Dermatologic Reactions to Immune Checkpoint Inhibitors

Skin Toxicities and Immunotherapy

Vincent Sibaud


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

In This Article

Oral Mucosal Toxicities

Patients receiving anti-PD-1/PD-L1 treatment can also exhibit oral symptoms, which are often neglected by clinicians. Xerostomia, oral lichenoid reactions and, to a lesser extent, dysgeusia, represent the main manifestations.[82] Oral involvement is clearly less frequent with anti-CTLA-4.[82]


Xerostomia has been reported to occur in 4–7% and in 3% with anti-PD-1 and anti-PD-L1 agents, respectively.[14,26,82,100] While it has been reported to be limited to grade 1/2 in all cases, we have personally seen severe forms in some patients that had a substantial functional impact.

Histologically, a predominantly CD4+/CD8+T-cell infiltrate is noted, surrounding the accessory salivary glands. The detection of serum anti-SSA/SSB antibodies is typically negative, and the xerostomia in general remains isolated, aside from in the exceptional setting of Sjögren's syndrome.

Oral Lichenoid Reactions

These reactions are not uncommon in clinical practice and probably remain undiagnosed.[23,30,34,38] They most often occur in an isolated manner. They can, however, be associated with skin, nail or genital lichenoid lesions.[38]

Reticulated white streaks, consistent with Wickham's striae, represent the most common presentation (Figure 6), although plaque-like, ulcerative or atrophic/erythematous lesions are also described.[38] The keratinized and nonkeratinized mucosae can be affected.[82] These lesions most often remain self-limited and of low grade.

The band-like T-cell infiltrate is predominantly CD4/CD8 positive.[38] The treatment relies first and foremost on topical corticosteroids, and oral lichenoid reactions do not lead to treatment interruption.


Dysgeusia affects less than 3% of the patients treated with anti-PD-1/PD-L1 therapies.[12,14,27]