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Prophylaxis algorithm

Healthcare Professionals (HCPs) play a key role in preparing patients and managing their expectations with regard to EGFRI treatment. A prophylactic skin regimen may be discussed before EGFRI treatment begins in order to manage early pathogenic mechanisms other than inflammation, such as minimising stressors and overcoming the absence of EGFR signalling in the skin.1 Approximately 10% of patients experience severe skin changes and would thereby benefit most from prophylactic treatment. As most patients respond reasonably well to reactive treatment, a careful risk-benefit evaluation of prophylactic treatment is advisable.

The role of prophylactic skin treatment in this setting is still under investigation. The use of topical calcineurin inhibitors (pimecrolimus, tacrolimus)2,3,4,5 is not recommended because of recent trial evidence demonstrating a lack of efficacy with pimecrolimus.6 The role of topical steroids is also controversial as although short-term application may be beneficial, extended application may result in the aggravation of skin changes.1,5,8,9,10 The currently available evidence5,6,10,11,12 and recommendations2,7,8,9 for prophylactic skin treatment during EGFRI-treatment comprise of the following.

The following measures should be advised to patients:

Measures for skin hydration7

  • Use lukewarm water, bath/shower oil to wash.
  • Daily use of emollients especially on hands, feet and limbs.

Sun protection2,7

  • Do not sunbathe or use a sunbed.
  • Wear protective clothing, particularly a hat when exposed to the sun.
  • Use SPF 20 or higher with UVA/UVB protection; apply to exposed skin areas before going outdoors and reapply every 2-3 hours while exposed to the sun.

Prophylactic antibiotics

  • ­Minocycline 100 mg qd,12 tetracycline 500 mg bid11 or doxycycline 100 mg bid orally.10
  • ­Effects are based on the anti-inflammatory and tissue-protective properties of tetracyclines.13
  • ­Systemic tetracyclines may exert additional anti-neoplastic effects.14

Nail care

  • ­Apply antiseptic soaks or creams (eg chloramines or povidone iodine) daily.
  • ­Avoid removal of cuticles.
  • ­Cut nails straight.

References

1Lacouture ME. Nat Rev Cancer 2006; 6: 803-812.
2Peréz-Soler R et al. Oncologist 2005; 10: 345-356.
3Lopez-Ilasaca M et al. J Biol Chem 1998; 273: 9430-9434.
4Lacouture ME et al. J Support Oncol 2006; 4: 236-238.
5Tan EH & Chan A. Ann Pharmacother 2009; 43: 1658-1666.
6Scope A et al. J Am Acad Dermatol 2009; 61: 614-620.
7Segaert S. Targeted Oncol 2008; 3: 245-251.
8Segaert S & Van Cutsem E. Oncology (Williston Park) 2007; 21: 22-26.
9Segaert S & Van Cutsem E. Ann Oncol 2005; 16: 1425-1433.
10Mitchell EP et al. J Clin Oncol ASCO Annual Meeting Proceedings (Post-Meeting Edition) 2009; 27(18S); CRA4027.
11Jatoi A et al. Cancer 2008; 113: 847-853.
12Scope A et al. J Clin Oncol 2007; 25: 5390-5396.
13Sapadin AN & Fleischmajer R. J Am Acad Dermatol 2006; 54: 258-265.
14Onoda T et al. Int J Cancer 2006; 118: 1309-1315.

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