Skin Reactions to Targeted Therapy and Immunotherapy

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

This content was last updated 1 November 2021.

Targeted therapy and immunotherapy are specific types of cancer medications. Like other cancer treatments, they often cause side effects. There are some similarities and differences in side effects between these types of cancer medications compared to chemotherapy drugs. This information explains changes to the skin, included related changes to hair, nails, and eyes, that can happen during treatment with targeted therapy or immunotherapy.

Let your health care team know about any symptoms you experience. This includes any new symptoms or a change in symptoms. Managing skin reactions and other cancer side effects is an important part of your medical care and treatment. This type of care is called palliative care or supportive care.

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, also called biologic therapy, is a type of cancer treatment. It uses the body's natural defenses to fight cancer by improving your immune system’s ability to attack cancer cells.

Common skin-related side effects of immunotherapy

Most skin reactions to immunotherapy are caused by a certain class of drugs called immune checkpoint inhibitors. These drugs target molecules such as PD-1, PD-L1, and CTLA-4. Examples of these medications include ipilimumab, nivolumab, and pembrolizumab, among others.

The skin-related reactions to immune checkpoint inhibitors are relatively uncommon but may include:

  • Rash

  • Skin that feels itchy, burning, or tight

  • Blistered skin, also called bullous dermatosis

  • Peeling or cracked skin

  • Reddening or other discolored patches of skin

  • Patches of purple spots called purpura

  • Painful skin

  • Patchy areas of hair loss

Skin reactions can occur anywhere on the body, even in the mucus membranes. Affected areas of skin may be small or cover large areas of the body. Treatment may include moisturizing skin creams, antihistamine medications, and/or steroids. Depending on the severity of the side effect, your doctor may pause or permanently stop treatment with the immune checkpoint inhibitor.

If you get care for your skin condition at a place not familiar with your cancer treatment, be sure to tell the health care team there that you are on immunotherapy. For instance, you may decide to go to an emergency room or see a dermatologist. If possible, give them the name of the drug, your oncologist, and cancer center where you receive immunotherapy. Keep this information in your wallet or phone in case you need it quickly. Download and print Cancer.Net's foldable wallet card to organize this information.

Learn more about the side effects of immunotherapy.

The information in this section is based on ASCO recommendations on managing side effects related to treatment with immune checkpoint inhibitors. Note that this link takes you to a different ASCO website.

Managing and relieving skin problems from targeted therapy and immunotherapy

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. If you have existing skin problems before starting immunotherapy, 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, itching, bumps or blisters, nail cracks, or dry skin.

  • Protecting your skin from the sun may help prevent skin problems while you are receiving immunotherapy. 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 and sun-protective clothing 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 or dexamethasone (available as generic drugs).

  • 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 the targeted therapies 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 that does not involve a rash, an anti-itch cream can be applied to the area for relief. For more serious itching or itching that affects sleep, talk with your doctor about whether other medications may be an option.

Related Resources

Skin Conditions

Side Effects of Immunotherapy

What People With Cancer Should Know About Immune Checkpoint Inhibitor Side Effects

What It's Like Taking Immunotherapy to Treat Cancer

ASCO answers; RashDownload ASCO's free Rash fact sheet. This 1-page printable PDF gives an introduction to rashes, including symptoms, how it is treated, ways to manage discomfort, words to know, and questions to ask the health care team. It also includes a tracking sheet to record when the rash started and where and how it appears.