New York – As breast cancer treatment has evolved, so have treatment teams, many of which now include doctors in several specialties who work together to provide patients with integrated care. Dermatologists are vital to these teams because they help minimize the need to delay or stop treatment based on their understanding and management of skin-related complications of cancer treatments.
"Dermatologists can work alongside the rest of the team, to improve the quality of life of a patient throughout their treatment by managing a variety of skin concerns, including rashes, skin changes, hair loss," and monitoring patients for skin cancer, said Angela J. Lamb, MD, associate professor of dermatology at the Icahn School of Medicine at Mount Sinai Hospital, New York.
Although more studies are needed to provide quantitative data on the impact that dermatologists have on cancer patients' well-being, Lamb presented strategies that dermatologists can use to manage cutaneous side effects of radiotherapy and targeted therapies at the 2023 annual Mount Sinai Winter Symposium on Advances in Medical and Surgical Dermatology.
Between 70%-100% of women who receive radiation therapy for breast cancer will experience acute skin toxicity. As such, Lamb suggested that dermatologists help prepare both patients and clinicians involved with the care of patients with breast cancer with information about radiation dosage, associated side effects, and the management of several cutaneous side effects of radiotherapy:
- 0-2 Gy: No need to inform patient because there should be no visible effects.
- 2-5 Gy: Advise patients that erythema may be observed but should fade with time.
- 5-10 Gy: Advise patients to perform self-examinations or ask a partner to examine them for skin effects (erythema, itching) from about 2 to 10 weeks after completing treatment.
- 10-15 Gy: Medical follow-up is appropriate; skin effects may be prolonged, and pain and necrosis may occur.
- > 15 Gy: Medical follow-up is essential; radiation-induced wounds may progress to ulceration and necrosis.
Desquamation: Dry desquamation requires treatment with a low- to mid-potency topical steroid to decrease progression and severity of itching, burning, and irritation; use of hydrophilic moisturizers is also encouraged. When moist desquamation occurs, Lamb recommend the application of a protective dressing, with or without mupirocin, but added that infection can be managed with mupirocin.
Ulcers and erosions:
- Hydrophilic or lipophilic barrier creams with or without hydrogel or hydrocolloid dressings
- Careful and selective debridement, eschar removal for infected or at-risk wounds, antibacterial agents as needed, and silver-based dressings
- Surgical intervention for nonhealing ulcers with skin flaps (less commonly with staged skin-muscle or axial-pedicle flaps or artificial or bioengineered skin)
- Supportive measures, which includes physical therapy, massage, and pain management
Fibrosis: Treatment with superoxide dismutase, interferon gamma, hyperbaric oxygen therapy, laser therapy with epidermal grafting, pentoxifylline with or without tocopherol, as well as physical therapy and massage are recommended.
Telangiectasias: These can be treated with pulsed dye laser.
In addition to managing skin injury and reactions from radiotherapy, newer breast cancer therapies that inhibit EFGR gene expression often cause papulopustular eruption (PE). A dermatologist's expertise is crucial in monitoring for and treating PE because this is often associated with efficacious EFGR blockade and can be confused with skin conditions unrelated to cancer treatment, Lamb said.
She noted that PE resulting from EFGR inhibitor therapy generally occurs in areas with sebaceous glands like the scalp, shoulders, and neck, with an onset 7-10 days after treatment and maximum severity reached around 2 weeks after onset.
When this occurs, Lamb recommends treatment with topical minocycline-doxycycline, tretinoin, topical clindamycin or metronidazole, and steroids for severe disease. Furthermore, if needed, histology can confirm PE, which does not include involvement of the sebaceous glands but appears as suppurative folliculitis, T cells present around the follicular infundibulum, and follicular destruction. Successful identification and management of PE makes it less likely that patients will have to interrupt cancer therapy or need a biopsy in the middle of treatment, resulting in better outcomes, Lamb said.
Nicholas Gulati, MD, PhD associate professor of dermatology at the Icahn School of Medicine at Mount Sinai Hospital, New York, when asked about the clinical takeaways of Lamb's presentation at the meeting, commented, "there is a wide array of skin, hair, and nail issues that commonly arise in breast cancer patients as they receive various therapies. These dermatologic concerns can often be treated in ways that are quite safe and will help patients comfortably stay on their life-saving cancer therapies."
Therefore, he added, "it is important for dermatologists and oncologists to be in close contact as breast cancer patients undergo their treatment journeys."
No relevant disclosures were reported.
Myles Starr in a medical journalist based in New York City.
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