Department of Medicine, Stony Brook University Hospital, NY (Drs. Zarrabi, Gemmill, and Baer); Division of Hematology/Oncology, Department of Medicine, Stony Brook University Hospital, NY (Dr. Baer); Division of Dermatology, University of Washington, Seattle (Dr. Safaee) Kayvan.zarrabi@gmail.com
The authors reported no potential conflict of interest relevant to this article.
Always counsel patients before a rash develops (and, ideally, before chemotherapy begins) that they should report a rash early in its development, to you or their oncologist, so that timely treatment can occur. Early recognition and intervention have proven benefits and can prevent the rash and its symptoms from becoming worse17; if the rash remains uncontrolled, dosage reduction of the chemotherapeutic agent is an inevitable reality, and the clinical outcome of the primary disease might therefore not be ideal.18
Prophylaxis. Daily application of an alcohol-free emollient cream is highly recommended as a preventive measure. Patients should be counseled to avoid activities and skin products that lead to dry skin, including long and hot showers; perfumes or other alcohol-based products; and soaps marketed for treating acne, which have a profound skin-drying effect.
Cornerstones of treatment include topical moisturizers, steroids, and antihistamines for symptom control. Once an identifiable skin rash has developed, a topical steroid cream is first-line treatment. Successful control has been reported with 1% hydrocortisone lotion applied daily to the affected area.15
Second- and third-line Tx. If the rash progresses in size or severity, we recommend switching to 2% hydrocortisone valerate cream, applied twice daily. For a moderate-to-severe rash, an oral tetracycline is a valid option for its anti-inflammatory effects and, possibly, to prevent secondary infection. In the event of progression, refer the patient to an oncologist, who can consider suspending the anti-EGRF drug temporarily until the rash improves. If disease persists, consultation with a dermatologist is appropriate for consideration of systemic prednisolone.
Alleviating discomfort. Patients commonly report pruritus and mild-to-moderate pain with the rash; standard analgesic therapy is appropriate.19 Severe pain might indicate secondary infection; in that case, consider antibiotic therapy for presumed cellulitis. Moreover, because of the risk of thrombosis in the cancer population, underlying deep-vein thrombosis must always remain in the differential diagnosis of an erythematous rash.
