What Kind of Rash Is It? A Tutorial About a Skin Rash Associated with Epidermal Growth Factor...

What Kind of Rash Is It?What Kind of Rash Is It?

A Tutorial About a Skin Rash A Tutorial About a Skin Rash

Associated with Epidermal Growth Associated with Epidermal Growth Factor Receptor Inhibitors used in Cancer Factor Receptor Inhibitors used in Cancer

TreatmentTreatment

Denise Portz RN, BSN, OCNDenise Portz RN, BSN, OCNAlverno College MSN 621Alverno College MSN 621

Spring 2009Spring [email protected]@alverno.edu

Welcome

Target AudienceTarget Audience

Oncology Nurses who want to learnmore about the skin rash associated

with Epidermal Growth Factor Receptor Inhibitors used in cancer

treatment

ObjectivesObjectives

At the end of this program the learner will At the end of this program the learner will be able to:be able to:

– Define Epidermal Growth Factor and Define Epidermal Growth Factor and Inhibitor treatments used in cancer Inhibitor treatments used in cancer treatment.treatment.

– Describe the function and structure of skin.Describe the function and structure of skin.– Describe the mechanism of the EGFR rash Describe the mechanism of the EGFR rash

and inflammatory response involved. and inflammatory response involved. – Explore if there is a genetic relationship.Explore if there is a genetic relationship.– Review assessment and treatment Review assessment and treatment

approaches.approaches.

Navigating through this Navigating through this tutorialtutorial

To advance to the next slide click onTo advance to the next slide click on

To review the previous slide click onTo review the previous slide click on

Roll mouse over Roll mouse over underlinedunderlined words to get a words to get a definitiondefinition

To return to the home screen to review a To return to the home screen to review a different section click ondifferent section click on

Content of the TutorialContent of the TutorialAt any time during the tutorial you may click on to come to this

screen and advance through the topics. Let’s start first by clicking on the first link.

Epidermal Growth Factor and Inhibitor Treatments

Skin Function and Structure

Genetic Relationship

Nursing Sensitive Patient Outcomes

Mechanism of EGFR Inhibitor Rash and Inflammatory Response

Common Side Effects and Incidence of EGFR Treatments

Assessment and Treatment Approaches

Case Study

Patient Teaching

What is Epidermal Growth What is Epidermal Growth Factor?Factor?

Epidermal growth factor Epidermal growth factor or EGF is a growth factor or EGF is a growth factor that plays an important that plays an important role in the regulation of role in the regulation of cell growth, proliferation cell growth, proliferation and differentiation by and differentiation by binding to it’s receptor binding to it’s receptor EGFR (epidermal growth EGFR (epidermal growth factor receptor).factor receptor).

Illustration of EGF

Wikipedia.org

What is Epidermal Growth What is Epidermal Growth Factor Receptor (EGFR)?Factor Receptor (EGFR)?

EGFR is a receptor essential for proper EGFR is a receptor essential for proper growthgrowth

and function of epidermis and hair.and function of epidermis and hair.

EGFR at the cellular level

Used with permission. Mario Lacouture MDLacouture M, 2006

What are EGFR What are EGFR inhibitors?inhibitors?

When Epidermal Growth When Epidermal Growth Factor is over expressed Factor is over expressed there is an increase in cell there is an increase in cell growth, proliferation and growth, proliferation and differentiation which can differentiation which can lead to cancer growth.lead to cancer growth.

Blocking or “inhibiting” Blocking or “inhibiting” EGFR results in EGFR results in apoptosis of cellsof cellsultimately causing cancer ultimately causing cancer cell death.cell death.

Cancerous Cell Destruction

http://nanotechie.blogspot

.com/

What cancers are treated What cancers are treated with EGFR Inhibitors?with EGFR Inhibitors?

EGFR-Inhibitors areEGFR-Inhibitors arecancer treatments cancer treatments used in:used in:

Breast cancerBreast cancerColorectal cancerColorectal cancerHepatocellular cancerHepatocellular cancerNon-small cell lung cancerNon-small cell lung cancerPancreatic cancerPancreatic cancerRenal Cell cancerRenal Cell cancer

All Illustrations retrieved from

Microsoft Clip Art March 23, 2009 unless otherwise

notedhttp://office.microsoft.com/en-us/clipart.com

What are EGFR inhibitor What are EGFR inhibitor agents?agents?

Panitumumab (Vectibix)Panitumumab (Vectibix)Cetuximab (Erbitux)Cetuximab (Erbitux)Gefitinib (Erlotinib)Gefitinib (Erlotinib)Lapatinib (Tykerb)Lapatinib (Tykerb)Erlotinib (Tarceva)Erlotinib (Tarceva)Sorafanib (Nexavar)Sorafanib (Nexavar)Sunitinib (Sutent)Sunitinib (Sutent)

More EGFR Inhibitor treatments are on the horizonMore EGFR Inhibitor treatments are on the horizon

Test your knowledgeTest your knowledge

EGFR is essential in epidermis and EGFR is essential in epidermis and hairhair

TrueFalse


EGFR-Inhibitor treatments have EGFR-Inhibitor treatments have shownshown

effectiveness in which types of effectiveness in which types of cancer?cancer?

A. A. Lung B. Pancreatic C. MelanomaD. A & B

What are the common side What are the common side effects from EGFR inhibitor effects from EGFR inhibitor treatments?treatments?

FatigueFatigue

DiarrheaDiarrhea

HeadachesHeadaches

Hypersensitivity ReactionsHypersensitivity Reactions

Skin toxicities including rashSkin toxicities including rashNursing Drug Handbook, 2009

What is the incidence of What is the incidence of skin rash?skin rash?

Rash is the most common reported Rash is the most common reported side effect to EGFR Inhibitor side effect to EGFR Inhibitor

treatmentstreatments

Rash occurs in 45-100% of patientsRash occurs in 45-100% of patients

Oishi, K., 2008


The most common side effect of The most common side effect of

EGFR inhibitors is skin rashEGFR inhibitors is skin rash

True False

Function of SkinFunction of Skin

The skin is the largest organ of the body

The skin serves several distinct functionsThe skin serves several distinct functionssimultaneouslysimultaneously

PProtection SSensation TThermoregulation CCommunicationSkin is also Skin is also self-repairing after injuryafter injury

Click on one of the Functions of the Skin

to learn more

Porth, C., 2005

Structure of the SkinStructure of the Skin

The skin’s structure is The skin’s structure is

composed of 3 layerscomposed of 3 layers

EpidermisEpidermis

DermisDermis

HypodermisHypodermis

Porth, C., 2005

Wikipedia.org

EpidermisEpidermis

Outermost layer of skin that is Outermost layer of skin that is avascularavascular

Made of 4 to 5 layers of cellsMade of 4 to 5 layers of cellsvariable thickness depending on variable thickness depending on locationlocation

Responsible for protection Responsible for protection properties of skinproperties of skin

Illustration of Epidermis on the cellular level

Porth, C., 2005

Epidermal cellsEpidermal cells

KeratinocytesKeratinocytes Make up 90% of epidermal layersMake up 90% of epidermal layers Communicate and regulate cells Communicate and regulate cells

of the immune response by of the immune response by secreting cytokines and secreting cytokines and inflammatory mediators including inflammatory mediators including Epidermal Growth FactorEpidermal Growth Factor

Lacouture, M., 2006

Scattered among the Scattered among the keratinocyteskeratinocytes

are a few other cell typesare a few other cell types

MelanocytesLangerhans cellsMerkel cells

Drag mouse over celltype for definition

Porth, C., 2005

Wikipedia.org

DermisDermis

Inner layer of skinInner layer of skin Links epidermis to hypodermisLinks epidermis to hypodermis Sweat glands, sebaceous glands and Sweat glands, sebaceous glands and

hair follicles reside mostly in this layerhair follicles reside mostly in this layer Roughly two layersRoughly two layers Variable thickness over different Variable thickness over different

regions of the bodyregions of the body Provides support and tensile strengthProvides support and tensile strength

Porth, C., 2005

Wikipedia.org

HypodermisHypodermis

not a true layer of the skin but not a true layer of the skin but subcutaneous tissuesubcutaneous tissue

links skin to body properlinks skin to body proper variable thickness in different regions variable thickness in different regions

of the bodyof the body allows for movement of skin over bodyallows for movement of skin over body

Porth, C., 2005

Wikipedia.org


The largest organ of the body is The largest organ of the body is A. LiverB. BrainC. Skin


The skin serves the following distinctThe skin serves the following distinct

functions:functions:A. ProtectionB. SensationC. ThermoregulationD. CommunicationE. All of the above


Keratinocytes are found in the Keratinocytes are found in the epidermis and are responsible for epidermis and are responsible for communicating and regulating communicating and regulating the immune response secreting the immune response secreting cytokines and inflammatory cytokines and inflammatory mediators including epidermal mediators including epidermal growth factor.growth factor.

TRUE FALSE

Mechanism of EGFR Mechanism of EGFR Inhibitor RashInhibitor Rash

Although the exact Although the exact pathophysiology of of

an EGFR inhibitor rash remains largelyan EGFR inhibitor rash remains largely

unknown; there are hypotheses about theunknown; there are hypotheses about the

mechanism.mechanism.

Lacouture, M., 2006

We do know that….We do know that….

EGFR is highly expressedEGFR is highly expressed

in keratinocytesin keratinocytes

Lacouture, M., 2006

and when…and when…

EGFR is inhibited,EGFR is inhibited,

keratinocytes are damagedkeratinocytes are damaged

Stimulating an Stimulating an inflammatory responseinflammatory response

Lacouture, M., 2006

The Inflammatory The Inflammatory ResponseResponse

Inflammation is an attempt by the Inflammation is an attempt by the bodybody

to restore and maintain to restore and maintain homeostasishomeostasis

after injury and is an integral part after injury and is an integral part ofof

body defense.body defense. Porth, C., 2005

Inflammatory ResponseInflammatory Response

The Inflammatory Response is The Inflammatory Response is initiated by:initiated by:

Tissue damage Tissue damage

and/orand/or

Bacterial invasionBacterial invasion

Porth, C., 2005

Stages of InflammationStages of Inflammation

1. Inflammatory mediators are 1. Inflammatory mediators are recruitedrecruited

2. Vascular response occurs2. Vascular response occurs

3. Cellular response occurs3. Cellular response occurs

Porth, C., 2005

Inflammatory Inflammatory MediatorsMediators Inflammation is produced by Inflammation is produced by

chemical mediators such as: chemical mediators such as: ((click on click on word for definition)word for definition)

HistaminePlasma proteasesArachidonic acid metabolitesPlatelet activating factorCytokines

Porth, C., 2005

After recruitment of chemical After recruitment of chemical mediators, there is dilation of mediators, there is dilation of vessels resulting in:vessels resulting in:– Redness, heat and swelling of Redness, heat and swelling of

tissuestissues– Cells are then recruited to the areaCells are then recruited to the area

Vascular Stage of Vascular Stage of InflammationInflammation

Porth, C., 2005

Cellular Stage of Cellular Stage of InflammationInflammation

White Blood Cells are White Blood Cells are

recruited including:recruited including: Neutrophils Lymphocytes Monocytes

Neutrophils migrate from blood vessels to the inflamed

tissue Wikipedia.org/inflammatory_response, 2009 Porth, C.,

2005

Drag mouse over celltype for definition

The inflammatory The inflammatory response causesresponse causes

keratinocyte damage keratinocyte damage in the epidermal in the epidermal

cells…..cells…..

Causing aCausing aSkin RashSkin Rash

The following slide is The following slide is a representation of a representation of

this response this response

Chemical MediatorExpression

Inflammatory Cell Recruitment

More chemicals and neutrophils expressed

Rash Develops

Inflammatory ResponseInflammatory Response

Keratinocyte damage

EGFR Inhibition

Adapted from Lacouture, M., 2006

The next slide is another The next slide is another representation explaining how representation explaining how rash develops when EGFR is rash develops when EGFR is

inhibited….. inhibited…..

a.Shows normal expression of EGFR

before treatment with inhibitor

b.Shows that during treatment, EGFR is abolished

in all epidermal cellsleading to

differentiationand cell death

c. Shows the release of chemical mediators and

recruitment of neutrophilscausing

apoptosis and cell death

d. Shows the decrease in epidermal

thickness indicatingabnormal celldifferentiation


When EGFR in inhibited, an When EGFR in inhibited, an inflammatory response occurs inflammatory response occurs which causes damage to which causes damage to keratinocytes leading to skin keratinocytes leading to skin rash:rash:

TRUE FALSE

You’re Right !You’re Right !

The inhibition of EGFR produces an The inhibition of EGFR produces an inflammatory response where inflammatory response where

chemical mediators and chemical mediators and inflammatory cells are recruited, inflammatory cells are recruited,

causing damage to the causing damage to the keratinocytes leading to skin keratinocytes leading to skin

rash.rash.

Actually….Actually….

the answer is true. the answer is true.

The inhibition of EGFR produces The inhibition of EGFR produces an inflammatory response where an inflammatory response where chemical mediators and chemical mediators and inflammatory cells are recruited, inflammatory cells are recruited, causing damage to the causing damage to the keratinocytes leading to skin keratinocytes leading to skin rash.rash. Try again

Is There a Genetic Link?Is There a Genetic Link?

Recent research identifies a Recent research identifies a strongstrong

correlation between genetics correlation between genetics andand

the effectiveness of EGFR the effectiveness of EGFR Inhibitors…Inhibitors… Wong, R., 2008

EGFR EGFR mutations have been have been discovered…discovered…

Wong, R., 2008

– The mutation is found in the K RAS The mutation is found in the K RAS gene of the tumor.gene of the tumor.

– Patients are unlikely to benefit from Patients are unlikely to benefit from EGFR Inhibitor treatment if they EGFR Inhibitor treatment if they have this mutation.have this mutation.

Wong, R., 2008

Is there a Genetic LinkIs there a Genetic Linkto the skin rash?to the skin rash? There is no specific genetic There is no specific genetic

indication behind the incidence of indication behind the incidence of rash.rash.

With more research it is possible With more research it is possible that we may identify a connection that we may identify a connection for those who develop rash more for those who develop rash more than others.than others.


All patients who receive EGFR All patients who receive EGFR inhibitors respond to therapyinhibitors respond to therapy

TRUE FALSE

NOPE!!NOPE!!

There is a genetic mutation that There is a genetic mutation that has been found on the KRAS gene has been found on the KRAS gene of the tumor. Patients who have of the tumor. Patients who have this mutation are unlikely to this mutation are unlikely to respond well to treatment with an respond well to treatment with an EGFR inhibitor. EGFR inhibitor.

Oncology Nursing ImpactOncology Nursing Impact

How do oncology nurses make How do oncology nurses make a difference?a difference?

Oncology Nursing ImpactOncology Nursing Impact

Oncology nurses can affect the Oncology nurses can affect the lives of oncology patients through lives of oncology patients through the development of nursing the development of nursing sensitive patient outcomes.sensitive patient outcomes.

Nursing Sensitive Nursing Sensitive Patient Outcomes Patient Outcomes

In 2003, the Oncology Nursing Society committed to develop ways to define, measure and educate nurses about nursing sensitive patient outcomes.

ONS, 2003

Nursing Sensitive Nursing Sensitive Patient OutcomesPatient Outcomes

Definition:Definition:

Nursing sensitive patient Nursing sensitive patient outcomes (NSPOs) are outcomes outcomes (NSPOs) are outcomes that are attained through or are that are attained through or are significantly impacted by nursing significantly impacted by nursing interventions.interventions.

ONS, 2003


The interventions must be within The interventions must be within the scope of nursing practice and the scope of nursing practice and integral to the processes of integral to the processes of nursing care.nursing care.

ONS, 2003


NSPOs represent the NSPOs represent the consequences or effects of consequences or effects of nursing interventions and result in nursing interventions and result in changes in patient symptom changes in patient symptom experience, functional status, experience, functional status, safety, psychological distress, safety, psychological distress, and/or costs.and/or costs.

ONS, 2003

What are the What are the NSPOs for EGFR NSPOs for EGFR Inhibitor rash?Inhibitor rash?

NSPOs for EGFR inhibitor rash focus on:NSPOs for EGFR inhibitor rash focus on:

1. Symptom management1. Symptom management– Promoting skin integrityPromoting skin integrity– Decreasing skin pain, burning, and itchingDecreasing skin pain, burning, and itching

2. Psychological Distress2. Psychological Distress– Improving self imageImproving self image

Early Assessment and Early Assessment and Intervention is keyIntervention is key Oncology nurses need to know:Oncology nurses need to know:

– How to describe the rashHow to describe the rash– When the rash developsWhen the rash develops– Where the rash develops Where the rash develops

Terms related to Terms related to skin rashskin rash Erythema Papule PustulePustule CrustingCrusting XerosisXerosis

Porth, C., 2005

Drag mouse over word for definition

When does rash develop?When does rash develop?

After treatment with EGFR inhibitor:After treatment with EGFR inhibitor:

Week 0-1: skin erythema and edema occurs Week 0-1: skin erythema and edema occurs Week 1-3: Papular- pustular eruption occursWeek 1-3: Papular- pustular eruption occursWeek 3-5: Crusting of skin occursWeek 3-5: Crusting of skin occursWeek 5-8: Dry skin occursWeek 5-8: Dry skin occurs

Rash usually resolves completely within 2-3 weeks of Rash usually resolves completely within 2-3 weeks of discontinuing treatmentdiscontinuing treatment

Lynch, T., 2007

Used with permission from Lacouture, M., 2006

An example of the course of rash: An example of the course of rash:

from erythema to papulopustulesfrom erythema to papulopustules

Where does rash Where does rash develop?develop?

EGFR-Inhibitor Rash occurs most EGFR-Inhibitor Rash occurs most frequently on the frequently on the

Face, Chest, and BackFace, Chest, and Back

How do we assess or How do we assess or grade skin rash?grade skin rash? Oncology nurses need to go Oncology nurses need to go

beyond just identifying if a patient beyond just identifying if a patient has a rash or not.has a rash or not.

Grading the rash can be Grading the rash can be subjective and needs to be subjective and needs to be consistent amongst the care consistent amongst the care team.team.

Grading ToolsGrading Tools

The National Cancer Institute (2006) The National Cancer Institute (2006) Common Toxicity Criteria (NCI-CTC) Common Toxicity Criteria (NCI-CTC) grading tool is often used but it can grading tool is often used but it can be very unspecific for grading an be very unspecific for grading an EGFR inhibitor rash.EGFR inhibitor rash.

Eaby, B., 2008

Grading ToolsGrading Tools

A tool developed by Lynch et. al., A tool developed by Lynch et. al., describing the rash asdescribing the rash as

MildMild

ModerateModerate

OrOr

SevereSevere

is a more simple and specific way to is a more simple and specific way to grade EGFR inhibitor rash. grade EGFR inhibitor rash.

Eaby, B., 2008

Lynch’s grading scaleLynch’s grading scale

Mild Rash is:– Generally

localized– Minimally

symptomatic– No impact on

ADLs– No signs of

superinfection

Lynch, T., 2007


Moderate Rash is:Moderate Rash is:– GeneralizedGeneralized– Mildly Mildly

symptomaticsymptomatic(pruritis, tenderness) (pruritis, tenderness)

– Minimal impact on Minimal impact on ADLsADLs

– No signs of No signs of superinfectionsuperinfection

Lynch, T., 2007


Severe Rash is:Severe Rash is:– GeneralizedGeneralized– Severely Severely

symptomaticsymptomatic Pain, pruritis, Pain, pruritis,

tendernesstenderness

– Significant impact Significant impact on ADLson ADLs

– Potential for Potential for superinfectionsuperinfection

Lynch, T., 2007

Other associatedOther associatedskin toxicitiesskin toxicities

EGFR inhibitors can also EGFR inhibitors can also

cause:cause: Hair changesHair changes

– Hair thinning/hair lossHair thinning/hair loss Nail changesNail changes

– Cracks and fissuresCracks and fissures Eyelash elongation and inversionEyelash elongation and inversion Itchy, dry skinItchy, dry skin

Lacouture M., 2006Used with permission. Mario Lacouture MD

What can make rash What can make rash worse?worse?Temperature changes to skinTemperature changes to skin

– BurnsBurns (eg. sunburn, radiation burn)(eg. sunburn, radiation burn)– FreezingFreezing

Friction on skinFriction on skin– bed shearing, turningbed shearing, turning

Pressure on skinPressure on skin– bedridden patientsbedridden patients

Skin damageSkin damage– Tape stripping (eg. tegaderm)Tape stripping (eg. tegaderm)– Surgical Incisions Surgical Incisions

Symptom ManagementSymptom Management

The following treatment algorithm The following treatment algorithm

should be used as a guideline forshould be used as a guideline for

EGFR inhibitor induced rash….EGFR inhibitor induced rash….

Oishi, K., 2008

Treatment algorithmTreatment algorithm

For a MILD Grade rash:For a MILD Grade rash: No treatment OR topical No treatment OR topical

hydrocortisone 1% or 2.5% cream hydrocortisone 1% or 2.5% cream and or Clindamycin 1% geland or Clindamycin 1% gel

Reassess after 2 weeksReassess after 2 weeks– If no improvement proceed to next If no improvement proceed to next

stepstep

Lynch, T., 2007


For a MODERATE Grade rash:For a MODERATE Grade rash: Continue EGFR-I treatment at current dose Continue EGFR-I treatment at current dose

and:and:– Hydrocortisone 2.5% cream or Clindamycin Hydrocortisone 2.5% cream or Clindamycin

gel or Pimecrolimus 1% creamgel or Pimecrolimus 1% creamPLUSPLUS– Doxycycline 100mg BID or Minocycline Doxycycline 100mg BID or Minocycline

100mg BID100mg BID

Reassess after 2 weeks ifReassess after 2 weeks if If no improvement proceed to next stepIf no improvement proceed to next stepLynch, T., 2007


For a SEVERE Grade rash:For a SEVERE Grade rash:– Reduce EGFR-I dose per label and:Reduce EGFR-I dose per label and:– Hydrocortisone 2.5% cream or Clindamycin gel Hydrocortisone 2.5% cream or Clindamycin gel

or Pimecrolimus 1% creamor Pimecrolimus 1% creamPLUSPLUS– Doxycycline 100mg BID or Minocycline 100mg Doxycycline 100mg BID or Minocycline 100mg

BIDBIDPLUSPLUS– MEDROL dose packMEDROL dose pack

Reassess after 2 weeks; if reactions worsen, dose interruption Reassess after 2 weeks; if reactions worsen, dose interruption or discontinuation may be necessaryor discontinuation may be necessary

Lynch, T., 2007

Key Points forKey Points forPatient teaching….Patient teaching….

Oncology nurses need to teach Oncology nurses need to teach patients to:patients to:– Remain hydratedRemain hydrated– Use mild soap such as dove or use oilUse mild soap such as dove or use oil– Use lukewarm water when bathingUse lukewarm water when bathing– Use alcohol free emollient twice daily Use alcohol free emollient twice daily

(eg. Aveeno(eg. Aveeno®®, Eucerin, Eucerin®®, Cetaphil, Cetaphil®®, , AquaphorAquaphor®®) ) (con’t…..)(con’t…..) Eaby, B., 2008 Oishi, K.,

2008

Key Points forKey Points forPatient teaching Patient teaching

(con’t)(con’t) Use dye-free, alcohol-free, and Use dye-free, alcohol-free, and

perfume-free products (eg.lotions, perfume-free products (eg.lotions, soaps, shampoos, laundry detergents)soaps, shampoos, laundry detergents)

DO NOT USE over the counter acne DO NOT USE over the counter acne medications that contain benzoyl medications that contain benzoyl peroxide (drying)peroxide (drying)

Use only hypoallergenic makeup Use only hypoallergenic makeup (Dermablend(Dermablend®®)can be used to conceal )can be used to conceal the rash, but remove daily with mild the rash, but remove daily with mild cleanser (Cetaphilcleanser (Cetaphil®®, Neutrogena, Neutrogena®®))Eaby, B., 2008 Oishi, K.,

2008

Key Points for Key Points for Patient teaching Patient teaching

(con’t)(con’t) Avoid sun exposureAvoid sun exposure Use sunscreen SPF 30 or higher Use sunscreen SPF 30 or higher

(titanium dioxide or zinc oxide (titanium dioxide or zinc oxide formulations)formulations)

Use protective clothing and brimmed Use protective clothing and brimmed hat outsidehat outside

Use of saline nasal spray followed by Use of saline nasal spray followed by petroleum jelly on nasal skin petroleum jelly on nasal skin breakdownbreakdown Eaby, B., 2008 Oishi, K.,

2008

Key Points for Key Points for Patient teaching Patient teaching

(con’t)(con’t) Keep finger and toe nails clean and Keep finger and toe nails clean and

trimmed. Avoid biting nails, using trimmed. Avoid biting nails, using artificial nails, or wearing tight fitting artificial nails, or wearing tight fitting shoes or socksshoes or socks

Moisturize hands and feet frequently Moisturize hands and feet frequently using petroleum jellyusing petroleum jelly

Use of skin sealant for finger or toe Use of skin sealant for finger or toe fissuresfissures

(eg. New Skin(eg. New Skin®®, Liquid Band-Aid, Liquid Band-Aid®®))Eaby, B., 2008 Oishi, K., 2008

Psychological DistressPsychological Distress

Nursing Sensitive Patient Nursing Sensitive Patient Outcome: Improved Self ImageOutcome: Improved Self Image– Rash may:Rash may:

be a reminder of cancerbe a reminder of cancer provoke negative self imageprovoke negative self image

Key PointsKey PointsPatient teaching…Patient teaching…

Tell patients rash is an expected Tell patients rash is an expected side effect:side effect:

Make sure they know the time frame of Make sure they know the time frame of when to expect the rashwhen to expect the rash

That the rash is not an allergic reactionThat the rash is not an allergic reaction The rash is an indication of positive The rash is an indication of positive

treatment responsetreatment response Treatment continuation is important for Treatment continuation is important for

best responsebest response

Key PointsKey PointsPatient teaching…. Patient teaching….

Offer SupportOffer Support Make ReferralsMake Referrals

Dermatologist if symptoms Dermatologist if symptoms continue/worsencontinue/worsen

Psychologist/counselorPsychologist/counselor Integrative Medicine Integrative Medicine MassageMassage American Cancer Society-look good, feel American Cancer Society-look good, feel

better programbetter program

Case Study Case Study

JK is a 55 y/o male diagnosed in Dec 2008 JK is a 55 y/o male diagnosed in Dec 2008 with colon cancer. He started treatment with with colon cancer. He started treatment with FOLFOX regimen. The tumor was sent for FOLFOX regimen. The tumor was sent for gene testing. He received his first dose of gene testing. He received his first dose of Cetuximab (Erbitux) Feb 20. He returns to the Cetuximab (Erbitux) Feb 20. He returns to the clinic a week later for his second dose of clinic a week later for his second dose of Erbitux. His face is reddened and slightly Erbitux. His face is reddened and slightly edematous. He denies any pain or edematous. He denies any pain or tenderness. He has a few macular papular tenderness. He has a few macular papular eruptions on his face.eruptions on his face.

Case Study Question #1Case Study Question #1

JK’s rash would be graded as:JK’s rash would be graded as:A.A. MildMild

B.B. ModerateModerate

C.C. SevereSevere

Case Study Question #2 Case Study Question #2

Recommended treatments for MildRecommended treatments for Mild

Grade include:Grade include:A. A. Hydrocortisone 2.5% cream or Clindamycin gel Hydrocortisone 2.5% cream or Clindamycin gel or Pimecrolimus 1% creamor Pimecrolimus 1% cream

B. B. Doxycycline & Medrol dose packDoxycycline & Medrol dose pack

C. C. No treatment OR topical hydrocortisone 1% or No treatment OR topical hydrocortisone 1% or 2.5% cream and or Clindamycin 1% gel2.5% cream and or Clindamycin 1% gel

Case Study Question #3Case Study Question #3

As the nurse treating JK, you As the nurse treating JK, you would emphasize the importance would emphasize the importance of the following:of the following:

A. Drinking fluidsA. Drinking fluids

B. Applying lotion BIDB. Applying lotion BID

C. Avoiding the sunC. Avoiding the sun

D. All of the aboveD. All of the above

Case Study Case Study Question #4Question #4

During JK’s 2During JK’s 2ndnd visit for visit for Cetuximab, he is worried and Cetuximab, he is worried and reports, “maybe the treatment reports, “maybe the treatment isn’t working for me since I isn’t working for me since I haven’t gotten a bad rash yet”. haven’t gotten a bad rash yet”. Your best response would be:Your best response would be:


A. You’re right, let me talk to the A. You’re right, let me talk to the doctor.doctor.

B. Rash may begin in 1-3 weeks. After B. Rash may begin in 1-3 weeks. After this dose, you may have some this dose, you may have some raised areas that are tender.raised areas that are tender.

C. Rash usually appears a good month C. Rash usually appears a good month after you receive the Cetuximab.after you receive the Cetuximab.

Correct!!Correct!!

Rash does generally begin Rash does generally begin

during the first 3 weeksduring the first 3 weeks

After treatment with an After treatment with an

EGFR inhibitorEGFR inhibitor

There’s a better answerThere’s a better answer

Try Try AgainAgain

Although a rash is a predictor Although a rash is a predictor marker of a positive response to marker of a positive response to treatment, it is too early to tell if treatment, it is too early to tell if there will be a rash or not. Rash there will be a rash or not. Rash can begin in the first 3 weeks can begin in the first 3 weeks after receiving treatment.after receiving treatment.

There’s a better answerThere’s a better answer

Try AgainTry Again

Rash generally Rash generally begins begins

during the first 3 during the first 3 weeks weeks

After treatment with After treatment with an an

EGFR inhibitorEGFR inhibitor


JK returns to the clinic for week 3 of JK returns to the clinic for week 3 of Cetuximab treatment. He seems Cetuximab treatment. He seems down and reports that he is down and reports that he is “embarrassed to go to work. I feel “embarrassed to go to work. I feel like a teenager again, I think I’m like a teenager again, I think I’m going to use Clean and Clear going to use Clean and Clear ®®, that , that usually worked on my zits” You usually worked on my zits” You would reply:would reply:


A. Try it, we’ll see if it works for A. Try it, we’ll see if it works for you.you.

B. Clean and ClearB. Clean and Clear® ® is not the best is not the best acne treatment, there are better acne treatment, there are better ones out there.ones out there.

C. This rash is not acne, and C. This rash is not acne, and applying Clean and Clear applying Clean and Clear ®® will will only increase the dryness.only increase the dryness.

Congratulations!!!Congratulations!!!

You have successfully completed You have successfully completed the the

case studies.case studies.

Nice Job!Nice Job!

Future DirectionFuture Direction

As the use of EGFR inhibitors As the use of EGFR inhibitors grows for many types of cancers, grows for many types of cancers, continued research is necessary continued research is necessary to develop evidenced based to develop evidenced based guidelines to provide the best guidelines to provide the best nursing sensitive patient nursing sensitive patient outcomes for patients with EGFR outcomes for patients with EGFR inhibitor rash.inhibitor rash.

ReferencesReferences

Eaby, B., Culkin, A., & Lacouture, M. (2008). An Eaby, B., Culkin, A., & Lacouture, M. (2008). An interdisciplinary consensus on managing skin reactions interdisciplinary consensus on managing skin reactions associated with human epidermal growth factor receptor associated with human epidermal growth factor receptor inhibitors. inhibitors. Clinical Journal of Oncology Nursing.Clinical Journal of Oncology Nursing. 12, 283-290. 12, 283-290.

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Thank you to my preceptor, Mary Thank you to my preceptor, Mary Pat Johnston RN, MS, AOCN for her Pat Johnston RN, MS, AOCN for her guidance. guidance.

Thank you to my coworkers and Thank you to my coworkers and family for their support. family for their support.

Questions, comments or Questions, comments or suggestionssuggestionsI invite you to contact me:I invite you to contact me:[email protected]@alverno.edu

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What Kind of Rash Is It? A Tutorial About a Skin Rash Associated with Epidermal Growth Factor...

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