Biological therapies and risk of cutaneous infections in immunocompromised patients

Abstract

Introduction: Biological therapies have transformed the management of autoimmune diseases, neoplasms, and transplant recipients through selective immunomodulation. However, their use in immunocompromised patients is associated with an increased risk of skin and soft tissue infections (SSTIs), characterized by etiological diversity, atypical presentations, and potentially severe outcomes. Objective: To synthesize the available evidence regarding etiologic agents, clinical patterns, and diagnostic challenges of SSTIs in immunocompromised patients receiving biological therapies. Methodology: A qualitative review was conducted in Web of Science (2015–2025) using the search descriptor “biological therapy AND immunocompromised patients AND skin infection.” Of 231 initial records, 12 articles were selected according to predefined inclusion and exclusion criteria. The sample primarily included solid organ transplant recipients (41.6%) and patients with hematologic malignancies (16.7%). Results: SSTIs were frequent in transplant recipients, hematologic patients, burn patients, and advanced mycosis fungoides. A broad etiological spectrum was identified: bacteria (including Pseudomonas aeruginosa and ecthyma gangrenosum), opportunistic fungi (late severe dermatophytosis, mucormycosis, alternariosis), and viruses (herpes simplex and herpes zoster). Atypical presentations, attenuated inflammatory responses, and rapid progression to systemic involvement predominated. Diagnosis required biopsy, cultures, and molecular techniques; management included early antimicrobial therapy, source control, and a multidisciplinary approach. Discussion: Selective immunomodulation does not eliminate infectious risk but rather shapes predictable yet heterogeneous patterns. The absence of a dominant microbiological profile necessitates a broad and early diagnostic approach. Conclusion: SSTIs in immunocompromised patients receiving biological therapies represent a clinically significant problem. Early suspicion, timely microbiological confirmation, and comprehensive management are essential to reduce morbidity and mortality.