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Skin Reactions to Targeted Therapies

 

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 eyes.

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 strategies.

Causes

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 growth
  • Easy bruising of the skin
  • 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.

Management

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 side effects.

The following suggestions may help with the management of these reactions:

  • 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 reaction.
  • 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 for recommendations.
  • 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 weeks.
  • Topical medicated creams, such as pimecrolimus (Elidel) and clindamycin gel (Cleocin T, Clinda-Derm, or Evoclin) may be effective in mild cases.
  • When the skin is very dry and flaky, your dermatologist may prescribe a moisturizer containing urea or lactic acid.

More Information

PLWC: Managing Side Effects

PLWC Feature: Understanding Targeted Treatments (Updated)

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