Educational Resources




Chemo/Radiation Side Effects

  • Chemotherapy - Induced Skin Toxicities

    Because chemotherapy targets rapidly growing cells, skin, hair follicles and nails are also frequently affected. The most common reactions to chemotherapy include hair loss, hyperpigmentation, hand-foot syndrome, extravasation injuries, and nail dystrophies. Hypersensitivity can also occur, but is less common.1 Although these disorders are not life threatening, they can cause significant distress to patients.

    Some chemotherapeutic agents cause skin rashes characterized by inflammatory papules and pustules on the scalp, face, neck and upper trunk. Depending on the agent and the type of cancer, rashes typically appear within 1 to 2 weeks after starting therapy.

    Chemotherapeutic agents are classified according to their mechanism of action (See Table below). Each class of drugs exerts a different set of dermatologic effects.

    Selected Chemotherapeutic Agents and Associated Cutaneous Reactions

    Treatment/Drug Type

    Agent(s)

    Adverse Skin Reaction

    Epidermal growth factor receptor (EGFR) inhibitors

    Gefitinib, cetuximab, erlotinib, panitumumab, lapatinib (combined EGFR/HER2 antagonist)

    Acne-like rash, erythema, dryness, papules/pustules, pruritus, xerosis, telangiectasia, fissures, alopecia, discolored or bumpy nails

    Multikinase inhibitors

    Imatinib, dasatinib, nilotinib, sorafenib, sunitinib

    Hand-foot syndrome, xerosis, subungual splinter hemorrhages, acne-like rash, pruritus, facial erythema, scalp dysesthesia, skin discoloration, bruising, thinning of skin

    Alkylating agents

    Busulfan, oxaliplatin, melphalan, temozolomide, carboplatin, thiotepa, mechlorethamine, chlorambucil, streptozocin, cisplatin, methyl-CCNU, cyclophosphamide, dacarbazine, ifosfamide

    Mucositis, paronychia, flushing, xerosis, pruritus, facial erythema, alopecia, pigmented bands on nails and teeth

    Spindle inhibitors

    Docetaxel, paclitaxel, vinorelbine, irinotecan, topotecan, vinblastine, vincristine, etoposide

    Palmar/plantar erythrodysesthesia plaques, dermatitis, xerosis, pruritus, edema, mucositis

    Antimetabolites

    Fludarabine, cladribine, capecitabine, clofarabine, cytarabine, floxuridine, hydroxyurea, nelarabine, pentostatin, methotrexate, mercaptopurine, thioguanine, 5-fluorouracil, tegafur, gemcitabine, pemetrexed

    Edema, pruritus, xerosis, facial flushing, photosensitivity, mucositis, palmar/plantar erythrodysesthesia

    Antitumor antibiotics

    Bleomycin, epirubicin, idarubicin, plicamycin, mitoxantrone, dactinomycin, daunorubicin, rubidomycin

    Rash (flagellate hyperpigmentation), pruritus, xerosis, palmar/plantar erythrodysesthesia, mucositis

    Antiangiogenesis

    Bevacizumab

    Mucositis, flushing, sores on mouth or lips, xerosis

    Corticosteroid hormones/other

    Prednisone

    Bruising, fungal infections (white patches in mouth, vagina), facial

    Hormones/aromatase inhibitors

    Aminoglutethimide, ibritumomab, bicalutamide, trastuzumab, flutamide, fulvestrant, tositumomab, tamoxifen, letrozole, goserelin, leuprolide, megestrol acetate

    Edema, angioedema, erythema, rash, flushing, hot flashes

    Radiation

    External beam therapy, intensity modulated radiation therapy, stereotactic radiosurgery (with gamma knife)

    Radiation dermatitis, dry desquamation, pruritus, moist desquamation, alopecia, generalized erythema

    NOTE: Some skin side effects are common to some but not all of the agents listed in each drug class. For example, among the multikinase inhibitors, dasatinib, imatinib and nilotinib are associated with rash and pruritus, whereas sunitinib and sorafenib are also associated with hand-foot syndrome and subungual splinter hemorrhages. Patients taking sunitinib may develop chronic sores and skin discoloration (yellowing of skin), whereas patients taking imatinib may become susceptible to bruising, thinning and/or tearing of skin.

  • Rash Associated With EGFR Inhibitors

    Human epidermal growth factor receptors (EGFRs), such as erlotinib, cetuximab and panitumumab, block the growth of tumor cells by targeting a protein in your body called human epidermal growth factor receptor (also known as HER1/EGFR). The goal of targeted therapy is to prevent or interfere with the growth and division of cancer cells and their ability to communicate with other cells. It is called a targeted therapy because it attacks only specific cancer cells in your body—and not the normal cells. As a result, there are fewer side effects.

    Side effects with HER1/EGFR inhibitors are mainly associated with skin reactions. These problems are rarely life threatening; however, they can cause physical and emotional distress for patients and caregivers. The most common side effect is a rash that affects the face and upper body. Rashes have developed in 50% to 100% of patients and usually occur within the first few weeks of starting an EGFR antagonist. Skin reactions can be independent of dose and can persist long after drug therapy has been discontinued. However, having a persistent rash is an atypical reaction and not the norm. Nearly all side effects are reversible and usually resolve with dose reduction or discontinuation of therapy.

    A rash can be erythematous, macular, or papular. The rash associated with the EGFR erlotinib has been described as acne-like or papulopustular. The rash is usually preceded by redness of the skin or a warm sensation on the face that may feel like sunburn. The surrounding skin will feel slightly tender, causing significant physical and cosmetic discomfort, usually a burning or an itching sensation.

    In one study, between 48% and 67% of patients receiving erolotinib experienced pustular eruptions. The eruptions usually occur 7 to 10 days after the start of treatment. The worst breakouts occur in the second week after initiating treatment. Most cases resolve without scarring, but sometimes the skin clears only partially even after therapy is stopped.

    General symptoms may include the following:

    • Pimples and red bumps on the face, neck and upper chest or back
    • Tenderness of facial skin, with a sunburn-like sensation
    • Itchiness, especially the scalp
    • Tender sores inside the nose, corners of the mouth or eyes
    • Inflammation around nails (paronychia), especially the thumbs
    • Nails that become brittle and may loosen from the nail bed
    • Hair loss over the entire scalp and decreased hair on legs or arms
    • Increased growth and curling of the eyelashes and eyebrows
    • Easily bruised skin
    • Dry, flaky skin
    • Dry, itchy eyes

    In addition to the cosmetic appearance of the rash, tenderness and itchiness can impair daily activities and sleep. Vigorous scratching can result in breaks (excoriations) that may make the skin more prone to infections. The inflammation around the nails (paronychia) can make grooming, dressing and other activities painful or difficult.

    After several months of treatment with these medications, some patients experience pain, redness and swelling around the nails, and small paper-cut–like fissures in the fingertips. It is important to see your doctor if these conditions or rash occur. Medical management of the rash by the oncologist or a dermatologist is the preferred course. Although the targeted therapy dose can be lowered, interrupted or stopped due to rash, decreasing or stopping chemotherapy will result in a suboptimal response of the cancer.

    If you do experience a rash with an EGFR inhibitor, however, this can be very good news. The rash may be a sign that the medication is really working. The skin side effects you may experience with an EGFR inhibitor are not a sign of an allergic reaction or infection.


    The Flip Side: Rash Can Be a Positive Clinical Benefit

    There is an association between rash development and how well a patient is responding to treatment. The first clinical trial to report this effect was with erlotinib. This trial showed that skin rashes (grade 2 or higher) induced by erlotinib may confer a survival advantage. There was a significant increase in the likelihood of survival and progression-free survival in patients who developed rash. In fact, the more severe the rash, the better are the outcomes.

    Because skin rash can have a negative effect on patients’ quality of life, some patients discontinue treatment. So it is very important to talk with your doctor about finding a strategy that will help you manage the rash while continuing therapy.


    Caring for Chemotherapy-Induced Skin Rash

    First and foremost, follow your doctor’s instructions. Taking your medication at the right time of day and in the correct amount is important to your well-being. Your doctor may temporarily stop treatment if your skin rash is too uncomfortable for you. In any case, this is something you should discuss with your doctor and not take upon yourself. Remember, the rash itself may be a sign that the medication is working.

    What You Can Do
    • Ask your doctor to recommend skin products that will be mild and safe enough for you to use. There are products made specifically for patients who are experiencing side effects related to cancer treatment. Some of these can be purchased online. But check with your doctor first to be sure they are the best product for your condition.
    • Use only mild soap. Avoid antibacterial soaps, as they are more drying. Consult your caregiver on which soaps might be best for you.
    • Avoid hot baths. This will further dry your skin. Take a quick shower instead.
    • Pat yourself dry with a towel instead of rubbing your skin.
    • Choose a thick moisturizer. Ointments work better than creams, and creams work better than lotions.
    • Avoid exposure to the sun, especially between 10 AM and 4 PM, when the sun is strongest. Wear a hat and sun-protective clothing when you are out in the sun. Always use a sunscreen with a sun protection factor (SPF) of at least 30 on whatever part of your body is not covered with clothing. Choose a product for sensitive skin (e.g., one that contains zinc oxide or titanium dioxide). Reapply sunscreen after 2 hours of continuous exposure.
    • Remove all makeup with gentle cleansers.
    • Avoid perfume, cologne or aftershave that contains alcohol.
    • Use only nonpigmented (colorless) lip balm.
    • Avoid wearing clothing such as wool next to your skin that will make your skin feel itchy.


    NOTE: We strongly encourage you to talk with your health care professional about your specific medical condition and treatments. The information provided in this Web site about skin reactions and other medical conditions is meant to be helpful and educational, but is not a substitute for professional medical advice.

  • What is Palmar Plantar Erythrodysesthesia (Hand-Foot Syndrome)?

    Palmar plantar erythrodysesthesia is also known as hand-foot syndrome. It occurs as a side effect of certain anticancer drugs. Hands and feet become red and irritated and begin to crack and peel. Patients may also experience swelling, numbing, tingling or redness. This syndrome can prevent patients from carrying out their activities of daily living. Hands can become so sore that driving, preparing food and dressing can be painful or nearly impossible. To overcome this problem, it is important to keep the skin hydrated (moisturized) with a gentle lotion.

    Drugs that can cause hand-foot syndrome include capecitabine, cytarabine, floxuridine, fluorouracil, idarubicin, sunitinib, sorafenib and liposomal doxorubicin.

    What you can do:

    • Having a pedicure to reduce calluses before you begin chemotherapy
    • Wearing loose-fitting clothing and comfortable shoes with cushioned soles; avoid walking barefoot
    • Reducing exposure to heat, especially as you wash dishes or if you take long showers or long tub baths with hot water
    • Patting yourself dry with a towel instead of rubbing your skin
    • Wearing lightweight dishwashing gloves. Heavy gloves will hold the heat against your skin. It is best to avoid washing dishes by hand if possible.
    • Avoiding jogging, aerobics, power walking, jumping or taking long walks
    • Avoiding using tools such as screwdrivers or wrenches that require squeezing your hand against a hard surface
    • Avoiding using a knife to cut your food. Have your caretaker cut the food for you, if possible.
    • Applying cold to the tender area for relief of pain or soreness. Using a pack of frozen vegetables (15 minutes on and 15 minutes off) can be helpful. Soaking your hands or feet in cold water may also be helpful.
    • Taking vitamin B6 can help to prevent or treat hand-foot syndrome. But be sure to check with your doctor first before you take a supplement.
    • Applying moisturizers to your hands or feet; keeping them moist can help prevent peeling or cracking of the skin
    • Elevating your hands or feet to reduce swelling
    • Taking an over-the-counter remedy, such as acetaminophen, for pain

    If your hands or feet become red or painful or if blisters develop or you become feverish, please call your doctor. He or she may recommend adjusting or holding of on your chemotherapy pills to prevent your symptoms from worsening.

    NOTE: We strongly encourage you to talk with your health care professional about your specific medical condition and treatments. The information provided in this Web site about skin reactions and other medical conditions is meant to be helpful and educational, but is not a substitute for professional medical advice.

  • What is Paronychia (Nail Inflammation)?

    While you undergo chemotherapy, your nails will grow more slowly. They may also develop patchy spots or streaks and become darker. Nail changes occur in 10% to 15% of patients and typically appear 4 to 8 weeks from the start of chemotherapy. Discolorations and vertical or horizontal bands on the nail will eventually grow out as new nail is formed. Paronychia involving the large toe can be very painful. Pyogenic granuloma, friable bloody tissue growths, can develop in the nailfold.

    • Avoid wearing shoes that are too tight.
    • Soak hands or feet in an antiseptic bath (fill a bucket of water with ¼ cup bleach) or use an antibiotic cream.
    • Wear protective gloves while gardening or washing dishes or doing household chores.
    • If pyogenic granuloma occurs, see your doctor.
    • Avoid wearing nail wraps or acrylic nails; these materials can trap bacteria that may cause an infection.
    • Clip nails short to keep them from chipping and breaking and keep them moisturized.
    • Avoid wearing nail polish; however, if you wish to hide nail discoloration or imperfections, use only a light-colored nail polish.
    • Use only a non-acetone-based nail polish remover to remove nail polish.
    • Push cuticles back rather than cutting them.
    • If you visit a professional manicurist, bring your own implements to prevent picking up an infection from improperly disinfected implements used.
    • Practice good foot hygiene: trim your toenails, use softening lotions and check for any problems such as athlete’s foot or signs of fungal growth.

    NOTE: We strongly encourage you to talk with your health care professional about your specific medical condition and treatments. The information provided in this Web site about skin reactions and other medical conditions is meant to be helpful and educational, but is not a substitute for professional medical advice.

  • What is Radiation Dermatitis?

    Radiation dermatitis is a common side effect of radiation therapy in which the skin of the treated area becomes red and irritated. It occurs to some degree in most patients who undergo radiation therapy. Radiation kills not only cancer cells, but also some healthy cells. This causes the skin to peel. Damage to the skin can occur within 1 to 2 weeks of treatment and usually resolves when treatment is finished.

    Symptoms of radiation dermatitis include hair loss, dry desquamation, wet desquamation, decreased sweating, edema, ulcerations, bleeding and skin cell death. The extent of symptoms depends on the total radiation dose, the size of the area treated, fractionation and the type of radiation used. In severe cases, radiation therapy must be discontinued until the skin heals. Unfortunately, discontinuing therapy can compromise treatment.

    Because radiation dermatitis is painful and can be a source of anxiety, patients sometimes delay treatment. Years after treatment, it can progress to radiation fibrosis, an inflammatory condition that results in scarring.

    Radiation recall may occur during chemotherapy in patients who had received radiation treatment in the past. During or shortly after chemotherapy, previously irradiated skin may turn red and may blister or peel. This may last several hours or several days and may occur several days to several years after treatment. To alleviate the discomfort associated with radiation recall, use a cool wet compress on the affected area. Wear loose comfortable clothing, preferably cotton.

    Radiation recall occurs commonly with antitumor antibiotics such as doxorubicin or dactinomycin.


    Caring for Radiation Dermatitis

    What You Can Do

    • Keep the skin moisturized and lubricated to prevent itching and cracking of the skin. Be sure to use fragrance-free products.
    • Wash with lukewarm water only, not hot water.
    • Avoid hot baths. This will further dry your skin. Take a quick shower instead.
    • Pat yourself dry with a towel instead of rubbing your skin.
    • Do not rub off the markings your radiation therapist made on your skin. They are necessary to show where to place the radiation.
    • Do not use heating pads, ice packs or bandages on the area receiving the radiation.
    • Use water-based creams that are free of steroids, alcohol or fragrance.
    • Avoid using oils that will reduce the efficacy of radiation treatment.
    • Use nonadhesive dressings, as traumatic removal could cause further damage to already compromised skin.
    • Do not wear tight clothing around the treated area.
    • Avoid using a skin care product immediately before radiation therapy. This could interfere with treatment.
    • Choose clothes and bed sheets made of soft cotton.
    • Use an electric razor if your doctor or nurse says you can shave.
    • Ask your doctor before using:
      • Cornstarch
      • Creams or lotions
      • Deodorants
      • Makeup
      • Ointments
      • Perfumes
      • Powder
      • Shaving cream
      • Soap
      • Sunscreen
    • Avoid exposing the treated area to the sun while you are being treated.
    • Wear sun-protective clothing, especially over the treated area.
    • After your treatment is over, ask your doctor or nurse how long you should continue to take precautions from the sun.

    NOTE: We strongly encourage you to talk with your health care professional about your specific medical condition and treatments. The information provided in this Web site about skin reactions and other medical conditions is meant to be helpful and educational, but is not a substitute for professional medical advice.



Content Produced by Oncology Nursing News in coordination with Lindi Skin.

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