Skin changes associated with Chemotherapy for Breast Cancer

Skin changes associated with Chemotherapy for Breast Cancer

October 03, 2021

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

  1. Direct extension of the cancer to the skin
  2. Spread of the cancer to the skin
  3. Side effect of chemotherapy
  4. Side effect of radiation
  5. 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.



Gaiam Meditation Collection


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.  



Physicians Formula


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 

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 

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

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 

Epirubicin Hydrochloride

Anthracycline

  • Alopecia
  • Eccrine squamous metaplasia
  • Nail changes

Eribulin Mesylate

Microtubule inhibitor

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 

Fareston (Toremifene)

Selective estrogen receptor modulator (SERM)

  • Rash
  • Hair loss

Faslodex (Fulvestrant)

Estrogen Receptor Antagonist

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

Gemcitabine Hydrochloride

Nucleoside

Gemzar (Gemcitabine Hydrochloride)

Nucleoside

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

Herceptin Hylecta (Trastuzumab and Hyaluronidase-oysk)

Monoclonal HER2 Antibody 

Herceptin (Trastuzumab)

Monoclonal HER2 Antibody 

Ibrance (Palbociclib)

Kinase inhibitor (Cyclin-dependent kinase 4/6 inhibitor)

Infugem (Gemcitabine Hydrochloride)

Nucleoside

Ixabepilone

Microtubule inhibitor

Ixempra (Ixabepilone)

Microtubule inhibitor

Kadcyla (Ado-Trastuzumab Emtansine)

Monoclonal HER2 Antibody 

Keytruda (Pembrolizumab)

Monoclonal HER2 Antibody 

Kisqali (Ribociclib)

Kinase Inhibitor

Lapatinib Ditosylate

Tyrosine Kinase Inhibitors (TKIs)

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

Margenza (Margetuximab-cmkb)

Monoclonal HER2 Antibody 

Margetuximab-cmkb

Monoclonal HER2 Antibody 

Megestrol Acetate

Progestin

  • Rash 
  • Skin discoloration
  • Thin skin
  • Increase body hair

Methotrexate Sodium

Folate antagonist

Neratinib Maleate

Tyrosine Kinase Inhibitors (TKIs)

Nerlynx (Neratinib Maleate)

Tyrosine Kinase Inhibitors (TKIs)

Olaparib

PARP inhibitor

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)

Pamidronate Disodium

Inhibits bone resorption

Injection site reaction

Pembrolizumab

Monoclonal HER2 Antibody 

Perjeta (Pertuzumab)

Monoclonal HER2 Antibody 

Pertuzumab

Monoclonal HER2 Antibody 

Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf

Monoclonal HER2 Antibody 

Phesgo (Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf)

Monoclonal HER2 Antibody 

Piqray (Alpelisib)

Phosphatidylinositol 3-kinase (PI3K) inhibitor

Ribociclib

Kinase inhibitor

selective cyclin-dependent 

Sacituzumab Govitecan-hziy

PARP inhibitor

  • Hair Loss
  • Rash 

Soltamox (Tamoxifen Citrate)

Anti estrogen

Talazoparib Tosylate

PARP inhibitor

  • Stomatitis
  • Rash

Talzenna (Talazoparib Tosylate)

PARP inhibitor

  • Stomatitis
  • Rash

Tamoxifen Citrate

Anti estrogen

Taxotere (Docetaxel)

Taxane 

Tecentriq (Atezolizumab)

PD-L1 monoclonal antibody

Tepadina (Thiotepa)

Nitrogen mustard type of alkylating agent

Thiotepa

Nitrogen mustard type of alkylating agent

Toremifene

Selective estrogen receptor modulator (SERM)

  • Rash
  • Hair loss

Trastuzumab

Monoclonal HER2 Antibody 

Trastuzumab and Hyaluronidase-oysk

Monoclonal HER2 Antibody 

Trexall (Methotrexate Sodium)

Folate antagonist

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)

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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