Pocket Oncology (Pocket Notebook Series), 1st Ed.

Dermatologic Adverse Events from Anticancer Therapies

Viswanath Reddy Belum and Mario E. Lacouture

25. Palmar-plantar erythrodysesthesia (PPE) syndrome grade 2, related to doxorubicin therapy. Treatment consists of topical emollients with keratolytics (6% salicylic acid/10–40% urea), high-potency topical corticosteroids (clobetasol, betamethasone), and oral NSAIDs and corticosteroids for grade 3 PPE.

26. Papulopustular (acneiform) rash grade 2, related to EGFR inhibitors (erlotinib, afatinib, cetuximab, panitumumab) therapy. Prophylaxis and treatment consists of low/medium potency topical corticosteroids (alclometasone, triamcinolone), oral antibiotics (minocycline 100 mg a day/doxycycline 100mg bid), and oral corticosteroids (prednisone 0.5 mg/kg/day for 7 days) for grade 3 acneiform rash. Bacterial cultures are recommended when secondary infections are suspected, to determine optimal antibiotic therapy.

27. Paronychia grade 2, related to EGFR inhibitor (afatinib, lapatinib, erlotinib, cetuximab, panitumumab) therapy. Treatment consists of topical antibiotics (mupirocin, polysporin)/antiseptic (povidone/iodine) ointments, chemical cauterization with silver nitrate, and oral antibiotics when secondary infections are suspected or confirmed with microbial cultures.

28. Palmar-plantar erythrodysesthesia (PPE) syndrome grade 2, with blisters and hyperkeratosis related to multikinase inhibitor therapy (sorafenib, sunitinib, regorafenib, axitinib, pazopanib). Treatment consists of topical moisturizing keratolytic emollients (6% salicylic acid or 40% urea) as prophylaxis, high-potency corticosteroids (betamethasone, clobetasol), and anesthetics (lidocaine, prilocaine); or oral (NSAIDs, opiates) analgesics for grade 3 PPE.

29. Nail loss (onycholysis) grade 2, related to taxane (paclitaxel, docetaxel) therapy. Treatment consists of antiseptic soaks (white vinegar in cool tap water 1:1 for 15 minutes daily), culture-driven oral antibiotics, and incision & drainage of the proximal nail fold abscess; prevention with frozen glove and sock therapy during chemotherapy administration.

30. Maculopapular rash grade 3, related to BRAF inhibitor (vemurafenib) therapy. Treatment consists of topical/oral corticosteroids and oral antihistamines (loratadine, cetirizine, fexofenadine during the day and hydroxizine, diphenhydramine at night) for associated pruritus.

31. Alopecia grade 1, persistent after completion of taxane (paclitaxel, docetaxel) therapy. Treatment consists of topical minoxidil 2–5% twice daily and biotin 2.5 mg a day. Evaluation for other abnormalities that may contribute to alopecia are also recommended (serum TSH, vitamin D, ferritin, zinc levels).

32. Paronychia grade 2, related to mTOR inhibitor (temsirolimus, everolimus) therapy. Treatment consists of topical antibiotics (mupirocin, polysporin)/antiseptic (povidone/ iodine) ointments and partial or complete nail avulsion. For thin or brittle nails from mTOR inhibitors, daily use of poly-urea urethane gel (Nuvail) or (hydrosoluble nail lacquer (Genadur) and PO biotin 2.5 mg a day.

33. Maculopapular rash grade 3, related to ipilimumab therapy. Treatment consists of medium/high potency topical corticosteroids, and oral corticosteroids and antihistamines.

34. Radiation dermatitis (RD) grade 2, related to radiation therapy. More frequent and severe during treatment of head and neck, breast, and genitourinary cancers and with concurrent chemotherapy or targeted therapy. Prevention consists of topical corticosteroids (mometasone, betamethasone) or antibiotics (silver sulfadiazine for breast, silver leaf nylon dressing for anal cancers). Once developed, secondary infections are common, so bacterial cultures are recommended in order to administer appropriate oral antibiotic therapy.

35. Maculopapular rash grade 2, post stem cell transplantation. Treatment consists of topical/oral corticosteroids and antihistamines.

36. Alopecia grade 1, related to hormonal (tamoxifen, aromatase inhibitors) therapy. Treatment consists of topical minoxidil 2–5% twice daily and biotin 2.5 mg a day. Evaluation for other abnormalities that may contribute to alopecia are also recommended (serum TSH, vitamin D, ferritin, zinc levels).

37. Basal cell carcinoma (BCC) on the upper lip. Most common type of non-melanoma skin cancer, with over 2 million cases diagnosed per year. Frequently occurring on the face, head, neck and upper trunk, photo-exposed areas, or in areas of prior radiation therapy. Treatment is usually topical (i.e. imiquimod, tazarotene) or local therapy (e.g. laser therapy) for superficial BCCs; whereas surgery or radiation are most common therapies for the other types of BCCs.

38. Squamous cell carcinoma (SCC) is the second most common type of non-melanoma skin cancer, with approximately 300,000 cases diagnosed per year. Treatment is usually topical (i.e. imiquimod, tazarotene) or destructive for SCCs that do not involve the entire epidermis (actinic keratoses or Bowen’s disease); whereas surgery or radiation are most common therapies for in-situ or invasive SCCs.

39. Melanoma representing only 8% of all skin cancers but nearly 80% of skin cancer-related deaths. Dermoscopy significantly aids in diagnosis and treatment is mostly surgical excision. Tumor thickness, mitotic rates and ulceration are the most important prognostic factors.

40. Oral mucositis (aphthous stomatitis-like) grade 2, related to mTOR inhibitor (temsirolimus, everolimus) therapy. Treatment consists of dexamethasone oral rinses or clobetasol ointment tid.