Skin Reactions in Patients With Multiple Sclerosis Receiving Cladribine Treatment

Leoni Rolfes, Steffen Pfeuffer, Jana Hackert, Marc Pawlitzki, Tobias Ruck, Wiebke Sondermann, Melanie Korsen, Heinz Wiendl, Sven G Meuth, Christoph Kleinschnitz, Refik Pul
Neurology® Neuroimmunology & Neuroinflammation 2021, 8 (3)

OBJECTIVE: To report 77 patients with multiple sclerosis (MS) who developed skin-related adverse events (AEs) following treatment with cladribine.

METHODS: We evaluated our prospective bicentric cladribine cohort. Cladribine-treated patients with a skin AE were identified.

RESULTS: Two hundred thirty-nine cladribine-treated patients with MS were evaluated. Seventy-seven patients (32%) showed at least 1 skin AE at median 1 month after cladribine initiation (range: 1-12). Within first 3 months following last cladribine exposition, hair thinning (n = 28, 12%), skin rash (n = 20; 8%), mucositis (n = 13, 5%), and pruritus (n = 6, 3%) were observed. Furthermore, 35 patients (15%) developed herpes virus infections (time since last cladribine exposition: median 83 [range: 10-305]). In 15 patients, herpes zoster infection was severe (CTCAE grade ≥ 3) and required hospitalization. Delayed skin AEs (≥3 months after a cladribine treatment cycle) involved 1 case of leukocytoclastic vasculitis and 2 cases of alopecia areata. Finally, 2 patients presented with in total 3 isolated precancerous lesions (1 leukoplakia simplex and 2 actinic keratosis) and 1 patient developed a squamous cell carcinoma.

CONCLUSION: Skin AEs are common in patients with MS treated with cladribine. Until risk management plans have been adjusted to include these phenomena, clinicians should perform a thorough clinical follow-up and in suspicious cases seek early interdisciplinary support. In light of the observed delayed skin reactions, we further emphasize the necessity of careful clinical surveillance of cladribine-treated patients for yet undescribed secondary autoimmune events.

CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that skin-related AEs are frequent in patients with MS following cladribine in a real-world setting.

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