case_images: PMC11750431_01
case_images: Patient presented initially with pruritic, erythematous patches on the (A) ankles and popliteal fossae, (B) posterior forearm, and (C) cubital fossa after the first cycle of EV/Pembrolizumab treatment. After the primary rash resolved, the patient developed a new morphology of tense, clear fluid-filled vesicles, and bullae on the (D) medial thighs, (E) ventral forearms, and (F) medial ankles. EV, Enfortumab vedotin.
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case_images: A 69-year-old man with metastatic upper tract urothelial carcinoma presented to the dermatology clinic after his second cycle of EV/P with a 4-day history of pruritic, erythematous intertriginous patches without mucosal involvement (Fig 1, A-C). He returned to dermatology 10 days later with bilateral ankle swelling and a recurrent, progressive eruption characterized by erythematous, edematous intertriginous plaques and small, clear fluid-filled bullae that progressed despite the use of topical therapy (Fig 1, D-F).
case_images: Punch biopsy of the left medial thigh showing interface dermatitis with superficial and perivascular lymphocytic infiltrate with eosinophils, suggestive of a drug reaction. A, Hematoxylin and eosin; magnification 2x (B) hematoxylin and eosin; magnification 5x (C) hematoxylin and eosin; magnification 20x.
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case_images: Two punch biopsies of representative skin of the second rash morphology were performed for hematoxylin and eosin staining and direct immunofluorescence (DIF) (Fig 2).
case_images: After a steroid taper, the patient was initiated on dupilumab with topical steroids and has maintained clear skin on (A) posterior legs, (B) ventral forearms, (C) right leg, and (D) left leg on reduced, but therapeutic dose of EV/P. EV/P, Enfortumab vedotin/pembrolizumab.
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case_images: fig3
case_images: The patient was able to be successfully rechallenged for the 10th cycle of EV/P with EV reduced to 0.5 mg/kg and the original dose of Pembrolizumab without active skin disease (Fig 3).
case_images: The complete timeline of EV/P treatment cycles and associated dAEs. dAEs, Dermatologic adverse events; EV/P, enfortumab vedotin/pembrolizumab.
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case_images: fig4
case_images: Refer to Fig 4 for a complete timeline of treatment cycles and dAEs.