Skin changes associated with Chemotherapy for Breast Cancer

October 3, 2021

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There are several ways that breast cancer can impact the skin.

Direct extension of the cancer to the skin
Spread of the cancer to the skin
Side effect of chemotherapy
Side effect of radiation
Stress induced changes to the skin, hair and nails

The first two ways I will cover in other posts as they are important to recognize for early detection and monitoring and the last two I will discuss in separate posts to focus on practical interventions.

Chemotherapy for breast cancer can impact the skin due to the fact that it tends to target cells that are actively dividing. Radiation has a direct impact on the skin treated simply because the skin is in the direct line of treatment. Redness, erythema, ulcers, pigmentation, soreness, scarring and potentially higher risk of skin cancer have been documented.

A study in Brazil reviewed the dermatological complaints during breast cancer treatment. It found that over 94% of breast cancer patients had dermatological complaints. Hair loss topped the list followed by nail changes, then thickening of the palms and soles. Other complaints included redness, ulcers, blisters, dryness, itching, hair growth, and changes in sweating.

This study was fascinating in that it found that 22% of patients actually had skin findings at the time of diagnosis! Mammary retraction, nipple inversion, p’eau d’orange skin changes and direct extension of cancer to skin were noted.

There have been a number of therapeutic agents that have come out for breast cancer of the past few decades. They can be grouped together by class with similar mechanism of action. These classes tend to have similar effects on the skin.

It is important to note that not every breast cancer treatment caused rash requires termination of treatment. Skin manifestations of treatment are exceedingly common and difficult to avoid altogether. Approaching these rash by discussion with your oncologist and consultation with a Dermatologist can help guide management to avoid unnecessarily discontinuing effective therapeutics.

Over the years I have been accumulating a list of medications used for breast cancer. As new ones come out I will continue to update this list. I also track the literature as case reports of specific skin reactions occur to help serve as a resource for these reactions. Accurate diagnosis leads to optimal management and the best chance of maintaining effective treatment for underlying carcinomas.

Hair loss, also known as alopecia, is one of the most common side effects noted with most treatments. I will discuss in another post the types of hair loss that can occur to help address them correctly.

Drug	Class / Mechanism of Action	Adverse effects related to skin, hair & nails
Abemaciclib	Cyclin-Dependent Kinase Inhibitor	Thinning of hair Itching Swelling of the face, arms, hands, lower legs, or feet Pale skin Sores, ulcers, or white spots on the lips or in the mouth Red spots on the skin Wrinkled skin
Abraxane (Paclitaxel Albumin-stabilized Nanoparticle Formulation)	Taxane	Hair loss Pigmentation changes of nails Rash (appears as a drug rash) Photosensitive reaction Radiation recall Scleroderma Palmar plantar erythrodysesthesia
Ado-Trastuzumab Emtansine	Monoclonal HER2 Antibody	Cutaneous and mucosal telangiectasias (report that these can be treated with propranolol) *Hair loss is not common*
Afinitor (Everolimus)	mTOR Kinase Inhibitor	Rash Swelling of arms, hands, feet, ankles, face Mouth ulcers and sores (managed with prescription mouth wash) Wound healing delays
Afinitor Disperz (Everolimus)	mTOR Kinase Inhibitor	Rash Swelling of arms, hands, feet, ankles, face Mouth ulcers and sores (managed with prescription mouth wash) Wound healing delays
Alpelisib	Phosphatidylinositol 3- Kinase Inhibitor	Rash in >50%- generalized macular or papular rash with itch (lessened severity if pretreat with antihistamine) ; low grade rashes only require topical steroids; if worsens consider oral steroids. Once rash resolves can resume therapy; if rash worsens can consider lower dose or discontinue by guidance of MD Hair loss Mouth sores
Anastrozole	Aromatase Inhibitor	Rash Itchy skin Hives Blistering of skin Vasculitis Erythema nodosum Subacute cutaneous lupus erythematosus Hair loss (Androgenetic alopecia) Can occur 5 days to 6 months after onset of therapy
Aredia (Pamidronate Disodium)	Inhibits bone resorption	Injection site reaction
Arimidex (Anastrozole)	Aromatase Inhibitor	Rash Itchy skin Hives Blistering of skin Vasculitis Erythema nodosum Subacute cutaneous lupus erythematosus Hair loss (Androgenetic alopecia) Can occur 5 days to 6 months after onset of therapy
Aromasin (Exemestane)	Aromatase Inhibitor	Rash Itchy skin Hives Blistering of skin Vasculitis Erythema nodosum Subacute cutaneous lupus erythematosus Hair loss (Androgenetic alopecia) Can occur 5 days to 6 months after onset of therapy
Capecitabine	Antimetabolite	Alopecia Erythema Rash Dry skin Photosensitive lichenoid reaction Palmoplantar Erythrodysesthesia
Cyclophosphamide	Alkylating agent	Alopecia Rash Pigmentation
Docetaxel	Taxane	Limb erythematous reactions Palmoplantar erythrodysesthesia Plaque-like erythrodysesthesia Erythema multiforme Nail changes Scleroderma Supravenous discoloration Radiation recall dermatitis Desquamation Flagellate erythema
Doxorubicin Hydrochloride	Anthracycline	Rash Palmar-plantar erythrodysesthesia Intertrigo-like dermatitis Diffuse follicular rash Melanotic macules Maculopapular rash Recall phenomenon
Ellence (Epirubicin Hydrochloride)	Anthracycline	Alopecia Eccrine squamous metaplasia Nail changes
Enhertu (Fam-Trastuzumab Deruxtecan-nxki)	Monoclonal HER2 Antibody	Cutaneous and mucosal telangiectasias (report that these can be treated with propranolol) *Hair loss is not common*
Epirubicin Hydrochloride	Anthracycline	Alopecia Eccrine squamous metaplasia Nail changes
Eribulin Mesylate	Microtubule inhibitor	Alopecia Radiation recall dermatitis Rash
Everolimus	mTOR Kinase Inhibitor	Rash Swelling of arms, hands, feet, ankles, face Mouth ulcers and sores (managed with prescription mouth wash) Wound healing delays
Exemestane	Aromatase Inhibitor	Rash Itchy skin Hives Blistering of skin Vasculitis Erythema nodosum Subacute cutaneous lupus erythematosus Hair loss (Androgenetic alopecia) Can occur 5 days to 6 months after onset of therapy
5-FU (Fluorouracil Injection)	Antimetabolite	Alopecia Inflammatory actinic keratoses Photosensitivty Skin discoloration
Fam-Trastuzumab Deruxtecan-nxki	Monoclonal HER2 Antibody	Cutaneous and mucosal telangiectasias (report that these can be treated with propranolol) *Hair loss is not common*
Fareston (Toremifene)	Selective estrogen receptor modulator (SERM)	Rash Hair loss
Faslodex (Fulvestrant)	Estrogen Receptor Antagonist	Hair Loss Toxic epidermal necrolysis Rash Oral mucositis
Femara (Letrozole)	Aromatase enzyme inhibitor	Hair Loss Increased sweating Mouth sores Leukocytoclastic vasculitis
Fluorouracil Injection	Antimetabolite	Alopecia Inflammatory actinic keratoses Photosensitivty Skin discoloration
Fulvestrant	Estrogen receptor antagonist	Hair Loss Toxic epidermal necrolysis Rash Oral mucositis
Gemcitabine Hydrochloride	Nucleoside	Rash (classic distribution along frontal and lateral sides of trunk but spares the upper and middle back) Itching Hair Loss Sweating Ulcerations Inflamed seborrheic keratoses Erysipeloid skin reaction Pseudofolliculitis Acute lipodermatosclerosis-like eruption Subacute cutaneous lupus erythematosus Skin necrosis
Gemzar (Gemcitabine Hydrochloride)	Nucleoside	Rash (classic distribution along frontal and lateral sides of trunk but spares the upper and middle back) Itching Hair Loss Sweating Ulcerations Inflamed seborrheic keratoses Erysipeloid skin reaction Pseudofolliculitis Acute lipodermatosclerosis-like eruption Subacute cutaneous lupus erythematosus Skin necrosis
Goserelin Acetate	LHRH agonist (hormonal therapy)	Hair loss Acne Hot flashes Vaginal dryness Breast swelling/tenderness Erythrodysesthesia in hands And feet
Halaven (Eribulin Mesylate)	Microtubule inhibitor	Alopecia Radiation recall dermatitis Rash
Herceptin Hylecta (Trastuzumab and Hyaluronidase-oysk)	Monoclonal HER2 Antibody	Cutaneous and mucosal telangiectasias (report that these can be treated with propranolol) *Hair loss is not common*
Herceptin (Trastuzumab)	Monoclonal HER2 Antibody	Cutaneous and mucosal telangiectasias (report that these can be treated with propranolol) *Hair loss is not common*
Ibrance (Palbociclib)	Kinase inhibitor (Cyclin-dependent kinase 4/6 inhibitor)	Alopecia Rash SJS- like eruption
Infugem (Gemcitabine Hydrochloride)	Nucleoside	Rash (classic distribution along frontal and lateral sides of trunk but spares the upper and middle back) Itching Hair Loss Sweating Ulcerations Inflamed seborrheic keratoses Erysipeloid skin reaction Pseudofolliculitis Acute lipodermatosclerosis-like eruption Subacute cutaneous lupus erythematosus Skin necrosis
Ixabepilone	Microtubule inhibitor	Hand-foot syndrome (palmoplantar erythrodysesthesia) Neutrophilic eccrine hidradenitis Radiation recall dermatitis Alopecia Hyperpigmentation Urticarial hypersensitivity reaction Sclerotic reactions
Ixempra (Ixabepilone)	Microtubule inhibitor	Hand-foot syndrome (palmoplantar erythrodysesthesia) Neutrophilic eccrine hidradenitis Radiation recall dermatitis Alopecia Hyperpigmentation Urticarial hypersensitivity reaction Sclerotic reactions
Kadcyla (Ado-Trastuzumab Emtansine)	Monoclonal HER2 Antibody	Cutaneous and mucosal telangiectasias (report that these can be treated with propranolol) *Hair loss is not common*
Keytruda (Pembrolizumab)	Monoclonal HER2 Antibody	Bullous pemphigoid Cutaneous and mucosal telangiectasias (report that these can be treated with propranolol) *Hair loss is not common*
Kisqali (Ribociclib)	Kinase Inhibitor	Alopecia Rare Stevens Johnson Syndrome
Lapatinib Ditosylate	Tyrosine Kinase Inhibitors (TKIs)	Rash (higher risk than with trastuzumab) Palmar-plantar erythrodysesthesia Itching Stomatitis
Letrozole	Aromatase Inhibitor	Rash Itchy skin Hives Blistering of skin Vasculitis Erythema nodosum Subacute cutaneous lupus erythematosus Hair loss (Androgenetic alopecia) Can occur 5 days to 6 months after onset of therapy
Lynparza (Olaparib)	PARP inhibitor	Hair loss Erythema nodosum Palmar-plantar erythrodysesthesia
Margenza (Margetuximab-cmkb)	Monoclonal HER2 Antibody	Cutaneous and mucosal telangiectasias (report that these can be treated with propranolol) *Hair loss is not common*
Margetuximab-cmkb	Monoclonal HER2 Antibody	Cutaneous and mucosal telangiectasias (report that these can be treated with propranolol) *Hair loss is not common*
Megestrol Acetate	Progestin	Rash Skin discoloration Thin skin Increase body hair
Methotrexate Sodium	Folate antagonist	Hair loss Cutaneous ulcers Leukocytoclastic vasculitis Epidermal necrosis Photosensitivity
Neratinib Maleate	Tyrosine Kinase Inhibitors (TKIs)	Acneiform rash Paronychia
Nerlynx (Neratinib Maleate)	Tyrosine Kinase Inhibitors (TKIs)	Acneiform rash Paronychia
Olaparib	PARP inhibitor	Erythema nodosum Palmar-plantar erythrodysesthesia Hair loss
Paclitaxel	Taxane	Hair loss Pigmentation changes of nails Rash (appears as a drug rash) Photosensitive reaction Radiation recall Scleroderma Palmar plantar erythrodysesthesia
Paclitaxel Albumin-stabilized Nanoparticle Formulation	Taxane	Hair loss Pigmentation changes of nails Rash (appears as a drug rash) Photosensitive reaction Radiation recall Scleroderma Palmar plantar erythrodysesthesia
Palbociclib	Kinase inhibitor (Cyclin-dependent kinase 4/6 inhibitor)	Alopecia Rash SJS- like eruption
Pamidronate Disodium	Inhibits bone resorption	Injection site reaction
Pembrolizumab	Monoclonal HER2 Antibody	Bullous pemphigoid Cutaneous and mucosal telangiectasias (report that these can be treated with propranolol) *Hair loss is not common*
Perjeta (Pertuzumab)	Monoclonal HER2 Antibody	Cutaneous and mucosal telangiectasias (report that these can be treated with propranolol) *Hair loss is not common*
Pertuzumab	Monoclonal HER2 Antibody	Cutaneous and mucosal telangiectasias (report that these can be treated with propranolol) *Hair loss is not common*
Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf	Monoclonal HER2 Antibody	Cutaneous and mucosal telangiectasias (report that these can be treated with propranolol) *Hair loss is not common*
Phesgo (Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf)	Monoclonal HER2 Antibody	Cutaneous and mucosal telangiectasias (report that these can be treated with propranolol) *Hair loss is not common*
Piqray (Alpelisib)	Phosphatidylinositol 3-kinase (PI3K) inhibitor	Rash in >50%- generalized macular or papular rash with itch (lessened severity if pretreat with antihistamine) Low grade rashes only require topical steroids; if worsens consider oral steroids. Once rash resolves can resume therapy; if rash worsens can consider lower dose or discontinue by guidance of MD Hair loss Mouth sores
Ribociclib	Kinase inhibitor selective cyclin-dependent	Alopecia Rare Stevens Johnson Syndrome
Sacituzumab Govitecan-hziy	PARP inhibitor	Hair Loss Rash
Soltamox (Tamoxifen Citrate)	Anti estrogen	Rash Steven Johnson syndrome Frontal fibrosing alopecia
Talazoparib Tosylate	PARP inhibitor	Stomatitis Rash
Talzenna (Talazoparib Tosylate)	PARP inhibitor	Stomatitis Rash
Tamoxifen Citrate	Anti estrogen	Rash Steven Johnson syndrome Frontal fibrosing alopecia
Taxotere (Docetaxel)	Taxane	Limb erythematous reactions Palmoplantar erythrodysesthesia Plaque-like erythrodysesthesia Erythema multiforme Nail changes Scleroderma Supravenous discoloration Radiation recall dermatitis Desquamation Flagellate erythema
Tecentriq (Atezolizumab)	PD-L1 monoclonal antibody	Rash (starts torso and spreads to extremities) Stevens Johnson Syndrome Bullous pemphigoid Psoriasis Lichenoid dermatitis Grover's disease TEN SJS
Tepadina (Thiotepa)	Nitrogen mustard type of alkylating agent	Hair loss Rash ( erythema starts intertriginous and spreads, then hyper pigmented) (Topical linked to depigmentation)
Thiotepa	Nitrogen mustard type of alkylating agent	Hair loss Rash ( erythema starts intertriginous and spreads, then hyper pigmented) (Topical linked to depigmentation)
Toremifene	Selective estrogen receptor modulator (SERM)	Rash Hair loss
Trastuzumab	Monoclonal HER2 Antibody	Dermatomyositis Cutaneous and mucosal telangiectasias (report that these can be treated with propranolol) *Hair loss is not common*
Trastuzumab and Hyaluronidase-oysk	Monoclonal HER2 Antibody	Dermatomyositis Cutaneous and mucosal telangiectasias (report that these can be treated with propranolol) *Hair loss is not common*
Trexall (Methotrexate Sodium)	Folate antagonist	Hair loss Cutaneous ulcers Leukocytoclastic vasculitis Epidermal necrosis Photosensitivity
Trodelvy (Sacituzumab Govitecan-hziy)	PARP inhibitor	Alopecia Rash
Tucatinib	Tyrosine Kinase Inhibitors (TKIs) of HER2	Palmar-plantar erythrodysesthesia syndrome Rash
Tukysa (Tucatinib)	Tyrosine Kinase Inhibitors (TKIs) of HER2	Palmar-plantar erythrodysesthesia syndrome Rash
Tykerb (Lapatinib Ditosylate)	Tyrosine Kinase Inhibitors (TKIs)	Rash (higher risk than with trastuzumab) Palmar-plantar erythrodysesthesia Itching Stomatitis
Verzenio (Abemaciclib)	Cyclin-Dependent Kinase Inhibitor	Alopecia Erythema Rash Dry skin Photosensitive lichenoid reaction Palmoplantar Erythrodysesthesia
Vinblastine Sulfate	Microtubule inhibitor	Hair loss Rare photosensitive
Xeloda (Capecitabine)	Antimetabolite	Alopecia Erythema Rash Dry skin Photosensitive lichenoid reaction Palmoplantar Erythrodysesthesia
Zoladex (Goserelin Acetate)	LHRH agonist (hormonal therapy)	Hair loss Acne Hot flashes Vaginal dryness Breast swelling/tenderness Erythrodysesthesia in hands And feet

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Skin changes associated with Chemotherapy for Breast Cancer

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