Skin Changes During Cancer Treatment

Last updated: January 2025 | Medical Reviewer: Oncol.net Editorial Board

Overview

Cancer treatments - including chemotherapy, targeted therapy, immunotherapy, and radiation - can affect the skin in various ways. The skin is particularly vulnerable because skin cells divide rapidly, making them targets for treatments that attack fast-growing cells. Additionally, many newer targeted therapies specifically affect pathways important for skin health.

Skin changes can range from mild dryness and rash to severe reactions requiring treatment modifications. Understanding what to expect, how to prevent problems, and when to seek help can significantly improve quality of life during cancer treatment.

Types of Skin Changes

Hand-Foot Syndrome (Palmar-Plantar Erythrodysesthesia)

• Causes: Capecitabine, 5-FU (continuous infusion), liposomal doxorubicin, sorafenib, sunitinib, regorafenib
• Incidence: 30-60% depending on drug and dose
• Symptoms:
  • Grade 1 (mild): Tingling, numbness, redness, slight swelling
  • Grade 2 (moderate): Painful redness, swelling, skin peeling, blisters
  • Grade 3 (severe): Severe pain, cracking, bleeding, inability to walk or use hands
• Onset: Usually 2-12 weeks after starting treatment
• Management:
  • Prevention:
    • Keep hands and feet cool (avoid hot water, heating pads, prolonged sun)
    • Moisturize frequently with thick creams (urea-based, petroleum jelly)
    • Wear comfortable, cushioned shoes; avoid tight footwear
    • Avoid prolonged pressure on hands and feet
  • Treatment:
    • Topical steroids for inflammation
    • Pain relievers (acetaminophen, NSAIDs if platelets normal)
    • Vitamin B6 (pyridoxine) 100-200 mg daily - limited evidence but commonly used
    • Dose reduction for Grade 2-3 (often necessary)

Acneiform Rash (EGFR Inhibitor Rash)

• Causes: EGFR inhibitors (erlotinib, gefitinib, osimertinib, cetuximab, panitumumab)
• Incidence: 50-90% of patients
• Appearance:
  • Looks like acne but is NOT acne (different mechanism)
  • Pustular lesions (pimple-like bumps filled with pus)
  • Most common on face, scalp, chest, upper back
  • Often itchy or painful
• Timing: Usually appears within first 2 weeks of treatment, peaks at 3-4 weeks
• Paradox: Rash severity correlates with treatment effectiveness - more rash = better tumor response
• Management:
  • Prophylactic (preventive) approach:
    • Start at treatment initiation
    • Topical hydrocortisone 1% or 2.5% cream to face twice daily
    • Gentle moisturizer (fragrance-free)
    • Sunscreen SPF 30+ (mineral-based)
    • Oral doxycycline 100 mg twice daily (anti-inflammatory, NOT for infection)
  • For established rash:
    • Continue preventive measures
    • Topical antibiotics (clindamycin, metronidazole)
    • Stronger topical steroids for severe cases
    • Oral antibiotics (doxycycline, minocycline)
    • Dose reduction rarely needed (prefer to treat through if possible)
  • Skin care:
    • Gentle cleanser (avoid harsh acne products)
    • DO NOT use benzoyl peroxide or salicylic acid (too irritating)
    • Pat dry, don't rub
    • Fragrance-free, alcohol-free products

Radiation Dermatitis

• Incidence: >90% of patients receiving radiation therapy (severity varies)
• Timing: Develops during radiation course, peaks 1-2 weeks after completion, then gradually improves
• Grades:
  • Grade 1: Faint erythema (redness), dry desquamation (dry peeling skin)
  • Grade 2: Moderate to brisk erythema, patchy moist desquamation (weeping skin)
  • Grade 3: Moist desquamation in areas other than skin folds, bleeding
  • Grade 4: Skin necrosis, ulceration (rare with modern techniques)
• Risk factors:
  • Breast, head/neck radiation (skin folds, friction areas)
  • Higher radiation dose
  • Concurrent chemotherapy
  • Smoking
• Management:
  • Prevention:
    • Gentle washing with lukewarm water and mild soap
    • Pat dry gently
    • Wear loose, soft clothing over treatment area
    • Avoid shaving in treatment field
    • No deodorant with aluminum during breast radiation (can interfere with treatment)
    • Protect from sun exposure
  • Moisturizers:
    • Aquaphor, petroleum jelly, or specialized radiation creams
    • Apply 2-3 times daily
    • Some centers recommend starting from day 1, others wait until skin reactions appear
    • Avoid application within 4 hours before radiation treatment
  • For moist desquamation:
    • Silver sulfadiazine cream (if not allergic to sulfa)
    • Hydrogel dressings
    • Keep area clean and dry
    • May require treatment break if severe

Hyperpigmentation and Photosensitivity

• Causes:
  • Hyperpigmentation: 5-FU, capecitabine, busulfan, bleomycin, cyclophosphamide, doxorubicin
  • Photosensitivity: 5-FU, methotrexate, dacarbazine, vinblastine, EGFR inhibitors
• Hyperpigmentation patterns:
  • Generalized darkening of skin
  • Darkening along veins where chemotherapy infused
  • Nail and tongue darkening
  • More noticeable in darker-skinned individuals
• Photosensitivity:
  • Exaggerated sunburn reaction (severe burn from minimal sun)
  • Can occur with brief sun exposure
  • May persist for months after treatment ends
• Management:
  • Sun protection (essential):
    • Broad-spectrum sunscreen SPF 30+ (apply every 2 hours outdoors)
    • Protective clothing (long sleeves, wide-brimmed hat)
    • Seek shade, limit sun exposure 10 AM - 4 PM
    • Sunglasses with UV protection
  • Hyperpigmentation usually fades gradually after treatment (may take months to years)
  • Skin-lightening creams generally not recommended during treatment

Dry Skin and Pruritus (Itching)

• Causes: Many chemotherapy drugs, targeted therapies, immunotherapy
• Incidence: 30-50% of patients
• Symptoms:
  • Dry, flaky, scaly skin
  • Itching (can be severe and interfere with sleep)
  • Cracking, especially on hands and feet
• Management:
  • Moisturize frequently:
    • Apply thick creams or ointments 2-3 times daily
    • Best time: immediately after bathing while skin still damp
    • Fragrance-free, hypoallergenic products
    • Options: CeraVe, Cetaphil, Eucerin, Aquaphor, petroleum jelly
  • Bathing:
    • Lukewarm (not hot) water
    • Limit bathing time to 5-10 minutes
    • Mild, fragrance-free soap (Dove Sensitive, Cetaphil)
    • Pat dry gently
  • For itching:
    • Oral antihistamines (diphenhydramine/Benadryl at night, cetirizine/Zyrtec during day)
    • Menthol or camphor lotions (Sarna, Gold Bond)
    • Cool compresses
    • Keep nails short to avoid scratching damage
    • Topical steroids if severe
  • Environment:
    • Use humidifier in bedroom
    • Wear soft, breathable fabrics (cotton)
    • Avoid wool and rough fabrics

Nail Changes

• Causes: Taxanes (paclitaxel, docetaxel), anthracyclines, EGFR inhibitors, capecitabine
• Types of changes:
  • Pigmentation: Dark bands or complete darkening of nails
  • Beau's lines: Horizontal grooves across nails (mark timing of chemotherapy)
  • Onycholysis: Nail separation from nail bed
  • Paronychia: Inflammation around nail fold (especially with EGFR inhibitors)
  • Nail loss: Complete shedding of nails (usually grows back after treatment)
• Management:
  • Prevention:
    • Ice gloves/boots during taxane infusion: Reduces blood flow to nails, protects from damage (not universally available)
    • Keep nails short and clean
    • Wear protective gloves for housework, gardening
    • Moisturize cuticles daily
  • For paronychia:
    • Warm soaks 2-3 times daily
    • Topical antibiotics (mupirocin)
    • Topical or oral antibiotics if infected
    • Avoid manicures, nail manipulation
  • Nail care:
    • Avoid artificial nails, gel polish
    • Regular nail polish is okay if desired (can hide discoloration)
    • Use acetone-free polish remover

Immune-Related Skin Reactions (Immunotherapy)

• Causes: Checkpoint inhibitors (pembrolizumab, nivolumab, ipilimumab, atezolizumab)
• Incidence: 30-40% (most common immune-related adverse event)
• Types:
  • Maculopapular rash (most common)
  • Pruritus without rash
  • Vitiligo (patchy loss of skin color - actually good sign in melanoma)
  • Lichenoid reactions
  • Severe: Stevens-Johnson syndrome, toxic epidermal necrolysis (very rare but life-threatening)
• Timing: Can occur anytime, typically within first 3 months
• Management:
  • Grade 1-2 (mild-moderate):
    • Topical steroids
    • Oral antihistamines for itching
    • Continue immunotherapy
  • Grade 3-4 (severe):
    • Hold immunotherapy
    • Systemic steroids (prednisone 0.5-1 mg/kg)
    • Dermatology consultation
    • May need to permanently discontinue if very severe

General Skin Care During Cancer Treatment

Daily Skin Care Routine

• Cleansing:
  • Gentle, fragrance-free cleanser
  • Lukewarm water
  • Pat dry, don't rub
  • Limit bathing to once daily (or less if very dry)
• Moisturizing:
  • Apply within 3 minutes of bathing
  • Use thick creams or ointments (not lotions - too thin)
  • Reapply throughout day as needed
  • Pay special attention to hands, feet, elbows
• Sun protection:
  • Daily broad-spectrum sunscreen SPF 30+ (even on cloudy days)
  • Reapply every 2 hours if outdoors
  • Protective clothing and hats
  • Avoid tanning beds (absolutely contraindicated)

Products to Avoid

• Fragranced products (perfumes, scented lotions)
• Alcohol-based products
• Harsh exfoliants or scrubs
• Retinoids (tretinoin, adapalene) unless prescribed
• Benzoyl peroxide, salicylic acid (for EGFR rash)
• Alpha-hydroxy acids (glycolic acid, lactic acid)

Recommended Products

• Cleansers: Cetaphil, CeraVe, Dove Sensitive, Vanicream
• Moisturizers: CeraVe cream, Eucerin, Aquaphor, Vaseline, Aveeno
• Sunscreen: Mineral-based (zinc oxide, titanium dioxide) - less irritating than chemical sunscreens

Emotional Impact

Visible skin changes can significantly affect quality of life and emotional well-being:

Common Concerns

• Self-consciousness about appearance
• Anxiety about social situations
• Frustration that rash indicates "being sick"
• Impact on intimate relationships
• Depression related to body image changes

Coping Strategies

• Cosmetic camouflage:
  • Foundation or concealer to cover redness
  • Green-tinted primers neutralize redness
  • Look What I Can Do (LWID) or similar programs teach camouflage techniques
• Psychological support:
  • Talk with counselor or therapist
  • Support groups for cancer patients
  • Share concerns with healthcare team
• Remember:
  • Most skin changes are temporary
  • For EGFR rash, severity correlates with treatment effectiveness
  • Your healthcare team can help manage skin issues
  • Don't suffer in silence - speak up about skin concerns

Frequently Asked Questions

Will my skin go back to normal after treatment?

Most skin changes improve significantly or resolve completely within weeks to months after treatment ends. Some changes (like hyperpigmentation or nail discoloration) may take 6-12 months to fully fade. Radiation changes can be permanent in the treatment area (skin may remain slightly darker or drier), but acute reactions resolve.

Can I wear makeup during cancer treatment?

Yes, generally makeup is fine and can help you feel better about your appearance. Choose fragrance-free, hypoallergenic, mineral-based products. Avoid makeup during radiation treatment (apply after daily session). Remove gently with mild cleanser. If you have an acneiform rash, use non-comedogenic (won't clog pores) products.

Should I see a dermatologist?

Your oncology team can manage most skin changes, but dermatology referral may be helpful for severe rash, uncertain diagnosis, or if skin issues aren't responding to initial treatment. Some cancer centers have oncodermatology specialists who specifically focus on cancer treatment-related skin issues.

Is the EGFR rash a sign that treatment is working?

Yes. Multiple studies show that patients who develop more severe EGFR inhibitor rash tend to have better tumor responses and survival. This doesn't mean you should avoid treating the rash - manage it aggressively while continuing treatment. The presence and severity of rash is considered a biomarker of drug effectiveness.

Can I shave during cancer treatment?

Use caution. Avoid shaving in radiation treatment fields. Use electric razor rather than blade to minimize cuts and irritation. Shaving can worsen acneiform rash - consider not shaving or using trimmer instead. If you must shave, use gentle shaving cream for sensitive skin and fresh, sharp blades.

Will I be more sensitive to the sun permanently?

Photosensitivity usually resolves within months after treatment, but you may remain more sun-sensitive than before cancer treatment. Some drugs (like 5-FU) cause photosensitivity that lasts several weeks after treatment. Radiation-treated skin remains permanently more sun-sensitive. Lifelong sun protection is recommended for everyone, especially cancer survivors.

Can I go swimming with radiation dermatitis?

Ask your radiation oncologist. During active treatment, many recommend avoiding chlorinated pools (irritating to skin). Salt water (ocean) is usually okay. After radiation is complete and skin has healed, swimming is fine. Keep radiation-treated skin well-moisturized afterward.

Why shouldn't I use regular acne products for my EGFR rash?

EGFR rash is NOT acne - it's an inflammatory reaction from EGFR inhibition in skin. Traditional acne products (benzoyl peroxide, salicylic acid, retinoids) are too harsh and will worsen irritation without helping the rash. The treatment approach is anti-inflammatory (steroids, antibiotics) rather than anti-acne.

Are there any supplements that help with skin issues?

Limited evidence supports supplements for cancer treatment skin changes. Vitamin B6 (pyridoxine) is often recommended for hand-foot syndrome (modest benefit). Some patients use vitamin E or aloe vera, but evidence is weak. Always discuss supplements with your oncology team before starting - some may interfere with treatment.

Can I get a tattoo during cancer treatment?

No. Avoid tattoos during active treatment and for at least 6-12 months after completion. Tattooing poses infection risk when immune system is compromised, and skin healing may be impaired. Discuss timing with your oncologist if you're considering a tattoo after treatment.

Sources and References

• National Comprehensive Cancer Network (NCCN) Guidelines: Cancer Treatment-Related Skin Toxicity
• Multinational Association of Supportive Care in Cancer (MASCC) Skin Toxicity Study Group
• American Academy of Dermatology Guidelines
• Lacouture ME et al. Clinical practice guidelines for the prevention and treatment of EGFR inhibitor-associated dermatologic toxicities. Supportive Care in Cancer. 2011
• Radiation Therapy Oncology Group (RTOG) Skin Toxicity Grading