherapy

Vincent Sibaud


Am J Clin Dermatol. 2018;19(3):345-361. 

In This Article

Hair and Nail Toxicities


In several pivotal studies, alopecia has been noted in 1–2% of the patients treated with anti-PD-1 or anti-PD-L1 agents.[4,12,19,27] It corresponds to a partial alopecia (alopecia areata involving scalp hair, eyebrows or beard) or a more diffuse universalis type (Figure 10).[105] In our experience, it is more frequent and more severe with ipilimumab. Histologic findings reveal a non-scarring alopecia with a perifollicular T-cell infiltrate.[105] Regrown hair frequently exhibits poliosis.[105]

Figure 10.

a Diffuse alopecia universalis (involving scalp hair and eyebrows); b grade 1 alopecia; c nail changes with paronychia (in a patient with associated cutaneous lichenoid reaction)

A change in the texture of the hair has also been described sporadically,[108] and it is not uncommon to encounter this in clinical practice. Likewise, depigmentation of the scalp hair, eyelashes or eyebrows is common in patients treated for melanoma, which is often associated with vitiligo lesions. By contrast, Rivera et al. have very recently reported a series of 14 patients treated with anti-PD-1/PD-L1 therapies for lung cancer who exhibited a diffuse progressive hair repigmentation.[106] This repigmentation started in the occipital and temporal areas, extending secondarily to frontal and parietal areas. Remarkably, 13 of the 14 patients remained in treatment with a partial response or a stable disease.

Nail Changes

Nail changes have only rarely been reported in the literature.[105] We have, however, observed several cases of nail dystrophy with immunotherapy, and these were sometimes associated with an onychomadesis or a proximal onychoschizia. Diffuse onycholysis and paronychia involving all finger- or toenails can also develop. Although no histologic analyses are available to date, it is likely that these nail changes are mostly psoriatic or lichenoid in nature (Figure 10).[49]