Skin and nail toxicity

Skin rash pathway¹

(Reproduced with kind permission of UKONS¹)

Always make sure that the Acute oncology Team are informed of the patient's assessment and/or admission as soon as possible.

Immediate advice is available from the Acute Oncology Service or the 24-hour Oncology on call rota.

Withhold SACT, including oral therapy, until you have discussed with the Acute Oncology or Site Specific Team.

Skin toxicity: Palmar-plantar erythrodysesthesia pathway¹

(Reproduced with kind permission of UKONS¹)

Always make sure that the Acute oncology Team are informed of the patient's assessment and/or admission as soon as possible.

Immediate advice is available from the Acute Oncology Service or the 24-hour Oncology on call rota.

Withhold SACT, including oral therapy, until you have discussed with the Acute Oncology or Site Specific Team.

Immune-related skin toxicity 

Symptoms: rash, pruritus, vitiligo 

Others: alopecia areata, stomatitis, xerosis cutis, photosensitivity, exacerbation of psoriasis, psoriasiform or lichenoid skin reaction 

Recent evidence suggests severe reactions such as Steven Johnson Syndrome and Toxic Epidermal Necrolysis are more common than initially thought. Consider these early in assessment of skin toxicity.

Immune-related skin toxicity pathway¹

1. Abridged from: NHS Lothian Immunotherapy toxicity management guidelines v7.0. S Clive & C Barrie. Last reviewed: 22.11.2021.

Management of symptomatic toxicity from EGFR inhibitor therapy (monoclonal antibodies and TKIs) pathway

Management of paronychia

• Use dermol 500 lotion.   
• Soaks such as warm water or white vinegar diluted with water (ratio of 1 vinegar:10 water increasing as severity/grade increases to max of 1:1) for 15 minutes/day. 
• Consider topical steroid cream to nail beds: clobetasone butyrate 0.05%  
  (Eumovate®) increasing to betamethasone valerate 0.1% (potent steroid) as severity/grade increases. 
• Swab any areas that look infected.  
• If mild treat with appropriate topical antibiotics (fusidic acid 2% cream 3-4/day for Gram +ve or metronidazole gel 0.75% 1-2/day for anaerobes) 
• If more severe treat with oral / IV antibiotics as indicated, depending on severity of infection 
• If suspicion of fungal infection treat with clotrimazole 1% cream 2-3/day. 

Interrupt EGFRi therapy if intolerable grade 2 (oral antimicrobial use, nail fold oedema/pain, limitation in instrumental ADLs) or grade 3 (as grade 2 plus self-care ADL limitation, IV antibiotic use or surgical intervention)

Management of finger and heel fissures/hacks

• Ensure regular emollient use to fingers and heels 3-4x/day (e.g zerobase cream) 
• Wear gloves and socks at night to ensure maximum emollient absorption. 
• Consider topical skin creams that contain urea and lactic acid.  
• Consider steroid tape to bind fissures (if available) 
• Swab and treat infections as per paronychia above.

Interrupt EGFRi therapy if intolerable grade 2 (oral antimicrobial use, pain, limitation in instrumental ADLs) or grade 3 (as grade 2 plus self-care ADL limitation, IV antibiotic use or surgical intervention)

1. UKONS Oncology Nursing Society. Acute oncology initial management guidelines. v.4.0. Publication date: 13.02.2023. Available from: https://ukons.org/news-events/acute-oncology-initial-management-guidelines-latest-version/