Although many cancers are unseen, different types of treatment can lead to painful, visible side effects, particularly when it comes to an individual's skin.
As she walked into Memorial Sloan Kettering Cancer Center, Erin Hazelton was struck by the appearance of the woman in front of her. Hazelton was at the New York, New York, cancer center to begin treatment for stage 2 invasive ductal carcinoma.
“I walked into the center right after another woman, and when I heard her give her date of birth (to the receptionist), I realized that she was only a couple of years older than me, but she looked like she was my mother’s age,” recalled Hazelton, who received her diagnosis in 2018. “When you (get a diagnosis) at age 37 (like I did), it’s scary. So much of my identity was tied up in how I looked. I was terrified.”
Although many cancers are unseen, different types of treatment can lead to painful, visible side effects. After starting treatment, Hazelton experienced skin side effects including universal hair loss; facial wrinkles and loss of collagen; melasma (dark/discolored patches) on her face; dry skin; seeping wounds; scars; and radiation tattoos.
“In addition to the regular side effects of chemotherapy, which can be devastating to quality of life, newer targeted therapies and immunotherapies have additional side effects of the skin that can be very frequent and very specific,” says Dr. Nicole LeBoeuf, a dermatologist at Brigham and Women’s Hospital and director of the skin toxicities program at Dana- Farber Cancer Institute in Boston, Massachusetts.
According to LeBoeuf, systemic cancer treatments can generally be grouped into three categories, and the types of side effects patients could experience will depend on the patient’s treatment regimen and cancer type.
The first category is cytotoxic, or classic, chemotherapy, which most commonly causes side effects including alopecia, or hair loss; painful rashes on the hands and feet; and general rashes elsewhere on the body that can lead to swelling, pain and itchiness.
Hazelton’s initial regimen included Adriamycin (doxorubicin), a chemotherapy drug known as “the red devil” because of its harsh side effects, followed up with Taxol (paclitaxel). “I lost all my hair — eyelashes, eyebrows, everything — and my skin looked like I had aged a good 15 to 20 years toward the end of it,” Hazelton says. “My cheeks had wrinkles because the collagen wasn’t being renewed; I had melasma, which I hadn’t expected, that was made worse by the sun.”
She also experienced skin-related side effects from radiation and scars from her lumpectomy. “My skin started slowly breaking down over the course of my radiation, and at the end of six weeks, I had seeping wounds,” Hazelton says. “My nipple looked like it was going to separate from my body.”
The second category of treatment that can lead to skin side effects are targeted therapies, which are linked to the specific drug used for that patient’s treatment. “The most commonly talked-about skin side effect of targeted therapy is called a papulopustular, or an acne-like, rash from EGFR inhibitors, or drugs that target the epidermal growth factor receptor mutation. This mutation is found in lung cancers, head and neck cancers, some colon cancers and, rarely, in breast cancer,” LeBoeuf says. “In fact, 85% of patients who are treated with drugs that target that particular genetic mutation will develop that rash.”
Another common skin side effect from targeted therapies is hand-foot skin reaction, which causes painful calluses and blisters on pressure points. “These blisters can occur from doing very normal activities,” LeBoeuf says. “Something as simple as going to the grocery store can make a patient’s feet look like they’ve just run a marathon. Someone who works on a keyboard may experience painful blisters on their fingertips when they type.”
Severe skin side effects such as these can prevent patients from resuming everyday activities and make them more likely to discontinue their cancer treatment, leading to a worse prognosis.
The third category of treatment leading to skin side effects is immunotherapy, a type of treatment that boosts the body’s natural defenses, or immune system, to fight the cancer. “Immunotherapy is a beast because once you unleash the immune system, you can turn on any and all skin diseases that would happen outside the cancer setting. Anything that could possibly happen in the field of dermatology has been triggered by activating the immune system,” LeBoeuf says. “It is amazing and it is groundbreaking...but it can also lead to autoimmune disease in any organ.”
The most common skin-related side effects of immunotherapies include psoriasis, with bumpy red patches covered in white scales; vitiligo, or whitish patches from lost pigment; and lichen planus, an autoimmune disease that can cause swelling and irritation of the skin, hair, nails and mucous membranes.
Sometimes the adverse immune events that are activated through immunotherapy persist after the treatment has ended. “Our approach to these side effects is always to try to uncouple the toxicity from the effects of the drug on the cancer, then target the side effects as specifically as possible,” LeBoeuf says. “This leaves the rest of the immune system intact to fight the cancer.”
Given the variety of possible side effects and the degree to which it may affect a given individual, it can be hard for patients to know which ones to expect and how to manage them if they arise during and after treatment.
Dr. Anisha Patel, an associate professor of dermatology at The University of Texas MD Anderson Cancer Center in Houston, recommends that patients follow good hair, skin and nail habits before starting treatment: “Moisturize often, avoid perfumed products, and decrease the use of lacquer on your nails,” she says.
Patients who have a history of skin conditions prior to their cancer diagnosis are more likely to see worsening during treatment. “If you already have eczema, psoriasis, or acne, those things are more likely to be exaggerated,” Patel says. “If you have a preexisting skin condition, that should be taken care of before your therapy starts, as well.”
During treatment, certain practices can help prevent the most common side effects. For example, wearing ice- cold gloves and socks and using scalp cooling treatments to restrict blood vessels reduces the chances of hair loss and hand-foot syndrome.
Patients should also take steps at home to minimize side effects. Wearing sunscreen, avoiding direct sun exposure and wearing a hat when outdoors can prevent photosensitivity side effects, Patel says.
To manage her symptoms, Hazelton applied organic shea butter daily and wore gloves and socks to bed to keep her skin as moisturized as possible. “My nails were actually amazing during treatment because I was moisturizing them so religiously,” she says. “Whatever your skin can drink up during that time that is nontoxic, contains no preservatives and has no scents will help.”
For patients who are undergoing targeted therapy or immunotherapy, dealing with side effects can be more complicated. “In general, the newer cancer therapies (like immunotherapy) have very specific side effects, which may require specific treatment,” Patel says. “Patients have to go into it with the mindset that they will have some sort of side effect and ask their treatment team what to expect and what they can do to minimize it.”
LeBoeuf recommends that patients seek the advice of a dermatologist, who can work with the medical oncologist to manage skin side effects. “Whenever possible, if a specific dermatologic diagnosis can (be) made, then the most appropriate treatment can be instituted as quickly as possible,” LeBoeuf says. “If you treat the side effect specifically, based on dermatologic literature, then often, patients will recover and can continue their cancer treatment, as well.”
Both Patel and LeBoeuf urge that the mental and emotional side effects of treatment-related skin conditions receive as much attention as the physical side effects. “Often, patients are embarrassed or they feel like they shouldn’t be concerned about a side effect that isn’t life-threatening,” LeBoeuf says. “But the reality is, if a side effect affects your quality of life, increases your stress or changes your course of treatment, it can also affect your ability to fight the cancer. So be open, ask for help and advocate for referrals if you feel you aren’t getting the treatment you need.” Maintaining skin health can also prevent secondary problems such as infections or ulcers and can minimize scarring.
Taking one day at a time helped Hazelton maintain a positive mindset. “Thinking ‘Am I going to burn during radiation?’ or ‘What’s my scar going to look like?’ doesn’t help you mentally. Just approach it as it comes,” she says.
Patients might be surprised to learn that there is a silver lining to skin-related side effects: “Skin side effects to some of the newer targeted and immune therapies is correlated to having a better tumor response,” Patel says. “It is correlated to the body’s immune system being revved up to fight the cancer.”
Post treatment, patients should be advised about options to help restore the health of their skin, hair and nails. “What happens after the treatment isn’t talked about as much,” Dr. Anthony Rossi, a dermatologist and surgeon specializing in skin cancer, lasers and cosmetic surgery at Memorial Sloan Kettering Cancer Center, says. “Radiation can cause chronic changes in the skin; surgery, obviously, leaves a lot of scars, and high-dose steroids can leave stretch marks that last forever.”
To combat these side effects, Rossi and his team at Memorial Sloan Kettering are working on what they call “restorative oncodermatology,” which, he says, aims “to restore patients who go through cancer treatment and help them get back the form and function of their skin.”
Through the use of treatments such as topical retinoids, topical skincare, chemical peels, lasers, botulinum neurotoxin (such as Botox) and platelet- rich plasma (or PRP) injections — an experimental therapy that uses injections of the patient’s own blood platelets to prompt hair growth — Rossi reports that many survivors are seeing life-changing results. “There is definitely a cosmetic aspect that people want to improve... but these treatments help with skin functionality and overall quality of life, most importantly,” he says.
Hazelton has received chemical peels and laser treatments to reduce her wrinkles and melasma, as well as used over- the-counter eyelash serums to help her hair grow back.
“I thought my life was over when I got my diagnosis. I thought I would never look the same or feel the same ... but there are people out there to help you fix these physical things that remind you of your sickness,” she says. “A lot of people bounce back more than they expect they will. ... Your body really does recover; you just have to give it a chance.”