Targeted therapies represent a new type of treatment against cancer,
in which specific molecules in cancer cells are blocked to slow or stop
the growth of cancer. One of the largest groups of targeted therapies are
those directed against a molecule known as epidermal growth factor
receptor (EGFR), such as erlotinib (Tarceva) and cetuximab (Erbitux). Although these drugs do not cause side
effects seen with conventional chemotherapy, such as lowering the number
of blood cells, they can cause problems with the skin, hair, nails, and
A team of dermatologists, oncologists, and ophthalmologists has
established the skin and eye reactions to inhibitors of EGFR and kinases (SERIES) Project, to increase awareness of
skin reactions to targeted therapies and develop adequate treatment
The causes of these skin reactions are drugs that block the EGFR,
including erlotinib and cetuximab.
Although EGFR fuels the growth of cancer cells, it also plays a role in
the normal growth of the skin, hair, and nails. Consequently, rashes and
changes to the hair and nails may occur after treatment with drugs that
block the action of EGFR. These side effects can be managed in most
patients so that appearance of the skin, hair, and nails is unaffected or
minimally affected, and treatment can continue. It is important to note
that the skin side effects associated with these drugs are not an
allergic or infectious reaction.
Signs and symptoms
A rash affecting the face and upper body develops in 45% to 100% of
patients and usually occurs within the first few weeks of taking these
medications. The rash is usually preceded by redness or a warm sensation
of the skin on the face that may feel like sunburn. After several days,
tender pimples and pus bumps appear, and the surrounding skin feels
slightly tender. Rashes tend to be mild; however, they can cause
significant physical and cosmetic discomfort.
Other symptoms may include the following:
- Pimples and red bumps on
the face, neck, and upper chest or back
- Tenderness in facial
skin, with a sunburn-like sensation and itching in pimples
- Itching of the skin,
especially the scalp
- Tender sores inside the
nose, corners of the mouth, or eyes
- Painful inflammation
around nails, especially the thumbs
- Nails that become
brittle and may loosen from the nailbed
- Hair loss over the
entire scalp and decreased hair on legs or arms
- Increased growth and
curling of the eyelashes and eyebrows
- Increased facial hair
- Easy bruising of the
- Dry, flaky skin
- Dry, itchy eyes
In some cases, the dose of the targeted therapy needs to be lowered,
interrupted, or stopped because of the rash. After several months of
treatment with these medications, some patients experience pain, redness,
and swelling around the nails, and small “paper-cut”
like fissures (breaks in the skin) in the fingertips. Some patients may
also develop dry skin with severe scaling and flaking.
Problems associated with EGFR reactions
In addition to the cosmetic appearance of the rash, the skin can
become very tender and itchy, impairing daily activities and sleep.
Vigorous scratching can result in breaks that may make the skin more
prone to infections. The inflammation around the nails can make grooming,
dressing, and other activities painful or difficult.
Although rashes, dry skin, and nail and hair reactions are rarely
severe, they can cause significant discomfort, in some cases leading to
the interruption of cancer treatment. Early and effective treatments for
these reactions are available and may be obtained from an oncologist,
dermatologist, or ophthalmologist familiar with these drugs and their
The following suggestions may help with the management of these
- Consult your oncologist
or a dermatologist familiar with the drug you are receiving and its
side effects before you start therapy and at the first sign of the
- Avoid the sun and use a
sunscreen with a high sun protection factor (SPF). Ideally, the SPF
should be at least 30, and the sunscreen should contain titanium dioxide
or zinc oxide. It should be applied every two hours or more
frequently if sweating or swimming.
- Remember to use an
adequate amount of sunscreen. Apply more than half a teaspoon of
sunscreen to each arm, the face and neck, and just over one teaspoon
to the chest and abdomen, back, and each leg.
- Use a broad-brimmed hat
if going outside.
- Use a mild soap in the
shower, and avoid soaps with strong scents. Also, avoid laundry
detergent with strong perfumes. Shower with lukewarm water, and
avoid long, hot showers.
- Apply a moisturizer
within 15 minutes of showering or bathing. Ask your doctor or nurse
- At the first sign of a
developing reaction (warm or burning sensation,
pimples, nail fissures, dry skin), tell your doctor or a
dermatologist familiar with these reactions.
- Avoid skin products
containing alcohol because they can dry out your skin.
- Antibiotics of the
tetracycline family (doxycycline, minocycline) by mouth are an effective therapy
for rashes and nail tenderness, usually administered for two to four
- Topical medicated
creams, such as pimecrolimus (Elidel) and clindamycin
gel (Cleocin T, Clinda-Derm,
or Evoclin) may be effective in mild
- When the skin is very
dry and flaky, your dermatologist may prescribe a moisturizer
containing urea or lactic acid.
PLWC: Managing Side Effects
PLWC Feature: Understanding Targeted Treatments (Updated)