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Summary

Targeted therapies act on cancer cells while having little or no effect on normal healthy cells. Targeted therapies can cause skin changes, such as a rash.

There are some things you can do to help prevent skin changes or at least to try to keep them under control. You should start to do them as soon as targeted therapy treatment begins - before any problems start.

Tell your doctor or nurse about any rashes or skin changes you notice. Left untreated, the rash can get worse and lead to infection, as well as the need to delay or even stop treatment. Do not treat your skin with over-the-counter medicines or stop taking your targeted therapy without talking to your doctor first.

There are some medical professionals who believe that the existence of a rash indicates that a targeted therapy is working. These therapies can work even if they do not cause a rash.

To learn more, see:

What are targeted therapies?

Many of the newer chemotherapy drugs used to treat cancer are calledtargeted therapies. These drugs act on certain parts of cancer cells to block the growth and spread of cancer. They work by affecting the processes that make normal cells become cancer cells and cause tumors to grow. The goal of targeted therapy is to destroy cancer cells while causing little or no damage to normal, healthy cells. Targeted therapies can be used to treat certain types of many different cancers, including lung, pancreatic, head and neck, liver, colorectal, breast and kidney cancers. Some examples of targeted therapy are:

  • erlotinib (Tarceva)
  • cetuximab (Erbitux)
  • panitumumab (Vectibix)
  • lapatinib (Tykerb)
  • bexarotene (Targretin)
  • sorafenib (Nexavar)
  • sunitinib (Sutent)

Targeted cancer therapies do not damage bone marrow or blood cells like most standard chemotherapy (chemo) drugs do. They can be used alone or along with other drugs. They are most often used with other cancer treatments, such as radiation or chemo. Targeted therapy is used this way to boost the effects of the main treatment.

Targeted therapy is newer than other forms of cancer treatment like surgery, radiation, or chemo. It is only within the last 10 years or so that it has proven useful as a cancer treatment. Even though these drugs mainly target the cancer cells, they are not perfect -- they can cause side effects and sometimes serious reactions.

Many of the targeted therapy drugs can cause a rash or other skin changes. These changes are side effects -- part of a normal body response to the targeted therapy drug. In this case, they are not signs of a drug allergy. The skin changes that have been linked to targeted therapy cancer treatments will be reviewed here.

Why do targeted therapies cause skin changes?

Targeted therapies help stop cancers from growing, but they also cause skin problems. These therapies target the epidermal growth factor receptor(EGFR) protein. EGFR has been found in larger than normal amounts on the surface of cancer cells from some types of tumors. EGFR tells the cancer cells to grow and divide. The problem is that normal skin cells also have a lot of EGFR. So drugs that target or block EGFR often affect skin cells by turning off the signal for them to grow normally and making it harder for them to retain moisture.

Some of the newer drugs target other proteins, such as vascular endothelial growth factor receptor (VEGFR) and platelet-derived growth factor receptor(PDGFR). These proteins help tumors build and keep a blood supply, but they also seem to be important to the very small blood vessels in the hands and feet. Damage to these tiny blood vessels can cause hand-foot syndrome (described in the next section).

What kind of skin changes can targeted therapies cause?

Rash

The most common skin change is a rash. The risk of getting the rash and how bad it is depends on the type of cancer and the type and dose of the targeted therapy drug used to treat it.

The rash is mild for most people. It often looks a lot like acne and shows up on the scalp, face, neck, chest, and upper back. In severe cases it can affect other parts of the body.

The rash most often starts as skin redness and swelling and is often worst within the first few weeks of treatment. By about the 4th week of treatment, the skin usually crusts and gets very dry and red. In the weeks after that, round, flat or raised red spots and pimples with pus in the center often appear. The rash can be itchy. It may get better or stay about the same during the rest of treatment, but it should completely go away about a month after treatment is stopped.

The rash can be very distressing and cause self-esteem problems. It may be painful and may lead to infections. Prevention and treatment are discussed in the next 2 sections.

Dry skin

The skin can become very dry and scaly and may even crack open. This can happen on its own or with the rash. When it happens with the rash it tends to be worse.

Itching

Many of the skin changes, like rash or dryness, can cause itching. Steps to prevent and treat skin changes, as discussed below, can help with itching. Some people may need to take medicine by mouth, such as diphenhydramine (Benadryl ®), to get relief.

Red, sore cuticles (the areas around the fingernails)

Some targeted therapies may cause swollen, red, open, and painful skin sores around the fingernails and toenails. (This can look a lot like an ingrown nail.) This most often happens to the big toes and thumbs. These sores may become infected. Nails may also become brittle and grow more slowly.

Hand-foot syndrome

Hand-foot syndrome (HFS) has been linked to many cancer treatment drugs, including some targeted therapies. The cause of this syndrome is not known for sure. It may have to do with damage to the tiny blood vessels in the hands and feet, or with the drugs themselves leaking out of the blood vessels and causing tissue damage.

A painful sensitivity of the hands and feet is the earliest symptom of HFS. Then, redness and swelling start in the palms of the hands and the soles of the feet. This redness looks a lot like sunburn and may blister. In severe cases, the blisters can open up and become sores. The affected skin also can become dry, peel, and crack. It may burn, tingle, or feel numb.

HFS can be painful and can affect your ability to walk and carry out normal activities. If it becomes severe, pain medicines may be needed. It is important to let your doctor know if you are having any symptoms of HFS -- even if they are mild. Treating HFS early can help prevent severe cases. Like the other skin changes discussed, it can be treated, and there are things you can do to try to prevent it. These are reviewed in the next section.

Changes in hair growth

Hair on your head can become thin, dry and brittle, or even curly. Long-term use of targeted therapy may lead to complete loss of scalp hair.

Facial hair for both men and women may grow faster than usual, including longer, thicker, curly eyelashes that may need to be trimmed. These changes usually do not happen right away, but you may notice them later as treatment goes on.

Changes in hair or skin color

Some of the newer drugs can cause the skin or hair to turn a yellowish color during treatment. This typically goes away once treatment is finished.

Other side effects

Many other less common side effects have also been linked to treatment with targeted therapies. These include the following:

  • diarrhea
  • nausea and vomiting
  • constipation
  • mouth sores
  • shortness of breath
  • cough
  • feeling tired all the time (fatigue)
  • headache
  • swelling in your hands and feet
  • high blood pressure

Your health care team will watch you closely during treatment and will check your blood counts often. Side effects can and should be treated as early as possible. It is important that you tell your health care team about any changes in how you feel or anything you notice that is new or unusual. Tell them right away so they can treat any problems and try to keep them from getting worse.

Can skin changes be prevented?

There are some things you can do to help prevent skin changes or at least to try to keep them under control. You should start to do them as soon as targeted therapy treatment begins - before any problems start. Your doctor may ask you to do the following:

  • Use a mild soap or body wash and shampoo that do not contain alcohol, perfume, or dye.
  • Take baths instead of showers, and try oatmeal bath products to soothe your skin.
  • Bathe with cool or lukewarm (instead of hot) water.
  • Moisturize your skin 2 times a day with a thick cream that contains no alcohol, perfume, or dye. Right after you bathe, while your skin is still damp, is the best time to do this.
  • Do not use laundry detergents with strong perfumes.
  • Stay out of the sun as much as possible.
  • If you will be outside, use a sunscreen with SPF of at least 30 and zinc oxide or titanium dioxide at least 1 to 2 hours before going out. Wear cotton clothing and a hat, too.
  • Though the rash may look like acne, do not use acne treatment medicines on it -- they can dry it out and make it worse.
  • Do not wear tight shoes.
  • Gel shoe inserts may help if soles of your feet are tender.
  • Some makeup brands, such as Dermablend ®, can cover the rash without making it worse.

Ask your doctor or nurse if there are other things you can do to help lower the chance of skin problems getting worse.

What should I do if I have skin changes?

It is very important to tell your doctor or nurse about any rashes or skin changes you notice. Left untreated, the rash can get worse and lead to infection, as well as the need to delay or even stop treatment. Do not treat your skin with over-the-counter medicines or stop taking your targeted therapy without talking to your doctor first.

Your doctor may give you a skin cream or a medicine you take by mouth to treat the skin changes you have. Use theses medicines the way the doctor tells you to and start them right away. Let your health care team know if your skin is not getting better after 2 weeks of treatment.

Be sure to let your doctor or nurse know if:

  • you notice any signs of a rash. There are creams you can use to try to keep it from getting worse.
  • your skin is dry, flaking, or cracked. Moisturizing cream may help with this.
  • your skin is itchy. There are creams and gels you can use to ease itchiness. There are also some medicines you can take by mouth to try to stop the itching.
  • the area around your fingernails or toenails becomes sore or red. Creams and soaks can help with this. But your health care team needs to watch to be sure you don't get an infection.

Can skin changes be treated?

Mild changes

Patients with mild skin changes may not need any treatment. These changes include rashes that are only in a limited area, not causing any distress, and not infected. The doctor may prescribe a mild corticosteroid cream (such as hydrocortisone) or antibiotic gel (such as clindamycin) to apply to the area.

The dose of the targeted therapy drug is usually not changed, and the patient is closely watched to see if the rash gets better or worse.

Moderate changes

These include a rash over a larger area of the body or skin changes causing mild distress from itching or soreness, but with no signs of infection. Skin treatment may be hydrocortisone cream, clindamycin gel, or pimecrolimus (Elidel ®) cream. The doctor may also prescribe an antibiotic such as doxycycline or minocycline to be taken by mouth.

The dose of the targeted therapy drug is usually not changed, and the patient is closely watched to see if the rash gets better.

Severe changes

These are bad rashes that cover a lot of skin, cause itching and soreness that affect the patient's quality of life (such as sleep problems or pain), and are likely to get infected. Treatment is much like that used for moderate changes, including a topical cream or gel (hydrocortisone cream, clindamycin gel, or pimecrolimus cream), as well as an antibiotic such as doxycycline or minocycline that is taken by mouth. Along with this, a course of an oral corticosteroid, such as methylprednisolone (Medrol ®) or prednisone, is often given.

The targeted therapy drug dose is often reduced for these skin changes. If the rash does not get better in 2 weeks, the targeted drug is often stopped until the skin changes improve. It may then be re-started with ongoing skin care.

A note about steroid skin creams and gels

Topical steroids (those that are spread on the skin in the form or creams, ointments, or gels) can be helpful for many skin problems. They can be used for up to 7 days after the problem has gone away. But it is important to know that long-term use of steroid creams can cause skin problems, and can make you more likely to get a skin infection. For this reason, steroid creams should not be used more than 14 days in a row. Many doctors suggest that patients who are given steroids to put on their skin use it in a cycle. For instance, you might use it every day for 14 days, and then stop using it for a 7 day break. This cycle can be repeated as long as you have skin problems, or until your doctor tells you to stop.

Skin rash as a sign that treatment is working

There is some thought that the skin rash may be a sign that the targeted therapy is working (the worse the rash, the better the treatment is working). But long-term follow-up is needed to link the rash to outcomes. People with no rash or with only a mild rash should not assume that the treatment is not working. The 2 most important things you can do is take good care of your skin when you start targeted therapy and let your doctor know right away about any skin changes you may have.