Three years ago, Tony, a 42-year-old man, began FOLFOX chemotherapy treatment for stage III colon cancer and achieved a complete response. Two years later, a biopsy of an intraabdominal lesion uncovered metastatic disease, and he was prescribed the epidermal growth factor inhibitor (EGFRi) cetuximab. Alex, the oncology nurse educating Tony on the side effects of EGFRi therapy, understands that skin toxicities are common with the class of drugs and looks for national guidelines for prevention and management direction.

What Would You Do?

The ONS GuidelinesTM were developed by a team of oncology experts using the GRADE (Grading, Recommendations, Assessment, Development, and Evaluation) approach to review clinical evidence and provide recommendations. The incidence of an acneiform rash is as high as 90%, making it the most common adverse event related to the EGFRi drug class. The rash typically presents where sebaceous glands are the most plentiful (i.e., scalp, face, and upper body). It develops within the first one to two weeks of treatment but can take up to three or four months to resolve, during which time patients may experience pain, itching, oozing, and secondary infections. Patients’ psychosocial well-being can also be affected.

The ONS Guidelines recommendations for EGFRi rash fall into two categories: prevention and treatment. Prevention includes the use of prophylactic oral antibiotics for individuals who place a higher priority on preventing the rash versus acquiring the possible side effects of antibiotics. Individuals who prefer to avoid potentially unnecessary medications may choose to wait until symptoms of the rash present. Because either recommendation is appropriate, oncology nurses should educate patients and families and then advocate for the patient’s personal preferences.

The strength of a recommendation falls into two categories: strong and conditional. The strength of the EGFRi rash recommendation is conditional with a low certainty of evidence. Therefore, each patient’s situation should be carefully evaluated. Treatment recommendations include usual skincare with the addition of topical corticosteroids and oral antibiotics.

Refer to the ONS Guidelines for Cancer Treatment-Related Skin Toxicities for more information. Or listen to an interview with ONS member George Ebanks, RN, BSN, OCN®, member of the guideline panel, on the Oncology Nursing Podcast, then subscribe to the podcast on your favorite listening platform to get other episodes about the ONS Guidelines and more—all with free NCPD—delivered directly to your phone.

Tony reports he did not have bad acne as a teenager and prefers to wait to see if a rash develops. His oncologist agrees with his plan. Alex educates Tony about usual skin care, including avoiding hot water and using fragrance- and alcohol-free skin care products, a cream-based moisturizer, and sunscreen with an SPF of 30 or higher.