Kathryn Ciccolini, RN, BSN, OCN
Dermatologic adverse events (AEs) associated with anticancer therapies can be complex and are best managed with a proactive and holistic approach—one that takes into account not only the physical demands of the regimen itself, but also the many challenges that patients often face involving treatment adherence, quality of life, and psychosocial concerns.
Developing a greater awareness and understanding of the toxicity profile of these agents is an important consideration for today’s oncology nursing profes-sional. When these events are managed successfully, patients are much more likely to adhere to their regimens and complete treatment.
“Oncology nurses play a key role in the research and patient education related to skin toxicities,” said Kathryn Ciccolini, RN, BSN, OCN, an oncology nurse at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York City.
Ciccolini is part of a team at MSKCC established a few years ago dedicated to managing skin toxicities associated with anticancer agents. The group includes a physician, two registered nurses, and a patient care technician who is also a trained medical photographer.
She recently sat down for an interview with OncLive TV to offer some insights and practical tips for nurses on the ways in which education and health promotion activities can lead to many positive health outcomes for patients, such as improved adherence and a greater understanding of their illness.
Preparing Patients on What to Expect
Ciccolini attributes much of the MSKCC team’s success to its members’ shared recognition of the importance of acting proactively with patients to identify and manage any dermatologic AEs.
Before treatment begins, the clinician sits down with the patient to ensure that he or she understands all aspects of care and develops short- and long-term goals. This pretreatment session, as well as a baseline total body skin evaluation, assists nurses in educating patients about possible cutaneous AEs and reduces unanticipated side effects.
“The education process runs parallel to the nursing process. We need to identify learning needs, knowledge deficits, and be prepared to deliver the information differently should the patient not understand on the first try,” she continued.
Although rarely fatal, dermatologic complications can profoundly affect the management of the patient with cancer because these AEs may result in significant morbidity, cosmetic disfigurement, and psychological distress.
One such complication is hair loss. “As one of the most common and anxiety-provoking side effects, educating the patient on the degree, pattern, and timing of hair loss, in addition to the variance in regrowth, is important to discuss prior to treatment,” Ciccolini explained.
She suggested laboratory testing for patients who experience hair thinning to determine whether a vitamin D, zinc, or thyroid deficiency might be a contributing factor. If the patient is a candidate, he or she may be advised to take vitamin supplements for hair regrowth.
Hair regrowth strategies for the scalp and eyelashes also may be discussed with the patient, including information about using hypoallergenic hair styling cleansing and coloring products.
Patients also can purchase wigs or powders to give the appearance of a fuller head of hair. Patients who experience increased but unwanted hair growth on the body can be educated about options for hair removal, such as threading, shaving, electrolysis, or laser hair removal.
Rash is another common side effect of treatment. For example, an estimated 50%-90% of patients receiving targeted therapies develop an acne-like rash during the course of treatment. It can appear on the face, scalp, neck, chest, and upper body, and while it may resemble common acne in appearance, it can become tender, itchy, and dry.
“Patients need to be educated about reporting their symptoms upon immediate onset by calling the dermatologist or their oncologist,” said Ciccolini, noting that rashes may be the result of allergy or infection, or they may be disease-related or drug-induced, and the root cause will affect treatment decisions.
Another important side effect to discuss prior to the start of treatment is the development of hand-foot skin reactions. Because these areas of the body have more blood flow and have faster dividing cells than other parts of the body, the cancer treatment may cause more of an effect.
Activities of daily living and quality of life may be affected depending on severity and may require topical keratolytics, topical steroids, oral nonsteroidal antiinflammatory medications, topical anesthetics, and/or topical antibacterials should there be a secondary infection. Upon reaching grade 3 and grade 4, this may result in disruption or discontinuation of the anticancer regimen.
Diagnosing and Treating Dermatologic AEs
Once patients notice a skin reaction, Ciccolini’s team encourages them to schedule an office visit to be interviewed, assessed, and evaluated. The objective is to determine whether the chemotherapeutic agent that the patient is taking is the actual offending agent.
Utilizing a standardized assessment tool, such as the Common Terminology Criteria for Adverse Events (CTCAE), can optimize the use of anticancer therapy and provide objective and subjective information. “For the multidisciplinary team to work together, the language used must be standardized,” said Ciccolini.
Some patients may require additional testing to determine whether the toxicity has a bacterial, fungal, or viral cause, she continued. If these skin reactions are determined to be definitively related to therapy and the treatment approaches not contraindicated to the patient’s care, the physician or the nurse practitioner may choose to do as follows:
Acneiform rash on the scalp, face, chest, and back
Targeted Therapies: Common Dermatologic Reactions
Acneiform, rash, dry skin, itching, paronychia, brittle nails, hair abnormalities (such as hair loss) and increased hair growth on the face and eyelashes
VEGF and PDGFR Inhibitors
Hand-foot skin reactions, alopecia, skin color changes, nail changes, and maculopapular rash
Maculopapular rash, pruritis, and xerosis
Maculopapular rash, pruritis, painful oral mucositis, or stomatitis
Maculopapular rash, photosensitivity, hair thinning, and hand-foot skin reactions
Pruritis and vitiligo
—The patient may be prescribed a low potent topical corticosteroid twice daily for direct application to the face, chest, and back for 2 weeks. Acneiform rashes on the scalp require a high potency topical steroid solution applied daily.
Dryness accompanied by flaking
—The patient may be prescribed a topical antifungal or topical steroid shampoo for the scalp and a topical keratolytic such as salicylic acid or ammonium lactate for application to the body.
Dryness with flaking and itching or redness
— A topical steroid solution, foam, or shampoo may be prescribed for the scalp, a low- to mid-potency topical steroid may be prescribed for the face, and a mid- to high-potency steroid may be prescribed for the body.
—May be treated with over-the-counter products such as oral antihistamines and topical corticosteroids or anti-itch creams containing benzocaine, lidocaine, menthol, or pramoxine. Should the itching persist or worsen, prescription topical steroids and oral antihistamines may be prescribed. A patient with severe pruritus, might be a candidate for oral nerve-modulating prescriptions or ultraviolet (UV) light therapy, also known as phototherapy.
In general, Ciccolini noted, it is recommended that patients keep baths and showers short, using cool or lukewarm water. Patients should avoid scrubbing the skin to reduce the chance of irritation and bacterial infections. It is recommended to apply a hypoallergenic moisturizer to dampen skin after showering or bathing and to avoid shower products that contain alcohol.
“The patient’s cuticles and nails may be affected in several ways such as having brittle nails, nail discoloration, and infection,” added Ciccolini. At first, the physician or nurse practitioner may recommend a topical antibiotic, topical antifungal, or antiseptic solution. If symptoms worsen, the patient may be prescribed an oral antibiotic and chemical cauterization or cryotherapy. If symptoms continue to persist at this point, a partial or complete nail evulsion may be recommended, and the anti-cancer therapy may be interrupted or decreased.
In addition, because the patient is often immunocompromised, the breaks and cracks in the skin from being dry and itchy create a portal of entry for bacteria that can lead to infections.
“Tell the patient to track his symptoms and take photos because the symptoms may change over time,” said Ciccolini. If the patient is trying to find relief through over-the-counter products, try one product at a time in case new skin reactions occur. This will help determine which product caused the skin irritation or new development of allergies.
Topical corticosteroids are the mainstay of dermatologic complications management. Corticosteroids treat chemotherapy-induced rashes, hand-foot skin reactions, pruritis, photosensitivity, and symptomatic scars.
Topical hydrocortisone, which is a low potency corticosteroid, can be used on the face. Topical triamcinolone can be applied to the body for up to 2 months. It is important to monitor and evaluate the patient when prescribing these types of medications. Topical steroids are applied twice a day for 2-4 weeks with 1 week of rest to prevent tachyphylaxis.
Topical steroids work best on inflamed, desquamated, thin, and hydrated skin. The potency of topical steroids and avoidance of their use in intertriginous areas should be explained upon initiation of therapy. Side effects from local applications include, but are not limited to, burning, stinging, itching, cracking of the skin, fissuring of the skin, dryness, erythema, irritation, or papular rash. Prolonged use can cause skin atrophy, telangiectasias, striae, hypertrichosis, and pigmentation changes.
Patients’ allergies and their medication list should be reviewed and allergic reactions to topical steroids and signs and symptoms of infection should be reported. Unless indicated in the treatment plan, the patient should be instructed to avoid applying occlusive dressings as this may increase percutaneous absorption.
Targeted therapies can result in a greater reduction in quality of life than the cytotoxic chemotherapies, noted Ciccolini, and with each classification of targeted agents, there are specific symptoms to prepare the patient for, either by prophylactic treatment or with education when treatment begins (Table). She suggested keeping a close follow-up protocol to ensure that all symptoms are monitored and evaluated throughout the course of treatment.
With the myriad of cutaneous AEs associated with these therapies, a unique dermatologic lens is required to accurately assess, diagnose, and implement a plan of care for the patient, she added.
Ciccolini stressed the importance of establishing a system for nursing documentation to record all nursing interventions, including nursing assessment and education of patients with these symptoms. She said that this is necessary for optimal interdisciplinary communication among caregivers, identification of appropriate services, quality assurance, legal accountability, reimbursement, and research.
Oncology nurses require a particular skill in implementing a dermatologic plan of care in patients who experience EGFR inhibitor toxicities. The plan can be either nursing-initiated or physician-initiated. Once the interventions are established, it is important to follow through on the plan of action and monitor the patient for signs of changes or improvement in symptoms.
The patient must be educated on the importance of follow-up, further health management, and following through on any necessary referrals, and this can take place over the course of hours, days, weeks, or even months. It is important to note that in addition to educating patients on the anticipated side effects of these agents, oncology nurses should also teach about hypersensitivity reactions and Steven-Johnson syndrome.
“We also need to be mindful of educating patients on sunscreen. Patients being treated with targeted therapy should protect their skin from the sun by using sunscreen,” said Ciccolini.
Overall, the ultimate goal in managing dermatologic events is to minimize therapy alteration by managing cutaneous side effects such as rash, hair, and nail abnormalities, hand-foot skin reactions, mucosal alterations, itching, dry skin, pigmentation abnormalities, skin infections, and hypersensitivity.
Ciccolini emphasized the importance of accurate dermatologic assessment of the oncology patient as vital to optimal diagnosis, treatment, and symptom management.
“A common dermatologic misconception is that because the symptom is visible on the skin, it is easy to diagnose. In fact, it takes a unique skill set to precisely assess in dermatology.”