We need to continue to press forward, making sure that dermatology is part of the continuum of cancer care for all of our patients.
— Mario E. Lacouture, MD
I first became interested in treating skin issues associated with cancer about 10 years ago, during my dermatology residency training at the University of Chicago. Many of the agents under clinical development at the time, such as cetuximab (Erbitux) or sorafenib (Nexavar), were causing dose-limiting side effects. Consequently, patients with severe facial rashes or blisters on the hands and feet were referred to us. Desperate to have their skin issues resolved so they could remain on their anticancer regimens, patients would implore me to give them any medication available that would ease their side effects.
Seeing this unmet need in patients with cancer made me realize that although we were making remarkable progress in developing agents that prolonged life, we were, to a great extent, overlooking the largest human organ: the skin. This realization was what motivated me to dedicate my career to treating patients with cancer.
Many of the skin conditions that arise as side effects from cancer therapies appear unexpectedly and progress rapidly. Therefore, we need to see patients in a timely fashion, within days of the first symptom, or whenever the first sign of a rash or other skin issue alerts the oncologist. We’ve documented a decreased quality of life in patients with cancer who have dermatologic side effects; the patient often thinks that the skin disorder will result in their oncologist stopping their treatment. It is vital to medicate dermatologic conditions as soon as they arise.
Since beginning my career, there has been increasing awareness of the importance of dermatologic care in oncology. Consequently, we’ve seen a number of significant scientific advances. One is the use of antibiotics to prevent rashes associated with epidermal growth factor receptor (EGFR) inhibitors. We’ve demonstrated that prophylactic use of antibiotics (for example, clindamycin and mupirocin) reduces—by about 50%—the acne-like rashes associated with these agents. Another important discovery has been the impact of using cold gloves and socks on the hands and feet to diminish nail changes, including separation, and infections induced by the taxanes.
A principal concept is that the majority of rashes are not allergic reactions, but rather, a direct result of the agent’s mechanism of action. Understanding this, we can perform damage control, letting the patient remain on life-prolonging therapy while minimizing symptoms and enhancing cutaneous health.
An advance that goes underutilized is the use of topical corticosteroids to prevent radiation dermatitis. In fact, about six randomized studies have demonstrated that prophylactic use of high-potency topical steroids minimizes the symptoms of radiation dermatitis, especially in breast and head and neck cancer.
Despite our knowledge about dermatologic adverse events from cancer treatments, we still see a large number of patients who are reluctant to mention skin-related issues with their oncologists, often due to the aforementioned fear of being taken off treatment. Many patients also feel a sense of guilt, believing that if they complain about skin issues, this trivializes their doctor’s efforts to cure or control their disease.
We need to show our patients that problematic dermatologic conditions can be managed in a way that allows them to have a good quality of life and maintain the healthy sense of “self” that comes with body image. Working with a dermatologist empowers patients to partner in their skin care, not only for cosmetic reasons, but also to be aware of painful or itchy dermatologic conditions that can affect activities of daily living or can result in life-threatening infections.
Work in the psychosocial aspects of cancer has shown that one of the most problematic features of this disease is the patient’s feeling of a loss of control. One way for patients to strengthen the very important sense of self-determination that helps define us as individuals is by maintaining their appearance and sense of personhood.
A patient’s skin care, which is essential to body image, needs to be addressed before, during, and after treatment. To that end, it is essential to provide patients with educational material that allows them to be actively engaged in their own cosmesis. For example, although various cosmetic options such as wigs, hats, scarves, powders, and sprays have helped many people cope with hair and eyelash loss, newer interventions such as minoxidil or bimatoprost (Latisse) may reduce the duration of hair and eyelash loss from chemotherapy. Similarly, supplements such as biotin and orthosilic acid have been shown to be effective in nail and hair health.
Patients with cancer are often hesitant about using cosmetics, and some products on the market should be avoided. However, a growing number of cosmetic products are safe for patients with cancer and can be used to hide facial side effects associated with chemotherapy, such as rashes, scars, and discoloration. While we generally think cosmetics are for women, male patients may need this type of intervention as well. For example, men who never thought about using a concealing foundation are now offered an option that will hide facial rashes or discolorations, allowing them to be less conspicuous and self-conscious in the work place—a significant quality-of-life advance.
Continuum of Care
Reducing or preventing dermatologic adverse events does not end at the physical level. Many patients have told me how skin intervention has improved their overall life, their interactions with friends and associates, their confidence, and most important, their ability to enjoy each and every day.
Although participating in the care of skin, hair, and nails in people living with cancer is but one part of the challenging work that oncologists do, it is a valuable one. We need to continue to press forward, making sure that dermatology is part of the continuum of cancer care for all of our patients. ■
Disclosure: Dr. Lacouture is a consultant for Amgen, Roche, Bristol-Myers Squibb, AstraZeneca, Bayer, ImClone, and Genentech. He is the author of Dr. Lacouture’s Skin Care Guide for People Living With Cancer.
Dr. Lacouture is a board-certified dermatologist with a special interest in dermatologic conditions that result from cancer treatments. He is an Associate Member at Memorial Sloan-Kettering Cancer Center, New York.