Dr. Linder is a board certified dermatologist, a fellowship trained Mohs surgeon, biomedical engineer and chemist. Dr. Linder holds a clinical faculty position in the department of dermatology at the University of California, San Francisco and is chief scientist for PCA Skin.
PCA Skin is the peel treatment company I use in my esthetic practice. I have attended their Skin Biology and Chemical Peel Seminar several times and most recently, Advanced Peeling Techniques Class.
I designed Okamura Farmacopia in response to what I learned from my Look Good Feel Better experience.
Skin Care and the Cancer Patient
A diagnosis of cancer is devastating to patients and their families. Depending on the type and location of the cancer, the patient may be treated with chemotherapy, radiation therapy or even surgery. While some patients are aware that cancer treatment may affect their skin, many are not adequately prepared for the varied and sometimes severe cutaneous side effects. By gaining a thorough understanding of the possible dermatological ramifications of cancer treatment, skin care professionals can help educate the patient while designing treatment plans to minimize damage and speed skin recovery.
Types of cancer
There are literally hundreds of types of cancer for which a patient may be receiving chemotherapy or radiation treatment. As a dermatologist or skin health clinician, patients that are battling non-skin-related cancers may be referred to you to help mitigate the potential negative effects that intravenous chemotherapy and radiation treatment can have on their skin. Providing cancer patients with effective tools to keep their skin feeling and looking healthy during these difficult, yet necessary medical interventions is an important and meaningful part of our work as skin care clinicians.
How chemotherapy affects the skin
The treatment of cancer is a complex endeavor for the scientists developing treatments, as well as for the oncologists treating patients. A highly simplified description of how these drugs work is that they target the genetic material within the nuclei of rapidly replicating cells, such as cancer cells. Some drugs damage the chromosomes before the cell splits, and others achieve this while they are splitting. Effective treatment typically involves a variety of chemotherapeutic drugs to target as many cells as possible. Due to these drugs’ mechanisms of action, cells that are not actively splitting are less likely to incur damage. Unfortunately, because hair and skin cells are constantly replicating, they are almost always damaged during these treatments.
Common dermatologic side effects of chemotherapy
Educating the cancer patient and setting realistic expectations about what may occur in their skin during chemotherapy is important. It is also helpful to make them aware of the strategies you can put in place for them to help minimize cutaneous discomfort and the complications they may experience. Below are the most common skin-related side effects to be aware of:
• Severe dryness
• Sensitivity, rashes or allergic reactions
• Folliculitis, a skin rash often mistaken for acne
The intensely dry skin that is a common complaint associated with chemotherapy can be minimized by boosting skin hydration and barrier function prior to starting the course of treatment. Topical serums and creams containing gentle humectant ingredients (such as urea, glycerin and hyaluronic acid) and occlusive ingredients (such as niacinamide, squalane, dimethicone and cyclomethicone) will help prepare skin for the upcoming challenges. The discomfort patients experience due to dryness can range from skin that feels slightly dry and stretched to being so dry that the skin cracks, peels and weeps. If the skin does develop open fissures, special care must be taken when recommending topical products, as the pH of the skin in those areas will be higher, making products that are pH appropriate for intact skin feel acidic and uncomfortable.
Skin rashes and topical allergic reactions can accompany chemotherapy treatment. To minimize the occurrence of possible rashes or reactions, counsel patients to avoid the use of skin care products containing synthetic dyes, perfumes or other known sensitizers during their course of treatment.
Photosensitivity can also result from chemotherapy. Some of the drugs used in treatment can increase the patient’s sensitivity to UVA and UVB rays, and cause sunburn. Daily use of a broad spectrum sunscreen with an SPF of at least 30, practicing sun avoidance and wearing protective clothing and wide-brimmed hats can prevent overexposure and limit damage.
Skin flushing is caused by a dilation of the blood vessels, and is common as a result of certain chemotherapeutic drugs. It cannot be prevented topically, but use of gentle, non-irritating topicals in conjunction with topical anti-inflammatory ingredients can help minimize redness and discomfort. It is not completely clear why hyperpigmentation is such a common side effect of chemotherapy treatment, but the fact that inflammation is a key driver of melanogenesis and pigment deposit likely plays a role. Gentle melanogenesis inhibiting ingredients, such as arbutin, licorice root and L-ascorbic, kojic, azelaic and lactic acids can be used prior to and during treatment to minimize the severity of the hyperpigmentation, and to keep it largely below the surface and invisible to the naked eye. Once chemotherapy is completed and the skin has returned to baseline, a series of gentle, blended, superficial chemical peels is recommended to lift any excess pigment that was deposited during treatment.
During chemotherapy, some patients will develop what looks like an acne breakout. This is actually folliculitis, resulting from the leukocytes drawn into the follicles due to irritation caused by the chemotherapy drugs. These follicular lesions can appear on the face, scalp or anywhere on the body. Traditional acne treatments are typically too aggressive for the compromised skin of cancer patients, so instead gentle anti-inflammatory and antibacterial ingredients are recommended. Low percentages of salicylic acid and azelaic acid can help fight bacteria and clear the follicles, while hydrocortisone, bisabolol and white willow bark are good choices to help calm irritated follicles.
The side effects of radiation therapy on the skin are usually more localized than those associated with chemotherapy. This form of cancer treatment works by sending high doses of energy directly to the cancer site in an attempt to eradicate cancerous cells while preserving the surrounding tissue. Due to the intensity of external radiation therapy, patients experience side effects similar to that of being in the sun unprotected. Common side effects include darkening of the skin and blisters. Patients may also experience dry, flaking or peeling skin, similar to patients who undergo chemotherapy. Avoiding the sun, wearing loose clothing and using gentle, occlusive balms can help to make patients more comfortable.
Providing the best information for your patient
Undergoing treatment for cancer can be a scary and confusing time for patients. Assisting them in sifting through the plethora of available information and presenting solutions to their skin problems is an invaluable service during this uncertain time. It is important to provide the patient with research-based solutions to their issues and ensure that they can comfortably carry out your recommendations, either on their own or with the aid of a caregiver. Patients should be instructed to cleanse the skin with mild cleansers and lukewarm water, avoiding the use of harsh detergents or exfoliants. Provide guidance in selecting a broad spectrum sunscreen that protects against both UVA and UVB rays, and contains one of the following UVA protection ingredients: zinc oxide, titanium dioxide, avobenzone or encamsule. This daily protection is critical for everyone, yet a non-negotiable for the patient undergoing cancer treatment.
Partnering with the oncologist
As a cancer patient undergoes the rigors of treatment, they need the support of a team of professionals, as well as that of friends and family. Clinical skin health professionals and dermatologists are well positioned to partner with oncologists to serve as mutual referral partners in order to provide the patient with the best overall care and possible outcome. Skin health professionals are indispensable in both the pre- and post-treatment environment. Patients can benefit greatly from assistance in promoting their skin health prior to chemotherapy or surgery, which will help to make treatment easier and reduce healing time afterward. Working with an oncologist, a detailed post-treatment plan can be developed to monitor and address any skin problems that may occur. Working with cancer patients to help maintain the health of their skin during treatment provides a unique opportunity to gain expertise in an area that has been historically underserved, and provide a service that can offer comfort and reassurance during a difficult time in a patient’s life.