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
How common a problem? The incidence of EGFR inhibitor (EGFRI)–related rash is noteworthy: Overall incidence ranges from 45% to 100% of treated patients, with 10% experiencing Grade 3 to 4 changes (covering > 30% of body surface, restricting activities of daily living, severe itching).9 Monoclonal antibody therapies that target EGFR, such as cetuximab, have a reported 90% risk of skin rash, with 10% also being of Grade 3 to 4.10 Risk factors for rash include skin phototype, male gender, and younger age.11,12 Common cancer therapies with known skin effects are listed in the TABLE.13
What should you look for? The most common clinical manifestation of dermatologic toxicity is an acneiform, or papulopustular, rash marked by eruptions characterized as “acne-like” pustules with monotonous lesion morphology (Figure 1a). A hallmark of these lesions that can be used to help distinguish them from acne vulgaris is the absence of comedones on eruptions.
The timeline of the rash has been well characterized and is another tool that you can use to guide management:
- During Week 1 of cancer treatment, the patient often experiences sensory disturbances, with erythema and edema.14
- Throughout Weeks 2 and 3, erythematous skin evolves into papulopustular eruptions.
- By Week 4, eruptions typically crust over and leave persistently dry skin for weeks.15,16
Of note, the rash is dosage related; we recommend scrupulous vigilance when a patient is receiving a high dosage of a targeted therapy agent.
Controlling a rash
Treatment of EGFRI-associated skin changes stems from recommendations from a number of individual investigators and studies; however, few consensus guidelines exist to guide practice. Understanding of the underlying pathophysiological mechanism of skin changes has evolved, but preventive and treatment modalities remain unchanged—and limited.
Continue to: Always counsel patients...
