Skin Reactions to Targeted Therapy and Immunotherapy

Approved by the Cancer.Net Editorial Board, 07/2019

Targeted therapy and immunotherapy are more specific treatments than chemotherapy. They may cause different side effects from those usually linked with chemotherapy. Chemotherapy side effects usually include nausea, vomiting, weakness, and changes in blood counts. Targeted therapy and immunotherapy side effects may include skin, hair, nail, and/or eye problems.

What is targeted therapy?

Targeted therapy is a treatment that targets the specific genes, proteins, or the tissue environment that contributes to cancer growth and development. Some targeted therapies can cause specific side effects to the skin, hair, and nails. These side effects are caused by the effect of medications on the healthy growth of these tissues.

Targeted therapies that may cause skin problems

The following are some of the types of targeted therapies that may affect the skin. If your doctor prescribes a targeted therapy, ask what side effects to expect and how they will be treated.

  • Drugs that target EGFR. This common type of targeted therapy focuses on a molecule known as epidermal growth factor receptor (EGFR). EGFR fuels the growth of cancer cells. It also plays a role in the normal growth of the skin, hair, and nails. This means rashes and changes to the hair and nails may occur during treatment with these drugs.

    Most people taking drugs that target EGFR develop a rash on their face and upper body. It usually happens within the first few weeks of taking these medications. You may notice redness or a warm sensation like a sunburn before the rash begins. After several days, pimples and pus bumps appear, and the surrounding skin feels slightly tender. Rashes are usually mild to moderate. But some people have severe rashes that cause major physical and cosmetic discomfort.

    The skin can also become very dry and itchy, interfering with daily activities and sleep. Skin on the fingertips may crack. Skin may also become more sensitive to sunlight. A lot of scratching can result in breaks in the skin. These openings make the skin more prone to infections. Inflammation around the nails can make grooming, dressing, and other activities painful or difficult.

  • Drugs that target VEGF. Another type of targeted therapy that may cause skin problems includes drugs that block a protein called vascular endothelial growth factor (VEGF). This protein helps make new blood vessels. This group of drugs may also be called angiogenesis inhibitors because they block the formation of blood vessels. When these drugs affect the blood vessels in the hands and feet, they can cause skin problems.

Your health care team can help you manage these side effects so treatment can continue. Managing these side effects can also help avoid major changes to your skin, hair, and nails. It is important to note that the skin side effects linked with these drugs are not allergic reactions or infections.

Common skin-related side effects of specific targeted drugs

Below is a list of common targeted therapy drugs that can cause skin related problems.

  • Afatinib (Gilotrif), cetuximab (Erbitux), erlotinib (Tarceva), gefitinib (Iressa), osimertinib (Tagrisso), and panitumumab (Vectibix). These drugs may be prescribed for colorectal cancer, head and neck cancer, lung cancer, and pancreatic cancer. Skin-related side effects include:

    • Acne-like rash on face and upper body

    • Inflammation around fingernails

    • Dry, itchy skin

    • Fingertip cracking

    • Hair loss on scalp

    • Increased, curly, or coarse hair on face and eyelashes

    • Increased sensitivity to sunlight

  • Lapatinib (Tykerb). This is used to treat breast cancer. Skin-related side effects include:

    • Sores on lips, mouth, or throat

    • Dry skin

    • Red, painful, numb, or tingling hands and feet

    • Rash

  • Sorafenib (Nexavar) and sunitinib (Sutent). This is used to treat renal cell cancer, gastrointestinal stromal tumor (GIST), and hepatocellular cancer. Side effects include:

    • Hand/foot skin reactions (tender, thickened areas sometimes with blisters on palms and soles)

    • Redness and flaking on scalp and eyebrows

    • Warm, burning sensation on the face along with redness

    • Dry, itchy skin

    • Hair loss

  • Vemurafenib (Zelboraf). This is used to treat melanoma. Skin-related side effects include:

    • Red rash on the face and upper body

    • Bumpy, rough rash on arms and thighs

    • Hand/foot skin reactions

    • Skin growths, including non-dangerous skin cancers

    • More sensitivity to sunlight

  • Everolimus (Afinitor, Zortress) and temsirolimus (Torisel). These targeted therapy drugs are used for renal cell cancer, non-small cell lung cancer (NSCLC), pancreatic neuroendocrine tumor (a type of pancreatic cancer), and subependymal giant cell astrocytoma (a benign brain tumor associated with tuberous sclerosis). Side effects include:

    • Mouth sores or canker sores

    • Bumpy rash on the upper body

    • Acne-like rash

  • Vandetanib (Caprelsa). This is used to treat medullary thyroid cancer. Side effects include:

    • Rash or acne

    • Dry, peeling, or itchy skin

    • Blisters or sores

    • Skin redness

What is immunotherapy?

Immunotherapy is also called biologic therapy. It is a type of cancer treatment that boosts the body's natural defenses to fight cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.

Many side effects are similar to those of an allergic reaction. They depend on the specific drug a person receives but may include skin, hair, nail, or eye problems.

Common skin-related side effects of immunotherapy

Below is a list of common immunotherapy drugs that can cause skin related problems.

  • Alemtuzumab (Campath). This medicine is used to treat chronic lymphocytic leukemia. Side effects include mouth sores.

  • Ipilimumab (Yervoy). This is used for melanoma. Skin related side effects include:

    • Bumpy red rash

    • Itching

    • Patches of pale skin and gray hair

  • Nivolumab (Opdivo). This medicine may be prescribed for renal cell cancer, NSCLC, and melanoma. Possible skin reactions include:

    • Hair loss

    • Yellowing of the skin and eyes

    • Itchy red rash

    • Blistering skin

  • Ofatumumab (Arzerra). This drug may be prescribed for chronic lymphocytic leukemia. Skin-related side effects include:

    • Sudden reddening of the face, neck, or chest

    • Pale skin

    • Small, flat, round, red spots under the skin

    • Rash

    • Hives

  • Pembrolizumab (Keytruda). This drug may be used to treat NSCLC and melanoma. Skin-related side effects include:

    • Change in skin color

    • Yellowing of skin and/or eyes

    • Hair loss

    • Blistering skin

    • Itchy red rash

    • Flushing, or skin redness

  • Rituximab (Rituxan, Truxima). This drug is used for non-Hodgkin lymphoma and chronic lymphocytic leukemia. Skin-related side effects include redness, tenderness, swelling, or warmth of part of the skin.

Managing and relieving skin problems

Rashes, dry skin, and nail and hair reactions are rarely severe. But they can cause major discomfort. Patients may even want to stop cancer treatment because of these reactions. It is important to talk with your health care team about what to expect. Also tell your doctor as soon as you start feeling or seeing any side effects. There are early and effective treatments for these reactions.

The following suggestions may help avoid reactions and help relieve them if they do happen:

  • Before you begin treatment, talk with your health care team about the side effects. You may wish to talk with a dermatologist. A dermatologist is a doctor who specializes in skin conditions. Ask what to do if a rash or other problems appear. This may include how to get a prescription filled or the best way to see the doctor.

  • At the first sign of a reaction, tell your doctor or a dermatologist familiar with these reactions. Signs of a reaction include a warm or burning sensation, pimples, nail cracks, or dry skin.

  • Avoid the sun, and use a sunscreen with a sun protection factor (SPF) of at least 15. If the sunscreen causes a burning sensation, you can try sunscreens that contain zinc oxide or titanium dioxide. Remember to use enough sunscreen. Apply more than half a teaspoon of sunscreen to each arm, your face, and your neck. Apply just over 1 teaspoon to your chest and abdomen, your back, and each leg. Re-apply sunscreen every 2 hours when outdoors, or more often if sweating or swimming.

  • Use a broad-brimmed hat if going outside. And avoid being in direct sunlight between 10 AM and 4 PM.

  • Use a mild soap in the shower. Avoid soaps with strong scents. Shower with lukewarm water and avoid long, hot showers. Also, avoid laundry detergent with strong perfumes.

  • Apply a cream-based moisturizer to all skin within 5 minutes of showering or bathing. Use hypoallergenic moisturizers that do not have perfumes or preservatives, such as Vanicream, Aveeno, CeraVe, Cetaphil, and Eucerin.

  • Avoid anti-acne skin products that have alcohol or retinoids. They can dry out your skin.

  • Your doctor may prescribe medicated skin creams for a rash. If the rash is severe or covers a large area of the body, you may need oral corticosteroids, such as prednisone (Rayos) or dexamethasone (available as a generic drug).

  • Antibiotics, usually taken for 2 to 4 weeks in pill form, are an effective therapy for rashes and nail tenderness.

  • Whenever there is discharge of pus, your doctor may take a sample of it to help choose the best antibiotic treatment.

  • For hand/foot skin reactions to sorafenib and sunitinib:

    • Use creams containing urea called carmol 20 or carmol 40, or salicylic acid (multiple brand names). Strong corticosteroids such as fluocinonide (multiple brand names) and clobetasol (multiple brand names) are also options.

    • Wear thick, comfortable socks and shoes, or try gel insoles. Also, do your best to protect against injury. Do not put too much weight on your hands and feet, especially during the first 2 months of treatment.

  • For itching in one specific area, called localized itching, apply a cream containing a corticosteroid or a numbing medicine, such as lidocaine 2% or cooling creams containing pramoxine, camphor, or menthol (multiple brand names for all drugs), several times a day.

    For more generalized itching or itching that affects sleep, talk with your doctor about taking an antihistamine pill, such as cetirizine (multiple brand names) or diphenhydramine (multiple brand names), as needed.

Related Resources

Skin Conditions

What You Need to Know About Immunotherapy Side Effects

What It's Like Taking Immunotherapy to Treat Cancer

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