Management of dermatological problems in cancer therapy

Cancer vs skin The skin is the largest organ in the body and, as such, is

vulnerable to damage as a result of cancer treatments. Chemotherapy damages rapidly dividing cells, a hallmark trait

of cancer cells. In the process, healthy cells that are also rapidly dividing—

such as skin cells—are also damaged. Radiation therapy damages skin cells that are in the path of the radiation beam.

Common skin reactions include the following:• Dry skin• Itchy skin• Hyperpigmentation (darkening of the skin)• Photosensitivity (tendency to sunburn easily)• Radiation recall (rash caused by the administration of certain

chemotherapy drugs with or after radiation) Rash• Pressure sores• Sweating • Acne form (pimple like) eruptions• Nail changes

Dry skin:

Management : - duofilm soln(Glaxo) 15 ml:185 rs - venusia cream 75g :170 rs - moisturex cream 25g :45rs

More common in patients with leukemia, lymphoma ,

multiple myeloma.

Signs : -Red, rough, flaky skin (although dry skin can look normal) -Cracks in the skin -Slight bleeding between the lines of skin covering joints, such as knuckles or elbows

Itchy skin:

Management :

• Itching as a result of cancer treatment may be acute or chronic.

-Acute itching :allergic reaction to that drug.

-Cancer treatment associated with chronic, or long-term itching, include: Interferon, Interleukin-2 and radiation therapy.

For the cause jaundice – cholestyramine allergy – antihistamines , (Atarax ) Hydroxyzine hydrochloride 25mg or diphenhydramine 25-50mg, may be given at bedtime when pruritus is usually at its worst. infection-antibiotic/antivirals/antifungal depending on the cause.

For soothing calamine lotion (Caladryl)

Note : For some types of treatment itching may be a sign that your treatment is working (erlotinib)

Hyperpigmentation :• Symptoms often appear two

to three weeks after chemotherapy treatment begins and go away as new skin cells replace the dead cells at approximately 10 to 12 weeks after treatment is over. However, this darkening may occasionally be permanent.

• Management : laser treatment

Drugs : cyclophosphamide , 5-FU , doxorubicin ,busulfan etc.,

Photosensitivity:

• Management -Use a sunscreen that is labeled as broad-spectrum (blocks UVA and UVB rays) and has a sun protection factor (SPF) of at least 15.

chemotherapy, radiation therapy, and stem cell transplants may

make the skin more sensitive to light.

Drugs: methotrexate ,5-FU, dacarbazine.

Radiation recall and rash :

Management : -topical corticosteroids (betnovate cream)

The term recall reaction refers to erythema (redness

of the skin) in areas of previously quiescent

sunburn or radiotherapy.

Drugs : GemcitabineMethotrexateDocetaxelEtoposideDoxorubicin.

Pressure sores :

Pressure sores are wounds that develop when constant pressure or friction on one

area of the body damages the skin. Constant pressure on an

area of skin stops blood flowing normally, so the cells die and the skin breaks down.

Signs: purplish or bluish patches on dark skinned peoplered or white patches on fair skinned peopleblistersswellingshiny areasdry patchescracks and wrinkles

Management :Alginate dressings, made from seaweed.Clear film dressings, like medical cling film.Hydrocolloids - gels put on to the wound that soak up fluid.Hydrogel - a gel that keeps wounds moist and helps to clean them.Foam dressings that absorb fluid from the wound.Honey dressings.Silver dressings.

Sweating:

• Sweating can be a symptom of cancer, or may be due to cancer treatment , infection, hormone changes, medicines. It can be very distressing.

Drugs:Tamoxifen.Aromatase inhibitors.Opioids.Tricyclic antidepressants.Steroids.

Management :Clonidine (a blood pressure and migraine medicine) can help women with breast cancerAnti depressants such as paroxetine or venlafexineGabapentin (an epilepsy drug) can help women with breast cancerProgestogen (a hormone) can help men with prostate cancerCimetidine (a drug to reduce stomach acid) can reduce sweating caused by morphine.

Acne form (pimple like) eruptions:

Also known as folliculitis, an acneform reaction begins as

facial erythema followed by papules(small bumps) and

pustules (small pockets of pus) over the face and upper trunk. Unlike true acne, the pustules are sterile (they

contain no bacteria).

Drugs: Actinomycin D, gefitinib and cetuximab.

Management: topical retinoids and benzoyl

peroxide

Nail changes :

Beau line – a transverse groove in the nail plate Onchylolysis – separation of the nail plate from the underlying nail bedOnchomadesis – loss of the entire nailNail pain, thickening and/or thinningHyper- or hypo-pigmentation (leukonychia) – pale or dark streaks in the nail plate .

Drugs:Taxanes e.g. docetaxel and paclitaxelAnthracyclines e.g. doxorubicin, idarubicin and epirubicin.Nail changes may also be seen with hydroxyurea.

Common skin-related side effects of specific targeted drugs

Drug Prescribed for Side effects (common)

Afatinib Colorectal cancer Mouth sores

Cetuximab Head/nails inflammation around finger nails

Erlotinib Lung Dry, itchy skin

Lapatinib Breast Sores on lips, mouth, or throatDry skin, Red, painful, numb, or tingling hands and feet, Rash

Sorafenib Renal cell cancer Hand/foot skin reactions (tender, thickened areas sometimes with blisters on palms and soles)

Common skin-related side effects of immunotherapy

Drug Prescribed for Side effects

Pembrolizumab NSCLC, melanoma Change in skin colourHair lossYellowing of skin and eyesItchy red rashBlistering skin

Nivolumab •Renal cell cancer (a type of kidney cancer)•Non-small cell lung cancer (NSCLC)•Melanoma

Hair lossYellowing of skin and eyesItchy red rashBlistering skin

Alemtuzumab Chronic lymphocytic leukemia (CLL)

Mouth sores

Skin care during chemotheraphy:

Dry skin Use a moisturizing cream at least twice a day and within 15 minutes of showering. Avoid products that irritate the skin. This includes soaps, detergents, and creams with fragrance.Avoid products that scratch or scrub the skin, such as sponges, bath scrubs, or loofahs.Shower and bathe with warm water. Hot water can dry the skin even more.

Itchy skin Avoid fragranced skin products.Use creams with menthol, camphor, or pramoxine, which are available over the counter.

Photosensitivity Cover up with clothing or a hat, especially from 10 AM to 4 PM.Apply sunscreen every 2 hrs.(sos)

Nails Trim your nails.Avoid manicures and pedicures.Wear gloves for tasks such as yard work or cleaning.Use oils or creams to keep the skin around your nails soft.Avoid wearing shoes that are too tight.If an infection is suspected, soak nails for 15 minutes every evening in a solution of white vinegar and tap water in equal amounts.