This month’s Featured Article:

Skin Reactions to Cancer Medications

What you need to know

By Morag Currin

Caring for clients with cancer in both a medical and spa setting can be complicated due to one or more medical conditions. Whether related or unrelated to each other, the complex nature of cancer treatment protocols and the numerous drugs the client may be taking, including over-the-counter (OTC) drugs, prescription drugs and natural supplements must be taken into consideration with spa modalities. Multiple drug intake increases the clients’ risk of a skin reaction and these can manifest in many different ways.

Contraindications for biological therapies

When a client is undergoing any treatment where the immune system is being suppressed by steroids, the use of topical steroids is contraindicated as this could affect the anti-tumor effects of the biotherapy drugs.

Personalized treatments

A client’s medical history is imperative and should list all drugs currently being taken and whatever skin reactions have resulted from them. Each person may respond differently and a standard protocol for all is not effective. Each client needs to be assessed individually and the therapy must be personalized to their skin at the time of treatment. If necessary, the protocol has to be adjusted during the treatment to suit the client’s skin.

Common drug interactions

Other factors that play a role in the skin’s response to drugs and can cause an increased risk of a skin reaction during cancer treatments and recovery are the client’s age, gender, immune system, hereditary genes and the drug type.
Older clients who take more than two or more drugs simultaneously are at higher risk for skin reactions. Females have a one-and-a-half times more reactive response than men do. If a drug is applied to the skin topically, it will usually present with a reaction faster than if it was administered orally. There can be an increased rate of exanthematous reactions due to a compromised immune system.
Most people today take one or more drugs on a daily basis for some condition. So, as estheticians we need to understand what the most general skin reactions are from common drugs that clients could be taking, and we must understand these before trying to deal with the added side effects from cancer treatments.
Most drug-induced skin eruptions appear within the first week after medications are started. So attributing an eruption to a specific drug can often be straightforward if you pay attention to what medication is taken and when.
However, antibiotics, used to treat bacterial infections, and Allopurinol, used to treat high levels of uric acid in the body caused by certain cancer medications, are drugs that are an exception to the above rule. For these medications, rashes will usually occur up to two weeks after the initial intake of these medications.
Pinpointing which specific medication is the cause of the skin eruption is difficult if the client is on many different drugs at the same time.

Exanthematous rash

The most common rash from drugs is the exanthematous rash. It is typically symmetric, presents with erythematous macules and papules that are blended into one, and is usually found on the trunk, thighs, upper arms and face.
Skin reactions in the form of a rash are likely caused from several medications.
• Antibiotics: particularly the penicillin-related antibiotics. Some of the more commonly prescribed antibiotics, such as tetracycline, are used to treat skin bacterial infections such as acne, rosacea and some forms of dermatitis. Tetracyclines cause skin sensitivity, which results when the skin is exposed to sunlight.
• Barbiturates: some barbiturates are used as general anesthetics in surgery. Itching on the skin results from barbiturate use.
• Sulfonamides: also known as sulfa medications, these are used to treat many kinds of infections caused by bacteria and certain other microorganisms. Skin rash or reddish/purplish spots on the skin, or blistering and peeling on the skin can result from sulfonamides.
• Non-steroidal anti-inflammatory drugs (NSAIDS): are commonly prescribed medications for pain and inflammation in the body. Two examples of well-known NSAIDS are aspirin and ibuprofen (Motrin). Aspirin is used for fever, pain and headaches. Skin reactions from the use of aspirin are typically hives and swelling. Ibuprofen is used for mild to moderate pain from cancer, surgery or other causes, and is especially helpful in relieving bone pain related to cancer. For severe pain, it is more helpful when used along with other pain-relieving drugs and is also used to reduce fever and inflammation. Skin reactions resulting from ibuprofen are commonly rashes defined as scaly patches of skin not caused by infection; scaly patches of skin produced by fungal or bacterial infection; and red, itchy bumps or patches.

Other reactions

Certain medications can cause a photosensitivity when the photoallergen initiates a reaction in the presence of ultraviolet light on the skin.
Urticaria, commonly known as hives, usually occurs as small wheels that may blend together in a circular form. This skin reaction is likely to develop abruptly after exposure to the offending medication such as NSAIDS, antibiotics and pain medications. It resolves rapidly when medication is stopped. Hives can also occur with or without angioedema, edema of the face and lips.
There are many side effects to common medications that an esthetician needs to find out before working with issues regarding cancer therapy drugs. Clients with cancer are also susceptible to skin reactions from multiple medications. They may take medications to treat both therapy-induced toxicity and cancer-related symptoms such as pain, seizures, etc. The risk of skin reactions can be increased because of the process by which the medications are absorbed, distributed, metabolized and eliminated by the body. This change in the body can be caused due to mucositis and malnutrition.
Caring for cancer patients is complicated when the skin’s integrity is disrupted, leaving the body’s first line of defense against microorganisms compromised or infected. The following are a few cancer treatments that can compromise the skin’s condition.

Chemotherapy

Phototoxic reactions are common if the client is given a high enough dose of the drug and sufficient light exposure. These photosensitivity reactions are usually evident within 5 to 20 hours of exposure and resemble an exaggerated sunburn (redness, swelling, blistering, weeping and peeling). The rash is confined to areas exposed to light. Chemotherapy drugs associated with these photosensitivity reactions are dacarbazine, fluorouracil (5-FU), methotrexate and vinblastine.

Hormonal agents

Dermatitis, a local skin reaction at the injection site, pruritus and hyperpigmentation commonly result from the use of luteinizing hormone-releasing hormone (LHRH) antagonists such as leuprolide acetate and goserelin. These hormonal agents are used in the treatment of breast and prostate cancers.
Professionals should note that the skin rarely reacts to anti-estrogens or aromatase inhibitors.

Biological therapies

Biotherapy drugs are used to stimulate one’s immune system in the hopes of attacking the cancer cells. The vast “group” of drugs that are used in biological therapies help to strengthen the immune system overall, doing so in many ways that are “softer” (less toxic) than chemotherapy.
The following are classes of biological therapies.
Interleukin (IL)-2: Skin manifestations with IL-2 usually begin a few days after the start of therapy and may occur as flushing, pruritis and an erythematous rash. Sloughing of the skin can also occur. Manifestations may last 7 to 10 days after the last dose is administered and will subside once chemotherapy has been completed. IL-2 is used in the treatment of melanoma.
Interferon alfa: Skin manifestations with this drug may present as pruritis, rash, mild alopecia and increased eyelash growth. As with many side effects from chemotherapy, these effects are temporary and should reverse with the discontinuation of these drugs.

Targeted therapies

The human EGFR or hEGFR (human epidermal growth factor receptor) may cause problems on normal/follicular keratinocytes, basal layer of the epidermis, outer root of hairs’ follicles, etc.
Skin manifestations that present themselves from the EGFR inhibitor drug are papulopustular rashes, which are dose dependent. Found commonly in seborrheic areas, such as the face, neck, shoulders, upper trunk and scalp, this skin reaction is very different from comedones or lesions associated with acne vulgaris.

Allergic versus toxic reactions

Skin reactions to drug therapy are extremely common, and this applies to medications that treat cancer. These drugs may induce skin reactions, although if they do occur, they are usually mild. However, some skin reactions are serious and potentially life-threatening.
The cause of skin reactions is often unknown, although many have an allergic or toxic basis. Skin reactions can be independent of dose and can persist long after the drug causing the allergic reaction has been discontinued.
For example, a client with a hypersensitivity reaction to penicillin will experience a skin condition that may worsen for 7 to 10 days after the drug has been stopped. It is especially important that allergic skin reactions are correctly identified, since future exposure to the same drug could cause much more severe skin reactions. Toxic reactions, in contrast, are dose-dependent and skin reactions generally resolve fairly soon after the drug causing the reaction is stopped.

Morag Currin, LE, CMLT, is the founder and international director of Touch for Cancer, the only Clinical Oncology Esthetics (COE) certification currently available, which she established when she recognized the lack of specialized training and skin care available for people undergoing cancer therapies. She is the president of Touch for Cancer Online (www.touchforcanceronline.com). Currin has also developed TecNiche Therapies™ skin care and authored Oncology Esthetics: A Practitioner’s Guide.