Skin care during chemotherapy

Learn some tips on skin care during chemotherapy focused on addressing the most common skin side effects.

Cancer treatment is a medical and research challenge. The chemotherapy Traditionally, it works by inhibiting phases of the cell cycle of cancer cells, but it can also affect healthy cells. The skin is one of the organs most affected, with the possible appearance of dermatitis, rashes, canker sores, spots, nail alterations and other injuries.

Conventional or traditional chemotherapy continues to be used to control tumors. Advances in cancer treatment and patient survival make it necessary for clinicians to know how to manage chemotherapy reactions on the skin and advise patients. In the following text I present some guidelines for managing side effects and skin care during chemotherapy.

Skin Side Effects of Chemotherapy

The classification of cutaneous side effects of chemotherapy is standardized by the National Cancer Institute's Common Terminology Critherapy for Adverse Events (CTCAE) (1) in a common tool for all side effects of chemotherapy and that allows unifying the evaluation of performed by oncologists, dermatologists, nurses and other clinicians (available clicking here and summarized in Table I). These effects they do not always occur, this is a classification of all possible skin conditions when a patient is treated with chemotherapy (2).

The majority of chemotherapy reactions on the skin are managed in oncology services, who are aware of its effects and with nursing professionals specialized in them. Only occasionally they notify the dermatologist, when the skin lesions cause diagnostic doubts or when they are more severe or do not respond to the usual treatments. In the following text I will explain the most frequent effects and general advice for their management (3). Alopecia due to chemotherapy would be its own content due to its entity, so in this text I will only address the effects on the skin.

Dermatologists study these effects and skin care during chemotherapy, since the priority in these patients is the response of the tumor to the treatments received, which means that sometimes, we are “companions” during the process.

Side effects and skin care during chemotherapy

1. Dry skin or cutaneous xerosis

It is one of the most common side effects of chemotherapy on the skin. The creams that I usually recommend to alleviate it are emollients and fats, with soothing and anti-inflammatory substances (calamine, vitamin PP, oats, omegas, etc.). The prototype of creams would be those used for children with atopic dermatitis, although there are specific lines on the market studied for oncology patients.

Some moisturizing creams contain keratolytic agents, which are added to also treat peeling. Above all, urea is used in concentrations from 3 to 30%, and lactic acid, salicylic acid and even glycolic acid can also be used. I recommend trying them first in low concentrations, as they are especially useful on dry skin with slight peeling, but at high concentrations they can cause irritation and itching on sensitive skin.

It is also important to use anti-aging facial care with caution, since very common substances in these products can irritate, such as retinoic acid or retinol, glycolic acid and other alpha and beta-hydroxy acids. Perhaps the most appropriate thing is to use “anti-aging” substances such as vitamin C, vitamin B3 or B5, melatonin, hyaluronic acid, resveratrol or coenzyme Q10 for the face, which have a low potential to irritate.

Regarding washing the skin, you can opt for shower oils or “soapless soaps” or “syndet” that moisturize the skin during the shower.

2. Pruritus or itchy skin

Itchy skin during chemotherapy can be due to several causes, including the drugs it contains. I emphasize that in this case we are talking about itching without lesions on the skin, when itching appears on the skin with lesions the treatment is that of the lesions. The approach, in my opinion, is to achieve skin that is as comfortable and hydrated as possible, with the measures in the previous point.

In addition, you can use hydrating or soothing baths, effective at night, when the skin tends to itch the most, to facilitate a night's rest, and oral antihistamines. Antihistamines are simple treatments that serve to relieve itching, and if they are sedative, facilitate sleep. There are more powerful oral treatments (in pills) and also anti-itch creams and you can even apply corticosteroid creams to the most itchy areas.

3. Dermatitis and eczema

Intense dryness of the skin and other added factors, such as chemotherapy or some irritant, can produce true inflammation of the skin, in the form of dermatitis and eczema. Management is with emollients or moisturizing creams that do not sting; it may be necessary to use pure Vaseline for a few days to avoid stinging. Corticosteroids in cream are added twice a day, which are effective in controlling dermatitis. In severe or extensive cases, oral corticosteroids and oral antihistamines can be added to control itching.

The measures on skin care during chemotherapy in points 1 and 2 are applicable in patients with dermatitis as well.

4. Thrush or mucositis

The appearance of thrush or mucositis during chemotherapy cycles has a significant impact, since it causes a lot of discomfort and makes eating difficult, in these patients where maintaining general condition is important (5). The term mucositis refers to inflammation of the mucous membranes, the most frequently affected is the oral mucosa, and it can also occur in the genitals.

Mucositis subsides in a few days and in the meantime, it can be treated with mouthwashes with anti-inflammatories (tetracyclines, corticosteroids) and anesthetics. Its management consists of relieving the patient. Anesthetics in the mouth can also be applied before eating, to avoid pain and facilitate feeding. There are also mouthwashes that moisturize the mucosa, and hyaluronic acid gels and other components to apply directly to canker sores. They act by protecting the skin and promoting healing. The patient must be monitored and if it is more intense or does not resolve with treatment, it could be a fungal superinfection or, more rarely, a herpes virus.

There is clearly no way to prevent this adverse effect, keeping the mucosa hydrated and vitamin supplements, especially A, important for the mucosa, could be used.

5. Alterations in the nails

Fragmentation, lines and striations (onycholysis) may appear in the nails during chemotherapy. It has been described with chemotherapy drugs such as taxanes, cyclophosphamide, doxorubicin, capecitabine, etoposide and 5-fluorouracil (2,3,5). For its management, it is advisable to avoid irritants to the nails, such as frequent contact with water and trauma. To carry out household chores, you can use plastic gloves with cotton gloves underneath (they are special and are found in pharmacies).

Manicures should be avoided and nails should be kept short. Moisturizing the nails and the periungual area benefits the nails, and you can use general moisturizing creams or specific nail care creams, also in the form of specific polishes (not coloring nail lacquer polishes). This side effect can be prevented by using cold gloves during the chemotherapy infusion, which produce vasoconstriction and reduce the arrival of the chemotherapy to the nail matrix.

Sometimes what occurs is a darkening of the nail (hyperpigmentation), as occurs with 5-Fluorouracil, taxanes, cyclophosphamide, doxorubicin and capecitabine (1,2). This pigmentation can appear in bands or diffusely on the nail plate. This is a side effect that does not require treatment and does not cause discomfort. It persists months after finishing chemotherapy and disappears with the progressive growth of the nail.

Rarely, the alterations produced by chemotherapy in the nails predispose to infection of the nail itself or the surrounding area (perionyxis). In this case, management by a dermatologist may be required and sometimes a culture may be performed to identify the infectious agent and be able to treat it.

6. Hyperpigmentation or appearance of spots on the skin

The appearance of spots on the skin and mucous membranes secondary to chemotherapy has a very varied clinical expression. It may be diffuse, with a tanned appearance, mottled, flagellated (lashed), serpentine, only in areas of flexion, or on the palms and soles (2,3).

It does not require treatment and subsides only months after finishing treatment. As general measures, within skin care during chemotherapy, sun protection is indicated in these patients and anti-blemish cosmetics can be used to treat and prevent their appearance. Hypothetically, pigment lasers could also be useful, and there is little about this use, remember that it is to treat an asymptomatic dermatosis that resolves on its own.

7. Photosensitivity

This is an exaggerated reaction to ultraviolet light from the sun and has been infrequently described with 5-Fluorouracil, Tegafur or Capecitabine (3). Erythema (redness) and intense inflammation occur in the area exposed to the sun. By default and to also avoid hyperpigmentation (spots), patients undergoing chemotherapy are protected from the sun and are encouraged to use sunscreen.

The recommended sunscreens are a factor 30 or higher, and use them before sun exposure. Let us remember that the sun protection index (SPF) measures only protection against ultraviolet radiation, which is responsible for phototoxic reactions. If we also want to protect ourselves from spots (hyperpigmentation), we must choose a filter that includes UVA protection, and if it also includes visible light, we protect ourselves from all light options that can darken the skin.

9. Palmar-plantar erythrodysesthesia

Also called hand-foot syndrome or acral erythema (4). It has been described with Capecitabine, doxorubicin, cytarabine, 5-fluorouracil and taxols (2,3,5). It consists of the appearance of a tingling sensation that can progress to burning in the palms and soles. Sensitivity to temperature and pain may be decreased and is accompanied by redness and swelling of the hands, and sometimes peeling. Erythrodysesthesia affects the palms more frequently than the soles and its severity varies.

To prevent the appearance of erythrodysesthesia, the way chemotherapy is administered is controlled by oncologists, and urea creams, non-steroidal anti-inflammatory drugs (NSAIDs) and hand cooling can be used during the chemotherapy infusion.

When it appears, treatment with powerful corticosteroids, local cold water compresses, and anti-inflammatories can be used. Other options are oral or topical calcium antagonists, anti-inflammatory COX-2 inhibitors, oral pyridoxine or topical heparin (2-4).

10. Maculopapular rash

This is a generalized rash from the treatment. It is common to any drug, and is treated according to its severity. Emollient creams, oral corticosteroid creams and oral antihistamines can be used for itching. In general, they are temporary and do not require discontinuation of treatment.

As part of skin care during chemotherapy, you can try to prevent these reactions by administering premedication before receiving the chemotherapy cycle, which includes antihistamines and oral corticosteroids (3).

To end and again, I would like to emphasize that this text is a transversal approach to all the possible effects of chemotherapy treatments and that They do not all occur at the same time with the same treatment. Prevention and treatment of chemotherapy side effects is essential in patients to avoid avoidable changes in administration protocols.

*On the other hand, if you are receiving radiotherapy, I recommend reading this article.

I hope it is useful to you.

References

1. https://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm

2. Cury-Martins J, Eris APM, Abdalla CMZ, Silva GB, Moura VPT, Sanches JA. Management of dermatologic adverse events from cancer therapies: recommendations of an expert panel. An Bras Dermatol. 2020; 95:221-237.

3. Reyes-Habito CM, Roh EK. Cutaneous reactions to chemotherapeutic drugs and targeted therapies for cancer: part I. Conventional chemotherapeutic drugs. J Am Acad Dermatol. 2014;71: 203. e1-203.e12; perhaps 215-6.

4. Miller KK, Gorcey L, McLellan BN. Chemotherapy-induced hand-foot syndrome and nail changes: a review of clinical presentation, etiology, pathogenesis, and management. J Am Acad Dermatol. 2014; 71:787-94.

5. Balagula Y, Rosen ST, Lacouture ME. The emergence of supportive oncodermatology: the study of dermatologic adverse events to cancer therapies. J Am Acad Dermatol. 2011 Sep; 65:624-635.