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
In the general population, acute and chronic paronychia entail infection with S aureus and Candida spp, respectively. To this end, there is a role for antibacterial and antifungal intervention. As is the case of the EGFRI-associated acneiform rash, inflammation in paronychia is sterile, with only rare pathogen involvement.
There is no role for topical or systemic antibiotics in the cancer population suffering from paronychia. A viable treatment option for moderate lesions is betamethasone valerate, applied 2 or 3 times daily; if there is no resolution, clobetasol cream, applied 2 or 3 times daily, can be prescribed.30 The role of tetracyclines as anti-inflammatory agents in paronychia has not been studied to the extent it has been for acneiform rash; however, studies have shown a protective effect in small patient samples.31 In severe disease, the patient can be instructed to temporarily discontinue the drug and you can provide a referral to a dermatologist.
Stomatitis is also an area of concern in this patient population (FIGURE 1c). Prior to initiating treatment, a thorough examination of the patient’s oral cavity and oropharynx should be conducted. Loose or improperly fitting dentures should be adjusted because they can prohibit effective healing after ulceration develops.
Stomatitis initially presents as erythematous or aphthous-like lesions, and can develop into acutely painful, large, continuous lesions.29 Timely management of stomatitis is beneficial to patient outcomes because it can lead to severe pain and interference in oral intake; uncontrolled disease requires interruption and dosage-reduction of cancer therapy.14,32
Patients should be encouraged to use soft-bristle toothbrushes and rinse with normal saline, not with commercial mouthwashes that typically contain alcohol. Grade 1 stomatitis (ie, pain and erythema) can be treated with triamcinolone dental paste, which can reduce inflammation caused by the ulcers. If disease progresses to Grade 2 to 3 stomatitis (erythema; ulceration; difficulty swallowing, or inability to swallow food), oral erythromycin (250-350 mg/d) or minocycline (50 mg/d) should be prescribed and the patient referred to a dermatologist.30
Continue to: Does rash correlate with cancer treatment efficacy?
