Management of skin toxicity of epidermal growth factor receptor inhibitors

Epidermal growth factor receptor (EGFR)-targeted therapies (monoclonal antibodies such as cetuximab and panitumumab as well as tyrosine kinase inhibitors like erlotinib and gefitinib) are responsible for a unique constellation of mechanism-based, class-specific side effects on the skin. Besides the well-known acneiform eruption, this skin toxicity consists of xerosis (leading to eczema and fissures), paronychia, hair changes, telangiectasia, hyperpigmentation, and mucosal changes. Dermatologic treatment is supportive and aims at maintaining quality of life while continuing EGFR-inhibitor therapy. Although a recent study demonstrated the effectiveness of prophylactic minocycline in cetuximab-induced acneiform eruption, randomized controlled trials remain sparse and evidence-based guidelines are lacking. Based on personal experience, most cases of acneiform eruption are well controlled by topical metronidazole and oral minocycline 100 mg qd. For severe reactions, minocycline dose is doubled and saline compresses have proven very valuable. For superinfection with Staphylococcus aureus, oral cefuroxim axetil can be added for a short term. Emollients and topical steroids can be administered for skin dryness or eczema. Paronychia is the hardest part to treat but antiseptic soaks and a corticosteroid paste can alleviate symptoms to some degree.