Dermatological Aspects of Nursing Oncology: Meaningful Observations Ensuring Better Quality of Life

Toxic erythema of chemotherapy

It includes palmoplantar erythrodysesthesia (PPED), intertriginous eruption of chemotherapy (IEOC), and neutrophilic eccrine hidradenitis (NEH). Direct toxicity of chemotherapeutic agents after their excretion through eccrine sweat glands, which are maximally concentrated on palms and soles, explains predominant acral affliction. Other factors such as friction and trauma may play a role in distribution. They usually present between 2 days and 3 weeks and doxorubicin, docetaxel, cytarabine, and capecitabine are most commonly implicated.

PPED is characterised by a prodrome of burning and itching followed by the appearance of well-defined erythema and oedema. This eruption may become bullous and erode. Paclitaxel has emerged as one of the drugs responsible for this eruption^[1,2] IEOC has dusky erythema, papules, and coalescing plaques in flexures, which resolves with hyperpigmentation.^[3,4] Similar eruption over palms, face, and trunk, along with pustules, urticated plaques and purpura is seen in NEH.^[5,6]

No standardised treatment regimen is available and thus symptomatic management is to be done.

Papulopustular eruptions

It is characterised by sterile pustules and papules in the seborrheic distribution of the face, scalp, chest, and back, usually within 2 weeks of drug administration. The most common culprits include EGFR inhibitors like cetuximab, tyrosine kinase inhibitors like erlotinib, and mitogen-activated protein kinase inhibitors like selumetinib.^[7] Multinational Association of Supportive Care in Cancer has given a severity grading scale.^[8]

Dyspigmentation

Dyspigmentation may involve hyperpigmentation and hypopigmentation and occurs within a few days to 6 months. Former may be generalised, involve nail or mucosa, localised to the injection site, or maybe in distinct patterns. Flagellate hyperpigmentation due to bleomycin and serpentine supravenous hyperpigmentation along the distribution of veins, secondary to drugs such as fluorouracil are well-described patterned pigmentation.^[9] Hyperpigmentation usually resolves post drug discontinuation. Hypopigmentation due to melanocyte toxicity, induced by drugs such as doxorubicin, imatinib, and dasatinib, occurs in symmetric distribution on the trunk or acrally and persists despite treatment termination.^[10]

Photosensitivity

Abnormal light reactivity following administration of certain chemotherapeutic drugs may be of phototoxic, photoallergic, or recall reactions to UV and visible lights.^[11] The phototoxic reaction appears within 12–24 h of culprit drug administration, presenting as well demarcated, painful erythema and oedema which may progress to vesiculation and desquamation, predominantly affecting photo exposed sites. This is due direct cytotoxic effects of the locally accumulated drug, which causes cell damage after absorption of a specific wavelength of light.^[11] Drugs commonly implicated include methotrexate, fluorouracil, and dacarbazine.^[12]

Eczematous eruption appearing primarily in photo distribution, after about 2–3 days, due to T-cell-mediated response to drug metabolite acting as photoantigen, is called photoallergic reaction. It resolves within 3 weeks with pigmentation. Tegafur and flutamide are implicated.^[13]

Recall reaction

It will be discussed in AE to radiotherapy.

Others

Less commonly encountered events include xerosis secondary to cetuximab, paclitaxel; hand-foot syndrome secondary to sunitinib, docetaxel, and ichthyosis secondary to methotrexate and generalised pruritus secondary to cyclophosphamide and epirubicin.^[14-16]

Hair changes

Chemotherapy-induced alopecia is due to hair being involved as an innocent bystander of cytostatic toxicity of hair matrix cells. Incidence is almost 65%.^[17] Taxanes, doxorubicin, and cyclophosphamide are most commonly implicated. Initial hair fall is focal, mainly confined over the vertex and above ears. By 2–3 months, a more diffuse pattern of hair loss becomes established. Resolution post discontinuation becomes evident between 3 and 6 months.^[18]

Chemotherapy-induced hypertrichosis on treatment with cetuximab, erlotinib, and gefitinib may involve face, scalp, or eyelashes (trichomegaly).^[19] Scalp hair may become a slow growing, brittle and curly. Trichomegaly causes trichiasis and facial hypertrichosis causes cosmetic concerns. These changes occur 2–6 months into chemotherapy and may resolve on stopping treatment.^[20]

Nail changes

The incidence of nail changes ranges from 0 to 44%.^[21] Nail plate, matrix, and bed may all be involved and lead to onycholysis, beau’s lines, onychomadesis, subungual haemorrhages, paronychia, and pigmentation. EGFR inhibitors, taxanes, and bleomycin are primary culprits. Photo-onycholysis and Mees lines secondary to Melphalan are well documented.^[22]

Radiation dermatitis (RD)

It generally manifests as well-demarcated cutaneous changes in the irradiated field. It can be classified into acute and chronic RD. Acute RD occurs within 90 days of irradiation as erythema and oedema followed by desquamation. Severe cases may progress to necrosis and ulceration. Chronic RD may occur anytime between 15 days and 10 years, primarily due to increased collagen deposition, damaged elastin, and follicular structure loss.^[26]

Recall reaction

Anticancer drugs such as methotrexate, docetaxel, and paclitaxel lead to ‘recalling’ of an eruption similar to that of an acute radiation reaction, in a previously irradiated field.^[27] Irradiation and subsequent drug administration should be at least 7 days apart, with the majority of reactions occurring when the interval is <2 months. The shorter the intervening duration, the more severe is the reaction.^[28] Occasionally, there may be the generalisation of the eruption beyond the irradiation field.

Others

Chronic ulceration, which may have to be biopsied to rule out secondary malignancy, may develop due to necrosis. Radiation-induced cutaneous vascular neoplasms such as angiosarcomas may occur in irradiated skin in breast conserving treatment.^[29] Post-irradiation burns and morphoea, erythema nodosum, and vitiligo have been reported.^[30-32]