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General management strategy for epidermal growth factor receptor inhibitor–associated papulopustular eruption
JAAD ONLINE: THERAPEUTIC
PEARL
General management strategy for epidermal growth factor receptor inhibitoreassociated papulopustular eruption Benjamin Farahnik, BA,a,b Bernice Kwong, MD,c and Jenny Murase, MDb,d Burlington, Vermont and San Francisco, Stanford, and Mountain View, California Key words: chemotherapy side effect; epidermal growth factor receptor inhibitor; management; papulopustular eruption; xerosis. Abbreviation used: EGFR:
epidermal growth factor receptor
THERAPEUTIC CHALLENGE Epidermal growth factor receptor (EGFR) inhibitoreassociated papulopustular eruption is the most common cutaneous complication during cancer therapy with EGFR inhibitors. Patients present with erythematous papules and pustules on the face, chest, and back approximately 1 to 2 weeks after initiation of therapy.1 A third of patients have significant associated pruritus and burning. The eruption, however, can be managed without need for chemotherapy dose reduction or cessation of therapy.
SOLUTION Patients should be advised of the potential for xerosis and photosensitivity from EGFR inhibition, which can potentiate skin eruptions. Liberal emollient use with petroleum jelly and strict photoprotection are critical. Cautious use of low- to mid- potency topical steroids is effective for the debilitating symptoms of pruritus and burning. Prophylactic therapy with systemic antibiotics such as minocycline and tetracycline is found to increase patient quality of life and should be considered on a case-by-case basis.2 Although eruptions begin sterile, significant skin crusting with secondary infection is common. Dermatologists should maintain a low threshold for obtaining bacterial or viral studies on lesions that appear atypical or severe and treat appropriately with culture-driven systemic antibiotics. Diluted bleach soaks consisting of 1 teaspoon of regular bleach in 1 gallon of water (or one-fourth of a cup in 1 bathtub of water) for 10 minutes daily is advised, followed by emollients immediately after bathing. REFERENCES 1. Lacouture ME, Anadkat MJ, Bensadoun RJ, et al. Clinical practice guidelines for the prevention and treatment of EGFR inhibitor-associated dermatologic toxicities. Support Care Cancer. 2011;19(8):1079-1095. 2. Lacouture ME, Mitchell EP, Piperdi B, et al. Skin toxicity evaluation protocol with panitumumab (STEPP), a phase II, open-label, randomized trial evaluating the impact of a pre-Emptive Skin treatment regimen on skin toxicities and quality of life in patients with metastatic colorectal cancer. J Clin Oncol. 2010;28(8):1351-1357.
From the University of Vermont College of Medicinea; University of California San Francisco, Department of Dermatologyb; the Department of Dermatology, Stanford University School of Medicinec; and the Department of Dermatology, Palo Alto Foundation Medical Group.d Funding sources: None. Conflicts of interest: None declared. Correspondence to: Benjamin Farahnik, BA, Department of Dermatology, University of California, San Francisco, 515
Spruce St, San Francisco, CA 94118. E-mail: benjamin. [email protected]. J Am Acad Dermatol 2016;75:e191. 0190-9622/$36.00 ª 2016 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2016.07.036
e191
PEARL
General management strategy for epidermal growth factor receptor inhibitoreassociated papulopustular eruption Benjamin Farahnik, BA,a,b Bernice Kwong, MD,c and Jenny Murase, MDb,d Burlington, Vermont and San Francisco, Stanford, and Mountain View, California Key words: chemotherapy side effect; epidermal growth factor receptor inhibitor; management; papulopustular eruption; xerosis. Abbreviation used: EGFR:
epidermal growth factor receptor
THERAPEUTIC CHALLENGE Epidermal growth factor receptor (EGFR) inhibitoreassociated papulopustular eruption is the most common cutaneous complication during cancer therapy with EGFR inhibitors. Patients present with erythematous papules and pustules on the face, chest, and back approximately 1 to 2 weeks after initiation of therapy.1 A third of patients have significant associated pruritus and burning. The eruption, however, can be managed without need for chemotherapy dose reduction or cessation of therapy.
SOLUTION Patients should be advised of the potential for xerosis and photosensitivity from EGFR inhibition, which can potentiate skin eruptions. Liberal emollient use with petroleum jelly and strict photoprotection are critical. Cautious use of low- to mid- potency topical steroids is effective for the debilitating symptoms of pruritus and burning. Prophylactic therapy with systemic antibiotics such as minocycline and tetracycline is found to increase patient quality of life and should be considered on a case-by-case basis.2 Although eruptions begin sterile, significant skin crusting with secondary infection is common. Dermatologists should maintain a low threshold for obtaining bacterial or viral studies on lesions that appear atypical or severe and treat appropriately with culture-driven systemic antibiotics. Diluted bleach soaks consisting of 1 teaspoon of regular bleach in 1 gallon of water (or one-fourth of a cup in 1 bathtub of water) for 10 minutes daily is advised, followed by emollients immediately after bathing. REFERENCES 1. Lacouture ME, Anadkat MJ, Bensadoun RJ, et al. Clinical practice guidelines for the prevention and treatment of EGFR inhibitor-associated dermatologic toxicities. Support Care Cancer. 2011;19(8):1079-1095. 2. Lacouture ME, Mitchell EP, Piperdi B, et al. Skin toxicity evaluation protocol with panitumumab (STEPP), a phase II, open-label, randomized trial evaluating the impact of a pre-Emptive Skin treatment regimen on skin toxicities and quality of life in patients with metastatic colorectal cancer. J Clin Oncol. 2010;28(8):1351-1357.
From the University of Vermont College of Medicinea; University of California San Francisco, Department of Dermatologyb; the Department of Dermatology, Stanford University School of Medicinec; and the Department of Dermatology, Palo Alto Foundation Medical Group.d Funding sources: None. Conflicts of interest: None declared. Correspondence to: Benjamin Farahnik, BA, Department of Dermatology, University of California, San Francisco, 515
Spruce St, San Francisco, CA 94118. E-mail: benjamin. [email protected]. J Am Acad Dermatol 2016;75:e191. 0190-9622/$36.00 ª 2016 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2016.07.036
e191