US Cutaneous Oncodermatology Management (USCOM): A Practical Algorithm

September 2021 | Volume 20 | Issue 9 | Supplement Individual Articles | 3ss | Copyright © September 2021

Published online September 1, 2021

Mario E. Lacouture MD,a Jennifer Choi MD,b Alice Ho MD,c Jonathan Leventhal MD,d Beth N. McLellan MD,e Anneke Andriessen PhD,f Maxwell B. Sauder MD,g Edith Mitchell MDh

aOncodermatology, Memorial Sloan Kettering Cancer Center, New York, NY
bOncodermatology Program, Department of Dermatology, Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL
cRadiation Oncology, Massachusetts General Hospital, Memorial Sloan Kettering Cancer Center, New York, NY
dOncodermatology, Smilow Cancer Hospital at Yale, New Haven, CT
eMontefiore's Division of Dermatology and Montefiore Einstein Center for Cancer Care; Dermatology, Jacobi Medical Center, New York, NY fRadboud UMC, Nijmegen and Andriessen Consultants, Malden, The Netherlands
gOncodermatology, Princess Margaret Cancer Centre, Pigmented Lesion Clinic, Toronto Dermatology Disparities; Gastrointestinal Centre, Toronto, ON, Canada
hCenter to Eliminate Cancer Disparities, Gastrointestinal Oncology, Thomas Jefferson University Hospital and Jefferson Methodist Hospital, Philadelphia, PA

complex regimens and applications viewed as a "chore," especially when initiated prophylactically, "wait and see" attitude, socioeconomic factors, and cost.12,50

Patients receiving cancer treatment [ie, chemotherapy or targeted therapy] have a higher risk of developing photosensitivity.23,47 In a phototoxic reaction, medications such as chemotherapy drugs absorb UV radiation. This absorption of UV light causes a change in the drug's chemical composition, which emits skin-damaging energy.23,47 Moreover, exposure to UV radiation is associated with skin cancer development.57 UV radiation has wavelengths shorter than visible light and is subdivided into UVA1, UVA2, UVB, and UVC.57 The shorter the wavelength, the greater the potential for UV radiation to cause biological damage.57

Sunscreens are part of a complete program for sun protection that includes protective clothing and sun avoidance.57-59 Sunscreens can be classified as UVB filters, UVA1, UVA2 filters, or physical blockers.57-59 Chemical filters, such as oxybenzone, avobenzone, octocrylene, and ecamsule, are aromatic compounds that absorb high-intensity ultraviolet radiation.57 UVA filters have a range of 320–400 nm, while UVB blockers are active in 290–320 nm.58 Octocrylene is a widely used UVB filter and has a thick, oily texture and a peak absorption at 303 nm (range, 290–360 nm).57 Sunscreens such as oxybenzone have UVA activity in the 320–340 nm range. Avobenzone, oxybenzone, and ecamsule (Anthelios SX) are effective in most of the UVA range.57-59 Most currently available sunscreen formulations aim for coverage of both UVA and UVB spectra.

Physical blockers, including zinc oxide, are effective in both the UVA and UVB ranges as they reflect or refract UV radiation.57-59 Many dermatologists recommend daily sunscreen of SPF 30 or higher, especially for sun-exposed areas, 15 minutes before sun exposure and every 2 hours after that. Special populations that are at higher risk for sun-induced toxicities and neoplasms should avoid sun exposure by using para-aminobenzoic acid (PABA) free UVA and UVB protection as well as sun-protective clothing.60 (Box 5: Sun protection and sunscreen)

Fissures, Blisters, and Wounds
Apply a wound dressing for patients with fissures, bullae, erosions, and ulcers. Depending on the wound bed condition and exudate levels, various dressings may be used, such as a foam dressing or a non-adherent wound contact layer, including silicone-coated dressings. The frequency of dressing changes depends on exudate level. Cleanse the peri-wound skin with water and a gentle cleanser and remove debris from the wound bed. For wounds at risk for infection, use an antiseptic. Avoid the use of prophylactic topical antibiotics to comply with antimicrobial stewardship preventing antibiotic resistance.51

Statement 9: Effective management of dermatologic toxicities associated with cancer treatment is a multidisciplinary effort involving dermatologists, oncologists, and APPs.

A collaborative, interprofessional approach is the most efficient method of connecting cancer patients with dermatological care from the start of their cancer care.8-12,45,50 cAEs often occur secondary to chemotherapeutic agents, yet up to 84% of cancer survivors with cAEs are not referred to a dermatologist.60

There is a high discordance on the decision to pause anticancer therapy between dermatologists and referring clinicians, with medical oncologists more likely to discontinue cancer therapy due to cAEs.9-11 Consequently, timely intervention by a dermatologist trained in supportive dermatology for oncology patients is critical to preventing avoidable treatment interruptions.7 Urgent access to a dermatologist is paramount to identifying and assisting in managing dangerous or lifethreatening cAEs.12,50,61 Equally important is a dermatologist's ability to improve quality of life related to cAEs and to preserve cancer treatment through managing cAEs.12,50

The USCOM panel recommends that education, optimal communication, access to support information, and early reporting of cAEs will enable efficient use of dermatology services.62 Telemedicine or virtual consultation can facilitate patients' and healthcare professionals' access to dermatological expertise. Telemedicine can also include online patient portals, patient apps, remote monitoring, patient education, and CME for healthcare providers.63 These virtual tools further offer a suitable solution for rural areas where