Chapter 44 • Etiology: Cytotoxic chemotherapy agents target hair follicles that are in the proliferative growing (anagen) phase, causing an “androgen effluvium.” Less common mechanisms include telogen effluvium. • Incidence: Chemotherapy-induced alopecia (CIA) is common. The incidence differs based on the agent, dose, and frequency of administration. • Manifestations: Increased hair shedding and hair fragility occur, with a diffuse or patching alopecia that is noticeable when 25% to 40% of scalp hairs are shed. It may be associated with symptoms of pruritus or pain but is most commonly asymptomatic. • Complications: CIA can dramatically affect patients’ psychosocial health, resulting in significant reductions in quality of life (QoL). • Treatment: Most treatment recommendations are based on expert opinion, although a few randomized controlled trials (RCTs) exist. Reported preventive strategies include counseling and the use of scalp cooling, ammonium trichloro(dioxoethylene-O,O-) tellurite (AS101), or scalp tourniquets. For acceleration of hair regrowth, minoxidil, 2% twice daily, has been shown to be effective. • Prognosis: CIA is typically completely reversible, although up to 60% of patients report changes in the texture, thickness, or color of their new hair. • Etiology: Extravasation injury is divided into irritant versus vesicant reactions. Irritant agents cause inflammation and erythema, whereas vesicant reactions may cause full thickness skin necrosis. • Incidence: The incidence of irritant reactions is unknown. The incidence of intravenous vesicant reactions is thought to approach 6%. • Manifestations: Extravasation of chemotherapeutics can cause a range of unintended adverse effects, including skin inflammation or necrosis. The severity of tissue injury after unintended extravasation ranges from mild erythema to blisters and full-thickness skin necrosis (Figs. 44-1 and 44-2). • Complications: Pain can be significant, and rarely, compartment syndrome can result. • Treatment: The offending drug must be stopped immediately. The subsequent treatment differs based on the chemotherapeutic agent used. A treatment algorithm is presented in Box 44-1 and Table 44-4 based on RCTs and expert opinion. • Prognosis: Mortality is low, but the QoL impact and related morbidity is severe with vesicant chemotherapeutics. • Etiology: A variety of patterns of cutaneous hyperpigmentation have been described in association with many different cytotoxic agents. • Incidence: The overall incidence of hyperpigmentation is unknown. • Manifestations: Cutaneous hyperpigmentation can be generalized or localized and can occur in drug-specific patterns (Table 44-5, Fig. 44-3). Mucous membranes, hair, teeth, and nails can also be affected by changes in pigmentation produced by cancer chemotherapy. • Complications: Cutaneous hyperpigmentation may be cosmetically displeasing with reduced QoL. • Treatment: Limited data are available regarding treatment options. • Prognosis: Skin hyperpigmentation resolves slowly after discontinuation of therapy, and nail pigmentation grows out distally. • Etiology: Hand-foot syndrome (HFS) has numerous synonyms, including palmar-plantar erythrodysesthesia and acral erythema. It is caused by a variety of cytotoxic chemotherapeutic agents. • Incidence: The incidence differs based on the cytotoxic agent used, the dose, and the administration frequency. Overall, the incidence ranges from 3% to 89%. • Manifestations: The clinical manifestations can vary based on severity, ranging from asymptomatic mild erythema or peeling to extremely painful full-thickness epidermal sloughing with significant functional impairment (Fig. 44-4). • Complications: Reduced QoL due to pain and functional impairment is common. However, rare complications can include prolonged dysesthesias with loss of fingerprints, rare distal necrosis, or secondary infection. • Treatment: Drug interruption or dose modification is the most well-documented intervention. In general, wound care to prevent infection, elevation to reduce edema, and symptomatic treatment, including routine use of topical emollients, is recommended. Celecoxib has been shown to be effective in preventing HFS in patients receiving capecitabine. Other preventive treatments suggested to be helpful include regional cooling during infusions, nicotine patches, oral vitamin E, and systemic steroids. Therapies reported to be helpful to reduce symptoms include oral steroids, oral vitamin E, celecoxib, and topical 99% dimethylsulfoxide. • Prognosis: Severe acral pain, inflammation, and possible blister formation can cause considerable morbidity and poor patient compliance. However, it is typically completely reversible after drug discontinuation. Reaction severity is not thought to be related to the patient’s disease status.
Dermatologic Toxicities of Anticancer Therapy
Summary of Key Points
Chemotherapy-Induced Alopecia
Cutaneous Extravasation Injury
Chemotherapy-Induced Hyperpigmentation
Hand-Foot Syndrome
Dermatologic Toxicities of Anticancer Therapy
