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Skin rash

This document is an evidence-based summary to complement treatment protocols and includes background and rationale for specific point of care actions. It is not intended to be a comprehensive literature review of all available evidence.

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Anti-cancer drugs can cause a number of changes in the skin with maculopapular rash the most common type of drug-induced skin reaction. Although rare, a few agents can cause severe, life-threatening Steven-Johnson syndrome (SJS), or toxic epidermal necrolysis (TEN) and patients who develop SJS or TEN should never be re-exposed to the causative agents.

Pathophysiology

The pathophysiology for many skin toxicities associated with anti-cancer drugs is not well understood. A common cause of skin rash is immuno-mediated hypersensitivity reactions (i.e., urticaria and angioedema, erythema multiforme, vasculitis, or contact dermatitis etc.).

Incidence/prevalence

The incidence and prevalence of skin rash vary between anti-cancer drugs. Refer to individual protocols for more information.

Onset

The onset of skin rash depends on the aetiology of the reaction. Infusion reactions typically develop within one hour of the infusion whilst "drug rash" usually occurs during the third or fourth cycle of treatment.

Assess patient for:

  • presence of rash and pruritus
  • signs of skin breakdown
  • signs of skin infection.

Grading

Grade Rash maculo-papular
1 Macules/papules covering < 10% body surface area (BSA) with or without symptoms (e.g., pruritus, burning, tightness)
2 Macules/papules covering 10-30% BSA with or without symptoms (e.g., pruritus, burning, tightness); limiting instrumental ADL; rash covering > 30% BSA with or without mild symptoms
3 Macules/papules covering > 30% BSA with or without associated symptoms; limiting self-care ADL
4 -

Common Terminology Criteria for Adverse Events (CTCAE) v55.0, November 27, 2017

Treatment

The management of patients with skin rash depends on the severity of the reaction with symptoms managed as clinically indicated (e.g. antihistamines, topical corticosteroids, and emollients). If required, referral to a dermatologist for ongoing management may be required.

For specific recommendations on dose modifications, please refer to individual treatment protocols.

For the management of immune-related skin toxicity, refer to ID 1993 Management of immune-related adverse events.

Educate patient:

  • about symptoms and how to manage them
    • wearing loose non-irritating clothing
    • using a soap-free wash when bathing
    • gently pat the skin when washing and drying instead of rubbing
    • to moisturise skin daily with a gentle non-perfumed moisturising cream like sorbolene or aqueous cream.
    • to keep nails short and avoid scratching
    • wearing a hat and/or broad spectrum UVA/UVB sunscreen (SPF 50+) to protect skin from the sun
  • to report symptoms to treating team
  • to seek immediate medical attention should severe skin reactions occur.

Version 3

Date Summary of changes
20/09/2010 First approved on eviQ. Version 1.
30/06/2015 Reviewed and reformatted. Version 2.

31/05/2017

Transferred to new eviQ website. Version 3.
24/04/2018 CTCAE information updated to v5.0 published November 27, 2017.
17/06/2022 Internal review. Link to ID 1993 Management of immune-related adverse events added. Document moved to clinical resources. Review in 2 years.
11/05/2023 Patient information updated with more detail around caring for skin.

This document reflects what is currently regarded as safe practice. While every effort has been made to ensure the accuracy of the content at the time of publication, the Cancer Institute NSW does not accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work. Any reference throughout the document to specific pharmaceuticals and/or medical products as examples does not imply endorsement of any of these products. While eviQ endeavours to link to reliable sources that provide accurate information, eviQ and the Cancer Institute NSW do not endorse or accept responsibility for the accuracy, currency, reliability or correctness of the content of linked external information source. Use is subject to eviQ’s disclaimer available at www.eviQ.org.au

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https://www.eviq.org.au/p/1853

13 Oct 2024