Supplement Individual Article: NECOM Skincare Algorithm for Patients With Cancer and Survivors

When determining the severity of the cAEs, check for fever, pain, bullae, pustules or erosions, mucosal involvement, and significant blood abnormalities.^{4,25-27,36-39,48,51,52,57-60-67} Further, check recent changes in the patient’s general condition: when changes occurred, how severe these are, and whether they impact QoL.⁴ Assess wellness: inquire about the intake of food and liquids, how the patient is coping with everyday living activities (eg, is assistance needed where it wasn’t before?]^.4,27 When assessing the cAEs, rule out other etiologies such as infections, effects of other agents, or other skin conditions.^{4,25-27,36-39, 48,51,52,64-67}

Severe cAEs require prompt clinical attention, urgent referral, and triage.^{4,13,25,26,39} Symptoms that raise suspicion for severe cAEs include fever, widespread rash, skin pain, skin sloughing, facial or upper-extremity edema, bullae, or erosions. ^{4,13,25,26,39}

A glossary containing photographs and a checklist for identifying cAE risk may support non-dermatologists in taking prompt and effective action.⁴

Telemedicine
The oncology nurse or other health care professionals treating patients with cancer can use telemedicine. The technology may help overcome organizational and logistic challenges or can be used as an adjunct to face-to-face evaluations. The NECOM advisors further stressed the need for using telemedicine or virtual consultation as a suitable way to give patients and health care professionals access to dermatological expertise.^{4,18,24-26,39}

Telemedicine can include online patient portals, patient apps, remote monitoring, patient education, and clinical medical education on cAEs for health care providers.^{4,18,24-26,39} These virtual tools further offer a suitable solution for rural areas where access to specialized multidisciplinary oncology teams may not be available. Finally, teledermatology software also allows for instant auditing of practices with the assessment of diagnoses, turnaround times, and outcomes.^{4,18,24-26,39}

Treatment of Non-Life-Threatening cAEs
Once it is determined that the cAE is non-life-threatening, home care nurses (HCPs) are used frequently in Nordic countries; these important HCPs can help assess the severity of cAEs and ensure compliance with skincare regimens.⁴

In addition, safe therapies for cAEs are essential in supporting optimal management of cAEs.^4,24-26,39

If after the skincare regimen is reinforced and basic skin therapy is instituted by the home care or oncology nurse the cAE is persistent, the oncologist or an oncodermatologist should be engaged. These health care professionals can examine whether the skin concern is an exacerbation of a pre-existing skin condition, a cAE, or the result of cancer.^{4,24-26,36-39} Where the morphology is unclear, biopsies can play a role in further diagnosing cutaneous immune-related adverse events.^4,24-26 Oncologists or oncodermatologists can initiate more aggressive supportive care and reaction-specific management. Reactionspecific management is beyond the scope of this paper.

Limitations include the inherent bias and lack of robust studies supporting skin care for cancer treatment-related cAEs. Strengths include the composition of a collaborative team including specialists from oncology and oncodermatology to formulate a practical treatment algorithm for skin care for patients with cancer and survivors.

Communication on best practices in the fast-evolving area of oncology is necessary to provide tailored general measures and skin care supported by evidence- and practice-based expert recommendations. The skincare algorithm for patients with cancer and survivors promotes healthy skin that reduces cancer treatment-related cAEs. Essential points in the implementation of oncology patient care include: 1) Skin care should be taught and recommended before the oncology treatment starts, 2) The oncology nurse should be educated in the early identification of cAEs, 3) Dermatologist - oncologist - nurse team/ close collaboration is vital for the wellbeing of the patients during their cancer treatment and survival.

The work was supported by an unrestricted educational grant from La Roche-Posay Nordic European Countries. All authors contributed to the manuscript, reviewed it, and agreed with its content and publication.

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