This document summarizes various cutaneous (skin) toxicities that can result from cancer therapies such as chemotherapy, radiation therapy, and targeted therapies. It discusses side effects including alopecia (hair loss), hyperpigmentation, hand-foot syndrome, radiation sensitivity and recall effects, hypersensitivity reactions, nail dystrophies, and extravasation injuries. Prevention and treatment strategies are provided for many of these side effects. The conclusion emphasizes the importance of recognizing both the physical and psychological impacts of cutaneous toxicities from cancer treatment.

5. Grading of alopecia Grade Minimal loss, grade 1 < 25%; obvious to the patient but not necessarily to others Moderate loss, grade 2 25 to 50 %; obvious thinning of scalp hair but not enough to lead to the use of a wig or alternate head covering Severe loss, grade 3 > 50% of hair lost; generally indicates the need for a wig or alternate head covering in those for whom alopecia is a major concern

13. Drugs causing hyperpigmentation Alley E. Green R, Schuchter. Cutaneous toxicities of cancer therapy. Curr Opin Oncol. 2002 Mar;14(2):212-6

15. Hand foot syndrome Acral erythema from docetaxel

17. Hand foot syndrome Grading Cancer Therapy Evaluation Program Common Toxicity Criteria for Adverse Events, version 3.0, June 2003 Scheithaur, W, Blum, J. Coming to grips with and-foot syndrome: Insights from clinical trials evaluating capecitabine. Oncology 2004; 18:1161 Grade Signs and symptoms 1 Minimal skin changes or dermatitis (eg, erythema) without pain 2 Skin changes (eg, peeling, blisters, bleeding, edema) or pain, not interfering with function 3 Skin changes with pain, interfering with function

21. Radiation sensitization and recall Alley E. Green R, Schuchter. Cutaneous toxicities of cancer therapy. Curr Opin Oncol. 2002 Mar;14(2):212-6

23. Drugs causing hypersensitivity Alley E. Green R, Schuchter. Cutaneous toxicities of cancer therapy. Curr Opin Oncol. 2002 Mar;14(2):212-6

26. Grading of nail changes Common terminology Criteria for Adverse events v 3.0 Nail changes with docetaxel Grade Nail changes/toxicity 1 Discoloration, ridging (koilonychias), pitting 2 Partial or complete loss of nail(s), pain in nailbed(s) 3 Interfering with ADL

29. Vesicants and irritants Alley E. Green R, Schuchter. Cutaneous toxicities of cancer therapy. Curr Opin Oncol. 2002 Mar;14(2):212-6

35. Cetuximab skin toxicity Moderate rosacea-like eruption from cetuximab 80 year old patient receiving cetuximab and radiation for nasopharyngeal cancer

36. Segaert S, Taberno J, Chosidow O et al. The management of skin reactions in cancer patients receiving epidermal growth factor receptor targeted therapies. J Dtsch Dermatol Ges. 2005 Aug;3(8):599-606

37. Erlotinib rash treatment Viale PH. Chemotherapy and cutaneous toxicities: implications for oncology nurses. Semin Oncol Nurs 2006 Aug;22(3):144-51. Review. Severity of Rash Treatment Protocol Mild Topical clindamycin 2%, with hydrocortisone 1% in lotion base applied twice-daily. Moderate Topical clindamycin 2%, with hydrocortisone 1% in lotion base applied twice-daily AND oral minocycline 100mg twice-daily for a minimum of 4 weeks and continuing thereafter as required, until resolution of the rash by one severity grade. Scalp lesions will be treated with a topical lotion clindamycin 2%, triamcinolone acetonide 0.1% in equal parts of propylene glycol and water. Severe Stop erlotinib therapy for 1 week and restart at 100mg once-daily. Treatment of rash with topical clindamycin 2%, with hydrocortisone 1% in lotion base applied twice-daily AND oral minocycline 100mg twice-daily for a minimum of 4 weeks and continuing thereafter as required. Scalp lesions will be treated with a topical lotion clindamycin 2%, triamcinolone acetonide 0.1% in equal parts of propylene glycol and water until resolution.

38. Dose modification guidelines for cetuximab (Erbitux) based upon dermatologic toxicity Payne AS, Harris JE, Saverese DMF. Cutaneous complications of chemotherapy. www.uptodate.com. Last updated Oct 7, 2008 Severe acneiform rash Initial management Outcome Dose modification First occurrence Delay infusion 1 to 2 weeks Improvement Continue at 250 mg/m2 No improvement Discontinue cetuximab Second occurrence Delay infusion 1 to 2 weeks Improvement Reduce dose to 200 mg/m2 No improvement Discontinue cetuximab Third occurrence Delay infusion 1 to 2 weeks Improvement Reduce dose to 150 mg/m2 No improvement Discontinue cetuximab Fourth occurrence Discontinue cetuximab