Managing dermatologic changes of targeted cancer therapy
Failure to control these dermatologic changes can lead to lower dosages of cancer agents or an interrupted course of Tx. These steps can help you to head off trouble.
PRACTICE RECOMMENDATIONS
› Counsel patients about their risk of rash before epidermal growth factor receptor–targeting treatment is initiated; early recognition of rash and intervention lead to milder symptoms. A
› Encourage daily skin care with an alcohol-free emollient cream. Instruct patients to avoid products that can cause skin drying, prolonged hot showers, perfumes, and soaps marketed for treating acne. B
› Instruct patients that oral hygiene to lower their risk of stomatitis should include a soft-bristle toothbrush and oral rinsing with normal saline—not with an alcohol-based commercial mouthwash. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
A short course of systemic steroids might be beneficial for pain control; however, no data from clinical trials suggest that this is beneficial. Dermatology consultation is recommended before prescribing a systemic steroid.
Regrettably, treatment options for pruritus are limited. Antihistamines, such as diphenhydramine and hydroxyzine, can be considered, but their effectiveness is marginal.20 If a patient reports a painful rash, we recommend that you collaborate with the dermatologist and oncologist to make adjustments to the cancer treatment plan.
Retinoids: Caution is advised. Several case reports and a small investigational study describe a potential role for retinoids such as isotretinoin, a 13-cis retinoic acid, in the treatment of chemotherapy-related skin changes.21,22 Isotretinoin is available under several trade names in pill and cream formulations.
Retinoids exert their effect at the level of DNA transcription, and act as a transcription factor in keratinocytes. Their downstream signaling pathway includes EGFR signaling ligands; introduction of exogenous retinoids has been shown to deter development of EGFRI-associated skin toxicity.23 Given the lack of clinical data, retinoid-based medications should be used at the discretion of a dermatologist; thorough discussion is encouraged among the dermatologist, oncologist, and primary care physician before employing a retinoid.
Recommend a sunscreen? Given the endogenous role of EGFR in protecting skin from ultraviolet B damage, some clinicians have recommended that patients use a sunscreen. However, randomized, controlled trials have failed to demonstrate any benefit to their use with regard to incidence or severity of rash or patient-reported discomfort.24 We do not recommend routine use of sunscreen to prevent chemotherapy-induced skin changes, although sensible use during periods of prolonged sun exposure is encouraged.
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